This patient has osteoporosis (T score less than 2.5) and experienced a fragility fracture of the left wrist. Osteoporotic patients who suffer a fragility fracture should be treated with calcium and vitamin D supplementation as well as alendronate to increase/maintain bone density and lower the risk of future fractures.
Osteoporosis is characterized by decreased bone mineralization yielding reduced bone mass and density. Causes may include post-menopausal state, long-term glucocorticoid therapy, physical inactivity, nutrient (calcium) deficiency, or hyperthyroidism. In addition to the above mentioned pharmacologic treatments, fall prevention and maintenance of regular physical activity are also important steps in the management of these patients. Alendronate has been shown to reduce the rate of hip, spine, and wrist fractures by 50%. Bisphosphonates work by inhibiting osteoclastic bone resorption.
Sweet et al. discuss the diagnosis and treatment of osteoporosis. Screening with DEXA scan is recommended to all females 65 and older as well as females 60-64 years of age with an increased fracture risk. Screening is recommended for men greater than 70 years of age. Adequate daily calcium intake for a patient with osteoporosis or prior fragility fracture is defined as at least 1,200 mg per day of calcium and 700-800 IU per day of vitamin D.
Gass et al. review the prevention of osteoporosis-related fractures. They advocate for a three-pronged approach to osteoporosis treatment. The first level incorporates fall prevention, physical activity, and Ca/vitamin D supplementation. The second level involves the treatment of secondary causes of osteoporosis (endocrine disease, medication-effect). Finally, the third level entails pharmacologic treatment that includes bisphosphonates, estrogen analogues, calcitonin, and teriparatide. Poor long-term medication compliance/adherence is a barrier to effective treatment of osteoporosis.
Figure A shows AP and lateral radiographs of a Colles' fracture of the left distal radius. Illustration A summarizes the three most common fragility fractures that may occur in osteoporotic patients: femoral neck fracture, vertebral body compression fracture, and distal radius fracture. Illustration B depicts an overview image of the mechanism of action of bisphosphonates.
Answer 1: Raloxifene, as an estrogen receptor agonist, slows bone resorption and decreases the risk of vertebral body fracture only. Given this patient's history of DVT, this medication should be avoided.
Answer 2: Activity limitation will further reduce a patient's bone mineral density and decrease the patient's baseline functional status, making a fall and potential fracture even more likely.
Answer 4: Risedronate is a bisphosphonate that reduces vertebral and nonvertebral fracture risk by 40% over 3 years. However, patients with fragility fractures should also receive calcium and vitamin D supplementation in addition to bisphosphonate therapy.
Answer 5: Intranasal calcitonin may be effective at reducing bone pain for a limited period of time; however, it is not the first line treatment for the management of osteoporosis and an associated fragility fracture.
Sweet MG, Sweet JM, Jeremiah MP, Galazka SS. Diagnosis and treatment of osteoporosis. Am Fam Physician. 2009 Feb 1;79(3):193-200.
PMID:19202966 (Link to Abstract)
Gass M, Dawson-Hughes B. Preventing osteoporosis-related fractures: an overview. Am J Med. 2006 Apr;119(4 Suppl 1):S3-S11.
PMID:16563939 (Link to Abstract)