Ploughing through the daily mound of letters from hospital, I came across one from the fracture clinic. It concerned Marie, a patient of ours in her mid-fifties, who had broken her wrist several weeks previously. The letter was full of the sort of technical details that interest orthopaedic surgeons – fracture type, alignment, degree of healing, range of motion – but made no mention of how Marie had sustained the injury. I went into her notes and retrieved the A&E letter from when she first presented. Again, nothing about what had caused the fracture in the first place.
While the management of Marie’s fracture had been excellent, she was in danger of slipping through a gaping hole in the health-care net. It would be one thing if she’d broken her wrist in a spectacular tumble down a flight of stairs but quite another if her injury had resulted from a simple slip or trip. A bone that breaks under low-impact conditions – a so-called fragility fracture – may be the first indication that a person has osteoporosis.
Osteoporosis is one of medicine’s Cinderella diagnoses. The big, ugly stepsisters, cancer and heart disease, quite properly consume vast amounts of our attention and resources. However, this is often at the expense of other, less dramatic conditions. Osteoporosis affects roughly three million people in the UK and causes high levels of pain and disability. The most serious fracture – that of the hip – results in 14,000 deaths in the UK annually, a mortality rate greater than for breast cancer, yet you’ll never have seen a “race for life” organised to raise money for bone health research.
Unless they experience complications or require sickness certification, patients with fractures are usually wholly under hospital care and don’t come near their GP. This was certainly true of Marie, so I contacted her and discovered that, yes, she had broken her wrist in a simple trip. I referred her for a bone density scan and she turned out to be one of the 35 per cent of patients with fragility fractures to have established osteoporosis. There’s a lot she can do with the information. Regular exercise and dietary and other lifestyle changes, together with calcium and Vitamin D supplementation, will all lessen her chances of a further fracture. And drug treatment with a bisphosphonate will approximately halve her risk of subsequent hip fracture.
Although Marie didn’t slip through the net, thousands of people do each year. The problem has been well researched. While most orthopaedic surgeons and almost all GPs say they are aware that patients with fragility fractures should be assessed for osteoporosis, each group of doctors seems to assume that the other will do what is necessary. Medicine has addressed such system failures in the past – the same used to be true for instituting preventative measures following heart attacks, something cardiologists and GPs now co-ordinate very well. But osteoporosis’s Cinderella status is an additional barrier to resolving the problem.
Another way of tackling it is through a fracture liaison service (FLS) – a dedicated clinical team responsible for identifying at-risk individuals out of the huge pool of fractures presenting to hospitals, ensuring appropriate referral for bone density scans and following up to ensure the best aftercare. The present rate of bone health assessment following fragility fracture is a woeful 25 per cent; an FLS improves that to close to 100 per cent. Treatment rates are greatly increased, with a resultant measurable reduction in hip fractures. An FLS is also cost-effective, the reductions in expenditure on fracture treatment more than paying for the service.
With such a win-win picture, you’d think an FLS would be standard practice, yet only about a third of acute NHS trusts in England currently provide one. The National Osteoporosis Society (NOS) is spearheading a drive to encourage FLS commissioning, with the eventual aim of making it the norm around the country. With the ageing of our population predicted to cause a relentless increase in osteoporotic fractures, there has never been a more important time to ensure that Cinderella gets to go to the ball.
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