Preventing Secondary Fractures

By Dato' Dr. Lee Joon-Kiong (Consultant Orthopaedic Surgeon) | Beacon Hospital | Wed Feb 07, 2018 11:59am

Preventing Secondary Fractures

What is Fracture Liaison Service (FLS)?
Fracture Liaison Service (FLS) is also known as Secondary Fracture Prevention Programme. It is a Coordinated Standard Clinical Practice in which patients present with fragility fractures are seen by a group of medical and paramedical personnel. This group includes the orthopaedic surgeon who will be treating their fractures, the physician who is looking into their concomitant medical conditions, the rehabilitation team and the dietician who assess their physical, functional and dietary status for bone health. Patients will receive the Bone Mineral Density Scan to assess underlying osteoporosis and subsequent treatment will be given in the form of anti-osteoporosis medicines. The compliance to medicines and functional status are assessed with phone calls or home
visits periodically. All these are being coordinated by a Fracture Liaison Service Coordinator.

Who are the patients concerned in regards to fracture prevention?
Patients with established osteoporosis as well as those diagnosed with osteopenia but having the risk factors for fractures. These include individuals with previous fragility fractures, family history of osteoporosis and fragility fractures; individuals with a frequent history of falls; and individuals with sarcopenia (loss of muscle bulk, strength and function).

What are the risk factors of secondary fragility fractures?
People with risk factors for secondary fragility fractures include those with previous fragility fractures, elderly people receiving polypharmacy treatment especially with the use of sedatives, individuals with wasting of muscles where there is a weakness of the lower limbs with a tendency to fall, elderly people with an unstable gait such as those having Parkinson’s Disease, individuals with poor vision such as cataracts, individuals with osteoporosis who did not receive adequate and appropriate medical treatment, and those with poor nutrition such as inadequate protein intake. Those living in an unsafe home environment are also at higher risk of sustaining fractures following a fall.

How is diagnosis done? 
DXA scans of the lumbar spine and hip are the gold standard to diagnose osteoporosis. It is available in most private hospitals and various general hospitals. DXA is also used to monitor the effectiveness of treatment. DXA scan is repeated two to three years after the initiation of medical treatment for osteoporosis. However, pharmacological treatment can be initiated after confirming the diagnosis of osteoporosis using DXA scan. Treatment can also be started based on clinical risk factors, such as the FRAX Score which predicts the possibility of fractures over the next ten years, even if the DXA scan shows that one has osteopenia.

What kind of treatments are available for patients to prevent secondary fractures?
In order to prevent secondary fractures, individuals presenting with primary fragility fractures should be assessed and managed via a team approach. They should ensure that they have adequate calcium, vitamin D and protein intake daily, which can be done through the dietician’s assessment and advice. Meanwhile, appropriate pharmacological treatments with bisphosphonates, SERMs, Denosumab or Teriparatide help to improve bone quality and bone density. Appropriate and adequate rehabilitation treatment helps to strengthen their muscle power to prevent falls. 

How could the rates of testing and treatment for osteoporosis in patients with fragility fractures be improved?
In order to improve the rates of diagnostic tests and treatment of osteoporosis, awareness among medical professionals and the public is very important. Identification of high risk individuals by medical professionals through a case-finding approach, early diagnosis using DXA scans and through clinical risk factors assessment are of utmost importance. All patients presenting with index fragility fractures can and should be assessed for future fracture risks. This is an important component in FLS.

What are the important aspects of treating patients at risk of secondary fragility fractures?
When physicians are treating patients with primary fragility fractures, they should ensure that their patients have adequate calcium and vitamins as well as the proper amount of physical exercise including weight bearing activities; select appropriate medicines to treat underlying osteoporosis and monitor the effectiveness of treatment. They should also encourage good compliance and adherence to medical treatment. Prevention of falls and secondary fragility fractures is essential in the management of these patients too as most fragility fractures happen following a fall from standing height. Physicians should invite and encourage the patient’s family members to participate in the discussion and prevention of secondary fragility fractures.

What is your advice to patients with fragility fractures?
Patients with primary fragility fractures should go for further assessment of bone mineral density and risk of secondary fractures. They should be more aware that they are at a higher risk of subsequent fractures which predispose them to a higher chance of morbidity and mortality.

Take Note 
• Patients with a history of fragility fractures are at increased risks of another fracture.
• Despite the increased risk, most patients who suffer an initial fracture do not receive evaluation or     treatment for underlying osteoporosis.
• High rates of secondary fracture have prompted efforts to develop secondary fracture prevention       strategies to identify at-risk patients and facilitate diagnosis and treatment of osteoporosis in
   these patients. 




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