Fragility Fractures in Older Adults: A Multidisciplinary Care Framework

This reality challenges healthcare providers to rethink how fragility fractures are managed. The research is clear: isolated orthopaedic care is insufficient. Success requires a coordinated, multidisciplinary team operating within a structured care pathway.

What Are Fragility Fractures?

Fragility fractures occur from low-impact trauma in individuals with compromised bone quality—typically osteoporosis. Over 85% of hip fractures happen in people aged 65 and above, driven by a combination of reduced bone mineral density, decreased muscle mass (osteosarcopenia), and impaired balance and neuromuscular coordination.

The epidemiology is sobering. The World Health Organization projects osteoporotic fracture cases will triple in the next 50 years. In Singapore and across the Asia-Pacific region, an ageing demographic means orthopaedic departments are managing increasing volumes of complex older patients—many with comorbidities that complicate surgical and rehabilitation planning.

Why Fragility Fractures Are Complex in Older Persons

Older patients typically arrive with:

• Multiple comorbidities (cardiovascular disease, diabetes, chronic kidney disease)
• Polypharmacy that increases delirium and fall risk
• Malnutrition (prevalence up to 85% in hip fracture cohorts)
• Cognitive impairment or baseline frailty
• High anaesthetic risk
  
  

These factors interact. A patient with heart failure, renal disease, and cognitive decline cannot simply be “fixed” surgically and discharged. Each complication amplifies recovery time and mortality risk.

---

The Multidisciplinary Care Model: Evidence and Outcomes

The gold standard is ortho-geriatric co-management—a structured partnership between orthopedic surgeons, geriatricians, physiotherapists, occupational therapists, nurses, dieticians, and social workers.

The evidence is robust:

• Hospital mortality: Ortho-geriatric co-management reduces in-hospital mortality by 40% (RR = 0.60, 95% CI 0.43–0.84)
• Pressure ulcers: Reduces development by 70% (OR = 0.3, 95% CI 0.1–0.7)
• Postoperative complications: Early mobilisation and coordinated care reduce pneumonia, thromboembolic events, and delirium
  
  

Successful international models include Canada’s “fast-track” pathway (priority analgesia, rapid diagnosis, timely surgery) and the UK’s “Blue Book” standards (arrival to orthopaedics within 4 hours, surgery within 48 hours, early mobilisation, ongoing fall prevention).

---

Pre-operative Phase: Stabilisation and Optimisation

The window between admission and surgery is critical. Delays beyond 24 hours (or 48 hours for anticoagulated patients) significantly increase mortality.

Key preoperative priorities:

1. Rapid surgical planning

• Aim for theatre within 24 hours of diagnosis
• Early surgical correction reduces mortality risk by 26% (OR = 0.74)

2. Comprehensive geriatric assessment

• Baseline cognitive status and delirium screening
• Functional status before fracture (informs rehabilitation prognosis)
• Hydro-electrolytic balance, polypharmacy review
• Pain control: pre-surgical regional nerve blocks reduce opioid use (which delays mobilisation and increases delirium)

3. Nutritional baseline

• Screen using MNA-SF or MUST
• If malnutrition present, initiate oral protein supplementation preoperatively

4. Thromboprophylaxis

• Initiate immediately if surgery cannot occur within 12 hours
• Thromboembolic complications are frequent; early prophylaxis is critical
  
  

Why multidisciplinary input matters pre-operatively:

Orthogeriatric teams identify comorbidities early, stabilise cardiac and metabolic status, reduce anaesthetic risk, and communicate clear functional expectations to the patient and family. This reduces surgical delays and anxiety.

---

Post-operative Phase: Mobilisation, Complication Prevention, and Early Rehabilitation

The first 72 hours post-operatively determine long-term recovery trajectory.

Common Postoperative Complications

Delirium is the most common severe complication (20–50% incidence). It is associated with prolonged hospital stay, functional decline, and increased mortality. Screen regularly using the Confusion Assessment Method (CAM)—a simple, quick tool requiring no special equipment.

Pressure ulcers develop in immobilised patients and correlate with worse functional outcomes. Risk assessment using the Braden Scale guides prevention: pressure redistribution, frequent repositioning, nutritional support, and—critically—early mobilisation.

Postoperative infections (pneumonia, urinary tract infection) result from immobility. Early physiotherapy and occupational therapy dramatically reduce these.

Rehabilitation Begins Immediately

Effective post-fracture rehabilitation must start within 24 hours:

• Progressive weight-bearing and resistance training under physiotherapist supervision
• Balance and gait retraining to address fear of falling
• Occupational therapy to restore activities of daily living
• Nutritional support (see section below)

The evidence is unambiguous: delays in rehabilitation increase in-hospital mortality (OR 2.2, P = 0.034). Duration of the complete recovery process typically spans 9–12 months (balance recovery in 9 months; walking speed recovery in ~12 months).

