This Nice guideline explains that we should be assessing risk of fracture in patients more widely, because fractures come with a high morbidity and mortality. It can be used even if they’ve had a fragility fracture (ie for both primary and secondary prevention). I would encourage you to have a play with the FRAX tool – it is really quick and simple to do and makes assessing patients much easier.
Fragility Fractures. Remember that this is a fracture that is sustained from an injury that should normally not cause a fracture. It is defined as a fracture from a force equivalent to a fall from standing height or less.
Who do you Asssess risk in? The guideline advises ‘considering’ assessing risk in higher risk patients. The list of who you should consider assessing risk in is very long. The most obvious cases are:
- People who’ve had a fragility fracture
- Women over 65
- Men over 75
- People under 50 with current or frequent use of corticosteroids, untreated premature menopause or previous fragility fracture.
In other patients, think about people who are having recurrent falls, have frequent or current corticosteroid use, a family history of hip fracture or other medical conditions that predispose to osteoporosis. There is a long list of the latter, but if in doubt, open up the FRAX tool below and it lists them there too.
How to Assess Fracture Risk
To assess risk, the simplest tool is the FRAX tool.
It is pretty self-explanatory. Click calculate to calculate the risk score. Then click on ‘view NOGG guidance’ which is at the bottom of the risk score box. This gives a colour code for the risk (red = high) and advice on what to do next.
- Red - treat
- Amber - DEXA
- Green - Lifestyle advice and reassurance
Beware that local Portsmouth guidance is a bit different to this. There is a very good local document on the PIP. Map of Medicine South Central also has a guideline for this.
The current NICE guidelines for primary and secondary prevention of osteoporosis will be updated soon to be based upon the above advice.
QOF currently just covers secondary prevention (ie people who’ve had a fragility fracture) and doesn't require you to use FRAX at the moment. Maybe next year?