Cathy Churchman with advice on who to assess for fracture risk in primary care
Practice nurses will frequently treat patients who have risk factors for fragility fracture. Those factors include:
- Increasing age.
- Prior fracture since turning 50 years old.
- Rheumatoid arthritis.
- History of falls.
- Parental hip fracture.
- Causes of secondary osteoporosis.
- Low BMI.
- Excessive alcohol intake.
Fracture risk assessment could be undertaken during annual health checks or flu clinics etc. You can identify patients aged 50 and over who have a history of fragility fracture and work with a local fracture liaison service (FLS), where available, and impact on a reduction in fracture rates through secondary prevention programmes.1 Flagging up patients with a history of fracture who have not had a DXA scan or who have not been prescribed bone protection to the GP is a vital part of the process.
Identifying at-risk patients
In the UK, population screening for the primary prevention of fracture is not widely adopted as it is felt to be more cost-effective to focus on those people at greatest individual risk who have fractured already (secondary prevention).²
A trial investigating the effectiveness and cost-effectiveness of screening older women in primary care for the prevention of fractures has shown a reduction in hip fracture.³ The cost-effectiveness analyses for the study are ongoing but the results may guide future policy.
Fracture risk assessment with a simple tool that expedites early diagnosis, treatment and concordance support is the key to prevention of further fracture. Bone protection treatments can reduce the patient’s risk of fracture by approximately 50%,4 so early intervention is vital as re-fracture risk is at its highest within the first six months of fracture.2
Tests to exclude secondary causes
FBC, ESR, bone biochemistry (vitamin D, serum calcium, phosphate, alk phos), liver and kidney function, TSH and coeliac screen (anti TTG)
In patients with vertebral fractures complete a myeloma screen (serum protein electrophoresis and urinary Bence Jones protein)
What about vertebral fracture?
Vertebral fracture identification is the most challenging issue for clinicians, with less than one third of patients with vertebral fracture coming to clinical attention. Height loss and spinal deformity (kyphosis) is not unique to osteoporosis, with degenerative disease also causing the same presentation. It is not uncommon for patients to have experienced marked loss of height insidiously over time, many without an acute episode of pain. Radiological confirmation of fracture is necessary to determine diagnosis.
Which fracture risk assessment tool shall I use?
The most widely used tool is FRAX. FRAX estimates the patient’s 10-year risk of major osteoporotic fracture (vertebral, hip, forearm and proximal humerus) and hip fracture probability. It can be used with or without a bone mineral density (BMD) measurement, making it ideal for a primary care setting.
FRAX is a free online calculator and can be opened during consultations to allow for patient participation in their fracture risk assessment. The assessment takes a few minutes to complete but is more accurate if actual rather than estimated height and weight are used. Patients have a tendency to overestimate their height especially if height loss has occurred gradually over time.
The National Osteoporosis Guideline Group6 recommends the use of FRAX as the first stage of a fracture risk assessment. Treatment is usually recommended without the need for a DXA scan in older ages.
The guidance is divided into three thresholds. The first is low risk (green) with patient reassurance and lifestyle advice. The second is intermediate risk (amber), which suggests BMD measurement. The third is high risk (red), with immediate treatment without the need for BMD assessment.
A nurse’s role in fracture risk assessment
Conduct a fracture risk assessment in:
Dietary assessment for calcium intake and give advice on vitamin D
Flag the patient for referral for a DXA scan
Cathy Churchman is a fracture liaison nurse specialist at University Hospitals Bristol NHS Foundation Trust
- Kanis JA, Oden A, Johnell O et al. The burden of osteoporotic fractures: a method for setting intervention thresholds. Osteoporosis International, 2001; 3: 148-53
- National Institute for Health and Care Excellence (2012) Osteoporosis: assessing the risk of fragility fracture Clinical guideline [CG146] https://www.nice.org.uk/guidance/cg146
- Shepstone L, Lenaghan E, Cooper C et al. Screening in the community to reduce fractures in older women (SCOOP): a randomised controlled trial. The Lancet, 2017; 391 (10122), 741-747 http://dx.doi.org/10.1016/S0140-6736(17)32640-5
- Black D, Thompson D, Bauer D, Ensrud K, Musliner T, Hochberg M, Nevitt S, Suryawanshi S and Cummings S (2000) Fracture risk reduction with Alendronate in women with osteoporosis: The Fracture Intervention Trial. The Journal of Clinical Endocrinology and Metabolism,85, 11, 4118-4124 https://doi.org/10.1210/jcem.85.11.6953
- Johansson H, Siggeirsdóttir K, Harvey N et al. Imminent risk of fracture after fracture. Osteoporosis International, 2017; 28 (3) 775–780
- NOGG (2017) Osteoporosis Clinical Guideline for prevention and treatment National Osteoporosis Guideline Group https://www.sheffield.ac.uk/NOGG/NOGG%20Guideline%202017.pdf