Pathological fractures complicating osteoporosis: clinical guidelines

List of Abbreviations

ARO — Association of Rheumo-Orthopedists

ATOR — Association of Traumatologist-Orthopedists of Russia

VTEO — venous thromboembolic events

DPD — deoxypyridinoline

HRT — hormone replacement therapy

CT — computed tomography

PT — physical therapy

MDT — multidisciplinary rehabilitation team

BMD — bone mineral density

MRI — magnetic resonance imaging

NSAIDs — nonsteroidal anti-inflammatory and antirheumatic drugs

AEs — adverse events

RAE — Russian Association of Endocrinologists

REMS — radiofrequency echographic multispectrometry

eGFR — estimated glomerular filtration rate

CTX-s — resorption marker, type 1 collagen degradation product

DVT — deep vein thrombosis

PE — pulmonary embolism

PRM — physical and rehabilitation medicine

DASH — Disabilities of the Arm, Shoulder and Hand Outcome Measure

DXA — dual-energy X-ray absorptiometry

FDPS — farnesyl diphosphate synthase

FRAX — fracture risk assessment tool

IGF-I — insulin-like growth factor-1

IGF-II — insulin-like growth factor 2

ISCD — International Society for Clinical Densitometry

P1NP — N-terminal propeptide of type I procollagen, a bone formation marker

RANKL — receptor activator of nuclear factor kappa-B ligand

TGF-β — transforming growth factor beta

VAS — visual analog scale

# — medicinal product for medical use used off-label regarding indications, contraindications, routes of administration, and dosages contained in the instructions for medical use

** — drug included in the essential medicines list

Terms and Definitions

Pathological fracture — a fracture that occurs against the background of structural and quantitative changes in bone tissue that reduce its strength, thus occurring with minor trauma or even without it.

Osteoporosis — a metabolic skeletal disease characterized by a decrease in bone mass per unit volume, disruption of the structural and strength characteristics of bone tissue, and, as a consequence, an increased risk of fractures.

According to the international classification, osteoporosis is included in class XIII of diseases, subgroup M80–82.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Pathological fracture in osteoporosis — a fracture that complicates the course of osteoporosis and occurs due to low-energy trauma or spontaneously upon coughing, sneezing, or lifting heavy objects [1].

Pathological low-energy fractures most frequently encountered in osteoporosis are classified as marker fractures of the disease.

Marker fractures of osteoporosis — pathological fractures of the proximal femur (PF), distal metaphysis of the radius, proximal humerus, and vertebral body(ies).

Against the background of osteoporosis, pathological fractures of the ribs, pelvic bones, and tibia are also possible.

Fractures of the ankles, hand bones, and foot bones are currently not classified as pathological fractures characteristic of osteoporosis [2], although their risk increases with the disease.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

A fracture against the background of osteoporosis occurs with minor trauma not only due to a decrease in bone mass, but also due to its structural abnormalities. A decrease in bone mass, as the main characteristic of osteoporosis, is not always accompanied by a decrease in mechanical bone strength. It has been established that bone quality (trabecular microarchitecture, accumulation of trabecular microfractures, increased cortical porosity) affects strength independently [3] of bone mass. According to some data [4], bone mineral density (BMD) accounts for only 40% of bone strength, while 60% is determined by impaired quality and structure of bone tissue.

The probability of a fracture in individuals with low bone mass is largely determined by the presence of such risk factors [5, 6–12] as:

• advanced age;

• tendency to falls;

• smoking;

• presence of more than 3 chronic diseases in the anamnesis;

• prior fractures;

• use of drugs affecting bone metabolism (glucocorticoids, antiepileptic drugs, antineoplastic drugs, antidepressants).

In turn, causes that increase the likelihood of falls can be divided into external and internal.

Internal causes are conditioned by the patient's physical state: asthenia, dementia, orthostatic disorders, decreased joint mobility, poor vision, hearing loss, low physical activity, as well as the use of certain medications affecting neurological status.

External causes include domestic and situational factors: insufficient lighting, slippery uneven surfaces, etc.

1.3 Epidemiology of the Disease or Condition

Worldwide, osteoporosis is the cause of more than 8.9 million fractures annually [13–15]. An analysis of hospitalizations of women over 55 years of age at the Mayo Clinic from 2000 to 2011 [16] showed that patients with fractures due to osteoporosis account for 40% and exceed those hospitalized for myocardial infarction, stroke, and breast cancer (respectively 1124 vs 668, 687, and 151 per 100,000 population per year). Although osteoporosis is more common in women, according to some data [17], in Russia every third pathological fracture associated with osteoporosis is a fracture in men. Projections suggest a further increase in the number of fractures, which is partly attributed to the aging of the population [18]. According to the International Osteoporosis Foundation (IOF), in European countries by 2025 the incidence of proximal femoral and vertebral body fractures will increase more significantly than that of distal forearm fractures — by 32%, 27%, and 21%, respectively [2]. The number of fractures associated with osteoporosis in men will also increase: in 2025 [18], the number of femoral fractures among them will be similar to the number of fractures that occurred in women in 1990, and by 2050 it will increase by 310% compared to 1990, whereas in women the increase will be 240%, while material and moral costs will simultaneously grow [19–21]. In Russia, based on an analysis of fracture incidence in two cities (Yaroslavl and Pervouralsk), it was calculated that the incidence of proximal femoral fractures [22] is 279 per 100,000 population in women and 176 in men, and it is projected that 1 in 14 women over 50 will suffer a fracture of this localization during her remaining lifetime, and over the next 25 years the number of fractures will increase by 40%.

Some studies [5] have revealed a trend toward an increased incidence of proximal humeral fractures in the age group over 70 years. Fractures are more frequently observed in women, and in individuals over 60 with a life expectancy up to 82 years, the risk of a humeral fracture reaches 8% [23]. Some researchers [24] noted an exponential growth in the number of proximal humeral fractures starting from the age of 50. There is a viewpoint [25] that in the period 2020–2030 the number of proximal humeral fractures will increase exponentially.

The number of hospitalizations for fractures associated with osteoporosis is also growing and in some countries reaches 70% of all cases hospitalized for musculoskeletal disorders [26]. In Russia, despite the noted trend toward an increased incidence of proximal femoral fractures associated with osteoporosis [27], the hospitalization of patients with fractures of this localization in a number of regions of the country, as reported previously [28], remains insufficient.

Fractures of the distal metaphysis of the radius, together with fractures of the proximal humerus associated with osteoporosis, account for over 30% of emergency hospitalizations in inpatient trauma departments, and the costs of surgical treatment for these patients are on average 2 times higher than for conservative treatment [29]. The incidence of distal radius fractures in Russia, depending on the region, ranges from 195 to 320 in men and from 790 to 186 in women per 100,000 population [22, 30]. A fracture of the distal metaphysis of the radius is not only a marker of osteoporosis, but in 32% of cases is also a predictor of a proximal femoral fracture over the subsequent 5 years [31, 32]. At the same time, this type of fracture in elderly patients with clinical risk factors for osteoporosis rarely serves as a basis for screening for its detection and initiating treatment to prevent secondary fractures [32].

1.4 Features of Coding the Disease or Condition

M80 — osteoporosis with pathological fracture

M80.0 — postmenopausal osteoporosis with pathological fracture;

M80.1 — osteoporosis with pathological fracture following oophorectomy;

M80.2 — osteoporosis with pathological fracture due to disuse;

M80.3 — postsurgical osteoporosis with pathological fracture due to malabsorption;

M80.4 — drug-induced osteoporosis with pathological fracture;

M80.5 — idiopathic osteoporosis with pathological fracture;

M80.8 — other osteoporosis with pathological fracture;

M80.9 — osteoporosis with pathological fracture, unspecified.

1.5 Classification of the disease or condition

Classification of proximal femur fractures

For proximal femoral fractures complicating osteoporosis, the same classifications are used as for post-traumatic fractures of this skeletal segment: femoral neck fractures, or intracapsular (medial), and trochanteric, or extracapsular (lateral) fractures.

Pauwels' classification takes into account the angle between fragments: the first degree corresponds to an angle of less than 30°, the second — to an angle from 30 to 50°, and the third — to an angle of more than 50°.

Garden's classification takes into account: the degree and nature of fragment displacement:

Type I – incomplete, impacted, valgus fractures;

Type II – valgus, complete, stable;

Type III – varus fractures with minor displacement;

Type IV – varus fractures with significant displacement.

In the AO classification, intracapsular fractures of the proximal femur are divided into 3 subgroups according to fracture severity and treatment prognosis: 31B1, 31B2, 31B3.

Trochanteric, or lateral (extracapsular), fractures are distinguished as:

a) intertrochanteric fractures — the fracture plane passes near the intertrochanteric crest;

b) pertrochanteric fractures — the fracture plane passes through the mass of the greater and lesser trochanters. These fractures may be with or without avulsion of the lesser trochanter.

Extracapsular (pertrochanteric and subtrochanteric) fractures according to the AO classification are also divided into 3 subgroups: 31A1, 31A2, 31A3 and 32A/B/C (1-3).

Classification of proximal humerus fractures

For proximal humeral fractures, the AO/ASIF and Neer classifications are used [33-36].

Analysis of the structure of proximal humeral fractures showed that the majority of them are stable [37, 38].

Classification of vertebral body compression fractures

The classification [39] is based on the degree of reduction in vertebral body height:

Grade I — height reduction by up to 20%;

Grade II — height reduction by 20–40%;

Grade III — height reduction by more than 40%.

Classification of distal radial metaphysis fractures

Stable and unstable fractures of the distal radial metaphysis are distinguished [40].

According to the AO/ASIF classification, unstable fractures are coded as B2–3, C1–3.

1.6 Clinical presentation of the disease or condition

Clinical presentation of proximal femur fractures

Patients report pain in the proximal femur region, inability to lift the straightened leg off the floor or couch, and impaired limb weight-bearing capacity.

Clinical presentation of proximal humerus fractures

A distinctive feature of proximal humerus fractures in osteoporosis is minimal displacement of fragments (observed in 80–85% of patients), which is due to the anatomical structure of the region: the joint capsule, periosteum, rotator cuff, and soft tissues [41, 42]. With slight rotation of the limb and a flexed elbow joint, the proximal region can often be palpated as a single unit.

Proximal humerus fractures may be complicated by injury to the axillary nerve or its branches supplying the deltoid muscle: the upper end of the lower humeral fragment can compress and sometimes injure the neurovascular bundle in the axilla. Compression of the neurovascular bundle causes edema, venous stasis, sensory disturbances, and paralysis of the upper limb.

Clinical presentation of vertebral body fractures

Due to their asymptomatic course [43–46], three quarters of patients with vertebral body fractures do not seek medical care at the time of their occurrence, subsequently attributing the pain to degenerative changes in the spine. At the same time, these pain sensations are primarily caused by the fracture, as its presence leads to additional overload of the facet joint and, consequently, overstretching of the capsular-ligamentous apparatus of the joint and the development of degenerative arthritis.

Unlike osteochondrosis, pain in a vertebral body fracture occurs only under static load, which is associated with the reaction of sensory nerve receptors to microfractures of trabeculae. The number of these microfractures increases against the background of bone mineral density (BMD) deficit and decreased strength of the remaining bone structures in the compressed vertebra [47].

In cases where patients associate back pain with an acquired vertebral body fracture, it appears suddenly in a state of complete well-being, and patients can point to circumstances preceding the onset of pain. Most often, this is lifting a heavy object, sometimes simply trunk flexion or a sudden twist; frequently, there is no history of trauma. Pain in these cases is felt at the level of the injured vertebra, and when localized in the thoracic spine, it may be girdle-like in nature [48], which requires differential diagnosis with myocardial infarction, pleurisy, and acute abdominal pathology.

Acute pain in a vertebral body fracture is caused by periosteal hemorrhage, an excessive number of simultaneously occurring trabecular microfractures, increased ligamentous tension due to these changes, and back muscle spasm [48]. The cause of pain can also be ligamentous tension due to height loss and the development of intervertebral joint arthritis, shortening and progressive spasm of back muscles caused by height reduction [48]. Some patients with multiple vertebral body fractures report pain in "all bones," which appears with any jolting [49]. At the same time, palpation of the vertebral spinous processes in osteoporosis is usually painless, and the axial load test (pressing on the head) may also be negative, but compression of the chest in the sagittal plane may be painful. These tests should be performed cautiously to avoid new vertebral body fractures.

In fractures of the lumbar vertebral bodies, limitations of movement in the lumbar spine may occur, and patients in such cases support the trunk in an upright position using their hands or a cane, especially during acute pain attacks.

With age, the perception of pain changes in some patients, which may be due to an altered pain threshold in the elderly [50].

If vertebral body fractures are incorrectly managed or left untreated during the acute period, a chronic pain syndrome develops. It is noted in 66% of women, with 26% of patients experiencing daily pain lasting over 10 hours [51]. In this case, the stimulus for pain receptor irritation becomes not only trabecular fracture, but also their stretching and compression. The pain syndrome is aggravated by myofascial disorders, changes in disc-body ratios, and the development of biomechanical disorders due to spinal column deformations.

Chronic pain in vertebral body fractures becomes the cause of phobias in osteoporosis patients. A characteristic feature of chronic pain in vertebral body fractures is its intermittent nature: after 3–4 months, its intensity decreases even without treatment, but this is inevitably followed by an exacerbation. Progression of spinal column deformation (thoracic kyphosis increases, lumbar hyperlordosis forms or, conversely, straightens) leads to the recurrence of pain.

Compensation for thoracic kyphosis deformation is the development of cervical hyperlordosis with neck muscle tension and occipital pain. Subsequently, due to trunk shortening and the pressure of the ribs against the iliac crests (costal arches "riding" on the iliac wings), pronounced skin folds form on the lateral surface of the chest, and pain appears in the lateral parts of the torso [52]. Due to overstretching of the facet joint capsular-ligamentous apparatus, the localization of pain does not always correspond to the fracture level [52]. Pronounced thoracic kyphosis, as a consequence of thoracic vertebral body fractures, forms gradually and is accompanied by progressive weakness of the muscles in the interscapular and paraspinal regions, which can cause the progression of lumbar scoliosis and a height loss of 10–15 cm.

Clinical presentation of distal radial metaphysis fractures

The patient reports pain in the distal forearm, the appearance of swelling or deformity in the fracture zone, and impaired function of the wrist joint and fingers.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Osteoporosis is very often asymptomatic prior to a fracture; therefore, the diagnostic criteria for a pathological fracture in the setting of osteoporosis are age over 50 years, association of the fracture with low-energy trauma, a history of low-energy fractures including in first-degree relatives, and concomitant diseases or medications that may cause bone tissue metabolism disorders and, consequently, a decrease in its strength. In low-energy fractures of the proximal femur, proximal humerus, and vertebral bodies, the association of the pathological fracture with osteoporosis does not require X-ray densitometric confirmation.

To standardize fractures in osteoporosis, the term "pathological" must be used in the diagnosis, indicating not only the localization of the fracture but also the disease "osteoporosis" that caused the fracture [1].

Example of formulating a diagnosis in a patient with a femoral neck fracture against the background of postmenopausal osteoporosis: Diagnosis: S72.0. M80.0.

2.1 Complaints and Anamnesis

A pathological fracture complicating the course of osteoporosis in the acute period, like a post-traumatic fracture, is characterized by pain (the VAS scale for its assessment is presented in Appendix G1) at the fracture level, deformity, and impaired limb function. Features of such fractures include their occurrence with low-energy trauma or without it (vertebral body fractures) and a possible history of low-energy fractures; in certain localizations, the fracture may be clinically silent.

A patient's history should be clarified for factors that may indicate an association between a pathological fracture and osteoporosis:

– presence of a marker fracture in the history (proximal femur fracture, typical radial fracture, proximal humerus fracture, vertebral body fracture);

– presence of risk factors for osteoporosis (age over 55 years, family history of osteoporosis, therapy with bone-affecting drugs (glucocorticoids, antiepileptic drugs, antidepressants), low body weight, smoking, alcohol abuse, early menopause, amenorrhea, hypogonadism, prolonged immobilization, inadequate calcium intake, vitamin D deficiency, propensity to falls).

