In the management of hip fractures, surgical treatment is considered as a first choice to hopefully reduce complications [1]Cannada, L.K. and B.W. Hill, Osteoporotic Hip and Spine Fractures: A Current Review. Geriatr Orthop Surg Rehabil, 2014. 5(4): p. 207-12.

, as well as try to give mobility back to patients. Surgical management usually comprises of pre-, intra- and post-operative stages. 

Even though the risk of severe complications due to immobilisation and therefore death is high with non-surgical management, this option can be selected when patients have severe co-morbidities that mean surgery is contraindicated. 

Overall, the long-term prognosis and risk versus benefits of surgery should be the subject of discussion between the orthopaedic surgeon and the patient (including his/her relatives, as hip fractures cause decreased mobility and independence).

Management of vertebral fractures if diagnosed includes surgery and non-pharmacological approaches. Currently in the standards of care to treat pain from vertebral fractures, despite the absence of consensus with respect to its long-term efficacy and safety, is vertebral augmentation surgery by percutaneous vertebroplasty or kyphoplasty [1]Cannada, L.K. and B.W. Hill, Osteoporotic Hip and Spine Fractures: A Current Review. Geriatr Orthop Surg Rehabil, 2014. 5(4): p. 207-12.

. Non-pharmacological approaches include orthoses/bracing and exercise.

Vertebroplasty and kyphoplasty
Vertebroplasty and kyphoplasty are minimally invasive surgical procedures which aim to relieve symptoms associated with vertebral compression fractures.

With vertebroplasty a needle is inserted into the compressed portion of a vertebra and surgical cement is injected to provide immediate pain relief through stabilization of the vertebral fracture. Prior to the injection of cement, inflatable bone plugs can be used to create a gap between the vertebra. In this case the technique is known as balloon vertebroplasty or kyphoplasty. The objective of this latter method is not only to stabilize the vertebra but also to restore the normal anatomy of the fractured vertebra and to reduce the curvature of the spine in the injured region.

As radiological control is necessary to guide the physician during the operation, it is recommended that vertebroplasty and kyphoplasty procedures be performed in a hospital setting and under sterile conditions. Both methods can be performed under local or general anaesthesia.

Although these procedures may improve quality of life for some patients, it is important to note that side effects such as cement leakage, pulmonary oedema, myocardial infarction and rib fractures have been described after both vertebroplasty and kyphoplasty. Furthermore, the problem of an increased incidence of new fractures in the adjacent vertebra, after such treatments has been raised in clinical trials.

These include any other site except the hip, spine and forearm; for example, the proximal humerus, ribs, tibia etc. These fractures, just like the traditional fracture sites at the hip, spine and forearm, cause immobilisation, pain and leads to significant morbidity. Again, treatment options are surgical or non-surgical and the decision will depend on the surgeon, patient factors and fracture patterns among others.

Treating AFF with surgery is recommended to ensure proper bone union and to give patients the best chance of recovery. Read more about atypical femur fractures.

It is known that hip fractures cause patients to be immobile. However, after surgery patients should be mobilised as early as possible and post-operative, inpatient and after hospital discharge exercises are just as important to maximise functional recovery. Methods to prevent falls should be implemented and exercises that strengthen hip muscles and to avoid atrophy of notably the quadriceps should be prescribed by a therapist. 
Post-fracture rehabilitation and exercise are key so that the patient can regain as much independence as possible, but also to avoid complications due to long bed rest periods. For example, exercises like ankle move can help in the prevention of deep vein thrombosis caused by immobilisation. 

Studies have shown that intensive exercise training can lead to improvements in strength and function in elderly patients who have had hip replacement surgery [2]Hauer, K., et al., Intensive physical training in geriatric patients after severe falls and hip surgery. Age Ageing, 2002. 31(1): p. 49-57.

. Patients who received the exercise therapy were significantly better at a variety of daily living fundamentals, such as getting up, walking, climbing stairs and maintaining posture. For example, they walked on average 50% faster and climbed stairs about 30% faster than patients who did not receive the exercise regimen. Emotionally, patients who had received the exercise therapy were less distressed by their overall condition than patients who did not, although both groups of patients were equally as fearful of falling [2]Hauer, K., et al., Intensive physical training in geriatric patients after severe falls and hip surgery. Age Ageing, 2002. 31(1): p. 49-57.

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As with hip fractures, in order to regain as much independence as possible, early mobilisation, potentially with a vertebral corset (back brace), is usually indicated. Fall prevention, maintaining overall musculature and back muscle exercises are recommended for these patients to avoid a second fracture. However, exercises should be prescribed by a therapist and caution is required to avoid injury.

In this case it is important that these individuals maintain their physical function with exercises to prevent falls and any additional fractures.

A review of the potential side effects and limitations of physical activity in osteoporotic patients with or without a previous fracture is outlined in the table below [3]Chilibeck, P.D., et al., Evidence-based risk assessment and recommendations for physical activity: arthritis, osteoporosis, and low back pain. Appl Physiol Nutr Metab, 2011. 36 Suppl 1: p. S49-79.

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Adapted from Chilibeck et al., Appl Physiol Nutr Metab, 2011 [1]Cannada, L.K. and B.W. Hill, Osteoporotic Hip and Spine Fractures: A Current Review. Geriatr Orthop Surg Rehabil, 2014. 5(4): p. 207-12.

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