Management of osteoporosis following minimal-trauma fracture

After acute management of a fracture in hospital, refer the patient to their general practitioner or a fracture liaison service for follow-up. Consider starting drug therapy for osteoporosis in any patient older than 50 years who has a minimal-trauma fracture at any site (excluding skull, face, fingers and toes).

Following a minimal-trauma fracture, measure bone mineral density (BMD). The decision to treat is based on fracture site, BMD and ongoing risk of fracture. The majority of minimal-trauma fractures occur in patients with a T-score in the osteopenic range (see World Health Organization categorisation by T-score for World Health Organization categorisation by T-score).

If the T-score is in the osteopenic or osteoporotic range, start drug therapy for osteoporosis.

If the T-score is within the normal range, consider further investigations based on patient history and clinical examination to exclude other causes of fracture. See Considerations before treating osteoporosis for more information. If other causes of fracture are excluded, the decision to treat depends on the fracture site:

• For a patient who had a minimal-trauma hip fracture, start treatment.
• A patient who had a minimal-trauma vertebral fracture is unlikely to have normal bone density. A T-score above –1 is much more likely to be attributable to a problem with the radiographic technique or other interference (see Assessment of bone status for more information). Although drugs for osteoporosis have not been studied in patients with normal BMD and a vertebral fracture, consider starting treatment in these patients, particularly in those with other risk factors for fracture. Specialist advice is recommended.
• For a patient who had a minimal-trauma fracture at another site (not a hip or vertebral fracture), evidence to guide management is not available. Treatment could be considered in patients with other risk factors for fracture. Specialist advice is recommended.

If BMD cannot be measured (eg dual energy X-ray absorptiometry [DXA] machine is not accessible), start drug therapy for osteoporosis in any patient who has a minimal-trauma hip or vertebral fracture. Measure BMD when possible to allow subsequent monitoring.

If treatment is warranted, see Choice of drug therapy for osteoporosis for information about choosing the right treatment for each patient.

If treatment is not yet warranted or desired, repeated measurement of BMD after 2 years and regular risk assessment is reasonable to monitor ongoing fracture risk.

For all patients, ensure calcium intake is sufficient and they are vitamin D replete. Provide advice about lifestyle measures to prevent minimal-trauma fracture.