2.2 Physical Examination

• To identify clinical signs of a pathological fracture regardless of its location, a physical examination is recommended, including palpation of the area, assessment of the limb axis, evaluation of deformity; in vertebral body fractures—measuring height, assessing the severity of kyphosis and the presence of skin folds on the lateral surface of the torso [42, 52, 333].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

2.3 Laboratory Diagnostics

• Laboratory tests, including a complete blood count (CBC), general biochemical blood test assessing parameters such as total blood calcium and/or ionized blood calcium, inorganic blood phosphorus, alkaline phosphatase activity, blood creatinine (with eGFR calculation), blood parathyroid hormone (PTH), and 24-hour urine calcium and phosphorus (Tab. 1) are recommended for all patients with pathological fractures for the differential diagnosis of osteoporosis from other metabolic osteopathies or conditions that can also be complicated by pathological fractures [42, 54, 75, 264, 314].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments: in osteoporosis, the complete blood count, routine urinalysis, and calcium homeostasis parameters are within the normal range [53, 54, 56, 314]. In cases of hypercalcemia and hypercalciuria, hyperparathyroid osteodystrophy and oncological pathology must be ruled out; for hypocalcemia—osteomalacia; abnormal PTH levels—hyper- or hypoparathyroidism of various origins; elevated ESR or abnormal blood cell count—bone marrow pathology [52, 54-57, 59]. At the physician's discretion, testing for serum 25-OH vitamin D, total blood protein, and protein fractions, or other tests (serum albumin, albumin/globulin ratio, protein fractions by electrophoresis, or protein fractions by high-resolution capillary electrophoresis) may be prescribed [58].

• To select an individualized dose of calcium and cholecalciferol** / alfacalcidol** preparations (basic therapy for fractures of any location complicating osteoporosis), evaluate treatment response, and rule out contraindications to these drugs, it is recommended to assess biochemical blood parameters (ionized and/or total calcium, inorganic phosphorus, blood creatinine) and 24-hour urine calcium before treatment and dynamically [51, 59, 107, 313, 314, 330, 331, 332, 334, 335, 336, 337, 338].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments: a personalized approach to selecting the dose of basic therapy drugs for pathological fractures in osteoporosis is based on evaluating blood calcium levels initially and dynamically after 1 month, followed by repeated laboratory tests every 3 months [51, 10, 314, 331]. Monitoring blood calcium dynamics helps prevent overdosing on basic therapy drugs.

• In case of delayed bone union of a pathological fracture and when deciding on adding antiresorptive (bisphosphonates [ATC M05BA] and denosumab**) or bone-formation-stimulating (teriparatide**) osteoporosis therapy to basic drugs (calcium preparations and #cholecalciferol**) or adjusting it (if the fracture occurred against the background of ongoing osteoporosis treatment), it is recommended to evaluate (Table 1) resorption markers (urinary deoxypyridinoline or serum beta-isomerized C-terminal telopeptide of type 1 collagen [β-CrossLaps]) and/or bone formation markers (serum N-terminal propeptide of type 1 procollagen [P1NP] or serum osteocalcin) [54, 55, 59, 62].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments: the advisability of assessing remodeling markers when prescribing pathogenetic osteoporosis therapy is considered primarily from the standpoint of evaluating the patient's response to treatment and treatment compliance [54-60]. At the same time, there is a viewpoint that pathogenetic osteoporosis therapy, aimed at normalizing bone metabolism, should be prescribed only after investigating remodeling marker levels [61, 62]. It is justified to test bone remodeling markers initially [63] and 3 months after therapy, as a 30% change in marker levels relative to baseline is expected by this time if the prescribed pathogenetic therapy is effective [55, 64]. In case of delayed bone union of a pathological fracture, either bone formation, resorption, or both mechanisms may be impaired. Given this possibility, in such cases, it is advisable to assess remodeling markers before prescribing pathogenetic osteoporosis therapy.

Table 1. Laboratory tests recommended for patients with pathological fractures as markers of osteoporosis

Note. * — performed upon admission to prescribe basic therapy for the pathological fracture and conduct differential diagnosis of osteoporosis with other metabolic osteopathies [53, 54, 56, 60];

** — performed dynamically to personalize the dose of calcium and cholecalciferol**/alfacalcidol** preparations [53, 107];

*** — performed in case of delayed fracture union to prescribe pathogenetic osteoporosis therapy aimed at correcting impaired resorption or bone formation and monitoring the effectiveness of the prescribed pathogenetic therapy [62, 63, 64].

**** — performed at the physician's discretion in case of hypercalcemia or hypocalcemia to rule out primary or secondary hyperparathyroidism or hypoparathyroidism [54, 56].

† — follow-up laboratory tests are preferably performed in the same laboratory [64].

2.4 Instrumental Diagnostics

Radiological manifestations of a proximal femoral pathological fracture

• For stable proximal femoral fractures, in case of ambiguous visualization of the fracture line on standard two-projection radiography, magnetic resonance imaging (MRI) of the bone tissue or computed tomography (single region) is recommended to clarify the diagnosis [64, 323].

GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)

Comments: some stable proximal femoral fractures can only be detected by MRI; therefore, if there is a clinical suspicion of a femoral fracture with normal radiographic findings, T1-weighted MRI is the method of choice for fracture identification [64].

Radiological manifestations of a proximal humeral pathological fracture

• For the diagnosis of a proximal humeral fracture, in addition to standard radiography of the shoulder joint, an "epaulet" view is recommended. In case of unclear radiographic findings—CT of the upper extremity in the proximal humeral region (to detect complex multifragmentary fractures) and MRI of the upper extremity in the proximal humeral region (to determine soft tissue damage) [9, 33, 67, 315].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: radiological criteria [67] for a stable proximal humeral fracture:

- no significant displacement of the greater tuberosity;

- no more than 3 fragments;

- fracture is not combined with dislocation;

- impacted fracture;

- good fragment contact.

Radiological manifestations of vertebral body pathological fractures

• In the presence of back pain complaints and a history of height loss (even without pain), spine radiography in two projections (thoracic spine radiography, lumbar spine radiography, lumbosacral spine radiography, or upright spine radiography) is recommended to rule out osteoporotic vertebral compression fractures; in doubtful cases, for visualization of the fracture and vertebral height loss, magnetic resonance imaging (MRI) of the spine or computed tomography (CT) (single region) should be performed in the areas corresponding to the localization of these symptoms [70, 324, 333].

GCR CLEL 4Grade of Recommendation C (Level of Evidence – 4)

Comments:

- lateral spine radiography should be performed in the lateral decubitus position («strictly on the side»);

- if necessary, use special bolsters to correct scoliotic deformity;

- vertebral body deformity is regarded as a compression fracture if its height in the anterior, middle, or posterior section is reduced by 20% or more compared to the adjacent superior and inferior vertebral bodies [43, 39].

Alternatively to X-ray imaging, computed tomography [324] or Th4-L5 spine magnetic resonance imaging with targeted analysis of vertebral body heights may be initially performed when a vertebral body fracture is suspected. In addition, if software is available, X-ray absorptiometric morphometry can be performed during osteodensitometry for the initial assessment of pathological vertebral body fractures.

As part of primary screening, an AI morphometric algorithm can be an effective tool for opportunistic detection of compression deformities and vertebral body fractures in patients over 50 years of age [69].

Radiological presentation of a pathological fracture of the distal radial metaphysis

• For the radiological diagnosis of a distal radial metaphysis fracture, radiography in two projections is recommended; for impacted fractures, upper extremity CT of the distal forearm region is recommended; and magnetic resonance imaging of the upper extremity should be performed to clarify capsule-ligamentous apparatus injuries accompanying bone damage [71, 72, 325].

GCR CLEL 4Grade of Recommendation C (Level of Evidence – 4)

Comments: criteria for instability of a distal radial metaphysis fracture [40, 71, 72]:

– dorsal tilt angle of the distal radial metaphysis greater than 20°;

– comminuted nature of the dorsal cortical layer fracture of the distal radial metaphysis;

– intra-articular fractures of the distal radial metaphysis;

– concomitant ulnar fracture;

– comminuted fracture of the palmar cortical layer of the distal radial metaphysis;

– age over 60 years.

The role of X-ray densitometry in confirming the association of low-energy fractures with osteoporosis

Low-energy bone fractures (femur, humerus, radius, vertebral body/bodies) in individuals over 50 years of age, regardless of densitometry results (due to the low sensitivity of the method) or FRAX (provided that bone diseases such as osteomalacia, hyperparathyroid osteodystrophy, Paget's disease, multiple myeloma, and metastatic lesions are ruled out), are regarded as osteoporotic pathological fractures [15, 75, 76].

• Dual-energy X-ray absorptiometry is recommended to confirm the diagnosis of osteoporosis in low-energy fractures of any localization (for men under 50 and premenopausal women, the Z-score is used) [76].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments: the International Society for Clinical Densitometry (ISCD) [76] recommends performing X-ray densitometry at three skeletal sites. The optimal approach is scanning the L1–4 region and the proximal femur (femoral neck and total hip). A diagnosis of osteoporosis can be established based on a decrease in BMD even in just one of the scanned sites. Bone mineral density in the lower third of the radius is evaluated if BMD measurement in L1–4 or the proximal femur is impossible for any reason, or if hyperparathyroidism is suspected.

In individuals of both sexes over 50 years of age [75, 76] presenting with low-energy fractures as markers of osteoporosis, densitometry is not mandatory; nevertheless, BMD assessment in these cases improves adherence to treatment administered for the prevention of secondary fractures (allowing patients to monitor the increase or stabilization of BMD loss).

Radiofrequency echographic multispectrometry (REMS), an ultrasound method for determining bone mineral density (BMD) and the bone fragility index, is currently also proposed for the diagnosis of osteoporosis [73, 77]. In addition to bone mineral density, analysis of the reflected ultrasound signal spectrum allows assessment of the bone's propensity for fractures using the fragility index, which is considered an independent predictor of fracture risk, distinct from BMD.

2.5 Other Procedures

• In cases of pathological vertebral body fractures in individuals over 50 years of age, multiple myeloma should be ruled out prior to initiating osteoporosis treatment [63, 265].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments: the radiological appearance of a vertebral body fracture in multiple myeloma is often identical to that of an osteoporotic fracture. The incidence of multiple myeloma, like osteoporosis, increases with age; therefore, in the presence of a low-energy vertebral body fracture in individuals over 50, blood and urine tests for paraproteins and M-spike are required, and in some cases, CT-guided vertebral body biopsy [63, 255]. If myeloma-positive tests are identified, the patient requires follow-up by a hematologist.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1. Conservative management

Currently, the expediency of a multidisciplinary approach to the management of fractures complicating osteoporosis is widely recognized. Since pharmacotherapy aimed at normalizing disrupted bone tissue metabolism is an integral part of treatment, such a patient should be managed simultaneously by an orthopedic trauma surgeon and a geriatrician (physician, endocrinologist, or any other specialist dealing with osteoporosis treatment). A multidisciplinary approach to managing patients with such fractures has been proposed by EULAR/EFORT [77], which is also consistent with Russian clinical guidelines for the treatment of osteoporosis [75].

However, real-world clinical practice and foreign studies show that until the fracture heals, the patient remains under the sole supervision of an orthopedic trauma surgeon, and consultation with another specialist capable of prescribing osteoporosis treatment either never occurs or happens 6–12 months after the fracture. The lack of osteoporosis treatment in these cases is fraught with complications such as delayed union or non-union, and the development of aseptic implant loosening [79, 80, 82].

• Regardless of the type of treatment—surgical or conservative (reduction and immobilization)—for a pathological fracture complicating osteoporosis, pharmacological correction of impaired bone metabolism is recommended to ensure timely bone union (typical for this localization in individuals without osteoporosis), prevent non-union, aseptic loosening of hardware, and secondary fractures [79, 80, 82].

LoE CGoE 5Level of Evidence C (Grade of Recommendation – 5)

Comments: delayed fracture union or increased complication rates following conservative and surgical treatment of osteoporotic fractures are most often associated with a lack of treatment for the underlying osteoporosis. Data indicate [31] that only 24% of women aged 55 and older who sustained a distal radial metaphysis fracture initiated treatment with one of the medications used for osteoporosis (hormone replacement therapy (HRT), bisphosphonates (ATC M05BA), or calcitonin**).

It has been noted [83] that treatment prescribed by an orthopedic trauma surgeon immediately after a fracture occurs is adhered to better than recommendations from other specialists.

3.1.1. Basic pharmacotherapy as the basis of conservative treatment for fragility fractures

• As baseline therapy for pathological fractures complicating osteoporosis, starting from the first days after fracture detection and regardless of its localization, daily intake of calcium compounds (A02AC) or Osteogenon (TN) is recommended, which should be combined with #cholecalciferol** 10–20 mcg per day or alfacalcidol** 0.5–1.0 mcg per day, or fixed-dose combinations of calcium carbonate + cholecalciferol or alfacalcidol + calcium carbonate should be used [82, 84, 85, 88, 93, 94, 267, 316].

Level of recommendation CLevel of evidence 2Level of recommendation C (level of evidence – 2)

Comments: fundamental to the treatment of a pathological fracture of any localization is the prescription of calcium and kolecalciferol** alphacalcidol** preparations — basic therapy for the timely formation of a strong bone callus. The unique role of calcium in ensuring the structure of bone tissue and regulating intracellular processes during the formation of bone callus has been demonstrated in numerous experimental and clinical studies, and the need for additional calcium supplementation in pathological fractures complicating osteoporosis is due to well-known data on inadequate dietary intake in 80% of the Russian population [87].

When prescribing calcium supplements, the amount of salt containing 1000 mg of Ca⁺⁺ is taken into account (Table 2), which is why calcium carbonate + kolecalciferol is most widely used in complex treatment.

Table 2. Calcium content per 1 g of calcium salt

Calcium carbonate absorption is reduced in achlorhydria, concurrent administration with tetracycline**, bisphosphonates (ATX M05BA), iron preparations (ATX B03A), systemic corticosteroids (ATX H02A), whereas thiazide diuretics (thiazides) (ATX C03A) increase renal calcium reabsorption.

• In the first year after a fracture, as a calcium preparation (calcium compound, ATX A02AC), it is recommended to use the combined preparation Osteogenon (tn) [82, 93, 94, 107].

GCR ALEL 1Grade of Recommendation A (Level of Evidence – 1)

Comments: a rapid rise in calcium levels within the first hours after calcium carbonate administration [91] can cause calcium deposition in blood vessels and kidneys. An alternative to calcium carbonate salt in this case can be osteogenon, in which calcium is in the form of hydroxyapatite (calcium 178 mg and phosphorus 82 mg), and calcium absorption in this case occurs without a sharp spike in ionized calcium levels [92]. Osteogenon also contains ossein, represented by non-collagen peptides and protein: TGF-b (transforming growth factor beta), IGF-I (insulin-like growth factor-1), IGF-II (insulin-like growth factor-2), osteocalcin, and type I collagen. Comparative studies of osteogenon and calcium carbonate have been conducted to evaluate the effects of the drugs on BMD preservation [93, 94], and in experiments on bone callus formation [95]. The efficacy of Osteogenon (tn) compared to calcium carbonate has been noted in women with senile osteoporosis [96], for normalizing the healing time of tubular bone fractures in patients with fractures against the background of osteoporosis or osteopenia and in patients with bone tissue metabolism disorders [82] (delayed consolidation after surgical treatment of pseudarthrosis complicated by regional osteoporosis). The healing time for femoral pseudarthrosis [82] was reduced on average by 34.3% compared to the control group (p<0.05).

Concerns about an increased incidence of cardiovascular diseases with long-term calcium intake have not been confirmed [97, 98], although it has been shown [98] that the risk of all-cause mortality, cardiovascular mortality, and stroke increases with a total daily calcium intake (from food and supplements) of more than 1400 mg.

