A 68-Year-Old with Fracture Neck of Femur — Risk of Further Fragility Fracture, Further Tests and Treatment Options

A hip fracture after low-energy trauma in a 68-year-old is by definition a fragility fracture and establishes a clinical diagnosis of osteoporosis irrespective of the DXA T-score.

Hip fracture carries substantial excess mortality, loss of independence and institutionalisation; non-hip, non-spine fractures also drive large healthcare utilisation.

A prior fragility fracture is one of the major independent risk factors in Pathy's list — it roughly doubles the risk of any subsequent fracture.

The risk is front-loaded: it is highest in the first 1–2 years after the index fracture — the "imminent fracture risk" window.

Around one in five patients sustains a second fracture, and a substantial proportion of these are contralateral hip fractures.

Yet the treatment gap is wide — most patients leave hospital after a hip fracture without any anti-osteoporosis medication; this is precisely the problem the Fracture Liaison Service was created to solve.

Additional determinants of further fracture in this patient: continuing falls risk, sarcopenia, postural hypotension, visual impairment, polypharmacy (Beers criteria), vitamin D deficiency and post-fall syndrome with fear of falling.

DXA of the contralateral hip and lumbar spine — not to decide whether to treat (treatment is already indicated), but to provide a baseline for monitoring and to grade severity.

Lateral thoracolumbar X-ray or VFA to detect silent vertebral fractures, which change risk category and drug choice.

Biochemistry: serum calcium, phosphate, alkaline phosphatase, creatinine/eGFR, full blood count, ESR, 25-OH vitamin D, TSH, liver function.

Targeted secondary-cause screen: PTH, serum and urine protein electrophoresis with free light chains (myeloma), coeliac serology, 24-hour urinary calcium, and in a man morning total testosterone (ng/dL) — late-onset hypogonadism is an under-recognised cause.

Renal function is decisive for drug choice — bisphosphonates are avoided if eGFR is below about 30–35 mL/min.

FRAX with BMD, adjusted for the recent fracture, plus TBS if available, to document the risk category.

Comprehensive geriatric assessment: multifactorial falls assessment, gait and balance testing (Timed Up and Go), cognition, nutrition (MNA), continence, medication review and social circumstances.

Early surgery (ideally within 48 hours) under a shared orthogeriatric model, multimodal opioid-sparing analgesia including fascia iliaca block, delirium prevention (HELP-type bundle), pressure-ulcer prevention, VTE prophylaxis and early mobilisation with rehabilitation. (ii) Bone-directed pharmacotherapy

Correct vitamin D and calcium first: Pathy's states that all people with a hip fracture should receive calcium, vitamin D and a bisphosphonate unless contraindicated (e.g. renal failure); 25-OH vitamin D should be above 30 ng/mL.

Zoledronic acid 5 mg IV once yearly is the preferred agent after hip fracture — it overcomes adherence problems, reduces clinical fracture by 33%, vertebral by 77% and peripheral by 25%; give at least 2 weeks after vitamin D repletion, ideally ≥2 weeks post-operatively.

Denosumab 60 mg subcutaneously 6-monthly is an alternative, particularly when eGFR is low; monitor calcium and never stop it without bisphosphonate cover.

Anabolic first-line (teriparatide, abaloparatide or romosozumab) if the patient is in the very-high-risk category — hip fracture plus multiple vertebral fractures or very low T-score — followed by an antiresorptive.

Local osteo-enhancement procedure (LOEP) may be considered where hip fracture risk is very high, particularly following a first hip fracture.

Avoid raloxifene and other SERMs after femoral neck fracture — Pathy's is explicit that they do not reduce femoral neck fracture and carry an increased thromboembolic risk in this setting. (iii) Non-pharmacological and systems measures

Falls prevention: progressive strength and balance programme of at least 50 hours, home hazard assessment, footwear, vision correction, withdrawal of culprit drugs (sedatives, antihypertensives, anticholinergics), management of postural hypotension.

Nutrition: protein ≥1 g/kg/day, calcium 1000 mg/day, treatment of sarcopenia by resistance exercise plus protein supplementation.

Hip protectors may be considered in the institutionalised, though adherence is poor, particularly with cognitive impairment.

Enrol in a Fracture Liaison Service with structured follow-up at 3–6 months for adherence, and repeat DXA in 1–3 years.