Fragility Fractures: Hip, Wrist, Forearm & Vertebral

Types of Fractures:

Hip Fractures:

What is the basic anatomy of a hip?
The hip joint is a ball-and-socket joint made up of the top of your femur (ball) and the bottom of the pelvis (socket).
How does a hip fracture occur?
A hip fracture occurs when any part of the structure breaks and the bones separate.
What are common causes for hip fractures?
There are a number of causes for hip fractures, which include a fall, a direct blow (i.e. – automobile accident) to the side of the hip, medical conditions such as osteoporosis, cancer, or repetitive stress.
What are the signs and symptoms of hip fractures?
  • Pain in your hip, groin or even the thigh.
  • Trouble walking on the affected side.
  • Pain when you rotate your hip in or out.
  • The affected leg may appear to be rotated instead of straight.
What are non-operative treatments for hip fractures?
Fractures of the hip should be assessed by an orthopaedic specialist immediately. Rarely recommended are some non-operative management which consists of:
  •  Early ambulation if deemed appropriate by the doctor, with the assistance of a walker or crutches.
  • Physical therapy may be used for safety training, improving balance and strengthening.
  • X-rays to monitor healing.
  • Evaluation of the bone density via bone scan or metabolic blood tests.
  • Lifelong treatment of the osteopenia or osteoporosis to prevent further fractures.
What does operative treatment entail?
Surgery may be necessary to restore the hip joint if the broken pieces of the bone are separated. There are a number of hip fracture surgeries. The X-ray results and type of fracture present will dictate what type of surgery is necessary. Some hip fractures are treated with a partial or total hip replacement.
Why is optimal patient care so important for advancing aged patients?
  • Recognition and treatment of a fragility fracture can reduce the risk of future fractures by up to 50 percent. 
  • Proper treatment of a fragility fracture can stop the downward spiral in health and quality of life that often follows fractures, especially in elderly patients.
  • Increasing age and sustaining a fragility fracture increases the risk of future fractures, so patients should become active participants in chronic disease management.
  • Diagnosis and treatment following an initial fragility fracture reduces the burden of suffering and further health care costs.
How can I prevent a fall?
Often times, a fall is the first indication of an undetected illness. Between 20-30 percent of those who fall suffer injuries that reduce mobility and independence and increase the risk of premature death. To prevent a fall:
  • Make regular appointments with your physician for bone assessments
  • Physical activity is important to the reduce further weakening of the bone
  • Wear sensible shoes
  • Remove home hazards
  • Keep home brightly lit
  • Use assistive devices

Wrist (Distal Radius) and Forearm (Humeral) Fractures:

What are wrist (distal radius) and humerus (upper arm) fractures?
The forearm and wrist are made up of the radius, ulna and carpal bones of the hand. Fractures of this area are often caused by a fall onto an outstretched upper extremity, a fall onto a hand or wrist, or a direct blow to the area.

Humerus fractures involve the upper end, the shaft and the lower end of the humerus (upper arm). Proximal humerus fractures occur near the shoulder joint, mid-shaft humerus fractures occur away from the shoulder and elbow joints, and distal humerus fractures occur near the elbow joint. While humerus fractures can occur in many ways, they are most commonly caused by a fall.
What are the signs and symptoms of wrist and forearm fractures?
  • Immediate pain and swelling.
  • A “pop” or “snap” is heard.
  • A deformity at the site of the injury.
  • Pain when using the affected arm.
How are wrists and forearm fractures treated?
Fractures of upper extremities should be evaluated immediately. An evaluation will consist of physical examination and X-rays. The fracture may need to be reduced (put back in place) and splinted or casted. Depending on the location and success of reduction will determine if operative or non-operative treatment is necessary.
What does non-operative management entail?
Non-operative management will likely involve casting or immobilizing for 4-6 weeks, followed by mobilization and physical therapy.
What is involved in the Pre-Op Care?
  • Pre-Operative History and Physical.
  • Pre-Operative screening labs.
  • Pre-operative X-rays .
  • Elevation of the injured extremity.
What is involved in the Post-Op Care?
  • Daily incision care.
  • Pain medication when needed.
  • Cast or splint to be worn daily for a specific time period.
  • Post-op clinical visits for suture removal at 2-3 weeks after surgery.

