Orthopaedics  |  Fragility Fractures Pathway - Follow Up and Further Investigation




Orthopaedics

Fragility Fractures Pathway - Follow Up and Further Investigation

Follow-up of your patient may be to discuss results, to choose the medication programme for your individual patient, to encourage compliance, to provide lifestyle advice or to manage recurrent fallers (see Bay Navigator Falls pathway - to follow).

Follow-up may also be required if your patient experiences further fracture. In this case please note:

  • Although the treatment regimen (usually with bisphosphonate) is highly effective it by no means removes completely the risk of further fracture. If your patient experiences a further fracture on anti-osteoporosis treatment, it is not necessarily an indication that the treatment should be changed or discontinued. Seek advice from the Fracture Prevention Service if unsure via an eReferral to Health in Aging annotate referral with Fracture Prevention Service.
  • Repeat DEXA scanning is of no additional value if repeated too early. At least two and possibly three years should elapse before further evaluation.
  • Detailed investigation and review may be carried out either:
  • By yourself as the primary care physician, in which case the information below will provide useful information on a suitable bone health history and Investigations.

or

By referral to the Fracture Prevention Service via an eReferral to Health in Ageing annotate referral with Fracture Prevention Service. This may be indicated because of factors such as:

  • Repeated fracture despite apparently adequate and appropriate therapy
  • Malnutrition
  • Frailty syndrome and/or dementia
  • Other related co-morbidity e.g. respiratory failure, steroids, high alcohol intake, male gonadotrophic block
  • Frequent falls

 

Before referral, ensure that any causes of secondary osteoporosis are identified and  managed optimally. Patients with severe and recurrent falls may be referred to the Health in Ageing Service.

Referral to the Fracture Prevention Service should include your patient's relevant bone health history and current medication list, and can be made by  eReferral or in writing.

Investigations:

In addition to an estimate of bone mineral density, a number of other investigations may be useful. They should not be used routinely as they are expensive and may lead to unnecessary distress to your patients. A DEXA scan is not a mandatory prerequisite to starting your patient on anti-resorptive medication, especially for routine age-related osteoporosis in patients  75 years old.

The following investigations may  be useful in most cases of suspected osteoporotic fracture:

  • FBC
  • U&Es and creatinine
  • Calcium (corrected for albumin level) and phosphate and magnesium
  • Alkaline phosphatase
  • ESR
  • TSH

The following investigations may be useful to detect underlying pathology other  than osteoporosis:

  • Vitamin D (specialist only)
  • Parathyroid hormone
  • LFTs (Primary Biliary Cirrhosis)
  • AMA & ANA antibody screen
  • CRP
  • PSA (Prostate Cancer)
  • Protein electrophoresis (Myeloma)
  • X-ray skeletal survey (Metastatic bone disease)
  • Various tumour markers / x-rays (underlying cancer)
  • Testosterone (male hypogonadism) Free androgen index?
  • LH/FSH (Ovarian failure)
  • HbA1c

The following investigations (specialist use only) may be useful in particularly complex cases to identify the current state of bone metabolism:

  • Beta - CTX (bone resorption)
  • P1NP (bone formation)
    • Current Osteoporosis management and treatment guidelines indicate taking a P1NP blood test at 6 months post starting oral bisphosphonate.
    • P1NP is an expensive blood test costing $ 47.41.
    • Oral bisphosphonate absorption is poor, and adherence to treatment has been known to be variable. P1NP may be useful to confirm a) effective absorption B) patient adherence to treatment.
    • Effective bisphosphonate treatment should reduce P1NP levels to <35mcg/L.


If you have concerns about the effectiveness of oral bisphosphonate treatment, consider IV Zoledronic Acid or consult with HIA Fracture Prevention Service for an opinion on the role of P1NP testing. 

Repeat bone mineral density (BMD) scanning should generally not be repeated within 2 to 3 years from the last. Thereafter, repeat DEXA scanning may assist in trying to decide whether to stop, continue or change anti-osteoporosis medication after 3-5yrs of treatment.



Last updated : Wednesday, November 22, 2017
Next review date : Thursday, November 22,2018


Disclaimer: This site is intended to be flexible and frequently updated. While every effort has been made to ensure accuracy, all information should be verified.