Sentinel fracture: the necessity of improved post-fracture care

The first goal of acute fracture treatment includes effective pain management and prompt mobilization. When using a plaster cast or plastic splint—common treatments for distal radius fracture—adjacent joints should be used in daily activities. In the case of a fracture of the proximal humerus treated with a shoulder bandage, the European Society for Trauma and Emergency Surgery (ESTES) recommends starting pendulum exercises and guided movement exercises up to 90 degrees after 3 weeks [21]. Surgically treated fractures are usually immobilized in a shoulder bandage for 2–4 weeks, usually with passive exercise (swinging) after 2 weeks and active exercise after 4 weeks [22]. After surgery, fractures near the hip are usually exercise stable [23]. Ideally, the patient should be transferred directly to a remobilization facility to swiftly regain their pre-fracture level of activities of daily living (ADL). Multidisciplinary rehabilitation, particularly with the inclusion of progressive strength training (inpatient/outpatient) for fractures close to the hip joint, reduces mortality and improves mobility [24, 25]. In accordance with the international consensus on the management of vertebral fractures, an individualized guided exercise program should be initiated when the pain level decreases or after medical clearance (around 4–12 weeks after the vertebral fracture) [26]. An exercise program supervised by a physiotherapist improves pain and function [27]. However, if pain persists, it is recommended to perform the exercises for the back extensors in a relieved position (supine position) [28]. Fracture healing (around the 12th week after fracture) is the time to initiate a multimodal training program that includes progressive strength training, functional training, and balance training [26]. In general, lifting heavy loads is prohibited for 12 weeks in the case of vertebral body fractures, and in the case of pronounced osteoporosis it is even strictly prohibited. Kyphoplasty/vertebroplasty procedures, either alone or combined with dorsal instrumentation, generally offer stable postsurgical weightbearing, depending on pain management [29]. In general, spinal orthoses should not be routinely prescribed but rather considered on an individual basis considering the pain situation, with acute pain being the primary factor for prescription [29, 30]. Orthoses can be used as a pain-relieving measure to improve pain and trunk muscle strength by wearing orthoses (2 h a day for 6 months) [28]. Patients with vertebral fractures and/or multiple fragility fractures are generally advised to avoid high-impact loads on the spine (above the level of everyday stress, e.g., higher impact loads than during brisk walking) [31].

The aim of any osteoporosis therapy is to prevent the first fracture or at least a further fracture. All patients after the age of 50 with an MOF must be assessed for the initiation of treatment. Does it make sense to prescribe a bone-specific medication in the acute setting within a few weeks after a fracture? There have been repeated concerns that osteoporosis treatment could impede fracture healing. However, some evidence exists from both preclinical and clinical studies that teriparatide accelerates fracture healing, that function is largely improved, and that pain is relieved [32]. Both the physiological processes of fracture healing and experimental investigations point toward enhanced fracture healing through administration of the sclerostin antibody romosozumab. However, this could not be verified in a clinical, albeit small, study [33]. Gao and coauthors [34] concluded in their meta-analysis that bisphosphonates do not influence fracture healing. A subgroup analysis of the fractures occurring in the pivotal study of the receptor activator nuclear factor B ligand (RANKL) antibody denosumab has shown that there is definitely no delayed healing in these patients [35]. Therefore, if necessary, bone-specific medication should be started as soon as possible.

The administration of calcium (1000 mg) and/or vitamin D (800 IU) is the basis of any osteoporosis treatment and is necessary as a supplement to the drug treatment of osteoporosis if the calcium intake with nutrition is low or if there is a vitamin D insufficiency. A vitamin D deficiency/insufficiency must be compensated before starting any osteoporosis-specific treatment. An adequate protein supply is also very important. The German Nutrition Society recommends a daily protein intake of at least 0.8 g/kg bodyweight (target weight) and 1.0 g/kg bodyweight for the age group 65+ [36].

