Treatment of Sacrum Fractures in Older Adults with Osteoporosis

Immediate Pain Management and Mobilization

The American College of Physicians recommends starting acetaminophen as first-line analgesia, avoiding NSAIDs if cardiovascular or renal comorbidities exist, for patients with sacrum fractures 1
The National Osteoporosis Foundation suggests using short-term narcotic medications only if necessary for severe pain in patients with sacrum fractures 1
Avoid prolonged bed rest as it accelerates bone loss, muscle weakness, and increases risk of deep vein thrombosis and pressure ulcers in patients with sacrum fractures 1
Begin early mobilization as tolerated to prevent complications of immobility in patients with sacrum fractures 1
Initiate range-of-motion exercises within the first postoperative days for patients with sacrum fractures 1
Kyphoplasty provides immediate pain relief and can be performed as outpatient care in the majority of cases for patients with persistent pain due to sacrum fractures 1

Consider surgical treatment for displaced fractures that prevent mobilization or for fractures combined with anterior pelvic ring injuries (fragility fractures of the pelvis) in patients with sacrum fractures 1
Persistent pain despite conservative management is an indication for surgical intervention in patients with sacrum fractures 1

The National Osteoporosis Foundation recommends oral bisphosphonates as first-choice agents because they are well-tolerated, cost-effective, and widely available as generics for patients with osteoporosis 1
Start oral bisphosphonates (alendronate or risedronate) immediately as they reduce vertebral fractures by 47-48%, non-vertebral fractures by 26-53%, and hip fractures by 40-51% in patients with osteoporosis 1, 4
Add calcium 1000-1200 mg/day plus vitamin D 800 IU/day, which reduces non-vertebral fractures by 15-20% and falls by 20% in patients with osteoporosis 1, 4, 5
Avoid high pulse dosages of vitamin D as they increase fall risk in patients with osteoporosis 1

Perform DXA of spine and hip to measure bone mineral density in patients with osteoporosis 2, 3
Obtain imaging of the spine for vertebral fractures (radiography or VFA) in patients with osteoporosis 2, 3
Evaluate falls risk with history of falls during the last year in patients with osteoporosis 2, 3
Order limited laboratory examination including ESR, serum calcium, albumin, creatinine, and TSH in patients with osteoporosis 2, 3
Use fracture risk assessment tools such as FRAX, Garvan, or Q-Fracture in patients with osteoporosis 2, 3

Begin early post-fracture physical training and muscle strengthening in patients with sacrum fractures 1
Establish long-term balance training and multidimensional fall prevention programs, which reduce fall frequency by approximately 20% in patients with sacrum fractures 1
Implement weight-bearing exercise programs to improve BMD and muscle strength in patients with sacrum fractures 1
Address environmental hazards in the home in patients with sacrum fractures 1
Review medications that may increase fall risk in patients with sacrum fractures 1

The Fracture Liaison Service (FLS) is the most effective organizational structure for risk evaluation and treatment initiation in patients with osteoporosis 2, 3
A dedicated coordinator (often a well-educated nurse) should identify all elderly patients with recent fractures and organize diagnostic investigations and start interventions under supervision of an orthopedic surgeon, endocrinologist, or rheumatologist 2, 3
RCTs demonstrate that a nominated coordinator significantly improves osteoporosis treatment implementation: 45% of patients receive appropriate management within 6 months versus only 26% in control groups 2, 3

Do not allow prolonged bed rest beyond what is absolutely necessary for acute pain control, as it accelerates complications in patients with sacrum fractures 1
Do not delay osteoporosis treatment in patients with confirmed sacral fractures 1, 4
Do not use calcium or vitamin D alone without bisphosphonates, as calcium alone has no demonstrated fracture reduction effect in patients with osteoporosis 1, 4

Monitor regularly for medication tolerance and adherence, as long-term adherence is typically poor in patients with osteoporosis 1
Reassess for bisphosphonate drug holiday after 5 years unless the patient remains at high fracture risk in patients with osteoporosis 4
Coordinate care between orthopedic surgery, rheumatology/endocrinology, and primary care in patients with sacrum fractures 1
Establish orthogeriatric co-management for frail elderly patients with multiple comorbidities in patients with sacrum fractures 1