Compression Fractures:

What are compression vertebral fractures and what causes such a fracture?
A compression fracture is a collapse of a vertebra or the bone. It can occur from trauma, weakening of the bone (from osteoporosis), primary or metastatic cancer of the bone, or infections. It can involve the neck, mid-back, or low-back and occur at any age.
Who is most susceptible to compression fractures?
The weakening of vertebra is most often seen in patients with osteoporosis or osteogenesis imperfecta, lytic lesions from metastatic or primary tumors, or infection. In healthy patients, it is most often seen in individuals suffering extreme vertical shocks, such as ejecting from an ejection seat.
What are the symptoms?
Compression fractures which develop gradually, such as with osteoporosis, may initially not cause any symptoms, but will later often lead to back pain and loss of height.
How are compression fractures diagnosed?
Compression fractures are diagnosed by a physical exam, but can also include imaging with X-rays, CT scans, or MRI of the spine. Sometimes a bone scan may be ordered.
What type of pain occurs as a result of compression fractures?
Often compression fractures are associated pain in the area where the fracture has occurred. Pain from these fractures typically improves as the bone heals, which may take up to 12 weeks.
How are compression fractures treated?
A brace is often worn while the fracture is healing and is intended to limit activities such as bending and twisting that could cause more pain and could affect the healing of the bone. Medications such as narcotics or muscle relaxers may be prescribed to help with managing  pain while the fracture heals.

In some patients, a kyphoplasty may be offered. This is a minimally invasive procedure in which small needles are put into the affected bone and a small balloon is inflated into the bone creating a space in which bone cement is inserted to stiffen the bone. This surgery typically improves pain quickly and allows patients to return to their activities. The surgery is done as an outpatient procedure.

After bracing or surgery, physical therapy is often prescribed to help patients improve their strength and allow them to return to their usual activities.
What is osteoporosis?
Also known as porous bone, osteoporotic bone is spongy and full of holes. This condition causing low bone mass, makes bone more fragile and likely to break. Many people are unaware of the link between fractures and osteoporosis. If you are over age 50, there is a very good chance that your fracture is related to osteoporosis.
What causes osteoporosis?
Osteoporosis may occur for several reasons. Heredity plays a role, as does ethnicity. It is more common among whites and Asians, though African-Americans and Hispanics may still be at risk. If you did not build bone sufficiently during your bone building years, you may be at risk as you age. Decreased level of estrogen (in women) and testosterone (in men) may contribute to bone loss. Inadequate intake of calcium and vitamin D may lead to osteoporosis. Some medications, although necessary, will cause bone depletion.
How do I know if I have osteoporosis?
A bone mineral density test (DEXA) can detect osteoporosis. The test compares your bone mineral density (BMD) with that of a healthy 30 year old, since that is when bones mass is at its peak. Results come as a T-score in these ranges: -1.0 and higher is normal bone density. A score between -1.0 and -2.5 indicates low bone density (osteopenia). A score of -2.5 or below indicates osteoporosis. As your bone density decreases, your T-score gets lower.
What if I have osteopenia?
If you have bone loss but not enough to be osteoporotic, you may have a condition called osteopenia. Osteopenia can progress to osteoporosis, but with changes in diet and exercise and early treatment, you can slow the bone loss process.
What Can I Do to Help?
  • Drinking alcohol in excess can lead to bone loss and risk of fall, so if you drink, do so in moderation. On an average, alcohol intake of three or more drinks per day is detrimental to bone health.
  • Don’t smoke! Tobacco is toxic to your bone health and may interrupt healing if you’ve incurred a fracture.
  • Eat calcium-rich foods to help protect your bones: dairy products rich in calcium (milk, cheese and yogurt), broccoli, almonds and sardines. Over-the-counter calcium supplements are also available. Adult men and women need 1,000 mg. of calcium daily.
  • Vitamin D3 is necessary for calcium absorption. Sunshine and fortified foods such as milk can help meet your daily quota. Despite these efforts, supplementation is often necessary!
  • Exercise daily! Even modest increases in weight-bearing exercises can be helpful to keep bones and muscles strong. Walking, dancing, hiking or tennis can make bones stronger and denser.
  • Fall prevention - If you are unsteady, physical therapy and/or an assistive device can prevent further risk of falling. To prevent a fall, minimize clutter and be sure that area rugs are anchored to the floor. Eliminate throw rugs and loose cords. Wear sturdy, rubber-soled shoes.
What factors are present that I can’t control?
Women who are thin and have small frames as well as those whom experience early menopause (before age 45) are more likely to develop osteoporosis. Some conditions, such as diabetes, rheumatoid arthritis, Crohn’s or celiac disease will put you at risk. A family history of osteoporosis and hip fracture will increase your risk. Often necessary, medications such as long-term glucocorticoid therapy (Prednisone or Prednisolone) can affect your bone health.
What does good patient care include?
  • Prompt admission to orthopaedic care.
  • Rapid comprehensive assessment – medical, surgical and anesthetic.
  • Minimal delay to surgery.
  • Accurate and well-performed surgery.
  • Prompt mobilization.
  • Early multidisciplinary rehabilitation (Prompt admission to orthopaedic care.
  • Early supported discharge and ongoing community rehabilitation.
  • Secondary prevention, combining bone protection and falls assessment through follow-up appointments with a fragility care specialist.