Chapters Transcript Identifying Fragility Fractures and Initiating Treatment Course: NYU Langone Orthopedics Webinar: Fragility Fractures and Geriatric Trauma Jumping into our first talk here, I'm gonna get started with uh identifying fragility fractures and how to initiate treatment. So, the World Health Organization defines osteoporosis as a bone disease that occurs when the body loses too much bone, makes too little bone, or both. And this is an electron microscope image of what osteoporotic bone looks like, and you can appreciate that the lattice of the bone it becomes very thinned out, and you can see how this makes patients susceptible to fractures. It's an alteration in the body's calcium and phosphate, uh, homeostasis, which leads to decreased, uh, density of the bones. And the gold standard for diagnosis is with dual X-ray, uh, excuse me, dual energy X-ray absorbed. Geometry, uh, or DEXA scanning, and it's reported as a T score, which is standard deviations compared to a normal healthy 30-year-old female. And, uh, -1 to -2.5 is a diagnosis of osteopenia, and once it's less than 2.5 standard deviations, uh, below a 30-year-old female, it is considered osteoporosis. So this is estimated to affect about 6.3% of males and 21.2% of females over the age of 50 so very high prevalence. Risk factors for osteoporosis, the non-modifiable are white race, increased age, a family history of osteoporosis, certain endocrine disorders like diabetes, GI disorders, or, or malabsorption symptoms syndromes, and certain malignancies, in particular, multiple myeloma. So, these are non-modifiable. On the contrary, modifiable risk factors are smoking, alcohol, and caffeine consumption, a low BMI, a dietary deficiency. Um, or a hormone deficiency. And again, these are modifiable, so these are really the ones that we want to be discussing with patients because we can play a role here in, uh, in decreasing this and potentially treating their osteoporosis. So why is this relevant to us as orthopedic surgeons? Well, osteoporosis leads to fragility fractures, and fragility fractures are low energy fractures that occur in osteoporotic bone, and they are actually very common. It's estimated that 20% of men and 50% of women will have at least one fragility fracture in their lifetime. These often occur in the metaphyseal region of the bone, so this is a thinner spongy bone in this region, and it's a transition zone from the dense cortical bone of the of the shaft and the the stronger subchondral bone of the articular surfaces, and so it leads to a concentration of stresses, and we'll often see this in the hip. In the distal femur, in the distal radius. In the proximal humerus. And also in the vertebrae of the spine. And you're gonna hear more specific examples about these from some of the subsequent speakers after me. So fragility fractures mostly occur in patients that are not even aware that they have osteoporosis. So, that's really why we need to, to have a heightened, uh, uh, sense of awareness for this so that we can start the unit, the workup for them, and, and, uh, um, and really be the first ones to discuss it. So, a workup should be considered for any patient above the age of 50 that presents with a fracture or really any fracture presenting from a low energy mechanism. Initiation should start with uh laboratory testing. Uh, a DEXA scan can be obtained non-urgently, generally after the acute fracture has been treated. And then there are certain risk calculators like this FRAX tool which helps calculate a 10-year fracture risk, and this can be used as an indication to start osteoporosis treatment if the fracture risk is high. In general, treatment starts with uh oral calcium and vitamin D supplementation for a diagnosis of osteopenia, but then once it becomes more severe and a diagnosis of osteoporosis is made, pharmacologic treatments are generally indicated, and the most common of these is with bisphosphonates. So, one important thing to note about fragility fractures and treatment of osteoporosis, whether patients are already on treatment before they have an injury, or whether we're considering initiating treatment after the injury, is that initiation of treatment will not affect the rate of their fracture healing, and it will not lead to increased complications for them. However, a delay in initiating treatment after an injury could place them at risk for sustaining a subsequent fracture. So, therefore, although there's no universally accepted guideline, most guidelines do recommend continuing osteoporosis treatment throughout the perioperative period for a fracture. As you can see in this patient here, they had a femoral neck fracture that was treated with a hemiarthroplasty, and then they came back with uh essentially the same exact injury on the other side. And so, the way I describe this to patients is that starting treatment is not going to help them recover from their current injury any faster, but it could prevent a second injury in the future. As you can see, 86% of there's an 86% increased risk of a patient sustaining a second fragility