• Patients with pathological fractures complicating the course of osteoporosis are recommended to be prescribed alphacalcidol** 0.5–1.0 mcg per day, the dose of which is determined by baseline calcium homeostasis parameters [88, 100, 101, 267].

GOR ALE 2Grade of Recommendation A (Level of Evidence – 2)

Comments: deficiency or insufficiency of D-hormone (the term vitamin D is often used in literature) [99] is common in patients with osteoporosis, especially in older and elderly individuals (its transport form, 25OHD3, is assessed). D-hormone deficiency leads to hypocalcemia and, consequently, to secondary hyperparathyroidism, in which the required amount of calcium is mobilized from the bone by activating osteoclasts that destroy bone tissue, which reduces its strength properties and increases the risk of fractures. These disorders are the basis for prescribing #kolecalciferol** 10–20 mcg per day [84] in combination with calcium supplements, which improves the formation and quality of the bone callus [88].

In osteoporosis (and therefore in fractures against its background), the administration of kolecalciferol** may not always be effective due to a possible decrease in the synthesis of D-hormone (calcitriol) in the kidneys and bones, or a decrease in D-hormone receptor (VDR) density and/or a decrease in the affinity of these receptors for D-hormone in target organs [102]; the risk of these disorders increases with age. Alphacalcidol** in such cases modulates the expression and activation of VDR receptors themselves [100]. D-hormone also inhibits 1α-hydroxylase and activates 24-hydroxylase, which promotes the formation of 25(OH)2D. This minor active vitamin D metabolite is important for healing microfractures and forming microscopic bone calluses [103].

Among the advantages of alphacalcidol** over kolecalciferol**, the following should be noted [88, 104]:

- significantly increases BMD [88];

- is safer even in the presence of renal impairment [105];

- in patients with initially repleted 25(OH)D levels (in case of 25(OH)D3 metabolism disorders) leads to an increase in active D-hormone forms;

- the risk of hypercalcemia is reduced compared to calcitriol, ** since the drug's effect is delayed due to the necessity of hepatic hydroxylation [105];

- controlled (by blood and urine calcium levels) treatment with alphacalcidol** does not increase the risk of nephrolithiasis [105, 106];

- being a prodrug, the D-hormone is activated in the liver and other target organs, including bone tissue, therefore D-hormone deficiency can be effectively repleted bypassing the natural renal regulatory system [105, 106];

- the advantage of alphacalcidol** over cholecalciferol** is also noted when prescribed in combination with bisphosphonates (ATC M05BA) [101] in patients with postmenopausal osteoporosis.

Dosages of basic therapy drugs (Osteogenon (TN)/alphacalcidol**) for the treatment of pathological fractures complicating the course of osteoporosis are presented in Table 3.

Table 3. Initial doses of calcium preparations (calcium compounds, ATC A02AC)/Osteogenon (TN) and alphacalcidol** (basic therapy) for pathological fractures complicating the course of osteoporosis, depending on the baseline blood calcium level [93, 107, 267]

Note. If cholecalciferol** is used, the drug dose is 800 IU [88].

3.1.2. Features of conservative treatment of proximal femur pathological fractures

• In proximal femur fractures associated with osteoporosis, to ensure fracture consolidation within standard timeframes (or stability during arthroplasty), reduce mortality, and prevent secondary fractures regardless of sex, 1–2 months after surgery and exclusively against the background of basic osteoporosis therapy (calcium compounds, ATC group A02AC / Osteogenon (TN), in combination with #cholecalciferol** 10–20 mcg per day or alphacalcidol** 0.5–1.0 mcg per day, or calcium carbonate + cholecalciferol or alphacalcidol + calcium carbonate (combination drugs)) administered from the first days after injury, antiresorptive drugs (bisphosphonates, ATC M05BA) are recommended [80, 109, 115, 119, 181, 268].

GCR ALEL 1Grade of Recommendation A (Level of Evidence – 1)

• In patients with proximal femur fractures (PFF) against the background of osteoporosis, to ensure fracture consolidation within the usual timeframe (or stability during arthroplasty), reduce mortality, and prevent recurrent fractures regardless of sex, 1–2 months postoperatively and strictly against the background of basic osteoporosis therapy (calcium compounds, ATC group A02AC / Osteogenon (tn), combined with #cholecalciferol** 10–20 mcg daily or alfacalcidol** 0.5–1.0 mcg daily, or calcium carbonate + cholecalciferol or alfacalcidol + calcium carbonate (combination drugs)) initiated from the first days after trauma, the antiresorptive drug denosumab** 60 mg is recommended [183, 184, 185, 186, 187, 269].

GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)

Comments: in patients with PFF complicating osteoporosis, it is necessary to consider the potential for significant enhancement of resorption caused by both the trauma itself and the presence of metal implants, which leads to the loss of adjacent bone tissue [114, 115], delays normal callus formation, and may cause nonunion, avascular necrosis of the femoral head, aseptic implant loosening [114], and even implant fracture [108]. The use of antiresorptive drugs (bisphosphonates (ATC M05BA) and denosumab**) prevents bone loss adjacent to the implant [114, 115]. The use of bisphosphonates (ATC M05BA) in patients with pathological PFF has the strongest evidence base [133, 268].

Randomized studies have shown no adverse effect of bisphosphonates (ATC M05BA) on fracture consolidation [109]; nevertheless, many orthopedic trauma surgeons hesitate to prescribe them to patients with low-energy femoral neck fractures prior to hospital discharge [116, 117], although initiating therapy in the hospital improves treatment adherence.

In recent years, publications have emerged regarding complications associated with bisphosphonate (ATC M05BA) therapy, such as atrial fibrillation, atypical femoral fracture, jaw osteonecrosis, and esophageal cancer [118-121]. However, a clear causal relationship between these complications and bisphosphonate (ATC M05BA) intake has not been established [122-124]. Epidemiological studies have shown that the risk of sustaining a stress fracture of the femur while on bisphosphonate (ATC M05BA) therapy is much lower than the risk of sustaining a fracture at this site without treatment — 1/1000 per year versus 15/1000 per year, respectively [124].

• #Zoledronic acid**, given its administration schedule (once a year, 5 mg), is recommended as the most promising drug from the bisphosphonate group (ATC M05BA) for patients with pathological PFF to ensure fracture consolidation within the usual timeframe or to establish biological stability during arthroplasty [80, 109, 114, 115, 125, 268, 269].

GCR ALEL 1Grade of Recommendation A (Level of Evidence – 1)

Comments: it has been demonstrated that #zoledronic acid** 5 mg in patients with PFF following osteosynthesis or arthroplasty reduces the risk of recurrent fractures by 35% and mortality by 28%, with results independent of baseline BMD deficit [125, 126].

Animal experiments [127] have established that the optimal timing for #zoledronic# acid** administration is the first 2 weeks post-fracture: a stronger callus with better mechanical properties is formed. However, in humans, unlike animals, the timing of drug administration after surgery is delayed due to comorbidities [128] or hypocalcemia, which is common in osteoporosis. Therefore, bisphosphonate (ATC M05BA) therapy is suggested to be initiated 1–2 months after a PFF and strictly against the background of calcium preparations (calcium compounds, ATC A02AC) / Osteogenon (tn) combined with #cholecalciferol** 10–20 mcg daily or alfacalcidol** 0.5–1.0 mcg daily, or calcium carbonate + cholecalciferol, or alfacalcidol + calcium carbonate (combination drugs).

• Denosumab** 60 mg once every 6 months as an antiresorptive drug for the treatment of osteoporosis complicated by PFF is recommended regardless of sex, due to its pharmacokinetic profile, in patients with marked cortical bone loss (femoral neck, radius), compromised renal function, and in patients with a pathological fracture occurring despite a year of prior osteoporosis treatment with bisphosphonates (ATC M05BA); denosumab** should be used only in combination with basic osteoporosis therapy (calcium compounds, ATC group A02AC / Osteogenon (tn), combined with #cholecalciferol** 10–20 mcg daily or alfacalcidol** 0.5–1.0 mcg daily, or calcium carbonate + cholecalciferol, or alfacalcidol + calcium carbonate (combination drugs)) initiated from the first days post-fracture [129, 186, 187, 258, 269].

GCR BLEL 2Grade of Recommendation B (Level of Evidence – 2)

Comments: in PFF complicating osteoporosis, denosumab** 60 mg is used as a first-line agent alongside zoledronic acid 5 mg, providing a greater increase in BMD than bisphosphonates (ATC M05BA) [110, 111], partly due to an increase in cortical bone mass and a reduction in its porosity [112, 113].

A comparative study of denosumab** and zoledronic acid** [130] noted that BMD increases were significantly greater across all studied skeletal sites—spine, femoral neck, and radius—with denosumab**. Regarding adverse events (AEs), this comparative study recorded 3 cases meeting the definition of an atypical femoral fracture (2 and 1 case with denosumab** and zoledronic acid**, respectively); there were no cases of osteonecrosis of the jaw, hypocalcemia, or delayed fracture healing. The safety profile of denosumab** has also been demonstrated by other studies [131]. Its lack of a negative effect on the consolidation of non-vertebral fractures, including PFF, was shown in the FREEDOM trial [129].

Denosumab** is the drug of choice for treating osteoporosis and concurrent fractures when a fracture occurs during ongoing bisphosphonate therapy lasting one year. This is because a subset of osteoporosis patients [56] do not respond to bisphosphonate (ATC M05BA) therapy due to genetic polymorphism in intron 1 of the farnesyl pyrophosphate synthase (FDPS) gene, which is the molecular target of aminobisphosphonates (ATC M05BA) in osteoclasts [132].

• Teriparatide** 20 mcg daily as anabolic therapy for osteoporosis complicated by PFF is recommended for intertrochanteric fractures. The drug is prescribed strictly in combination with basic osteoporosis therapy (calcium compounds, ATC group A02AC / Osteogenon (tn), combined with #cholecalciferol** 10–20 mcg daily or alfacalcidol** 0.5–1.0 mcg daily, or calcium carbonate + cholecalciferol, or alfacalcidol + calcium carbonate (combination drugs)) initiated from the first days after trauma [86, 133, 134, 135, 267].

GCR CLEL 4Grade of Recommendation C (Level of Evidence – 4)

• Teriparatide** 20 mcg daily as anabolic therapy for osteoporosis complicated by PFF is recommended in cases of delayed consolidation of pathological intertrochanteric fractures (no signs of union from 6 to 12 months post-surgery with satisfactory fragment alignment), or radiological/clinical signs of implant instability (treatment duration for fracture union up to 6 months). The drug is prescribed strictly in combination with basic osteoporosis therapy (calcium compounds, ATC group A02AC / Osteogenon (tn), combined with #cholecalciferol** 10–20 mcg daily or alfacalcidol** 0.5–1.0 mcg daily, or calcium carbonate + cholecalciferol, or alfacalcidol + calcium carbonate (combination drugs)) initiated from the first days post-injury (tn) [84, 86, 133, 134, 135, 267].

GCR CLEL 4Grade of Recommendation C (Level of Evidence – 4)

Comments: teriparatide** belongs to agents that stimulate bone formation [136]. In a randomized, placebo-controlled trial involving 158 patients with femoral neck fractures [137], no differences were found between the comparison groups at 12 months: teriparatide** did not reduce pain compared to placebo, did not decrease the risk of reoperation, and did not alter the time to radiological fracture union.

At the same time, evidence indicates that teriparatide** treatment reduces the risk of non-vertebral fractures [139] and has a positive effect on cortical bone thickness and quality in severe osteolysis of the bone adjacent to the endoprosthesis [133]. Supplementation of calcium compounds combined with #colecalciferol** and teriparatide** (comparative study) revealed a significant reduction in the time to union of intertrochanteric fractures compared to the group receiving only calcium preparations and colecalciferol**, whereas the efficacy of teriparatide** in this combination increases non-significantly if osteoporosis treatment with alendronic acid** was administered prior to the fracture [134]. Regarding pain intensity and functional activity, the advantage of teriparatide** administration was observed at 3 and 6 months post-surgery. At 9 and 12 months, there were no differences between the groups. A positive effect of teriparatide** on the fracture union time and the risk of complications such as hardware instability was noted when administered from the first days in intertrochanteric fractures with DHS osteosynthesis [135]. Administration of teriparatide** 20 mcg to osteoporosis patients exhibiting loosening of a cementless endoprosthesis may be a useful adjuvant for bone tissue restoration [133].

The feasibility and safety of using anabolic steroids [141, 142], protein supplements, and multivitamins combined with micronutrients [143] for proximal femur fractures have not been proven.

3.1.3. Specifics of Conservative Treatment of Pathological Fractures of the Proximal Humerus

Despite the fact that low-energy proximal humeral fractures in osteoporosis are frequent, there is still no unified treatment protocol [144–146] aimed at restoring segment integrity and the function lost by the patient within the timeframe typical of healthy bone [147]. Evidence shows [41, 36, 37, 38, 67, 148–151] that stable fractures, which account for 80–85% of cases, are amenable to conservative treatment, which is optimal for elderly patients [42]. A good outcome of conservative treatment can also be expected in displaced fractures if solid fragment contact is achieved after closed reduction [152–154].

• For stable pathological fractures of the proximal humerus (impacted, isolated greater tuberosity fractures without displacement or with minimal displacement — up to 10 mm in elderly, up to 5 mm in young patients) or fractures with a small number of fragments, conservative treatment is recommended, the mainstay of which is the relief of pain syndrome as early as possible after trauma, achieved through functional immobilization (application of an immobilization bandage for bone fractures) and early functional loading [155, 156, 157, 224].

GGR BLoE 2Recommendation Grade B (Level of Evidence – 2)

Comments: the core strategy of conservative treatment is pain relief, activity restriction, and fixation with gradual mobilization [155, 158, 159, 160].

One of the fixation methods for surgical neck fractures of the humerus is orthotic management. Modern orthoses are built on a modular principle, making it possible to select a device individually taking into account anatomical features and patient management tactics. The orthoses incorporate all necessary solutions for the reduction and fixation of proximal humeral fractures in the setting of osteoporosis (Table 4). However, using an orthosis (brace) for a proximal humeral fracture does not always neutralize all deformations (too many multidirectional forces) [147].

A standard arm sling in a stable fracture provides adequate immobilization [161] and slight distraction due to gravitational forces, which reduces pain [162].

Comments: hanging arm casts are less well tolerated by patients; furthermore, excessive distraction may lead to the formation of a pseudoarthrosis [148, 158, 320, 321]. Plaster casts used previously (Turner, Desault, thoracobrachial), splints (TsITO abduction splint or other abduction orthoses), and skeletal traction through the olecranon are poorly tolerated by elderly patients [147, 12, 320, 321].

• In cases where, despite satisfactory fragment alignment, a proximal humeral fracture does not heal within the usual timeframe, it is recommended, without discontinuing basic drug therapy, to evaluate remodeling markers (both bone formation markers — determination of blood alkaline phosphatase activity and/or blood osteocalcin level, and resorption markers — determination of urine deoxypyridinoline level and/or serum beta-isomerized C-terminal telopeptide of type I collagen (CrossLaps)) for the additional prescription of antiresorptive (bisphosphonates (ATX M05BA) and denosumab**) or bone formation-stimulating (teriparatide**) agents of pathogenetic osteoporosis therapy [107, 62, 134, 135, 164, 308].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments: There is no reliable evidence that antiresorptive drugs (bisphosphonates (ATC M05BA) and denosumab**) or bone formation-stimulating drugs (parathyroid hormones and their analogs — #teriparatide**), recommended for the treatment of osteoporosis, normalize the healing time of proximal humeral fractures. For instance, the administration of teriparatide** [164] immediately after a proximal humeral fracture did not shorten the fracture consolidation time, whereas the early administration of bisphosphonates (ATC M05BA) following trauma in proximal humeral fractures [165] even increased the risk of non-union. At the same time, the use of osteoporosis medications for delayed fracture consolidation or non-unions of the humerus is necessary, as there is evidence that these drugs positively affect impaired remodeling in fractures at other sites in the presence of osteoporosis; therefore, their use in cases of impaired consolidation may be appropriate [134, 135, 164, 308]. Since pathogenetic therapy drugs for osteoporosis affect calcium homeostasis (have a hypocalcemic effect), bisphosphonates (ATC M05BA) and denosumab** should be used only in combination with basic osteoporosis therapy (calcium compounds, ATC group A02AC / Osteogenon (TN), combined with #cholecalciferol** 10–20 mcg per day, or alfacalcidol** 0.5–1.0 mcg per day, or calcium carbonate + cholecalciferol, or alfacalcidol + calcium carbonate (combination drugs)). Before prescribing pathogenetic therapy drugs, it is necessary to test the levels of total blood calcium and urinary calcium to adjust the dosage of basic osteoporosis therapy drugs.

