Rationale for secondary fracture prevention

Rationale for secondary fracture prevention

Hip fracture is all too often the final destination of a thirty year journey fuelled by decreasing bone strength and increasing falls risk.

  • Fracture begets fracture. Systematic reviews tell us that patients who have suffered a fragility fracture are at double the risk of suffering second and subsequent fractures, as compared to their fracture-free peers.
  • Approximately one half of patients who suffer a hip fracture experienced another fragility fracture before they broke their hip.
  • Estimates suggest that around a sixth of postmenopausal women, and a smaller proportion of older men, have suffered a fragility fracture.
  • Effective drug treatments for osteoporosis are available in a wide range of formulations, including oral tablets and injections, which can be administered at various frequencies, from daily to yearly.

Taken together, these statements underpin the rationale for prioritisation of efforts to respond to the first fracture to prevent the second and subsequent fractures i.e. secondary fracture prevention. The pyramid below illustrates the systematic, top-down approach that is being implemented or advocated for in a growing number of countries. The International Osteoporosis Foundation’s 2012 World Osteoporosis Day Report on the Capture the Fracture Campaign provides more details.

Older patients who present to urgent care services – whether based in hospital or the community – with a fragility fracture present an obvious opportunity for intervention to assess future falls and fracture risk. However, international, national, regional and local audits conducted across the world reveal a pervasive and persistent care gap for these fracture patients. In the absence of a systematic approach to deliver secondary prevention, it simply doesn’t happen for the majority of patients.

2012 Pyramid

A large group of professionals have a role to play in assessing fracture risk and treating osteoporosis, including general practitioners/family physicians, endocrinologists, rheumatologists and internal medicine specialists, and geriatricians/aged care specialists.

Orthogeriatric-orthopaedic co-care models and Fracture Liaison Services (FLS) play a complementary role in eliminating this care gap. A systematic review from Ganda and colleagues in Australia provides a very useful overview of the organisation of FLS throughout the world and the outcomes achieved:

  • Models of care for the secondary prevention of osteoporotic fractures: a systematic review and meta-analysis. Osteoporos Int. 2013 Feb;24(2):393-406. PubMed ID 22829395

Download simply referenced PDF