Review articleAn evaluation of Fracture Liaison Services in the detection and management of osteoporotic fragility fractures: A narrative review
Introduction
Osteoporosis is a bone disease characterised by a loss of bone density and deterioration in bone structure. For patients with osteoporosis, the resilience of the bone is compromised, placing the patient at an increased risk of a fragility fracture. Osteoporosis is often referred to as a ‘silent disease’, where the patient is often asymptomatic until a fracture occurs. Fragility fractures are defined as those which occur from low-impact mechanical forces that would not normally result in fracture; these are due to low bone density and structural deterioration of bone tissue. The World Health Organisation (WHO) has quantified these forces as being equivalent to those experienced from a fall from standing height or less.1
This type of injury can have a very poor prognosis, with fragility fractures of the hip and spine associated with increased 5-year mortality rate. A recent study has revealed that 24% of women and 20% of men re-fractured, and 26% of women and 37% of men died without re-fracture in this 5-year period. Of those who re-fractured, a further 50% of women and 75% of men died, resulting in a total 5-year mortality rate of 39% in women and 51% in men.2 An added complication is that approximately 50% of people with a fragility fracture will suffer another. Warning signs do exist for this patient group, as almost half of those that present with a hip fracture will have suffered a previous fragility fracture,3 thus highlighting the missed opportunities to identify and treat this population.
This paper presents a synthesis of the current evidence base for the detection and management of osteoporotic fragility fractures, including Fracture Liaison Service initiatives. A systematic approach was undertaken to identify relevant sources, charting the key findings to generate an integrative narrative review and highlighting implications for future commissioning and service delivery.
Section snippets
An ageing population, a cost to society
Large increases in life expectancy are being observed in the majority of developed countries. As a consequence, the number of fractures in the elderly population is expected to increase.4 In Australia it is expected that 66% of those aged over 50 will be affected by osteoporosis.5 This is similar to the UK, where osteoporosis and the associated consequences are becoming ever more prevalent, with 1 in 2 women and 1 in 5 men expected to have a fragility fracture after the age of 50.1 The synergy
Fragility fracture identification: the role of radiology
Positive identification of fragility fractures is critical to the care of patients with osteoporosis. Vertebral fractures are the most common type of fragility fracture, accounting for almost half of all fractures due to osteoporosis.12, 13 They are a significant health concern due to the increased risk of future fractures and an associated increase in morbidity and mortality.14, 15 In this patient group, a previous fracture is thought to double the risk for subsequent fractures, and in the
Fracture Liaison Services: a long-term solution, not a quick fix
To reduce the risk of re-fracture a co-ordinated approach is needed to identify patients most at risk. A Fracture Liaison Service (FLS) is a proven approach to delivering comprehensive secondary prevention, which requires a multidisciplinary approach to be an effective service. This should comprise osteoporosis assessment and treatment together with a falls risk assessment. Ideally this would occur in a streamlined ‘one-stop shop’ setting. However, the challenge of organising such services and
A gap in care
The adoption of FLS is not universal worldwide, or even throughout the NHS. Reduced or alternative models have been implemented, with reliance on referral letters being sent to primary care physicians in general practice or to endocrinologists. Those systems have been found to be less effective than FLS, which leads the way in terms of diagnosis and treatment to prevent secondary fracture.26 These less intensive models that focus on improving knowledge of bone health have not yielded positive
Conclusion
The financial value of FLS is based on reducing fragility fractures and the investment should reduce the cost of ongoing care in a population. However, the initial cost of implementation appears to be a significant factor affecting the adoption of FLS within the NHS despite the service being associated with better diagnosis of osteoporosis and a reduction in the number of secondary fractures.
Radiology has a key role to play in the positive identification of fragility fractures to ensure
Conflict of interest
There is no conflict of interest.
Acknowledgement
The lead author received a grant of 10 h writing support from Council for Allied Health Professions Research (CAHPR) for the development of this work.
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