Primary prevention

The identification of decreased bone mineral density in people with any risk factors for osteoporosis suggests a greater risk of osteoporotic fracture.[23]​ Primary prevention of wrist fractures requires optimization of peak bone mass in childhood, which is influenced mainly by genetic factors, adequate nutrition, and exercise. Thereafter, primary prevention depends on minimizing loss of bone mass and maintaining skeletal trabeculae microarchitecture and cortical thickness. Important factors to consider are good nutrition (especially adequate intake of protein, calcium, and vitamin D), regular physical activity, and avoiding smoking and excessive alcohol consumption.[24] Pharmacologic treatments available for prevention/treatment of osteoporosis include antiresorptive drugs (to inhibit bone resorption) and anabolic drugs (to stimulate bone formation).[24] Patients with osteoporosis, regardless of prior fracture history, should be assessed for fall risk.[16] There is some evidence that multifaceted interventions in hospital inpatients may reduce the relative risk for number of falls; this may be more likely in a subacute setting.[25][26] See  Osteoporosis.

The use of wrist guards has been shown to reduce the incidence of wrist fractures in snowboarders and inline skaters. They act by lowering the strain on the distal radius and ulna by sharing the load on the wrist in low-energy falls.[27][28] Comparative data are not available for wrist fractures in other age groups.

The table that follows summarizes recommendations on prevention and treatment of osteoporotic fractures from the Bone Health and Osteoporosis Foundation (BHOF).[23]

Note that an individual patient may fall into more than one group and so interventions might be additive; please review all population and subpopulation groups to assess all that apply.

Man ages ≥50 years, or postmenopausal woman

All

Intervention
Goal
Intervention

Advice on balance training, muscle-strengthening exercise, and safe movement strategies

Counsel or refer patients for advice and instruction on:

  • Balance training

  • Muscle-strengthening exercise, for example weight training and resistive exercises such as yoga, Pilates, and boot camp calisthenics

  • Safe movement strategies

Supervision is recommended to ensure physical activities are safe and sustainable given an individual’s health status and overall fitness. To avoid injury, it is recommended that patients are evaluated before initiating a new exercise program, particularly one involving compressive or contractile stressors (such as running or weightlifting).

Consultation with a trained physical therapist and/or participation in group exercise led by certified fitness personnel may help ensure patient safety, motivate daily participation, and promote social engagement.

Providing principles of safe movement are followed, walking and daily activities such as housework and gardening are practical ways to contribute to maintenance of fitness and bone mass.

Goal

Prevention of fracture(s) in the activities of daily life

Maintaining independence by preventing an injury that could lead to nursing home admission is likely to be a priority for many individuals.

Adherence with a recommended lifestyle change may be challenging; linking the change to something of value to an individual may help to improve motivation.

With osteoporosis or osteopenia meeting criteria for treatment

Intervention
Goal
Intervention

Treatment of osteoporosis or osteopenia

Offer treatment for osteoporosis or osteopenia using lifestyle interventions with or without medication in line with published clinical guidance on management of osteoporosis/osteopenia.

Medication for osteoporosis/osteopenia:

Management plans are highly individualized and recommendations may differ according to sex, investigation findings, personalized fracture risk assessment results, and whether or not glucocorticoid use is a contributing factor to bone mineral density loss.

It is recommended that treatment is stratified according to fracture risk; combination or sequential treatment with different classes of medication may be required to lower risk to acceptable levels in people at particularly high risk of future fracture.

Patient adherence to prescribed treatment is key. An estimated 25% to 30% of people with osteoporosis do not start taking their prescribed medication and 50% or more do not continue treatment after 1 year; nonadherence to treatment is associated with higher morbidity and mortality.

Ensure a good foundation for treatment is in place, including focused support and monitoring early in treatment, which may help improve a patient’s long-term adherence to prescribed treatment and, consequently, fracture outcomes.

Ask questions about patient preferences and address fears and misconceptions as part of the medication selection process, as this can not only promote better adherence to prescribed treatment but also lead to better outcomes in terms of prevention of fractures and disability.

Lifestyle interventions for osteoporosis:

A multicomponent program is recommended, encompassing:

  • Progressive resistance training

  • Balance training

  • Back extensor strengthening

  • Core stabilizers

  • Cardiovascular conditioning

  • Impact or ground-reaction forces to stimulate bone

Note that recreational pursuits and athletic activities that exert intense forces on weakened bone and/or involve abrupt or high-impact loading can break bones in people with osteoporosis.

For safety, it is recommended that any program of physical activity is developed and supervised by certified fitness personnel experienced with skeletal fragility in older adults.

See Osteoporosis.

Goal

Increased bone mineral density; improved falls outcomes; reduced fracture risk

Like any lifelong chronic disease, osteoporosis is most successfully managed with continued therapy and monitoring.

Recommended duration of treatment varies according to patient characteristics and the type of medication used.

Periodically review pharmacotherapy to determine whether treatment should be continued, changed, stopped, or resumed. It is reasonable to evaluate patients every 1 to 2 years during any hiatus from active bisphosphonate treatment.

For patients on pharmacological therapy, a reasonable 3-year target outcome could be to increase the T-score from −2.8 to > −2.5 and have no fractures.

Stable bone mineral density and a year with no new fractures could be a measurable goal for someone with low bone mineral density and prior fragility fractures.

If the patient is not on track to reach their target or does not reach their target, consider clinical reassessment and possibly a change in therapy.

