A Comprehensive Approach to Fragility Fractures
To address the cause of fragility fractures, an understanding of the determinants of bone strength is needed. Identifying patients at increased fracture risk should take into account bone quantity, quality, and turnover. Postmenopausal osteoporosis remains the most common derangement of bone strength; however, decreased bone strength can also result from secondary causes of osteoporosis. In order to properly manage patients with fragility fractures, assessment should include a focused medical history and physical examination, proper laboratory investigation, dual-energy x-ray absorptiometry screening, and, if necessary, use of the fracture risk assessment tool (FRAX). Treatment options will include nonpharmacologic treatment such as calcium and vitamin D and pharmacologic treatment with antiresorptive or anabolic agents to prevent future fractures. Bisphosphonates remain the standard treatment for osteoporosis. Concerns of oversuppression of bone turnover on long-term bisphosphonate treatment can be addressed with a drug holiday depending on the patient's fracture risk. An anabolic agent such as teriparatide is a powerful tool for the prevention of fragility fractures and should be reserved for patients at high risk for fracture, such as those with declining bone mineral density despite bisphosphonate treatment. Careful evaluation of all patients with a fragility fracture will enable the orthopaedic surgeon to identify the cause of fracture and implement a treatment plan that can prevent subsequent fractures in this vulnerable population.