Assessing Fracture Risks Copy

Osteoporosis does not develop overnight. Bone mass can be lost steadily for many years without experiencing any symptoms or signs of the disease until a bone fractures. For this reason, osteoporosis is often called "the silent thief" - literally stealing our bone mass without giving us any indication whatsoever. If osteoporosis is first diagnosed at the time a fracture occurs, it is already fairly advanced. A fragility fracture is the most significant clinical consequence of osteoporosis, and therefore preventing a fracture, or the second fracture if one has already occurred, is of paramount importance.

There are various ways to determine the risk of fracture in a client. Below are some general guidelines of who should be assessed, the current methods for assessment and the most common methods for calculating a future fracture risk.

Not every client or environment lends itself to being able to determine fracture risk using these methods and tools, so in our webinars we will discuss practical ways to determine fracture risk and what that information is important for in your environment.

Who should be assessed for risk of fracture?

Women and men over 50
Anyone over 50 who has experienced a fragility fracture

Assessment Procedures

Detailed history to identify risk factors for low BMD, future fractures and falls

Physical Examination

Who should have a BMD test?

What is a BMD (Bone Mineral Density) Test?

What exactly happens during a bone mineral density test?

The most common bone density test in use today is called dual energy x-ray absorptiometry (DXA). This test involves lying on a table for several minutes while a small x-ray detector scans the spine, one hip, or both.

The amount of light (x-ray) that passes through the bone is measured, thus indicating how dense (thick or

thin) the bones are. The test is safe and painless and does not require any injections or any other discomfort. A very small amount of radiation from a DXA test is transmitted.

The patient’s bone density is compared to the bone density of an average young adult.

A T-score is calculated that describes the density of the bones (usually at the spine and hip) compared to this average.

The T-score is expressed in units, “standard deviations (SDs),” indicating how far the score deviates from what is considered normal for a young adult.

Below normal is always indicated with a minus (-) sign.

All women and men 65 years or older

Talk to your doctor about a BMD test.

Postmenopausal women and men 50 – 64 with risk factors for fracture including:

Fragility fracture after age 40
Vertebral fracture or low bone mass identified on x-ray
Parental hip fracture
High alcohol intake
Current smoking
Low body weight, i.e. less than 132 lbs or 60 kg
Weight loss since age 25 greater than 10%
High risk medication use: prolonged glucocorticoid use, aromatase inhibitors for breast cancer, androgen deprivation therapy for prostate cancer
Rheumatoid arthritis
Other disorders that may contribute to bone loss

Younger men or women (under 50) with a disease or condition associated with low bone mass or bone loss:

Tools to assess fracture risk

CAROC

In 2005, Osteoporosis Canada, in association with the Canadian Association of Radiologists, launched the 10-year absolute fracture risk assessment - CAROC.

In addition to BMD (lowest T-score of hip and lumbar spine), age, gender, fracture history and steroid use are taken into consideration to determine an individual’s 10-year risk of fracture.

The presence of both a fragility fracture and steroid use puts the patient at high fracture risk regardless of BMD result.

Version 2, now available for Canadian physicians, uses only femoral neck (hip) BMD rather than the lowest of hip and lumbar spine.

The 10-year fracture risk will change with advancing age or with the development of new risk factors. Repeat assessment is appropriate in five to 10 years in those with low risk and in one to five years in those with moderate risk.

View the CAROC tool here.

FRAX

To use FRAX, click on the image and you will be taken to the website.

In 2008, the World Health Organization (WHO) launched the FRAX tool (Fracture Risk Assessment) – www .shef.a c .u k /FR A X . In 2010 Canadian data were added to this tool. In addition to femoral neck (hip) BMD, age, gender, fracture history and steroid use, FRAX also takes into account other clinical risk factors to calculate the absolute 10-year risk of a hip fracture or other major osteoporotic fracture (spine, forearm, upper arm). These factors include:

BMI (weight to height ratio calculation)
Parental hip fracture
Rheumatoid arthritis
Other secondary conditions that contribute to bone loss
Current smoking
Alcohol intake (three or more drinks per day)

Fracture Risk Scale

A validated tool for assessing fracture risk in long-term care residents. The FRS is the first tool developed and validated to predict hip fracture over a 1-year time period using risk factors specific to long-term care residents such as prior fractures, wandering, dementia and falls. The FRS can support clinical decisions in care-planning by identifying who is at risk.

What are the benefits of FRS?

Prevent fractures by identifying those are at the greatest risk for fractures so that preventive measures can be used
Improve quality of life for residents as fractures can have life-changing and debilitating consequences
Improve care to reduce pain, disability, and transfers to hospital

Treat those at high risk! How can fractures be prevented?

Eating calcium-rich foods
Taking calcium and vitamin D supplements Protecting hips from injury during a fall
(through hip protector use)
Exercising to promote balance & strength
Multifactorial interventions for falls prevention
Osteoporosis medications for those at high risk of fracture

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