3.1.4. Features of conservative treatment for vertebral fragility fractures

Prolonged unloading of patients with vertebral body fractures due to osteoporosis, unlike post-traumatic fractures, is a factor in the further progression of the disease and deterioration of physical condition, causing muscle hypotrophy, pressure ulcers, lower extremity venous thrombosis, respiratory diseases, disorientation, and depression.

• For pathological vertebral body fractures, oral or injection forms of nonsteroidal anti-inflammatory and antirheumatic drugs (NSAIDs) and centrally acting muscle relaxants (tolperisone) are recommended from day one to relieve acute pain [166, 167, 172, 317].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments: To reduce pain, various regimens of pharmacotherapy with analgesic effects [166, 167] are used, along with spinal unloading using orthoses [168, 171], physical therapy in the absence of contraindications [169, 173], and continuous administration of medications for osteoporosis [167]. The use of spinal orthoses in neurologically healthy elderly patients with low-energy vertebral compression fractures leads to improved spinal biomechanical stability, reduced kyphotic deformity, enhanced postural stability, greater muscle strength, and superior functional outcomes [171].

To relieve pain in the acute period, rolling support devices with manual brakes can be used. In this case, straightening the back and reducing the load on the spine not only reduce pain during movement but also lower the risk of new fractures [171].

• In case of a pathological vertebral body fracture and lack of analgesic effect from oral pain relief medications, including for the purpose of preventing the development of chronic pain syndrome, it is recommended to use local anesthesia in the form of topical patches containing nonsteroidal anti-inflammatory drugs, paravertebral blocks (Appendix A3.3) [166, 167].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments: for joint and muscle pain, topical medications are used as applications to the area of pain projection for 4–6 hours, 5–6 procedures; reflexology (stimulation of acupuncture points with other physical factors, e.g., electropuncture, and electropuncture in reflexology, stimulation of acupuncture points with other physical factors, laser acupuncture).

When chronic pain syndrome develops in a pathological vertebral body fracture, opioids and other analgesics and antipyretics are used [172].

Physiotherapy for pathological vertebral fractures in osteoporosis is limited due to concomitant diseases [173]. There is convincing data lacking on the feasibility of radiofrequency denervation of the medial branches of the dorsal rami innervating the facet joint for managing chronic pain in osteoporotic fractures.

• Patients with chronic pain from osteoporotic vertebral body fractures who develop depression on this background are recommended to be referred to a medical psychologist [174].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments: to reduce psychological problems associated with chronic pain syndrome, antidepressants are used [174], which can themselves affect bone tissue metabolism. The relationship between "osteoporosis" and "antidepressants" requires further study [174].

• In vertebral body fractures complicating osteoporosis, bed rest is recommended for no more than 3 days, followed by verticalization in a brace and resting in bed during the day (for pain relief) every 2–3 hours [166, 167, 171, 175].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

• In osteoporotic vertebral body fractures, braces (orthoses) are recommended for long-term wear throughout the day to unload the spine, as braces increase intra-abdominal pressure or create an extension force via three-point fixation [175, 171].

GOR ALE 2Grade of Recommendation A (Level of Evidence – 2)

Comments: a brace for osteoporotic vertebral body fractures reduces pain not only by limiting the mobility of the fixed spinal segment and blocking backward hyperextension, but also by increasing intra-abdominal pressure, which unloads the vertebral bodies and thereby not only reduces pain but also helps prevent the risk of new fractures and promotes early restoration of physical activity [175, 176, 171].When choosing a brace, the level of the fracture, severity of pain syndrome, general physical activity, and emotional state of the patient are taken into account.

• For lumbar and thoracic vertebral body fractures, it is recommended to use active spinal orthoses; for thoracic vertebral fractures, thoracolumbar orthoses (braces) can additionally be recommended, which ensure the straightening of the spinal column and reduction of kyphosis severity by activating the back extensors [171, 175].

GOR ALE 2Grade of Recommendation A (Level of Evidence – 2)

Comments: the use of spinal orthoses in neurologically healthy elderly patients aged 60 years and older with osteoporotic vertebral compression fractures throughout the day, provided they walk daily for at least 1.5–2 hours a day and perform daily exercise therapy without axial loading, leads to improved biomechanical stability of the spine, reduction of kyphotic deformity, increased postural stability, greater muscle strength, and excellent functional results [170, 175].

• Manual therapy is strictly not recommended for patients with pathological osteoporotic vertebral body fractures [177].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: manual therapy increases the risk of new fractures and clinical worsening, up to the appearance of neurological symptoms [177].

• To reduce the risk of chronic pain syndrome in patients with vertebral body fractures, it is recommended to timely prescribe osteoporosis medications [166, 168, 185, 252, 309].

GCR BLEL 2Grade of Recommendations B (Level of Evidence – 2)

Comments: the likelihood of developing chronic pain syndrome in vertebral body fractures can be reduced by the timely prescription of alfacalcidol + calcium carbonate with or without bisphosphonates (ATC M05BA). The analgesic effect of this combination has been noted previously [179, 180].

• In patients with pathological vertebral body fractures, for pain relief and reduction of the risk of recurrent fractures, it is recommended to use #zoledronic acid** 5 mg annually, which has an advantage, including regarding the administration frequency, compared to alendronate sodium** and ibandronic acid [181].

GCR ALEL 1Grade of Recommendation A (Level of Evidence – 1)

Comments: in low-energy vertebral body fractures in osteoporotic patients, bisphosphonates (ATC M05BA) are widely used to prevent new fractures [182, 181]. A combination of a low baseline T-score and a high serum CTX-s level is regarded as a predictor of ibandronic acid efficacy [182]. However, #zoledronic acid** proved to be the most effective in preventing new vertebral body fractures [181] compared to alendronate sodium** and ibandronic acid.

• Denosumab** 60 mg once every 6 months is recommended for osteoporotic vertebral body fractures (regardless of gender) to prevent recurrent fractures; it also has an advantage in patients with impaired renal function and in cases where the fracture occurred during ongoing (long-term) bisphosphonate therapy (ATC M05BA) [183, 186].

GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)

Comments: the expediency of using monoclonal antibodies in the presence of a vertebral body fracture for pain relief and prevention of recurrent fractures has been demonstrated in patients, including those with impaired renal function, in a randomized placebo-controlled trial [183, 184].In the group of patients receiving the monoclonal antibody, new vertebral body fractures [184] were noted in 2.3% of cases, and in the placebo group in 7.2% (p<0.001), i.e., the fracture rate during treatment decreased by 68%.

The potential of using denosumab** to reduce fracture risk has also been noted in secondary osteoporosis in men: in a blind randomized trial [185], after 36 months, the number of new vertebral body fractures in the denosumab** group was lower than in the placebo group—1.5% and 3.9%, respectively (p=0.006). In a 2-year study [186], the incidence of new vertebral body fractures in the denosumab** group was 3.6% versus 10.3% in the placebo group (p=0.0001). However, due to the fact that discontinuation [187] of the drug leads to a recurrence of fractures, it is suggested to continue treatment with bisphosphonates after completing denosumab** therapy if a high risk of recurrent fractures persists.

• In the presence of a history of vertebral body fractures, which indicates a high risk of recurrent fractures, and low values of bone remodeling markers (both bone formation markers—osteocalcin, alkaline phosphatase, and resorption markers—DPD, CTX-s), it is recommended to use #teriparatide** 20 mcg daily to prevent new fractures regardless of gender [188, 189, 308, 329].

GCR CLoE 3Grade of Recommendation C (Level of Evidence – 3)

Comments: it has been shown that administration of #teriparatide** for 21 months [188] reduces the likelihood of new fractures: new vertebral body fractures were detected in 14% of women in the placebo group and in 5% and 4% of women receiving 20 and 40 mcg of #teriparatide**, respectively. The relative risk of fractures in groups of women receiving 20 and 40 mcg of #teriparatide** compared to the placebo group was 0.35 and 0.31, respectively. This reduction in fracture risk was combined with an increase in BMD at L1–4, which was 9% and 13% greater than in the placebo group. The possibility of increasing trabecular bone mass under the influence of #teriparatide** was confirmed by histomorphometric analysis of paired biopsies [189]: administration of #teriparatide** 20 or 40 mcg for 19 months contributed to an increase in trabecular bone volume by an average of 14%, whereas in the placebo group the loss was -24% (p=0.001). According to 3D micro-CT structural analysis of trabecular and cortical bone, it was revealed [189] that #teriparatide**, compared to placebo, significantly reduced bone marrow adipose tissue volume (respectively -16% and 12%; p=0.004), increased bone density (respectively 19% and -14%; p=0.034), and cortical bone thickness (22% vs. 3%; p=0.012). According to the authors, these changes in trabecular and cortical bone morphology underlie the improvement in its biomechanical properties and are associated with a substantial reduction in the number of new vertebral body fracture cases.

3.1.5. Features of conservative management of pathological fractures of the distal radial metaphysis

• In elderly patients with stable fractures of the distal radial metaphysis, bone fragment reduction and immobilization with a plaster cast (application of a plaster cast for bone fractures, application of an immobilization bandage for bone fractures) for 6 weeks are recommended, followed by monitoring throughout the entire immobilization period, as collapse of the distal radial metaphysis and secondary displacement of fragments cannot be ruled out during this time [190, 191, 192].

GCR BLEL 2Grade of Recommendation B (Level of Evidence – 2)

Comments: a systematic review [190] noted that plaster immobilization yields the worst radiological outcomes, but this treatment method is associated with the lowest complication rate and provides functional results comparable to those of surgical management. A meta-analysis [193] showed that radiological parameters, range of motion, and DASH scores at 3 and 12 months are better with internal fixation than with closed reduction, and the rate of infectious complications is also lower; however, at 1 year and beyond, there are no statistically significant differences. A meta-analysis of DASH results [194] from 3 cohort and 2 randomized studies (involving 515 patients) 12 months after the completion of treatment revealed no advantages of surgical treatment over conservative management. Furthermore, based on a comparative analysis of surgical and conservative treatment outcomes, it was concluded [195] that in treating elderly patients with osteoporosis, surgical and non-surgical methods yield similar results, and minor objective functional differences do not affect the subjective assessment of the outcome and quality of life.

• For low-energy fractures of the distal radial metaphysis from the first days, as part of fracture treatment, basic osteoporosis therapy is recommended (calcium compounds, ATC group A02AC/Osteogenon (TN) in combination with #cholecalciferol** 10–20 mcg per day or #alfacalcidol** 0.5–1.0 mcg per day, or calcium carbonate + cholecalciferol or alfacalcidol + calcium carbonate (combination drugs)) [80, 84, 86, 88, 82, 93, 94, 267].

GCR CLEL 2Grade of Recommendation C (Level of Evidence – 2)

• For low-energy fractures of the distal radial metaphysis, pathogenetic osteoporosis therapy (if the patient has not been previously treated) is recommended for the prevention of secondary fractures as early as possible after the fracture [194, 196, 129, 300, 308, 326].

GCR CLEL 4Grade of Recommendation C (Level of Evidence – 4)

• In cases where a fracture of the distal radial metaphysis occurs against the background of ongoing antiresorptive (bisphosphonates (ATC M05BA) and/or denosumab**) or bone formation-stimulating (teriparatide**) therapy prescribed in accordance with clinical guidelines for the treatment of osteoporosis, this treatment is recommended to be continued [32, 77, 272, 273, 308].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments: the advisability of prescribing bone formation-stimulating drugs (teriparatide**) or antiresorptive agents (bisphosphonates (ATC M05BA) and denosumab**) to normalize the bone healing time of a distal radial metaphysis fracture is under discussion. A comparative placebo-controlled study in postmenopausal women (aged 45 to 85 years) with a distal radial metaphysis fracture tested the hypothesis that teriparatide** could influence the healing of a fresh radial fracture [196]. The drug at a dose of 20 or 40 mcg was administered 10 days after the fracture. The mean time from fracture to the first radiological confirmation of complete cortical healing across the groups was 9.1, 7.4, and 8.8 weeks for placebo and #teriparatide** 20 and 40 mcg, respectively (overall p=0.015). There was no significant difference between the #teriparatide 40 mcg and placebo groups (p=0.523). In post hoc analyses, there was no significant difference between #teriparatide 40 and 20 mcg (p=0.053). However, healing time was shorter in patients taking teriparatide** 20 mcg than in the placebo group (p=0.006). The reduction in the consolidation period with teriparatide 20 mcg compared to placebo, according to the study authors, should be interpreted with caution, as this fact requires further study.

Regarding denosumab**, as noted in the FREEDOM study [129], the drug, compared to placebo, has no negative impact on the healing of a fracture at this site or on complications during surgical treatment.

The effect of bisphosphonates (ATC M05BA) on distal metaphyseal fracture healing also remains unclear, but guided by preclinical and clinical study data, there is a viewpoint [194] that antiresorptive drugs (bisphosphonates (ATC M05BA) and denosumab**) do not adversely affect fracture healing; therefore, in cases where they were prescribed before the fracture, treatment should be continued.

Based on the data presented above, the same approach should be applied to denosumab**, if the drug was prescribed for the treatment of osteoporosis before the fracture. However, in all cases, pathogenetic osteoporosis therapy must be supplemented with basic osteoporosis therapy (Table 3).

3.2. Surgical treatment

3.2.1. Surgical treatment for proximal femoral fragility fractures

In Russia, hospitalization rates in trauma departments for individuals over 60 years of age with pathological fractures complicating osteoporosis are extremely low and on average do not exceed 37%. Of those hospitalized, only 12.5% receive surgical treatment [198, 199]. Mortality among non-hospitalized individuals with fractures of this localization reaches 52.6%. In contrast, with nearly universal hospitalization of patients with proximal femur fractures and timely surgical care [200], mortality after 6 months was 26.46%, and after 1 year—29.8%, which emphasizes the need for surgical treatment of fractures of this localization.

• Upon admission, a patient with a pathological proximal femur fracture is recommended to be hospitalized in the intensive care unit to prepare for emergency surgery [202–204].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments: preparation of a patient with a pathological proximal femur fracture for surgery must be rapid [201] and consists of non-pharmacological (antithrombotic stockings, lower limb sequential compression devices, or electrical muscle stimulation) and pharmacological (adequate hydration and various antithrombotic agents with strict adherence to drug administration instructions) prevention of PE. Special attention is paid to patients who were already receiving anticoagulant therapy prior to the fracture [203].

• In elderly patients with proximal femur fractures, postponing surgery during preoperative preparation is not recommended in the absence of absolute contraindications (for example, in patients with diabetes mellitus, hyperglycemia without signs of ketoacidosis and/or dehydration is not a reason to postpone surgery), since performing surgical treatment no later than 48 hours after hospital admission minimizes the incidence of thromboembolic, hypostatic, respiratory, and cardiac complications [201, 204, 270, 271].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

• In patients with low-energy proximal femur fractures, it is recommended to determine the cause of the fall in order to develop prevention measures for subsequent falls [206, 201].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

• Patients with low-energy fractures, including stable ones, with femoral neck and intertrochanteric fractures are recommended to be operated on no later than 48 hours [201, 204, 205, 207].

