Interim Results and Lessons Learned in Implementing a Fragility Fracture Protocol at a Suburban Community Hospital
Sonya Khurana, MD; New York Medical College-Westchester Medical Center, Valhalla, NY; Alexander Lundy, MD; New York Medical College, Valhalla, NY; Haik Kavookjian, MD; Stamford Hospital, Stamford, CT
Introduction: There's been an increased focus in recent years on bone health and prevention and treatment of fragility fractures. This study reports interim results and lessons learned after implementation of a fragility fracture protocol.
Methods: In March 2016, a protocol was established at our community academic hospital. Patients over the age of 50 years presenting to the emergency department (ED) with low energy distal radius fractures were referred by the consulting orthopaedic surgery resident to outpatient endocrinology for a bone metabolic work up and treatment, if warranted. All patients were called at least four times after their ED visit for fragility fracture education and follow up reminders.
Results: Seventy-six patients have met inclusion criteria for the protocol thus far, with an average age of 72 years (range 53-96). There were 67 females and 9 males. All suffered a low energy fall. Twenty-five patients were not reachable by phone, 8 lived outside the local area, and 8 were not interested. Of the remaining 35 patients, 25 (71%) followed up with an endocrinologist or their primary care physician (PCP). Twenty-three patients were referred by their PCP and 2 by their orthopaedic surgeon.
The average 25-OH Vitamin D level was 32.4 ng/mL, (range 20-56), and 12 patients (48%) had a level below 30. The average values for other labs were: PTH 62.43 pg/mL, alkaline phosphatase 76.3 U/mL, TSH 3.24 uIU/mL, free T4 0.99 ng/dL, and calcium 9.49 mg/dL.
Fourteen patients (56%) underwent DEXA scan and all had osteoporosis or osteopenia at the distal radius.
Two patients didn't require further treatment. Remaining patients were started on daily calcium/Vitamin D supplementation; 7 were started on additional Vitamin D3 50,000 units weekly and 8 were started on injectable bisphosphonates or teriparatide.
Conclusions: Interim results after implementation of a distal radius fracture fragility protocol show these patients are at risk for having an underlying Vitamin D deficiency, osteoporosis/osteopenia, and future fragility fractures, such as a devastating hip fracture. Our moderate patient follow up rate with endocrinology demonstrates the importance of patient education regarding risks and prevention of future fragility fractures. Orthopaedic surgeons and PCPs play a critical role in recognizing fragility fractures and referring patients appropriately. Our institution has recently established an Osteoporosis Center, where bone metabolic care is streamlined. Future analysis will determine if this process improves patient follow up.
Back to 2018 Program