Staying Healthy–Follow-Up After a Fracture

According to recent studies, many patients in the United States aren’t receiving recommended follow-up care after a fracture whose underlying cause is osteoporosis. These types of fractures are referred to as “fragility fractures.” They occur most often in the spine, hip, and wrist.

One of two women in the United States will have a fracture related to osteoporosis in her lifetime. One in five patients dies in the first year after a hip fracture.

Key strategies that support the guidelines for patients who have had a fragility fracture:

1. Order a bone mineral density (BMD) test. As soon as possible after fragility fractures, refer your patients for BMD testing if they have not already been tested.

• The results of the BMD are measured as a “T-score.” The lower the BMD measurement, the greater risk for a fracture to occur.
• A patient with a T-score between -1 and -2.5 has low bone mass (osteopenia).
• A patient with a T-score at or below -2.5 has osteoporosis.
Dual X-ray absorptiometry (DXA) is the preferred technique to test bone density. Bone density should be re-tested every 1-2 years.

2. Recommend the following lifestyle changes for your patients:
• Consume 1200 mg calcium per day.
• Consume 400-800 IU of vitamin D per day.
• Engage in weight-bearing (walking, jogging, Tai-Chi, dancing, stair climbing, dancing, and tennis) and muscle-strengthening exercise.
• Stop smoking.
• Limit alcohol to 1-2 drinks a day.

3. Initiate drug therapy in female patients who have:
• BMD T-scores below -2.0 (measured by hip DXA) with no risk factors.
• BMD T-scores below -1.5 (measured by hip DXA) with one or more risk factors.
• Had a prior hip or vertebral fracture.

FDA-approved drugs to treat osteoporosis include:
• Bisphosphonates
• Calcitonin
• Parathyroid hormone
• Raloxifene
Estrogen/hormone therapy is approved for prevention of osteoporosis but may not be the best choice
because of increased risk for myocardial infarction, stroke, breast cancer, and other problems associated with it.

4. Work with patients to develop an effective rehabilitation program.
• Refer them to a physiatrist for evaluation, or refer them to a physical therapist for help with balance, gait, strength training, and recommendations for walking aids.
• Refer them to an occupational therapist who can make suggestions about making a patient’s home safer, or enlist family and friends to go into the home and make changes to increase safety.
• Make sure their pain is being managed appropriately.
• Talk to them about their anxieties and fears. Fear of falling again might prevent your patients from returning to their normal activities. This lack of activity in turn can make them more likely to fall again, because of weakening of bones and muscles.

5. Develop strategies with your patient to decrease risk of another fracture.
• Suggest your patient wear a “hip protector,” a padded undergarment that can absorb some of the impact of a fall.
• Recommend vision and hearing tests for your patients.
• Evaluate for neurological problems.
• Review with your patients any chronic conditions (arthritis, endocrine disorders, seizure disorders, and gastrointestinal diseases, for example) and any medication side effects that might affect balance and stability.

Doctors no longer use hormone replacement or estrogen replacement therapy as a main treatment for osteoporosis in women. Health risks have been found with these therapies.

Provided as an educational resource by Merck