GGR BLoE 2Recommendation Grade B (Level of Evidence – 2)

Comments: the efficacy of surgery performed no later than 48 hours from the moment of the fracture has been proven [207, 208]. The provision of comprehensive specialized care to this group of patients is most fully represented in foreign publications on the management of low-energy fractures complicating osteoporosis, which discuss the timing of intervention, surgeon qualifications, type of surgical intervention, and the presence of a geriatrician on the orthopedic ward team [201–207]. It must be borne in mind that stable proximal femur fractures turn into unstable ones in 20% of cases under conservative management, and in individuals aged 70 years and older, this risk increases to 70% [209, 210].

• Surgical interventions for pathological proximal femur fractures complicating osteoporosis are recommended to be performed by orthopedic trauma surgeons proficient in surgical techniques under conditions of poor bone quality [201, 203].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments: age and comorbidities as a cause of osteoporosis [201, 209] create difficulties for fragment fixation and increase the complexity of surgical intervention [211].

• For internal fixation of proximal femur fractures in patients with osteoporosis, it is recommended to prefer implants that cause minimal bone tissue damage [213].

GCR CLEL 4Grade of Recommendation C (Level of Evidence – 4)

Comments: the fixation strength of a fracture, regardless of the fixation method, is significantly reduced [41] due to altered structural properties of cortical and trabecular bone: under cyclic loading (walking) in osteoporosis, micro-motion of the implant within the bone increases, making the implant a factor that increases bone loss and leads to implant migration or failure [212]. Biomechanical studies [213] have revealed a correlation between the extent of adjacent bone destruction and the size of the implant: for instance, when using smooth osteosynthesis pins (orthopedic bone wire***) bent in a V-shape, this figure is 8%, and for AO screws, it is 22%. The risk of instability is also increased by the invasiveness of the surgical procedure itself [211].

• In subcapital, transcervical, and basal fractures (fracture type I–II according to Pauwels, I–II according to Garden, or 31B1 according to AO) complicating osteoporosis in individuals under 60 years of age, it is recommended to perform osteosynthesis using cannulated screw constructs (orthopedic bone screw, non-absorbable, non-sterile***, orthopedic bone screw, absorbable***, orthopedic bone screw, non-absorbable, sterile***) or dynamic extra- and intramedullary fixation devices (femoral intramedullary nail, non-sterile***, femoral intramedullary nail, sterile***) capable of achieving compression across the fracture line, which is a prerequisite for bone healing [211, 214, 216].

GCR CLEL 4Grade of Recommendation C (Level of Evidence – 4)

• In subcapital, transcervical, and basal fractures (fracture type I–II according to Pauwels, I–II according to Garden, or 31B1 according to AO) complicating osteoporosis in individuals under 60 years of age, it is recommended to perform osteosynthesis using smooth osteosynthesis pins (orthopedic bone wire***) bent in a V-shape, which are capable of creating compression across the fracture line while causing minimal bone tissue damage, which is a prerequisite for bone healing [213].

GCR CLEL 4Grade of Recommendation C (Level of Evidence – 4)

Comments: most commonly, 2–3 cannulated screws (orthopedic bone screw, non-absorbable, non-sterile***, orthopedic bone screw, non-absorbable, sterile***, orthopedic bone screw, absorbable***) (more frequently 3) are used to fix stable femoral neck fractures. The use of additional washers improves fixation. The screw head should be positioned above the lesser trochanter to reduce stress concentration in the subtrochanteric region, which can lead to a subtrochanteric fracture [216]. The screw threads should not cross the fracture line but lie entirely within the femoral head. The revision rate when using screws does not exceed 10%. Fixation stability in femoral neck fractures (fracture type I–II according to Pauwels, I–II according to Garden, or 31B1 according to AO) can also be achieved using smooth osteosynthesis pins (orthopedic bone wire***) bent in a V-shape, which cause minimal damage to the adjacent bone tissue, are cost-effective, and provide good surgical outcomes [213].

• In persons older than 60 years with subcapital, transcervical, and basicervical fractures complicating osteoporosis, regardless of fracture type according to Pauwels, Garden, or the AO classification, hip arthroplasty is recommended: in those who were physically active prior to the injury and in persons with a life expectancy of 4 years or more — total hip arthroplasty, in persons older than 80 years with a predicted life expectancy of less than 4 years — unipolar (hemiarthroplasty) hip arthroplasty (using bone cement without medicinal substances***, bone cement containing medicinal substances***) [212, 215, 217, 218].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments: in unstable femoral neck fractures, the treatment algorithm depends not only on the fracture pattern and the severity of bone mass deficit. In such cases, the patient's premorbid status, as well as the decisions of the surgeon and the patient, are of importance.

Hemiarthroplasty (unipolar hip arthroplasty) is indicated for frail elderly patients or for medical reasons [212, 215, 218].

In active elderly patients with a relatively normal acetabulum, total hip arthroplasty provides better clinical outcomes [215, 217, 218].

To date, the superiority of one type of endoprosthesis component fixation over others has not been proven; therefore, the choice of the prosthesis type (total hip replacement with metal-on-polyethylene bearing surface***, total hip replacement with metal-on-metal bearing surface, total hip replacement with ceramic-on-ceramic bearing surface, total hip replacement with ceramic-on-polyethylene bearing surface, total hip replacement with ceramic-on-metal bearing surface) and fixation method (cemented or cementless) is determined by surgeon preference and economic factors [212, 214, 215, 217, 218].

• In pertrochanteric and intertrochanteric fractures complicating osteoporosis, it is recommended to perform intramedullary nail osteosynthesis using medical devices of various modifications (femoral intramedullary nail, non-sterile***, femoral intramedullary nail, sterile***) or orthopedic fixation systems with plates/screws (non-absorbable plate, sterile***, bone plate for fracture fixation with screws, non-absorbable, sterile***); if the fracture line extends distal to the lesser trochanter, it is preferable to use a long version of the medical device. The use of a dynamic hip screw*** is possible if medial support is preserved (type 31A1 — stable fracture) [219].

GCR CLEL 4Grade of Recommendation C (Level of Evidence – 4)

Comments: in pertrochanteric and intertrochanteric fractures, intramedullary nails provide sufficient support for the proximal fragment [220, 219].

Surgical treatment should be deferred in the presence of the following concomitant conditions:

– acute myocardial infarction or acute cerebrovascular accident;

– pneumonia requiring mechanical ventilation;

– acute surgical condition requiring immediate intervention;

– coma of any etiology;

– chronic or acute purulent infection in the area of the proposed incision;

– terminal stage of a somatic disease that rendered the patient immobile even before the fracture;

– severe cognitive impairment or psychiatric illness causing the patient to be immobile prior to the fracture [199].

3.2.2. Management features of proximal humeral fragility fractures

• When choosing a method for fixing proximal humeral fractures, it is recommended to consider the type of injury, number of fragments, degree of displacement, bone quality, patient's somatic status, and presence of osteoporosis [41, 149, 227].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments: for complex multi-fragmentary fractures, high-level evidence studies have not demonstrated significant differences in outcomes between conservative and surgical treatment [221-224, 156, 225, 226]. Furthermore, choosing a surgical method significantly increases the risk of complications and re-operations within the first 2 years after the initial surgery [145], as osteoporosis can cause implant destabilization [41, 227].

In complex low-energy multi-fragmentary proximal humeral fractures, the choice between surgical and conservative treatment takes into account the patient's opinion and the operating surgeon's preference [221, 223, 224].

• For comminuted fractures of the humeral head and surgical neck, displaced fractures, isolated displaced fractures of the greater tuberosity (greater than 1 cm), and a satisfactory general somatic status of the patient with high functional demands, surgical treatment (bone fragment reposition in fractures) is recommended using medical devices for intramedullary nail osteosynthesis (humeral intramedullary nail, sterile***, humeral intramedullary nail, non-sterile***) or smooth osteosynthesis Kirschner wires (orthopedic bone wire***), bent in a V-shape, or for open reduction — specialized locking plates (bone plate for fracture fixation with screws, non-absorbable, non-sterile***, bone plate for fracture fixation with screws, non-absorbable, sterile***, bone plate for fracture fixation with screws, absorbable***, set of devices for bone fracture fixation with a plate, non-absorbable, sterile***) [145, 146].

GCR CLoE 3Grade of Recommendation C (Level of Evidence – 3)

• In case of a high risk of surgical intervention, conservative treatment with the application of an immobilization bandage for bone fractures is recommended [145, 146, 151].

GCR ALEL 1Grade of Recommendations A (Level of Evidence – 1)

Comments: when comparing the ability to relieve pain in the early post-fracture period, an advantage of surgical treatment was revealed: with conservative fracture treatment, pain reduction was noted in 61% (98 of 161) of cases, with osteosynthesis — in 76% (122 of 161), and with shoulder arthroplasty — in 93% (150 of 161) [144].

It is believed that indications for surgical treatment exist in approximately 20% of proximal humeral fracture cases [67].

• For open fractures, only surgical intervention (osteosynthesis) is recommended [228].

GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)

Comments: absolute indications for surgery are open fractures and fractures with neurovascular bundle injury [144, 221, 228].

Three-part displaced fractures quite rarely remain stable after closed manual reduction [151], since significant displacement of the tuberosities is difficult to eliminate without surgery [147]. Nevertheless, if a solid fragment contact is achieved after a single closed reduction, a good outcome of conservative treatment can be expected [151-153], although the authors note that anatomical restoration as a result of surgery is achieved in 72% of cases, while with conservative treatment it is only 56%.

For unstable fractures, various fixators are used (Table 4), which are chosen individually taking into account the patient's preferences [230].

• For comminuted proximal humeral fractures with significant displacement, fracture-dislocations (Neer IV–V), and the impossibility of stable osteosynthesis in patients with a high level of functional activity prior to the fracture, shoulder arthroplasty is recommended provided that technical feasibility and appropriate experience of the surgeon performing the operation are available [231].

GOR ALE 2Grade of Recommendation A (Level of Evidence – 2)

Comments: in comminuted fractures, arthroplasty [144] restores shoulder joint function. In addition, the probability of reducing pain intensity with arthroplasty significantly exceeds that for both the conservative method and osteosynthesis: 93% versus 61% and 76%, respectively. The risk of re-interventions is lower after arthroplasty than after osteosynthesis [224]. At the same time, no significant difference [144] was found between the rate of infectious complications after osteosynthesis operations (13%) and arthroplasty (10%). Functional results after reverse shoulder arthroplasty (total reverse shoulder joint prosthesis***) are better than after hemiarthroplasty [231].

When planning arthroplasty, it must be taken into account that hemiarthroplasty is significantly inferior in terms of outcomes to total reverse arthroplasty [231]. After 2001, the frequency of hemiarthroplasty use worldwide has been steadily declining due to, on the one hand, the development of osteosynthesis technology (medical devices for intramedullary nail osteosynthesis and locking plates (humeral intramedullary nail, sterile***, humeral intramedullary nail, non-sterile***, bone plate for fracture fixation with screws, non-absorbable, non-sterile***, bone plate for fracture fixation with screws, non-absorbable, sterile***, bone plate for fracture fixation with screws, absorbable***, set of devices for bone fracture fixation with a plate, non-absorbable, sterile***)), and on the other hand, the development after 2006 of reverse shoulder prostheses (total reverse shoulder joint prosthesis) [38].

Table 4. Options for proximal humeral fracture fixation depending on the type of injury

3.2.3. Features of surgical treatment for vertebral fragility fractures

• Vertebroplasty or kyphoplasty for osteoporotic compression fractures of vertebral bodies is not recommended [234, 274].

Level of Evidence AGrade of Evidence 2Level of Recommendations A (Grade of Evidence – 2)

Comments: the popularity of vertebroplasty declined after 2009, when two randomized controlled trials failed to demonstrate any benefit from this intervention [232, 233]. A meta-analysis [234] including 21 studies (evaluating the efficacy of vertebroplasty versus a sham/placebo procedure, vertebroplasty versus standard conservative treatment, vertebroplasty versus kyphoplasty, and one study comparing vertebroplasty with facet joint glucocorticoid injection) revealed no clinically important advantages of vertebroplasty over the sham procedure in pain relief. Sensitivity analysis confirmed that open-label studies comparing vertebroplasty with standard conservative treatment likely overestimated any benefit from vertebroplasty.

Numerous serious AEs following vertebroplasty were also identified. However, reliable evidence that vertebroplasty increases the risk of new symptomatic vertebral fractures and/or other serious adverse effects has not been established [234]; patients should be informed about the lack of high-level evidence confirming the benefit of vertebroplasty [234, 235]. Vertebroplasty may be superior to placebo when performed several weeks after a fracture in patients with persistent pain, and strictly for fractures in the lower thoracic spine and L1 and L2 vertebral fractures [232]. However, even in these cases, pain reduction was observed in only 1 out of 4 patients. The procedure should not be performed within the first week following a fracture, as pain resolves spontaneously in many patients without vertebroplasty. Compared with vertebroplasty, kyphoplasty reduces the risk of cement leakage outside the vertebral body, but does not affect VAS pain scores [236].

3.2.4. Specific aspects of surgical treatment for pathological fractures of the distal radial metaphepiphysis

To date, the debate continues regarding the optimal management of distal radius fractures in patients with osteoporosis [190, 191, 237, 238, 239]. International clinical guidelines lack clear instructions on the surgical management tactics for radial fractures in elderly individuals [190, 239].

The following treatment options are discussed:

- percutaneous pin fixation of bone fragments***;

- open reduction with internal plate osteosynthesis (bone fixation plate with screws, non-absorbable, sterile***; bone fixation plate with screws, absorbable***; bone fracture fixation plate device set, non-absorbable, sterile***; bone fixation plate with screws, non-absorbable, non-sterile***);

- screws (orthopedic bone screw, non-absorbable, non-sterile***, orthopedic bone screw, non-absorbable, sterile***, orthopedic bone screw, absorbable***);

- use of external fixation devices.

• When choosing a treatment method for distal radius metaepiphyseal fracture in individuals over 50 years of age, it is recommended to consider the patient's quality of life expectations, premorbid background, and compliance with medical recommendations [194, 240, 241].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments: the necessity of cautious surgical intervention in patients of any age with a low pre-fracture functional status has been noted [239].

In a systematic review [192] based on 59 articles on distal radius metaepiphyseal fractures (including 8 studies with a total of 440 patients in the surgical groups and 449 patients in the conservative treatment groups), no significant differences were found between the groups in the DASH score, pain severity on the visual analogue scale, grip strength, wrist extension, pronation or supination, and ulnar deviation. Patients after conservative treatment had significantly greater wrist flexion range, radial deviation, and ulnar variance, as well as a lesser radial tilt, compared to patients who underwent surgery.

• Surgical intervention for distal radius metaepiphyseal fractures is recommended for working-age individuals who exhibit the following deviations on follow-up radiographs after reduction:

— radial shortening of more than 3 mm;

— dorsal angulation (in Colles fractures) of more than 10°;

— intra-articular step-off of more than 2 mm;

— radiographic signs of scapholunate ligament tear (diastasis between the scaphoid and lunate bones greater than Gilula's line, which determines the width of the midcarpal joint);

— instability of the distal radioulnar joint (tear of the triangular fibrocartilage complex) [85, 190, 191].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments: in pathological unstable fractures in working-age individuals, conservative treatment with a plaster cast (in the absence of contraindications to surgical treatment) leads to malunion, which subsequently necessitates corrective osteotomies, prolongs the period of disability, and increases the cost of treatment [40, 195].

Arthroscopic assistance in distal radius metaphyseal fractures with concomitant ligamentous injury, while not significantly affecting long-term outcomes, allows for the repair of the triangular fibrocartilage complex, scapholunate, and lunotriquetral ligaments in a single surgical session [241, 242].