Drugs used in osteoporosis treatment can be divided into two broad categories depending on their primary mode of action: antiresorptive drugs primarily inhibit osteoclastic bone resorption, with subsequent secondary effects on bone formation. Osteoanabolic drugs primarily stimulate bone formation via increased osteoblast activity, with various effects on bone resorption. Anabolic drugs lead to a rapid improvement in bone microarchitecture and subsequently to an improvement in mineralization. Romosozumab, however, has a dual action by stimulating bone formation and inhibiting bone resorption, which also leads to a rapid improvement in microarchitecture and mineralization.

Assessment of the 10-year fracture probability for an MOF and the isolated near-hip fracture using the Austria-specific FRAX® version enables grading of the individual fracture risk into a low, high, or very high fracture risk [37]. Individuals with a low risk of fracture should receive advice on adopting a “bone-protective” lifestyle (diet, exercise, nicotine abstinence, low alcohol consumption). Patients with a high fracture risk without prevalent fractures should primarily be treated with antiresorptive substances. Men and women with a very high fracture risk should preferably be given osteoanabolic therapy by a specialist with knowledge and experience in the field of osteoporosis. The presence of a recent (more recent than 24 months) MOF is the corresponding indication. In case of contraindications to first-line therapy, anabolic drugs, or medication with a dual mode of action, antiresorptive therapy represents an alternative treatment option. In the event of a hip fracture, zoledronate should be administered at the earliest 14 days afterwards; denosumab can be administered immediately. Of course, this applies only in the absence of contraindications. The choice of medication depends on any existing contraindications, the patients’ health and mental state, and their compliance. Additionally, it is important to plan a long-term treatment strategy for each patient before starting osteoporosis-specific treatment, as the timing and sequencing of the use of certain drugs is important.

To meet the requirements of the Austrian osteoporosis guidelines, all patients over the age of 50 with an MOF (hip, spine, humerus, or forearm) should be investigated with regard to the initiation of treatment.

The risk of falling increases with age. Looking at the 65+ age group, one third fall at least once a year [38]. In the 80+ age group, the frequency is even higher. If the impact of a fall—depending on impact location, soft tissue attenuation, muscle activity, and the surface—is high, the structural capacity may not be able to withstand the applied loads, leading to fractures. Not vertebral fractures, but most fractures occur because of a fall, defined as an “unexpected event in which the subject comes to rest on the ground, floor, or lower level” [39]. Regardless of fracture occurrence, a recent fall (within the previous 4 months) indicates an imminent risk of fracture in the following year [40]. This increase in fracture risk is largely independent of BMD [41]. Hence, fall prevention is important.

Regarding the identification of older adults at a high risk of falling, a distinction needs to be made between opportunistic case finding in clinical practice and assessing patients who have experienced a fall or fall-related injury. For a subject aged 65 years or older without a fall-related injury in the preceding year, the Task Force on Global Guidelines for Falls in Older Adults recommends gait speed or, alternatively, the timed up and go test for fall prediction [42]. Most often, both external and internal factors, such as balance deficits, contribute to the onset of falls [43]. We should ask older adults presenting with a fall-related injury about the details of the event. In subjects with a recent fragility fracture, a multifactorial assessment may be indispensable.

Since most falls are of multifactorial origin, it is often necessary to address numerous modifiable risk factors associated with falls. A Cochrane Review showed that multifactorial intervention following assessment of the participants’ risk profile reduced the rate of falls by 23%. Besides medication review, interventions included psychological interventions, environment or assistive technologies, and/or exercise [44]. Exercise as a single intervention reduces the rate of falls by 23%; looking at different exercise modalities, balance and functional exercises reduce the rate of falls by 24%, combined with resistance training they are even more effective [45]. According to the world guidelines for fall prevention, especially tailored exercises for balance, gait, and strength are an essential part of fall prevention [42].

Therefore, it is crucial to focus on balance training and functional exercises following immediate post-fracture mobilization. Instructions on how to perform the exercises correctly and safety during the exercises are vital. This is especially important in frail subjects with a recent fragility fracture. There are some aspects worth mentioning: balance training is most effective in persons with a high risk of falling [46]; however, these effects generally do not endure beyond the completion of training. After a fall at home leading to a fragility fracture, it additionally makes sense to remove tripping hazards like carpets. Home fall-hazard interventions are most effective when targeted to people at a higher risk of falling ([47]).