With insufficient intake of calcium

Intervention
Goal
Intervention

Advice on increased calcium intake ± calcium supplementation

Adequate total calcium intake is defined as:

  • 1000 mg/day for men ages 50-70 years and women ages 50 years

  • 1200 mg/day for women ages ≥51 years and men ages ≥71 years

Increasing dietary calcium is the first-line approach when there is inadequate calcium intake.

Advise people to eat a balanced diet rich in foods that provide calcium as well as numerous nutrients needed for good health, such as:

  • Low-fat dairy products

  • Select dark greens

  • Fish with bone

  • Fruits

  • Vegetables

  • Fortified foods (e.g., nondairy supplemented beverages including orange juice, and soy and almond milk)

Calcium supplements are recommended when an adequate dietary intake cannot be achieved.

Supplemental calcium is most widely available as calcium carbonate and calcium citrate:

  • Calcium citrate is useful for people with achlorhydria, inflammatory bowel disease, absorption disorders, and those on proton-pump inhibitors that reduce gastric acid as it doesn't require stomach acid for absorption and can be taken on an empty stomach.

Doses may need to be split to ensure optimal absorption.

Goal

Achieve targets for recommended calcium intake according to sex and age; fracture prevention

Goals are the following:

  • 1000 mg/day for men ages 50-70 years and women ages 50 years

  • 1200 mg/day for women ages ≥51 years and men ages ≥71 years

There is no evidence that calcium intake in excess of recommended amounts confers additional bone benefit.

Supplemental calcium intake above 1200-1500 mg/day can increase risk for developing kidney stones in at-risk individuals.

With vitamin D deficiency or insufficiency

Intervention
Goal
Intervention

Vitamin D supplementation

Vitamin D sufficiency is defined as 30-50 ng/mL.

Prescribe supplemental vitamin D as needed for individuals ages 50 years and older to achieve a sufficient vitamin D level.

Higher doses may be necessary in some adults, especially those with malabsorption.

See Vitamin D deficiency. 

Goal

Maintenance of serum vitamin D sufficiency; fracture prevention

Maintain serum vitamin D sufficiency (30-50 ng/mL).

In healthy individuals a serum 25(OH) vitamin D level ≥ 20 ng/mL may be sufficient, but in the setting of known or suspected metabolic bone disease ≥30 ng/mL is appropriate.

With tobacco use

Intervention
Goal
Intervention

Smoking cessation advice ± referral

Provide guidance for smoking cessation; advise the patient that use of tobacco products is detrimental to the skeleton as well as to overall health.

Refer for smoking cessation care as appropriate.

See Smoking cessation.

Goal

Cessation of smoking; fracture prevention

With alcohol intake＞two drinks/day (in women) or＞three drinks/day (in men)

Intervention
Goal
Intervention

Advice on avoidance of excessive alcohol intake ± substance use referral

Provide guidance for avoidance of excessive alcohol intake; advise the patient that alcohol intake of more than two drinks a day for women or three drinks a day for men may be detrimental to bone health, and that it has been associated with reduced calcium absorption and increased risk for falls.

Identify patients at risk for chronic heavy drinking and/or binge drinking who require further evaluation and treatment.

See Alcohol-use disorder.

Goal

Alcohol intake within safe drinking limits; fracture prevention

In women: ≤ two drinks/day is recommended.

In men: ≤ three drinks/day is recommended.

With major risk factors for falls

Intervention
Goal
Intervention

Fall prevention strategies

Identify and address modifiable risk factors associated with falls, such as:

  • Sedating medications

  • Polypharmacy

  • Hypotension

  • Gait or vision disorders

  • Out-of-date prescription glasses

In community-dwelling patients, refer for at-home fall hazard evaluation and remediation.

Many risk factors for falls are modifiable: muscle strength and balance can be improved through targeted exercise; visual impairment can be addressed; fall hazards in the home and work environment can be remediated; medications that induce dizziness and disorientation can be replaced or reduced.

See Optimizing functional status in the elderly.

Goal

Reduced risk of future falls and fractures

Secondary prevention

Patients with osteoporosis, regardless of prior fracture history, are assessed for fall risk prior to discharge and advised of targeted interventions to reduce their specific risks for falling. Physical or occupational therapy may be prescribed if impaired gait or weakness is present. Weight-bearing and balance-promoting exercises, and maintenance of calcium and vitamin D supplementation, is recommended.[45]

Alendronate, a bisphosphonate, is associated with statistically significant reductions in vertebral, nonvertebral, hip, and wrist fractures in postmenopausal women with osteoporosis who have had previous fractures; however, it is not considered useful for primary prevention of wrist fractures, although this may be changing.[97][98] Denosumab is another potential option to help decrease the risk of osteoporotic fractures.[99] In the FREEDOM trial, a phase 3 randomized controlled trial, it was shown that denosumab treatment for up to 10 years was associated with low rates of adverse events, low incidence of fracture compared with that observed during the original trial, and continued increases in bone mineral density without plateau.[100]

Patients who have undergone a bone mineral density exam are more likely to receive treatment. Ordering a bone mineral density exam in patients over 50 years of age can improve osteoporosis evaluation and treatment rates following fragility fractures of the distal part of the radius.[16][51] The American Orthopaedic Association piloted the Own the Bone initiative in 2005 with a goal to prevent secondary fractures. In 2009, the project was launched as a tool for hospitals, medical centers, and private practice groups to implement a fragility fracture prevention program.[101] See Osteoporosis.

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