• When performing external fixation for unstable distal radius metaphyseal fractures, it is recommended to avoid excessive wrist traction as a factor provoking or exacerbating complex regional pain syndrome, and instead apply the principle of "non-bridging external fixation of distal radius fractures" (Figure 1) or non-bridging external fixation [311].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

• As an alternative to external fixation for distal radius metaphyseal fractures in patients over 65 years of age, it is recommended to use angle-stable locking plates (non-absorbable sterile bone fracture fixation plate with screws***, absorbable bone fracture fixation plate with screws***, non-absorbable sterile bone fracture plate fixation set***, non-absorbable non-sterile bone fracture fixation plate with screws***) [189, 239, 195].

GOR ALE 2Grade of Recommendation A (Level of Evidence – 2)

Comments: the main method of surgical treatment for distal radius fractures in recent years is internal fixation using volar plates (non-absorbable sterile bone fracture fixation plate with screws***, absorbable bone fracture fixation plate with screws***, non-absorbable sterile bone fracture plate fixation set***, non-absorbable non-sterile bone fracture fixation plate with screws***) [195, 240]. Meta-analysis results (including 3 studies with patients of various ages) demonstrated the superiority of volar plates over external fixation [243], although assessment of pain intensity at 3, 6, and 12 months postoperative revealed no dependence on the fixation method. To avoid excessive wrist traction as a factor provoking or exacerbating complex regional pain syndrome, the principle of "non-bridging external fixation of distal radius fractures" or non-bridging external fixation is used (Fig. a).

Figure 1. a Bridging external fixation. Indirect reduction using ligamentotaxis, with a tube-to-tube construct. b–c Non-bridging external fixation. Direct reduction by fragment manipulation using fixation pins.

For unstable distal radius metaphyseal fractures, inpatient treatment is performed with the necessary technical equipment (availability of an image intensifier, a qualified orthopedic trauma surgeon, and an anesthesiologist-intensivist) [40, 239].

• In cases of significant impaction of the distal radius metaphyseal cancellous bone and shortening by more than 5 mm, it is recommended intraoperatively to use bone grafts or synthetic materials (synthetic bone matrix implant***, antibacterial synthetic bone matrix implant***, composite bone matrix implant***, human-derived bone matrix implant***) [40, 239, 322].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

• For distal radius metaphyseal fractures in patients over 50 years of age, following stable internal fixation, it is recommended to use orthoses for up to 6 weeks due to the potential collapse of reduced fragments [261, 275].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

• If symptoms of complex regional pain syndrome develop, therapeutic blocks should be performed; for the sympathetically maintained form of regional pain syndrome, it is recommended to perform thoracoscopic sympathectomy in a single surgical session with internal osteosynthesis or to use minimally invasive techniques [244].

GGR CLeL 4Grade of recommendation C (Level of evidence – 4)

• If clinical signs of compressive-ischemic neuropathy of the median nerve at the carpal tunnel level are detected after reduction of a distal radial metaphysis fracture and plaster cast immobilization, it is recommended to remove the plaster cast and perform surgical treatment (neurolysis and nerve decompression, ligament division, and revision of the first dorsal extensor tendon compartment of the forearm) in order to eliminate compression, prevent irreversible nerve tissue degeneration, and avoid trophic disorders [259, 260].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments: in compressive-ischemic neuropathy of the median nerve at the carpal tunnel level after reduction of a distal radial metaphysis fracture and plaster cast immobilization, surgical treatment consists of division of the carpal ligament and decompression of the median nerve.

3.3. Surgical antibiotic prophylaxis

• In the surgical treatment of patients with pathological fractures complicating osteoporosis, it is recommended to perform surgical antibiotic prophylaxis (SAP) of surgical site infections by a single preoperative administration of a systemic antibacterial drug to reduce the risk of infectious complications [278, 279].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments. In accordance with international clinical guidelines for the prevention of surgical site infections [278, 280], the objective of SAP is to create bactericidal concentrations of the antibacterial drug in tissues exposed to microbial contamination during surgery to prevent surgical site infections. The need for SAP is determined by the surgical wound class of the upcoming operation: SAP is not required for "clean" surgical wounds not involving the placement of orthopedic implants and metal hardware. SAP should be performed for clean-contaminated and contaminated surgical wounds, and for "clean" surgical wounds involving the placement of orthopedic implants and metal hardware. For infected ("dirty") wounds, SAP is not indicated, and antibiotic therapy is administered instead.

• In patients with pathological fractures complicating osteoporosis, it is recommended to use first- and generation cephalosporins (I and II generation, ATC J01DB, J01DC) (cefazolin**, cefuroxime**) as the primary drugs for surgical antibiotic prophylaxis during surgical interventions in traumatology and orthopedics, and as an alternative in case of beta-lactam allergy – glycopeptide antibacterial drugs (vancomycin**), lincosamides (#clindamycin**) [278]. The use of these medicinal products should take into account age restrictions specified in the instructions for medical use.

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments. For patients with an unburdened allergic history and without significant risk factors for methicillin-resistant Staphylococcus aureus carriage, first- and second-generation cephalosporins (I and II generation) (cefazolin**, cefuroxime**) are used for SAP, administered intravenously 30 to 60 minutes before skin incision. In case of beta-lactam intolerance, a combination of vancomycin** with one of the fluoroquinolones (ATC J01MA) (ciprofloxacin**, #levofloxacin**) administered over at least 60 minutes with the intravenous infusion starting 2 hours before the incision, or #clindamycin**, should be prescribed. In case of significant risk factors for methicillin-resistant Staphylococcus aureus (MRS) carriage, the SAP regimen must include systemic antibacterial drugs (ATC: J01) with anti-MRS activity (vancomycin**). In most cases, a single preoperative dose of a systemic antibacterial drug is sufficient for effective prophylaxis. For prolonged procedures (more than 3 hours) or massive blood loss, an additional intraoperative dose of a systemic antibacterial drug (ATC: J01) should be administered (estimated timing of intraoperative administration is two half-lives after the preoperative dose). Administration of systemic antibacterial drugs (ATC: J01) after wound closure in the operating room is inappropriate even in the presence of placed drains.

A prospective randomized clinical trial showed that administering an antibacterial drug for SAP 1 minute after tourniquet application demonstrated a statistically significant advantage in reducing the incidence of surgical site infections, wound healing time, and overall patient satisfaction compared to administering the antibiotic before tourniquet application [281].

Single doses of main antibacterial drugs for SAP during surgical interventions in traumatology and orthopedics in adults: cefazolin** 2 g (if patient weight ≥120 kg — 3 g), cefuroxime** 1.5 g, #clindamycin** 900 mg, vancomycin** 15 mg/kg as a slow IV infusion, ciprofloxacin** 400 mg, #levofloxacin** 500 mg [278].

Comments. In open fractures, prophylactic antibiotic administration is effective in preventing early infection, and the drug should be administered as soon as possible after trauma. Cefazolin** is the antibiotic of choice, but in patients with open high-energy fractures with displacement and segmental bone loss, major vessel injury, or heavily contaminated wounds, it is advisable to broaden the spectrum of prescribed antibiotics to cover gram-negative pathogens. In such cases, adult patients may be considered for the addition of #gentamicin** (at a dose of 6 mg/kg once daily) to cefazolin** [283, 284]. An alternative to this combination for patients over 18 years of age may be #ampicillin + sulbactam** (at a dose of 3.0 g every 8 hours for 3 days) [285], the latter being particularly relevant in case of the risk of clostridial infection. According to most researchers, in Gustilo and Anderson type III open fractures, antibiotics should not be continued for more than 72 hours after soft tissue wound closure [286].

• In the surgical treatment of patients with pathological fractures complicating osteoporosis, it is recommended to perform antibiotic prophylaxis of surgical site infections for a duration of no more than 24 hours [287].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments: in accordance with current regulatory documents in the Russian Federation (SanPiN 3.3686-21) and clinical guidelines [287], to achieve an effective concentration of the antibacterial drug in tissues and blood serum at the time of skin incision, antibiotics for surgical site infection prophylaxis should be administered intravenously 30 to 60 minutes before skin incision, and within 2 hours before incision when using vancomycin**. The maximum duration of systemic prophylactic antibacterial drug administration must not exceed 24 hours after the end of surgery. In most cases, a single dose of a systemic prophylactic antibacterial drug is sufficient for effective prophylaxis. Additional doses should be administered during prolonged surgeries when the half-life of the administered systemic antibacterial drug elapses from the moment of preoperative administration, creating a risk of the systemic antibacterial drug concentration dropping below the bactericidal level and increasing the risk of surgical site infection.

3.4. Prevention of venous thromboembolic events

• In patients requiring surgical treatment for pathological fractures complicating osteoporosis, it is recommended to prescribe pharmacological prophylaxis of venous thromboembolism (VTE) with low molecular weight heparins from the heparin group (ATC code B01AB) for elective spine surgeries in cases where the risk of VTE outweighs the bleeding risk, taking into account individual patient characteristics and surgical factors (long, major surgery, surgery with a combined anterior-posterior approach), as well as in accordance with the clinical assessment performed by the attending physician [288, 289, 290].

GGR BLoE 2Recommendation Grade B (Level of Evidence – 2)

Comments: to assess the individual risk of venous thromboembolism (VTE), it is advisable to use the Caprini scale (Appendix G3). Recommended doses, frequency, and routes of administration of anticoagulants for VTE prophylaxis in high-risk patients during conservative treatment and in the preoperative period are presented in Appendix A3.1.

• In patients at high risk of bleeding, it is recommended to use mechanical thromboprophylaxis before surgery, and the first administration of a low-molecular-weight heparin from the heparin group (ATC code B01AB) should be delayed until hemostasis is achieved (12–24 hours postoperatively) [288, 289, 290].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments: when prescribing anticoagulants and other antithrombotic agents, one should consider the time intervals between the administration of drugs from these groups and the performance of neuraxial blockade or catheter removal (Appendix A3.2).

• If a patient is admitted with restricted mobility, including due to hemi- and tetraparesis/-paralysis, it is recommended to initiate pharmacological VTE prophylaxis in the preoperative period [291].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

4. Medical Rehabilitation and Sanatorium-Resort Treatment

4.1. Rehabilitation for proximal femoral fragility fractures

• Patients with proximal femoral fractures associated with osteoporosis are recommended to undergo medical rehabilitation prescribed by a physical and rehabilitation medicine physician, a therapeutic exercise (physiotherapy) physician, and a medical rehabilitation physician in the early postoperative period to prevent hypostatic complications, expand mobility, and promote self-care [246, 247, 257, 262].

GIB CGrade of Recommendation C (Level of Evidence – 5)

Comments: in the postoperative period, early mobilization of patients starting from the first days after surgery on the proximal femur (arthroplasty or osteosynthesis), combined with pain management and anticoagulant therapy, increases survival [245, 246, 247, 257].

Rehabilitation is carried out by a multidisciplinary rehabilitation team (MDRT) according to individual programs prescribing:

- positioning therapy for the operated limb and knee joint

- passive assisted sitting up and training to sit on the bed

- active exercises for healthy limbs combined with breathing exercises

- isometric exercises for the muscles of the operated leg

- training in standing and walking with assistive devices.

- training in correct motor skills (turning to the side, sleeping position, sitting on a chair, getting up from a bed and chair, picking up objects from the floor, and using the toilet) [246, 247].

During the rehabilitation period for proximal femoral fractures, physical activity plays a very important role. The more a person moves, the higher the likelihood of recovering independent mobility and the lower the risk of developing severe diseases.

Medical rehabilitation improves blood circulation, promotes fracture consolidation and restoration of joint function, and prevents the development of contractures [246, 247, 248]. In the first days of rehabilitation, positioning therapy for the operated leg is applied. Activity is determined by the patient's condition: usually, this involves changing the position of the arms and legs, moving from a supine to a sitting position (with the assistance of a nurse and special devices). Subsequently, under the supervision of a medical rehabilitation specialist, the load on the injured limb is gradually increased, and training of the anterior and posterior muscle groups of the thigh is added [246].

Patients should avoid falls, hip flexion beyond 90°, crossing their legs, and excessive leg abduction. In most cases, following hip replacement surgery, walking for the first 2 months [246] is permitted only with the aid of two crutches and moderate weight-bearing on the operated limb, and subsequently up to 6 months with a cane held in the hand opposite the operated joint.

4.2. Rehabilitation for proximal humeral fragility fractures

• Inpatient medical rehabilitation is recommended for all patients immediately after fracture fixation, regardless of whether conservative or surgical treatment was used for a proximal humeral fracture; it is prescribed by a physical and rehabilitation medicine physician, a therapeutic exercise (physiotherapy) physician, and a medical rehabilitation physician, and is carried out by a multidisciplinary rehabilitation team [224, 249].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments: regardless of the treatment method, rehabilitation begins immediately after fracture fixation to prevent complications, reduce pain in the injury area, progressively restore shoulder mobility, restore arm function and working capacity, and enable self-care and return to work [158, 249, 161].

Comments: in each period, specific tasks are addressed through individual programs in accordance with the degree of fracture consolidation and the functional state of the limb. The programs utilize therapeutic physical exercises, mechanotherapy for bone fractures, medical manual therapy of the upper extremity, hydrokinetotherapy for bone fractures, therapeutic pool swimming, and occupational therapy.

4.3. Rehabilitation for vertebral fragility fractures

• Patients with pathologic vertebral body fractures are recommended to undergo medical rehabilitation prescribed by a physical and rehabilitation medicine physician, a therapeutic exercise (physiotherapy) physician, and a medical rehabilitation physician from the moment of hospital admission; it is carried out by specialists of the multidisciplinary rehabilitation team to prevent hypostatic complications, mobilize the patient to accelerate fracture consolidation, and improve quality of life and daily functioning [171, 252, 251].

GIB CGrade of Recommendation C (Level of Evidence – 5)

Comments: a specific feature of the treatment of pathologic vertebral body fractures is early mobilization in an orthopedic brace, which ensures the achievement of set goals and objectives [167].

Comments: rehabilitation programs include three periods: bed rest with physical exercises in the supine position, semi-bed rest with exercises in the supine, prone, and all-fours positions. The ward-based regimen concludes with the patient's verticalization in a brace and involves the continuation of physical exercises, as well as gait training and practice.

Therapeutic gymnastics for patients with pathologic vertebral body fractures is prescribed from the first days of fracture detection; the choice of exercises and their intensity are adapted individually, with limitations on exercises involving flexion, spinal rotation, and a kyphotic posture. Exercises are performed at a slow pace, regularly, and only against the background of analgesics and NSAIDs, excluding exercises that increase pain [171, 176, 252, 251].

Gentle exercises in the supine position with a pillow under the lower legs help prevent the progression of vertebral deformity and reduce painful kyphotic deformity. From days 2–3 (after verticalization), therapeutic physical training for spinal trauma is prescribed, aimed at strengthening the pectoral and intercostal muscles. The role of therapeutic exercise in muscle strengthening in osteoporosis has been convincingly demonstrated in a comparative study [251].

Exercises for neuromuscular stabilization of the thoracolumbar spine that do not require verticalization (passive and active exercises with mobilization of the upper and lower extremities and cervical spine) are prescribed from the first day of pathology detection. Therapeutic physical training reduces pain severity by increasing the tone of extensors and improving coordination [177, 252]. General principles of therapeutic exercise in vertebral body fractures are presented in Table 5.

Comments: the orthopedic regimen includes: performing physical exercises without spinal mobilization, early ambulation and delayed sitting, correct movement biomechanics when getting up, turning, sitting, picking up objects from the floor, carrying heavy objects, using the toilet and bathroom, and doing housework.

In patients with vertebral body fractures due to osteoporosis, it is extremely important to develop a movement stereotype while maintaining an upright posture to reduce spinal load and lower the risk of subsequent fractures. Heavy work, lifting heavy objects (more than 3 kg), and bending forward and to the sides are contraindicated. After 3 weeks and for the subsequent 3 months, patients with vertebral body fractures should follow an intermittent horizontal rest regimen: after 2 hours in a vertical position, 20 minutes must be spent in the supine position [251, 252].

Pain is alleviated by continuous (except during sleep) bracing [172]. Soft and semi-rigid designs do not cause muscle atrophy [171, 176], as the ability to perform physical therapy is preserved in these cases; in addition, patients are advised to walk for at least 1.5–2 hours a day.

