Fractures
Red flags
- NOF fracture - time-critical: analgesia (femoral nerve block), surgery ideally <48h, delay independently raises mortality
- Vertebral fracture with new neurology - cord/cauda equina compression
- Fracture with disproportionately minimal trauma - pathological fracture (myeloma, metastasis) until excluded
- Compartment syndrome signs post-fracture/cast
- Fat embolism (long-bone fracture) - hypoxia, confusion, petechiae 24-72h post-injury
- Concurrent head strike, anticoagulation, or inability to weight-bear pre-injury (baseline function)
Differential by mechanism
Fragility fracture (low-trauma, the dominant geriatric pattern)
- Fall from standing height or less in a patient with reduced bone strength
- Sites: hip (NOF), vertebral (often asymptomatic/incidental), distal radius (Colles - often the sentinel fracture), proximal humerus
Pathological fracture
- Myeloma, bone metastasis (breast, prostate, lung, renal, thyroid), Paget disease, osteomalacia
High-trauma
- MVA, high fall - less age-discriminating, assess as any trauma patient
Contributing mechanism to identify
- Underlying osteoporosis/osteopenia (the fracture is the sentinel event for undiagnosed bone disease)
- Falls risk factors (see Falls note) - the fracture is falls + fragility together
Focused history
- Mechanism - trauma energy, height of fall, preceding symptoms (syncope, pain before the fall suggesting pathological fracture)
- Prior fragility fractures - strongest predictor of future fracture
- Falls history and risk factors
- Secondary osteoporosis causes - steroids, hyperthyroidism, hypogonadism, malabsorption, CKD, myeloma symptoms (bone pain, fatigue)
- Baseline function and mobility, living situation, carer supports (determines rehab goals)
- Medications - bone-active drugs, anticoagulants (affects surgical timing), sedatives
- Nutrition, alcohol, smoking, vitamin D/calcium intake
Focused examination
- Classic NOF sign: shortened, externally rotated leg
- Neurovascular status distal to injury
- Height loss and thoracic kyphosis - suggest undiagnosed vertebral fractures
- Full falls/frailty examination (gait, cognition, postural BP) once acute injury stabilised
- Screen for pressure injury risk, nutritional status
- Signs of malignancy (lymphadenopathy, breast/prostate exam) if pathological fracture suspected
Investigation strategy
- Plain X-ray of injury site; CT if occult NOF suspected with normal X-ray and high clinical suspicion; MRI most sensitive for occult fracture
- Bloods: FBE, UEC, calcium, phosphate, ALP, vitamin D, LFT, myeloma screen (EPG, free light chains) if pathological fracture suspected
- Every fragility fracture triggers bone health work-up - DEXA (may be delayed until post-acute phase), secondary cause screen (TFT, PTH if calcium abnormal, coeliac serology if malabsorption suspected)
- Pre-operative work-up for surgical candidates - ECG, bloods, medical optimisation
- CXR if fat embolism or aspiration risk
Management
A. Acute
- Analgesia early - nerve block for NOF, avoid excess opioids (delirium risk)
- Pressure injury prevention, VTE prophylaxis, early urinary catheter avoidance
- Orthogeriatric co-management from admission - reduces mortality, delirium, length of stay
- Surgical fixation for NOF - within 48 hours where medically feasible; delay only for correctable acute medical instability, not routine anticoagulation reversal beyond guideline timeframes
B. Perioperative
- Anticipate and prevent delirium (see Delirium note) - orientation, hydration, sensory aids, avoid deliriogenic drugs
- Early mobilisation post-fixation - day 1 where possible
- Nutrition support - malnutrition common and worsens healing/rehab
- VTE prophylaxis per surgical protocol
C. Bone health - every fragility fracture is an indication to treat
- Correct vitamin D and calcium
- Start anti-osteoporotic therapy (see Osteoporosis note) - do not wait for DEXA in a fragility fracture over 50; treat empirically and confirm with DEXA
- Fracture liaison service / secondary fracture prevention pathway referral
D. Rehabilitation and disposition
- Multidisciplinary rehab - physio, OT, dietetics, social work
- Falls risk multifactorial assessment before discharge
- Realistic goal-setting - many NOF patients do not regain pre-fracture mobility
- Advance care planning discussion where trajectory is poor
Traps
- Delaying NOF surgery for minor, correctable medical issues - delay itself increases mortality
- Treating the fracture and not the bone disease - missing the empirical anti-osteoporotic treatment opportunity
- Assuming vertebral fractures are always symptomatic - most are incidental findings on imaging done for other reasons
- Under-treating pain for fear of delirium, which itself worsens delirium
- Omitting orthogeriatric involvement, losing the mortality/delirium benefit of shared care
- Missing a pathological fracture because the trauma "seemed enough" - always sense-check the energy against the fracture
Talk track
A fragility fracture is a sentinel event for both falls risk and undiagnosed osteoporosis - manage the break (early surgery, orthogeriatric co-management, nerve block analgesia, early mobilisation) and the bone (empirical anti-osteoporotic therapy, don't wait for DEXA) and the faller (multifactorial falls assessment before discharge). NOF fracture surgery within 48 hours is the single highest-yield timing target.
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