---

Nutrition: A Cornerstone of Recovery

Malnutrition in hip fracture patients is associated with higher complications, longer hospital stays, and increased mortality. Yet it is one of the most modifiable risk factors.

Calcium and vitamin D:

• Target: 1200 mg elemental calcium daily (from food and/or supplement)
• Vitamin D: 700–800 IU daily minimum (improves calcium absorption and balance/muscle strength)
• Assess baseline status; supplement as needed
  
  

Protein supplementation:

• Critically important. Early enteral protein (0.8–1.3 g/kg body weight, escalating to 1.5 g/kg if frail or inflamed) reduces bed rest duration and improves 3-month quality of life
• Combined nutritional support + rehabilitation reduces postoperative mortality by 39%
• Prioritise food-based sources where possible; use protein-based vegetable supplements cautiously in renal disease (lower phosphate bioavailability)
  
  

Prolonged pre-operative fasting is a missed opportunity. Most anaesthetic guidelines recommend 6–8 hours fasting for solids. Yet protocols that extend fasting to 14+ hours worsen metabolic control and dehydration. Work with anaesthesia to minimise preoperative fasting duration.

---

Osteoporosis Treatment: Starting Early, Preventing Recurrence

After the first fragility fracture, the risk of a subsequent fracture increases to 25% within 2 years—particularly in women. Without intervention, this risk persists and rises over time.

Pharmacological therapy should begin early—ideally before hospital discharge.

A persistent barrier is the misconception that osteoporosis medications interfere with bone healing (delayed osteosynthesis). This is unfounded. Evidence shows the opposite: early pharmacological therapy improves healing outcomes and prevents future fractures.

Common agents:

• Bisphosphonates (alendronate, risedronate)
• Denosumab
• Teriparatide (for severe osteoporosis)
  
  

Decision-making: Use FRAX (Fracture Risk Assessment Tool) to stratify risk and guide treatment initiation. Tailor therapy based on renal function and comorbidities.

The practical challenge: Less than 20% of patients receive adequate fall prevention intervention post-discharge. Ensure clear communication between hospital, primary care, and allied health practitioners about osteoporosis treatment plan and adherence monitoring.

---

Falls Prevention and Fear of Falling

Post-fracture, many older adults develop “fear of falling”—a disabling anxiety that restricts activity. This paradoxically increases fall risk: reduced activity worsens muscle strength and balance.

Only approximately 40% of older adults return to their previous daily activities after hip fracture without structured falls prevention intervention.

Multidisciplinary falls prevention includes:

1. Environmental assessment
   • Home safety audit; removal of rugs, obstacles, poor lighting
   • Provision of mobility aids (walkers, grab rails) and hip protectors
2. Physical training
   • Progressive resistance exercises (improve muscle strength)
   • Balance training (reduce postural instability)
   • Gait retraining (improve confidence and symmetry)
3. Psychological support
   • Falls Efficacy Scale-International (FES-I) to quantify fear of falling
   • Structured reassurance and activity progression
4. Medication review
   • Deprescribe sedatives, anticholinergics, and other high-risk medications
   • Educate patient and carers on medication-fall risk associations
5. Ongoing assessment
   • Regular comprehensive geriatric assessment to identify new fall risk factors
   • Cognitive impairment, visual changes, hearing loss, neuropathy

 

---

Follow-Up Care: The Critical Outpatient Phase

One in three patients who suffer a hip fracture will suffer another within 12 months; over 50% will have another within 5 years.

Post-discharge care gaps are significant:

• Less than 20% of patients receive adequate falls risk assessment and intervention
• Osteoporosis treatment adherence is poor without coordinated follow-up
• Comorbidity-related complications (cardiac decompensation, constipation, infection) are often missed
  
  

Best-practice follow-up protocol:

Week 2 post-discharge:

• Clinical review (wound healing, pain, medication adverse effects)
• Early identification of complications (infection, thromboembolic symptoms)

Weeks 4–8:

• Intensive physiotherapy and occupational therapy review
• Nutritional assessment and protein intake check
• Osteoporosis medication tolerance and adherence

Month 3 onwards:

• Structured falls prevention review
• Reassessment of fear of falling (FES-I)
• Comorbidity management (blood pressure, cardiac function, glycaemic control, renal function)
  
  

Fracture Liaison Services (FLS) are vital. When available, FLS teams coordinate early identification of osteoporosis, prevent future fractures, and improve patient outcomes while reducing healthcare costs.