fracture without appropriate treatment. This also requires coordination between the treating orthopedist and the patient's primary care doctor, or uh an endocrinology consultant afterwards. So, what's the role of the orthopedic surgeon here? So, it goes back to 2005 when the AOA started the Own the bone campaign to assess the practice habits of orthopedic surgeons regarding bone health, and see if there were any ways we could implement uh improved coordination of care between orthopedists and primary providers and prevent secondary fractures. One of the big initiatives that came from this on the bone movement is the, the creation of a fracture liaison service. So, that is a mid-level provider, often a nurse practitioner, that's responsible for identifying patients with fragility fractures, initiating the bone health workup as an inpatient, and then coordinating outpatient follow-up after discharge from the hospital. Subsequent studies have shown that the use of the fracture liaison service has led to increased utilization of DEXA scans, increased initiation of pharmacologic treatments, and patient adherence to treatments after discharge and an outpatient follow-up. This is also a preferred model among surgeons. There's a, a survey-based study that was done of, uh, surgeons at a level one trauma center assessing their comfort level with treating osteoporosis, and they found that less than 50% of the respondents felt that they were comfortable initiating the treatment and prescribing medications on their own. However, greater than 95% of the respondents were comfortable with the creation of a fracture liaison service and would support it. So since its inception in 2005, the on the Bone campaign has expanded to now over 260 medical centers, and it's represented in all 50 states in the United States. So, uh, secondary to the success of this program, the International Osteoporosis Foundation launched a secondary campaign called Capture the Fracture in 2012, and, and the goal of Capture the fracture was to support a worldwide implementation of the fracture liaison service model. And they've had pretty impressive results so far. So, in the 13 years since they started in 2012, they've now expanded to 62 countries around the world, and uh over 1200 medical centers. So, it's pretty impressive, however, despite the the success of both of these campaigns, the adherence to treatment remains pretty low in the United States. So it's, uh, a retrospective study of 50,000 patients that had fragility fractures from 2010 to 2018 at, uh, Level One trauma center showed that despite presenting with fragility fractures, only 20% of these patients received any kind of osteoporosis treatment or a DEXA scan, and even more concerning was that 8.4% of these these patients did present with another fragility fracture in two years. Taking a closer look at the data. Male patients were found to be 4 to 5 times less likely to have treatment initiated. Patients that did not have a pre-existing diagnosis of osteoporosis were almost 12 times less likely. So, it, it basically demonstrated that we were comfortable carrying on a workup if it had already been started, but we did not feel very comfortable starting that workup ourselves, which is, which is really a problem. So, the barriers to treatment, insufficient public understanding of the morbidity associated with fragility fractures, a lot of patients will say, oh, yeah, I probably have osteoporosis, but they don't really understand the severity of that. Surgeons feeling uncomfortable providing treatment recommendations for bone health. Patients' denial of their own bone health, or patients' perceptions of risks associated with osteoporosis medications. And so, particularly with this one here about surgeons feeling uncomfortable, it really lies on us to, to take it upon ourselves that, that to play a more active role in treating these patients and providing education for them. So, as the orthopedic surgeon, we are often the first patient, the first person that is speaking to this patient about bone health. Uh, many of them won't even know what osteoporosis is and have never had a conversation with their primary care, and often will have never had a bone density test. Even if us as orthopedic surgeons are uncomfortable prescribing medications for bone health or providing any kind of specific treatment recommendations, all of us should be capable of identifying a fragility fracture, and just by identifying a fragility fracture, it will significantly improve the likelihood of them receiving any subsequent care or workup for that fracture. Implementation of a fracture liaison service does relieve the surgeon of much of the burden of treating bone health, and it's why it's a preferred model among surgeons. However, it still relies on the surgeon being the first person to identify the pre the the patient with the fracture and refer them to the fracture liaison service. So this is really kind of the direction we wanna be moving forward. Published November 19, 2025 Created by
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