UAB’s Fragility Fracture Program
Jason Lowe, MD
When you’re ten and fall out of a tree, breaking your arm hurts, but it heals—usually with no more than the routine drama that is part of exploring the world
But when you’re seventy, and time and illness have been wearing away at your bones, a simple misstep can cause a disaster. Even if a broken hip doesn’t lead to premature death, it can put an end to the life you once knew.
Although advances in orthopaedics continue to redefine what is possible, preventing a bad break is definitely preferable to dealing with shattered bone after the damage is done.
UAB’s Fragility Fracture Program is putting that principle into practice.
“Low energy fractures can be the shot across the bow signaling danger ahead,” Program Director Jason Lowe, MD, said. “If patients, especially women over 55, come into the ER with a wrist or finger fracture more severe than we would typically expect from that amount of force, it’s a strong signal that we need to get our fragility fracture team involved.”
When the program was launched two years ago, it was originally aimed at reducing the number of hip fractures. It has since expanded to include other types of broken bones.
“Identifying those at risk is the first step,” Lowe said. “The ER is often the place where indications of a fragile bone problem come to light. The next step is seeing that patients get the appropriate evaluation and treatment to reduce the risk of future fractures.”
When medical providers find potential problems, the program contacts patients’ primary care physicians to alert them to the need for an evaluation. For patients who don’t have a primary care physician, the program arranges referrals to a clinic for a scan and follow-up with a program of countermeasures as needed.
What causes bone to become fragile?
“When estrogen levels fall off, the rate of bone formation slows down. Vitamin D deficiency seems to be pandemic, and calcium and magnesium levels may also be low,” Lowe said. “Add that to a genetic predisposition to osteoporosis and the effects of some disease and medications, and it’s easy to see why so many patients are developing fragile bones.
Another part of the program that is showing good results is the emphasis on expediting the time from the ER to the OR for patients needing surgery.
“Getting patients with broken hips into surgery within 24 hours optimizes outcomes,” Lowe said. “From the moment patients hit the ER door, we’re evaluating whether they need surgery, the risk of blood loss, possible complications from heart disease and other problems. The only exception to the 24-hour rule is someone with a medical condition that must be addressed and stabilized before going into surgery.”
In performing surgery on patients with fragile bones, experience can be a valuable tool.
“Patients with poor bone quality often have complex medical conditions,” Lowe said. “If you have to tackle such a case, you need someone experienced in handling details and getting the patient on and off the table quickly. The sicker the patient, the more expertise is needed.”
Patients typically begin rehab on or one day after the day of surgery.
After two years, UAB has compiled a good set of data and the Fragility Fracture Program seems to be making a difference.
“We’re decreasing length of stay and time to OR, and preliminary mortality and complication rates seem to be trending downward,” Lowe said.
Given that 30% of patients over 55 with hip fractures die within a year, taking proactive steps to identify those at risk and begin countermeasures before fractures occur can save lives.
Taking the effort beyond the ER, the Fragility Fracture Program is offering outreach programs and screenings at nursing homes and other locations to educate people about who is at risk and discuss questions they may want to bring up with their doctor.
After age 60, the WHO suggests DEXA bone density scans every two years. Exercise to strengthen bones, muscles and to improve balance can help. Patients may need Vitamin D, magnesium and calcium supplements. If so, they may need to consult with their cardiologist if they have heart problems.
Although bisphosphonates have been associated with osteonecrosis of the jaw, in serious cases of osteoporosis, the benefits may outweigh the risks. A dental exam and completion of dental work before beginning the medication is often advised as a precaution.
In dealing with fragile bone fractures, as with so many other health issues, the most effective treatment is prevention.