Table 5. General principles of physical therapy in pathological vertebral body fractures [177]

4.4. Rehabilitation for distal radial metaphyseal fragility fractures

• Patients with distal radius fractures are recommended to undergo medical rehabilitation, which is prescribed by a physical and rehabilitation medicine physician early after hospital admission and carried out by a multidisciplinary rehabilitation team (MDRT) to accelerate fracture consolidation, prevent hand and finger joint contractures, and improve quality of life and functioning [194, 276, 328].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments: physical therapy for the fingers and elbow joint should begin within the first hours after fracture fixation, and the limb should be elevated. Physical therapy exercises are selected individually depending on the type of intervention and the patient's condition [194].

• For conservative treatment of proximal radius fractures, it is recommended to undergo outpatient rehabilitation according to the immobilization period programs (2–5 weeks), post-immobilization period (2–4 weeks after immobilization removal), and recovery period (1.5–2 months after the fracture), prescribed by a physical and rehabilitation medicine physician [276].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: immobilization of the distal radius fracture is performed using a plaster cast or a rigid orthosis. Rehabilitation is carried out at home. To improve blood circulation in the limb and prevent joint contractures during the immobilization period, physical exercises are prescribed for the joints free from immobilization. After cast removal, to restore hand and finger function, exercises for all joints are performed with the assistance of the healthy hand, along with aquatic exercises (hydrokinesitherapy for joint diseases and injuries), low-frequency pulsed electrostatic field therapy, and magnetotherapy.

The objectives of the recovery period are the full restoration of hand and finger function, self-care, and upper limb working capacity. The outpatient rehabilitation program includes: active movements in all joints of the upper extremity, resistance exercises to restore muscle strength, training in gripping and holding objects of various shapes and sizes, training in daily living skills and self-care (occupational therapy), and manual massage of the hand and forearm [276].

5. Prevention and Dispensary Observation

• To personalize the dosage of baseline osteoporosis therapy (calcium compounds ATC, group A02AC, or Osteogenon (INN) in combination with #cholecalciferol** 10–20 mcg per day or alfacalcidol** 0.5–1.0 mcg per day, or calcium carbonate + cholecalciferol or alfacalcidol + calcium carbonate (combination drugs)) and to prevent complications during the treatment of pathological fractures, it is recommended to perform monitoring: determination of the total blood calcium level and, if necessary, 24-hour urinary calcium excretion throughout the entire treatment period under the supervision of an orthopedic trauma surgeon [77, 86, 53, 60, 107, 267].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

• Upon achieving consolidation of a pathological fracture, regardless of its location, to prevent recurrent fractures, it is recommended to continue osteoporosis treatment in accordance with existing Federal Clinical Guidelines for the Diagnosis and Treatment of Osteoporosis or under the supervision of a geriatrician, general practitioner, or other specialist treating osteoporosis [77].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

• To evaluate the "response" to ongoing antiresorptive (bisphosphonates (ATC M05BA) and denosumab**) or bone formation-stimulating (teriparatide**) therapy for osteoporosis complicated by pathological fractures, it is recommended to re-evaluate bone resorption markers (urinary deoxypyridinoline or serum beta-isomerized C-terminal telopeptide of type I collagen (CrossLaps)) and bone formation markers (serum N-terminal propeptide of type I procollagen (P1NP) or serum osteocalcin) 3 months after initiating this therapy [54, 58, 59, 62, 140].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments: remodeling markers after trauma and during fracture consolidation may show bidirectional changes depending on the nature of the fracture itself and baseline characteristics of bone remodeling disorders in osteoporosis; nevertheless, their evaluation when prescribing drugs affecting resorption (bisphosphonates (ATC M05BA) and denosumab**) or bone formation (teriparatide**) can be beneficial for the patient [140].

• For elderly and senile individuals with preserved autonomy, it is recommended to conduct group and individual educational programs to prevent falls under the supervision of a geriatrician or any other outpatient specialist at the patient's place of residence [312].

UC RLE 3Recommendation Strength Level C (Level of Evidence – 3)

Comments: for elderly and senile individuals, the prevention of falls as a potential cause of recurrent pathological fracture requires not only osteoporosis treatment, but also regular walking and systematic exercises to improve trunk muscle condition and coordination, which the patient started doing in the hospital after the fracture. These measures will allow a return to the physical activity the patient had before the fracture. Proper and balanced nutrition is of particular importance, considering that pathological fractures often develop against the background of secondary osteoporosis, which may be caused by type 2 diabetes mellitus or gastrointestinal pathology. Prevention of recurrent fractures also includes creating a safe home environment [253, 256].

Dispenser surveillance (active clinical monitoring) of patients with frailty syndrome at high risk of falls and recurrent fractures is carried out by a geriatrician in accordance with an individual patient management plan, as presented in the Federal Clinical Guidelines for Fall Prevention, "Fall Prevention in Elderly and Senile Individuals" [256].

Patients at high risk of falls without frailty or with pre-frailty are monitored by a general practitioner (primary care physician) in accordance with current regulations for preventive examinations and health check-ups. During follow-up visits, the effectiveness of the interventions is evaluated and adjusted as needed.

6. Organization of Medical Care

Suspicion of a fracture of any localization resulting from a fall in individuals over 50 years of age is an absolute indication for a consultation with an orthopedic trauma surgeon.

Suspicion of a proximal femur fracture (pain arising after a fall, limited joint mobility, inability to bear weight on the limb, and its forced position) is grounds for calling an ambulance immediately after the event and emergency hospitalization.

The emergency medical team transports the patient in accordance with the regional routing plan to a medical facility providing specialized medical care in the field of "traumatology and orthopedics".

A patient with suspected proximal femur fracture cannot be denied hospitalization. Universal hospitalization, maximum and early surgical activity, as well as optimal organization of inpatient medical care are prerequisites for improving the survival of this patient profile [254].

In the absence of absolute contraindications, surgery for a proximal femur fracture is performed no later than 48 hours from the moment of injury [255].

Indications for discharging a patient with a proximal femur fracture from the hospital include the completion of the surgical procedure, patient mobilization within the ward, and the ability to ambulate with the support of a walker.

Until the fracture heals or biological stabilization of the endoprosthesis is achieved, a patient with a pathological fracture due to osteoporosis remains under the supervision of an orthopedic trauma surgeon.

7. Additional Information

The greatest impact on the course and outcome of a pathological fracture is exerted by adequate reduction, osteosynthesis or arthroplasty, and timely prescribed basic fracture therapy in the form of calcium preparations and cholecalciferol** / alfacalcidol**. The role of these drugs in the consolidation of low-energy fractures is significantly greater than in post-traumatic fractures in healthy individuals. The prescription of pathogenetic osteoporosis therapy after a low-energy fracture does not negatively affect callus formation and aims to normalize fracture healing time and prevent recurrent fractures. It is important to understand that the prescription of pathogenetic osteoporosis therapy by an orthopedic trauma surgeon after a fracture increases patient adherence to medical therapy for the disease.

The duration and sequence of osteoporosis therapy in an outpatient setting are regulated by the federal clinical guidelines on "Osteoporosis".

To assess treatment outcomes in patients with fractures at the shoulder girdle and arm level, questionnaires have been developed to evaluate the functional result of treatment.

1) Disabilities of the Arm, Shoulder, and Hand (Disabilities of the Arm, Shoulder, and Hand, English – DASH) was developed jointly by the American Academy of Orthopaedic Surgeons, the Council of Musculoskeletal Specialty Societies, and the Institute for Work and Health (Canada). It belongs to patient-reported outcome measures and was introduced in 1996 for the standardized assessment of the impact of various musculoskeletal injuries and diseases on upper extremity function [295]. DASH is a 30-item questionnaire with response options presented as a 5-point Likert scale. Scores range from 0 (no functional limitations) to 100 (most severe functional limitations). The questionnaire is intended for patients with any musculoskeletal disorders of the upper extremities [296]. DASH has two optional modules (four items each) intended for athletes, musicians, and workers whose activities require special physical conditioning and whose functional limitations may arise only under high loads exceeding the scope of the 30 DASH items. Approved translations of DASH into 56 languages and dialects, including Russian, are available on the website of the Institute for Work and Health (Canada), which owns the copyright to the questionnaire (https://dash.iwh.on.ca/available-translations).

2) QuickDASH (QuickDASH) is a shortened 11-question version of the DASH questionnaire with the same response options [297, 298]. Like DASH, it is intended for patients' self-assessment of the degree of upper extremity function impairment in various diseases and injuries. QuickDASH also features two optional modules (four items each) intended for athletes, musicians, and workers whose activities require special physical conditioning and whose functional limitations may arise only under high loads exceeding the scope of the 11 QuickDASH items. The optional modules are evaluated separately. In a number of studies, comparison of the DASH and QuickDASH questionnaires showed that both instruments have approximately equal sensitivity, specificity [299-303], and minimal clinically important difference in values (12–14 points for DASH and 12–15 points for QuickDASH) [304]. In a systematic review of 23 self-assessment instruments for patients with various upper extremity pathologies, the QuickDASH questionnaire demonstrated the highest content and construct validity, reliability, and responsiveness [305]. There are reports of successful use of QuickDASH in children aged 8–18 years [306, 307]. Approved translations of QuickDASH into 56 languages and dialects, including Russian, are hosted on the website of the Institute for Work and Health, which holds the copyright (https://dash.iwh.on.ca/available-translations). The author-version Russian translation of QuickDASH is provided in Appendix G2.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

Afaunov A.A. – MD, Professor. Krasnodar, member of AOR.

Akhtyamov I. – MD, Professor. Kazan, member of AOR.

Belaya Zh.E. – MD, Moscow, member of RAS.

Geroeva I.B. – MD, rehabilitation specialist.

Golubev I.O. – Moscow, member of AOR.

Darchiya L.Yu. – PhD, Moscow, member of AOR.

Zagorodniy N.V. – MD, Professor, Corresponding Member of the RAS. Moscow, member of AOR.

Kokorev A.I. – PhD, Moscow, member of AOR.

Kolesov S.V. – MD, Moscow, member of AOR.

Kotelnikov G.P. – MD, Academician of the RAS. Samara, member of AOR.

Kuleshov A.A. – MD, Moscow, member of AOR.

Lazarev A.F. – MD, Professor. Moscow, member of AOR.

Makarov M.A. – PhD, member of AR.

Minasov B.Sh. – MD, Professor. Ufa, member of AOR.

Nazarenko A.G. – MD, Moscow, member of AOR.

Otdelenov V.A. – PhD, Moscow, clinical pharmacologist.

Ochurenko A.A. – MD, Professor. Moscow, member of AOR.

Rodionova S.S. – MD, Moscow, member of AOR.

Rozhinskaya L.Ya. – MD, Professor. Moscow, member of RAS.

Solod E.I. – MD, Moscow, member of AOR.

Torgashin A.N. – PhD, Moscow, member of AOR.

Farba L.Ya. – Moscow, member of AOR.

Shumskiy A.A. – PhD, Moscow, member of AOR.

Conflict of interest: the authors declare no conflict of interest regarding the development of these clinical guidelines.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Trauma and orthopedic surgeons;

2. Spine surgeons;

3. Radiologists;

4. General practitioners;

5. General practitioners;

6. Other medical specialists involved in the diagnosis and treatment of pathological fractures and their consequences.

Stages of evaluating the levels of evidence and grades of recommendation:

1. Definition of search and selection criteria for publications on clinical trials (CT) regarding the efficacy and/or safety of the medical intervention described in the recommendation statement.

2. Systematic search and selection of CT publications in accordance with the previously defined criteria.

Systematic search and selection of publications on clinical trials:

The evidence base for the recommendations consisted of publications retrieved via information retrieval in the following databases: Central Scientific Medical Library (CSML) "Russian Medicine", MEDLINE (US NLM), and COCHRANE Library; scientific electronic libraries eLibrary.ru and "CyberLeninka"; as well as on the Internet using Yandex, Google, and Google Scholar search engines, by reviewing leading specialized peer-reviewed domestic medical journals on the subject and treatment guidelines for fractures from the international Association for Osteosynthesis AO/ASIF.

The level of reliability of evidence contained in the publications was assessed in accordance with Tables 1 and 2. Publications with the highest level of evidence reliability were selected.

Table 1. Scale for assessing levels of evidence (LE) for diagnostic methods (diagnostic interventions)

Table 2. Level of Evidence (LoE) grading scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Levels of Evidence (LE) rating scale for prevention, diagnostic, treatment and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

Appendix A3.1 Recommended doses, frequency, and route of administration of anticoagulants for VTE prophylaxis in high-risk adults

It should be noted that spinal or epidural anesthesia may only be performed 12 hours after the administration of a low-molecular-weight heparin (LMWH) from the heparin group (ATC group code B01AB) and no earlier than 4–6 hours after the administration of unfractionated heparin from the heparin group (ATC group code B01AB) (meanwhile, aPTT or ACT values must be within the normal range) [288, 294].

Appendix A3.2 Recommended intervals between prophylactic anticoagulant administration and neuraxial procedures

Time intervals between neuraxial procedures and anticoagulant administration are presented in accordance with the European Guidelines on Perioperative VTE Prophylaxis [292].

Appendix A3.3 Technique for paravertebral block

Paravertebral block is performed using a mixture of a glucocorticoid drug (ATC H02AB) and ropivacaine** at a concentration of 7.5 mg/ml in a volume of 10–40 ml [339].

Block technique:

A. Patient preparation:

Position: prone, with a pillow under the abdomen for slight spinal flexion.

Identification of the block level: palpation of spinous processes, skin marking (ultrasound guidance is possible).

Skin disinfection: with an antiseptic (from the center to the periphery).

B. Anatomical landmarks:

Insertion site: 2–3 cm lateral to the spinous process (at the level of the target segment).

Depth: 3–5 cm (depending on body habitus).

C. Performing the injection:

Perform local infiltration anesthesia of the skin.

Insert the needle perpendicularly to the skin until contact with the transverse process is made.

Withdraw the needle slightly and direct it caudally/cranially, advancing 1–2 cm deeper (into the paravertebral space).

Aspiration test (to rule out intravascular placement).

Administer the drug (3–5 ml) – resistance should be minimal.

D. Post-procedure:

Observe for 20–30 minutes (dizziness and hypotension are possible).

Assess the effect (pain reduction within 10–15 minutes) [166, 167].

Appendix B. Physician Action Algorithms

Appendix B1. Management algorithm for a patient with a pathological proximal femur fracture (associated with osteoporosis)

Appendix B2. Management algorithm for a patient with a pathological proximal humerus fracture (associated with osteoporosis)

Appendix B3. Management algorithm for a patient with pathological vertebral body fractures (associated with osteoporosis)

Appendix B4 Management algorithm for a patient with a pathological distal radial metaphysis fracture (associated with osteoporosis)

Appendix C. Patient Information

What are the types of fractures?

The primary classification of fractures is based on their location, i.e., which bone is damaged. However, there is another important classification that divides fractures into 2 groups based on the magnitude of the force required to damage the bone tissue, which is normally strong:

High-energy fractures occur as a result of excessive force applied to the bone (referred to as post-traumatic)

Low-energy fractures— occur as a result of minimal force applied to the bone. In osteoporosis, they are termed "pathological," since osteoporosis is a systemic metabolic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to increased bone fragility and an elevated risk of fractures.

How to suspect osteoporosis?

This disease can be asymptomatic for a long time and often clinically manifests specifically as a low-energy fracture. What "red flags" might suggest possible osteoporosis?

Pain in the sacrum and lumbar region that worsens with walking and physical activity; a feeling of heaviness between the shoulder blades;

fatigue and the need for frequent daytime rests in the "lying down" position;

stooping and loss of height (from 2 to 5 cm;)

If these signs are present, you should consult a doctor; do not take painkillers on your own, and do not visit massage therapists or manual therapists without a preliminary X-ray examination.