---

Building a Sustainable Multidisciplinary Team in Private Practice

The barriers are real: Coordinating multiple specialists, communication gaps, resource constraints, and patient access all challenge private practitioners.

Practical solutions for private clinics:

1. Develop a care protocol
   • Write a clear care pathway (preoperative, perioperative, postoperative, follow-up phases)
   • Define roles: who screens for delirium? Who initiates nutritional support?
   • Agree on communication touchpoints (structured handoffs reduce errors)
2. Use standardised tools
   • MNA-SF for nutrition screening
   • Braden Scale for pressure ulcer risk
   • CAM for delirium
   • FES-I for fear of falling
   • FRAX for fracture risk
3. Invest in staff education
   • Many postoperative complications (delirium, pressure ulcers, constipation) are preventable with staff awareness
   • Regular training sessions improve compliance with protocols
4. Leverage technology
   • Shared electronic health records improve communication
   • Automated reminders for follow-up appointments and medication refills
5. Develop partnerships
   • Formal agreements with local physiotherapists, occupational therapists, and geriatricians
   • Clear referral pathways; documented outcomes for feedback

 

---

Implications for Allied Health Professionals

Physiotherapists and occupational therapists are central to recovery. Your role extends beyond exercise prescription:

• Early mobilisation reduces complications and shortens hospital stay
• Personalised gait retraining and balance work prevent fear of falling
• Activities of daily living retraining restores independence and reduces caregiver burden
• Home safety assessment and environmental modification prevent recurrent falls
  
  

The evidence is unambiguous: Delayed rehabilitation increases mortality and functional decline. Advocate for early involvement and ongoing follow-up. Your input shapes outcomes as much as surgical skill.

---

Key Takeaways

1. Fragility fractures require multidisciplinary management. Isolated orthopaedic care leaves 25–75% of patients severely disabled post-discharge.
2. Timing matters. Surgery within 24 hours and mobilisation within 48 hours reduce mortality, delirium, and complications.
3. Nutrition and rehabilitation are non-negotiable. Combined nutritional support and structured rehabilitation reduce postoperative mortality by 39%.
4. Early osteoporosis treatment prevents recurrence. Begin pharmacological therapy before discharge; achieve high medication adherence through coordinated follow-up.
5. Falls prevention is ongoing. Address environmental, physical, and psychological factors. Fear of falling is as disabling as the fracture itself.
6. Follow-up is where prevention happens. Structured post-discharge care—week 2, weeks 4–8, month 3+—identifies complications early and ensures adherence to osteoporosis therapy.

 

---

Frequently Asked Questions

Q: Can osteoporosis medications be started immediately after fracture surgery?

A: Yes. There is no evidence that osteoporosis therapy delays bone healing. Early initiation (even before discharge) improves outcomes and prevents future fractures. Start within the first 2 weeks if possible.

Q: What is the longest safe timeframe to delay surgery after a hip fracture?

A: Surgery should occur within 24 hours of diagnosis. For anticoagulated patients, up to 48 hours is acceptable with appropriate thromboprophylaxis. Delays beyond 48 hours significantly increase mortality and complications.

Q: How long does rehabilitation typically take?

A: Complete recovery varies. Balance deficits resolve in ~9 months; return to normal walking speed takes ~12 months. However, many patients plateau before full recovery, especially if frail or with significant comorbidities. Ongoing activity and strength work should extend beyond the formal rehabilitation period.

Q: Is delirium after hip fracture surgery permanent?

A: Most postoperative delirium resolves within days to weeks with appropriate management (good sleep, pain control, early mobilisation, constipation management, avoiding sedatives). However, underlying cognitive impairment may be unmasked. Screen regularly and manage causes early.

Q: What is the role of nutrition in fracture healing?

A: Protein is essential for collagen synthesis and bone healing. Malnutrition (present in up to 85% of hip fracture patients) is associated with delayed healing, prolonged hospital stay, and higher mortality. Early protein supplementation (0.8–1.5 g/kg daily) combined with rehabilitation reduces mortality by 39%.

Q: How do we prevent “fear of falling” after a hip fracture?

A: Structured, progressive physiotherapy and psychological reassurance are key. Use the Falls Efficacy Scale-International (FES-I) to quantify fear and track progress. Environmental modification, hip protectors, and mobility aids provide tangible safety. Activity should be graded and progressed to rebuild confidence.

Q: What should a post-discharge follow-up schedule look like?

A: Week 2 (complication screening), weeks 4–8 (rehabilitation progress and osteoporosis medication tolerance), month 3+ (structured falls prevention and comorbidity management). Fracture Liaison Services can coordinate this if available.