Session IX - Injury Prevention
Looking Beyond the Fracture: Risk Assessment in Patients with a Recent Clinical Fracture
Purpose: New guidelines have been developed for screening osteoporosis and fall risk in fracture patients. Despite this, several reports point out that these screening guidelines are not well implemented in the daily practice of orthopaedic and trauma surgeons. We tested the feasibility and outcome of such a screening program for bone density and fall risk in fracture patients.
Methods: In a large regional hospital all the patients with a recent fracture from the age of 50 were offered a fracture risk and a fall risk assessment during a 1-year period. These investigations were done in parallel with the fracture treatment in the "outpatient department for fractures and osteoporosis". Clinical risk factors for fractures, falls, and bone mineral density (BMD) were systematically evaluated in patients who agreed and were able to participate in the evaluation. Risk factors were based on the Dutch guidelines for prevention of osteoporosis and falls.
Results: 568 patients were included (406 women and 162 men) with a total of 600 recent clinical fractures. Mean age was 67 years (range, 50-95). Upper limb fractures (clavicle, humerus, radius/ulna/hand) were present in 51%, lower limb fractures (pelvis, femur, patella, tibia/fibula/foot) in 39%, clinical vertebral fractures in 3%, and multiple simultaneous fractures in 5%. Osteoporosis in the hip or spine(T <-2.5) was found in 35% of patients, osteopenia in 44%, and normal BMD in 21 %. Using morphometry of the spine by DXA, 48 additional patients with previously undiagnosed vertebral fractures were identified.
At least one clinical risk factor for fractures (fracture history, mother with hip fracture, body weight <60 kg, severe immobility, use of corticosteroids) was found in 56% of cases (including 33% with 2 risk factors, 8% with 3 risk factors, and 4 patients with 4 risk factors). 131 (23%) patients already had a previous fracture after the age of 50 years.
The prevalence of clinical risk factors for fractures was similar between women and men except low body weight, which was more frequently found in women (20% vs. 12% in men). Mean calcium intake was 795 mg/d (range, 300-2700 mg/d; 89% had intake of <1200 mg/d).
The presence of at least one risk factor for falls (timed step-and-go test >12 sec, >1 fall last year, on psychopharamaca, low ADL (before fracture), articular complaints, disturbed vision, urine incontinence, Parkinson's disease) was present in 79% of cases; 32% had one, 21% had 2, 12% had 3, and 5% had >4 fall risk factors. Fall risk factors were more frequent seen in women, except disturbed vision that was found in 25% of women and 31% of men.
Conclusions/Significance: Bone- and fall-related risk factors for fractures occur frequently in women and men with a recent clinical fracture. These factors are highly heterogeneous. Osteoporosis or osteopenia is present in 79% of patients and at least one fall risk is present in 79%. These findings are helpful for diagnostic staging and focusing therapy in patients with a recent fracture: medical interventions for low BMD and fall prevention in patients with serious fall risk. When both risk factors are present in the same patient, treatment should be undertaken accordingly.