Diagnostic methods

X-ray diagnostics is the most accessible method, but it has a significant drawback in diagnosing osteoporosis: bone loss on radiography is detected only when the deficit exceeds 30%. However, radiography makes it possible to detect vertebral body fractures and perform differential diagnosis with a number of other diseases that can also be asymptomatic.

Dual-energy X-ray absorptiometry (DEXA) is an examination that measures the amount of bone based on the mineral content (primarily calcium) in the bone tissue, assesses the progression dynamics of the disease, and evaluates treatment efficacy.

Upper limb fractures usually occur when falling from a standing height onto an outstretched hand. As a rule, either the radius near the wrist joint or the humerus near the joint breaks. Both types of fractures are very painful, so you must seek medical attention urgently.

Femoral neck fracture associated with osteoporosis occurs in elderly individuals (60–80 years) as a result of a fall from a standing height. Due to osteoporosis becoming "younger," these fractures are increasingly seen in individuals aged 40–50 years. This fracture is among the most severe complications of systemic osteoporosis.

Vertebral body fractures are painless in nearly 70% of cases and are detected only on radiography, so you may remain unaware of both your disease and the fracture for a long time. Be careful! If your height has decreased by 2 cm or more, consult a doctor urgently and get a spinal X-ray.

Features of fracture management in osteoporosis

Treatment tactics for fractures are determined individually by an orthopedic traumatologist depending on the complexity, type of fracture, and complications. In any case, the following types of therapy are distinguished: conservative (without surgery, but with immobilization of the injured limb), surgical (e.g., osteosynthesis using metal implants), and pharmacological (prescription of drugs for osteoporosis treatment). Treatment of fractures resulting from osteoporosis is always combined: surgical or conservative, including pharmacological therapy for osteoporosis.

In proximal humeral fracture

According to indications (determined by the traumatologist), the following is performed:

– conservative treatment – immobilization in a sling or abduction splint;

– surgical treatment (osteosynthesis) — fragments are either fixed with various metal implants or, as indicated in certain cases, arthroplasty is performed.

Femoral neck fracture

In individuals over 60 years of age, it accounts for nearly 30% of all fractures, and this specific fracture most frequently leads to disability and even death. This fracture location requires hospitalization and surgical care within the first 48–72 hours after injury. Conservative methods are used only if there are serious contraindications to surgery, such as a myocardial infarction. They are a kind of "methods of desperation."

Two types of surgery are performed for a femoral neck fracture: osteosynthesis or hip replacement (arthroplasty).

Osteosynthesis is the most popular surgery performed for a femoral neck fracture. It is carried out under general anesthesia and under X-ray guidance. The surgeon restores the normal position of the bones and secures them with metal hardware (screws, pins, etc.). Fracture consolidation (healing) in the presence of osteoporosis occurs very slowly, and the prescription of medications that normalize processes occurring in bone tissue is required.

Rehabilitation after femoral neck fracture

After surgery, the fracture site must be monitored to assess the rate of fracture healing. Once the fracture has completely consolidated, the metal implants are removed. In the case of joint replacement surgery, the patient is recommended special rehabilitation programs. In the postoperative period, it is necessary to learn self-care skills and how to perform daily tasks using special assistive devices.

ATTENTION.

Following hip surgery, flexion of the hip joint beyond 90 degrees must be avoided.

You must not lift the knee higher than the hip joint (even when sitting), cross your legs, or spread them too far apart; falls must be avoided.

In most cases, following hip replacement surgery, walking with crutches and moderate weight-bearing on the operated limb is recommended for the first two months, followed by walking with a cane in the opposite hand for up to six months.

Recovery after surgery depends not only on how well you follow the doctor's recommendations, but also on your general state of health prior to the fracture. During the rehabilitation of patients with a femoral neck fracture, physical activity plays a very important role. The more a person moves, the higher the likelihood of recovering their unassisted mobility and the lower the risk of developing severe diseases.

Medical gymnastics improves blood circulation, promotes fracture healing and the restoration of joint functions, and prevents the development of contractures. In the first days of rehabilitation, activity is determined by the patient's condition—usually this involves moving the arms and legs, transitioning from a "lying" to a "sitting" position (with the help of a nurse and special devices). Then, under the supervision of a rehabilitation physician, the load on the injured limb is gradually increased.

Vertebral body fractures

This is the most common fracture in osteoporosis and, unfortunately, not always "noticed." Treatment of vertebral body fractures is generally conservative and rarely requires surgical intervention. To create conditions that promote fracture healing, it is necessary to monitor posture and strive to keep the spine in a neutral position.

Neutral position

The spine can be imagined as a tower of bone blocks stacked on top of each other and secured to one another, like LEGO bricks. Each of the 24 vertebrae has a specific shape and size. When they are all stacked on top of each other, they form three natural, slight curves. This position is called neutral.

Getting out of bed

• Try to keep your spine in a straight position—to do this, imagine it is a metal rod;

• Lower your legs down while simultaneously pushing with your hands against the bed to raise your torso;

• Try to sit on the edge of the bed as upright as possible;

• It is convenient to have a walking frame (walker) near the bed that you can hold onto with your hands. If you do not have a walker, place a chair with a high back;

• When moving to a vertical position, hold on to the chair or walker.

Getting into bed

When getting into bed, you need to perform the reverse actions:

• Sit on the edge of the bed;

• Slowly lower yourself sideways and swing your legs onto the bed;

• Straighten your spine and carefully roll onto your back;

• Turn your head, and then your hips and shoulders as a single unit.

Walking

Following a vertebral fracture, it is recommended to walk and stand more and sit less. Try to get out of bed and walk for a few minutes at least every hour. Keep your spine as straight as possible while doing so. You should sit with a straight back; use a chair with a high back and a firm seat for this, keeping your spine pressed as tightly as possible against the back of the chair.

In a car

Fastening the seatbelt requires twisting the torso. Strong twisting increases the risk of a re-fracture. Try to elongate your spine as much as possible and move in coordination with your hips. It is recommended to use a wedge cushion in the car to make it easier to get out of the vehicle.

Bending while maintaining a neutral spine position

When bending forward, use the so-called "hinge position" between the spine and the hip.

This significantly reduces the load on the spine and lowers the risk of recurrent fractures. To assume the correct position, bend your knees while keeping your back straight. Initially after the fracture, this may feel uncomfortable, but soon you will notice how the load on the spine decreases. Look in the mirror to make sure you are bending correctly.

Braces and orthoses

It is necessary to wear a brace from the very first day after a vertebral body fracture. The primary function of a brace in osteoporosis is to increase intra-abdominal pressure, thereby reducing the load on the spine.

Even with a thoracic vertebral fracture, semi-rigid lumbar braces can be worn. Thoracolumbar braces can also be used.

CAUTION!!!

In cases of vertebral body fractures or significant bone loss, the brace is worn all day and its use may be prolonged, as modern designs do not contribute to spinal and abdominal muscle atrophy.

6–8 weeks after the fracture, you can begin exercises to strengthen the back muscles under the supervision of an exercise therapy (PT) specialist. At the same time, increase periods of activity and reduce rest time.

Physical therapy for vertebral body fractures

• Begins under the supervision of a physician.

• Exercises are aimed at strengthening the back muscles.

• Exercises are performed lying supine (on your back), with a pillow under your head if necessary.

• Bend the knees up to 90 degrees.

Returning to daily life

You must remember the basic rules:

• keep the spine in a neutral position;

• walk and stand more, sit less;

• walk with your head up;

• use the "hinge position" for bending;

• do not lift more than 3 kg;

• perform exercises while lying on your back.

How to reduce pain?

• Consult a doctor immediately and strictly follow all their recommendations.

• The intake of analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), and antirheumatic drugs must be supervised by a physician.

• Maintain the correct position of the limb, engage in physical therapy only under the supervision of a specialist, and monitor your daily routine and nutrition.

Treatment of chronic pain syndrome is generally individualized. The choice of method depends on the injury, the patient's general condition, and the causes of the pain. At this stage, the doctor may recommend more active use of the affected limb despite persistent pain. If you are afraid to perform certain movements or actions, this is normal. Pain memory can be strong, and the fear of re-fracture can lead to anxiety and decreased overall activity.

In this case, movements must be performed under the guidance of a rehabilitation specialist.

General recommendations for fractures

1. Under no circumstances remove the cast or other immobilization devices prematurely.

2. Be careful and do not hesitate to ask loved ones for help and use assistive devices.

3. Take care of your nutrition and ensure an adequate intake of calcium and vitamin D in your diet.

4. Begin gymnastics only under a doctor's supervision.

5. Strictly follow your doctor's recommendations and take all prescribed medications.

Diet and nutrition

The skeleton contains 99% of the body's calcium, where, together with phosphate, it forms hydroxyapatite crystals. When external calcium intake is insufficient, calcium is released from the bone tissue to maintain blood calcium at a constant level. To ensure the body receives enough calcium and other substances vital for bone health, you need to eat a balanced diet.

• Exclude foods that accelerate calcium excretion from the body: coffee, strong tea, chocolate, cocoa.

• Limit the inclusion of foods rich in fatty acids in your diet as much as possible:

margarine, butter, mayonnaise.

FOODS CONTAINING BENEFICIAL NUTRIENTS:

• Calcium: almonds, cottage cheese, cabbage, etc.

• Vitamin D: eggs, sesame seeds, sour cream, cheese.

• Zinc: celery, seafood, liver, legumes.

• Vitamin B6 and folic acid: seafood, beef liver, grains, legumes.

• Magnesium: grains, bananas, walnuts, dairy products, legumes, leafy greens.

Drug therapy of fractures

Average fracture healing times, including low-energy fractures associated with osteoporosis, have increased significantly over recent decades (by 1.5–2 times according to the Vreden National Medical Research Center of Traumatology and Orthopedics). This is attributed to rising calcium and vitamin D deficiencies, sedentary lifestyles, comorbid conditions, an increase in hormonal disorders, and other factors.

Prolonged fracture healing times or, even worse, nonunion can lead to pseudarthrosis, restricted activity, a significant decline in quality of life, and extended periods of disability.

It is often the case that excellently performed fragment reduction, immobilization, or osteosynthesis surgery fails to achieve fracture healing even after a long period of time. In practice, such cases are by no means rare. That is precisely why drug therapy for fractures aimed at restoring normal bone tissue regeneration is essential.

General recommendations for drug treatment of fractures

Any drug therapy must be prescribed and monitored by a physician, as it is necessary to select the optimal, most effective and safe regimen, doses, and administration schedule. Uncontrolled intake of medications can, on the one hand, cause severe complications, and on the other hand, be completely ineffective.

It must be remembered that in osteoporosis, the risk of recurrent fractures is very high. To prevent them, treatment for osteoporosis must be continued under the supervision of specialists who manage this chronic condition.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. Visual Analog Scale (VAS) for pain

Russian title: Visual Analogue Scale for pain.

Original title: Visual analogue scale (VAS).

Source (official developer website, validation publication): Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken). 2011; 63 Suppl 11: S 240–252.

Type: rating scale.

Purpose: pain assessment.

Content:

Key (interpretation): The VAS is a straight line 10 cm in length. The patient is asked to make a mark on the line corresponding to the intensity of the pain they are experiencing. The left end of the line corresponds to "no pain", and the right end to "worst pain imaginable". The distance between the left end of the line and the mark is measured in millimeters and recorded in the observation sheet.

Notes: It is recommended to perform the assessment when enrolling the patient in the study prior to any intervention (treatment, surgery). Since completing the VAS questionnaire does not take much time, the assessment can be performed daily throughout the course of treatment. Data obtained in this way can provide a valuable reflection of the analgesic effect of the treatment administered. In dynamic assessment, a change in pain intensity is considered objective and significant if the current VAS value differs from the previous one by more than 13 mm.

Typically, a paper, cardboard, or plastic ruler 10 cm in length is used. On the reverse side of the ruler, centimeter graduations are marked, allowing the physician (or nursing staff in foreign clinics) to record the obtained value and enter it into the observation sheet. The undeniable advantages of this scale are its simplicity and convenience.

Appendix G2. QuickDASH upper extremity disability questionnaire

Russian title: The shortened disabilities of the arm, shoulder and hand questionnaire.

Original title: The shortened disabilities of the arm, shoulder and hand questionnaire (Quick DASH).

Source: Quick DASH Outcome Measures: Russian translation. Institute for Work & Health, 2006. https: //dash.iwh.on.ca /available-translations

Type: questionnaire.

Notes: If more than 3 questions are left unanswered, the result is considered invalid.

There are also additional modules (4 questions each):

Work

Sports/performing arts

These are scored similarly to the main part and interpreted separately

Purpose: assessment of the impact of musculoskeletal injuries and diseases on upper extremity function.

Key (interpretation):

The questionnaire contains 30 questions, each scored on a 5-point scale

1 — no difficulty / pain

2 — mild

3 — moderate

4 — severe

5 — unable to perform / extreme

Calculation of the final DASH score:

Sum the scores for all answered questions

Subtract 30 (this is the minimum possible total score)

Divide the result by 1.2 (this scales it to 100 points)

0–20 points — minimal restrictions

21–40 — moderate

41–60 — severe

61–80 — heavy

81–100 — extremely severe limitations of upper extremity function.

Content:

INSTRUCTIONS: This questionnaire asks about your symptoms as well as your ability to perform certain activities. Please answer each question based on your condition over the past week by circling the appropriate number. If you did not have the opportunity to perform a specific activity last week, please choose the most appropriate response. It does not matter which hand you use to perform the action; please answer based on your ability, regardless of how you independently perform the task.

OPTIONAL MODULE SCALING. All 4 questions must be answered. Simply add the assigned values for each response and divide by 4 (number of items); subtract 1 and multiply by 25.

Appendix G3. Caprini Risk Assessment Model for Venous Thromboembolism

Russian title: Caprini risk assessment model for venous thromboembolism.

Original title: Caprini Score for Venous Thromboembolism.

Source: Lobastov K.V., Barinov V.E., Schastlivtsev I.V., Laberko L.A. Caprini score as a tool for individual risk stratification of postoperative venous thromboembolism in high-risk group. Pirogov Russian Journal of Surgery. 2014; (12):16-23.

Type: scale.

Purpose: Assessment of the risk of venous thromboembolism.

Notes: The Caprini score allows for calculating the total VTE risk score based on the patient's individual risk factors. The final score is interpreted as follows:

Content:

1 point

Age 41–60 years

Lower extremity edema

Varicose veins

Body mass index > 25 kg/m²

Minor surgery

Sepsis (< 1 month)

Severe pulmonary disease (including pneumonia < 1 month)

Oral contraceptive use, hormone replacement therapy

Pregnancy and postpartum period (< 1 month)

History of unexplained stillbirths, spontaneous abortions (≥3),

Premature birth with preeclampsia or intrauterine growth restriction

Acute myocardial infarction

Chronic heart failure (< 1 month)

Bed rest in a non-surgical patient

History of inflammatory bowel disease

History of major surgery (< 1 month)

Chronic obstructive pulmonary disease

2 points

Age 61–74 years

Arthroscopic surgery

Malignant neoplasm105

Laparoscopic procedure (duration >45 min.)

Bed rest > 72 h

Limb immobilization (< 1 month)

Central venous catheterization

Major surgery (duration >45 min.)

3 points

Age > 75 years

Personal history of VTE

Family history of VTE

Factor V Leiden mutation

Prothrombin G20210A mutation

Hyperhomocysteinemia

Heparin-induced thrombocytopenia

Elevated anticardiolipin antibodies

Lupus anticoagulant

5 points

Stroke (< 1 month)

Multiple trauma (< 1 month)

Major joint arthroplasty

Femur and lower leg fractures (< 1 month)

Spinal cord injury/paralysis (< 1 month)

Key (interpretation):

Depending on the sum of scores obtained during history taking and patient examination, the patient is assigned to a specific risk group:

• low risk: 0 - 1 point;

• moderate risk: 2 points;

• high risk: 3 - 4 points;

• very high risk: 5 points or more.