The vast majority of DRFs can be considered fragility fractures, and the importance of both recognising the underlying pathology (osteopenia or osteoporosis-bone health), and the cause (falling) is essential part of the treatment. This can lead to prevention of future, more debilitating injuries such as vertebral or hip fractures, which are associated with significant morbidity and mortality. The DRF is usually the first medical presentation of these, and the opportunity to prevent future injury.
Fragility fractures are low-energy fractures resulting from everyday activities, with either no trauma or a fall from standing height or less1. Underlying contributing factors include both bone fragility and tendency to fall, both of which can be significantly increased in older adults. With an aging population, all fracture clinics should have embedded screening for bone health and falls risk and a clear onward referral pathway to falls and fracture liaison services.
The common sites of fragility fracture are hip, spine, proximal humerus and distal forearm; they affect up to one-half of women and one-third of men over age fifty, and lead to increased disability, dependence, morbidity, mortality and poorer quality of life scores in older people.
DRF is the commonest type of fracture in perimenopausal women and is associated with an increased risk of later non-wrist fracture of up to one in five in the subsequent decade2.
Treat the first fracture, prevent the second
Primary prevention of DRFs is possible. In a very large US study3 examining >500,000 records from US Healthcare Management Organisations (HMOs), screening for, and pharmacologic management of, osteoporosis using a multidisciplinary team approach in a comprehensive osteoporosis management program resulted in a statistically significant decrease in the risk of distal radius fracture.
However, this primary prevention is beyond the remit of orthopaedic services who will not have contact with the patient until an index fracture has been sustained. Once a patient presents with a fragility fracture a proactive approach to secondary
prevention is vital – treat the first fracture, prevent the second.
When an older person sustains a DRF what additional elements should be addressed to prevent future falls and injury? The orthopaedic surgeon may be the only doctor they see – rarely will a physician or geriatrician be involved in an uncomplicated distal radius fracture – orthopaedic services thus have a vital role to play in recognising and using the first fracture as a trigger to prevention of future fractures. Many patients will be unaware of their elevated risk profile and should be fully informed of the need for preventative action and onward referral.
Bone health and fracture prevention
Fragility fractures are often associated with low bone density, but many occur in osteopaenic rather than osteoporotic bone density values.
NICE CG 146 Osteoporosis: Assessing the risk of fragility fracture4 NICE recommends targeting risk assessment to the following groups.
TARGETING RISK ASSESSMENT
1.1 Consider assessment of fracture risk:
- In all women aged 65 years and over and all men aged 75 years and over
- In women aged under 65 years and men aged under 75 years in the presence of risk factors, for example:
- previous fragility fracture
- current use or frequent recent use of oral or systemic glucocorticoids
- history of falls
- family history of hip fracture
- other causes of secondary osteoporosis
- low body mass index (BMI) (less than 18.5 kg/m2)
- alcohol intake of more than 14 units per week for women and more than 21 units per week for men.
1.2 Do not routinely assess fracture risk in people aged under 50 years unless they have major risk factors (for example, current or frequent recent use of oral or systemic glucocorticoids, untreated premature menopause or previous fragility fracture), because they are unlikely to be at high risk.
In the case of low energy DRFs risk assessment will apply to all aged 50 or over, and younger if they have major risk factors.
The guidance now recommends that a 10-year assessment of absolute fracture risk be undertaken in addition, and prior to, Bone Mineral Density (BMD) assessment with dual–energy X-ray absorptiometry (DXA) scanning. Treatment decisions should be based on fracture risk not BMD alone. Situations where assessments may underestimate risk are noted, including age >80, multiple fractures, glucocorticoid use, alcohol, some medications, living in care home.
METHODS OF FRACTURE RISK ASSESSMENT
1.1 Estimate absolute risk when assessing risk of fracture (for example, the predicted risk of major osteoporotic or hip fracture over 10 years, expressed as a percentage).
1.2 Use either FRAX (without a bone mineral density [BMD] value if a dual-energy X-ray absorptiometry [DXA] scan has not previously been undertaken) or QFracture, within their allowed age ranges, to estimate 10-year predicted absolute fracture risk when assessing risk of fracture. Above the upper age limits defined by the tools, consider people to be at high risk.
1.3 Interpret the estimated absolute risk of fracture in people aged over 80 years with caution, because predicted 10-year fracture risk may underestimate their short-term fracture risk.
1.4 Do not routinely measure BMD to assess fracture risk without prior assessment using FRAX (without a BMD value) or QFracture.
1.5 Following risk assessment with FRAX (without a BMD value) or QFracture, consider measuring BMD with DXA in people whose fracture risk is in the region of an intervention threshold for a proposed treatment, and recalculate absolute risk using FRAX with the BMD value.
1.6 Consider measuring BMD with DXA before starting treatments that may have a rapid adverse effect on bone density (for example, sex hormone deprivation for treatment for breast or prostate cancer).
1.7 Measure BMD to assess fracture risk in people aged under 40 years who have a major risk factor, such as history of multiple fragility fracture, major osteoporotic fracture, or current or recent use of high-dose oral or high-dose systemic glucocorticoids (more than 7.5 mg prednisolone or equivalent per day for 3 months or longer).
1.8 Consider recalculating fracture risk in the future:
- if the original calculated risk was in the region of the intervention threshold for a proposed treatment and only after a minimum of 2 years, or
- when there has been a change in the person's risk factors.
1.9 Take into account that risk assessment tools may underestimate fracture risk in certain circumstances, for example if a person:
- has a history of multiple fractures
- has had previous vertebral fracture(s)
- has a high alcohol intake
- is taking high-dose oral or high-dose systemic glucocorticoids (more than 7.5 mg prednisolone or equivalent per day for 3 months or longer)
- has other causes of secondary osteoporosis.
1.10 Take into account that fracture risk can be affected by factors that may not be included in the risk tool, for example living in a care home or taking drugs that may impair bone metabolism (such as anti-convulsants, selective serotonin reuptake inhibitors, thiazolidinediones, proton pump inhibitors and anti-retroviral drugs).
Asking about falls is important. A current fall is a predictor of future falls, and similarly a current fragility fracture is a predictor of future fragility fractures. NICE falls guidance CG161 (2013)5 include the following recommendations for older people (aged >65 years):
- Older people in contact with healthcare professionals should be asked routinely whether they have fallen in the past year and asked about the frequency, context and characteristics of the fall/s. 
- Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. This assessment should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualised, multifactorial intervention. 
A history of either frequent falls or those with obvious poor balance should be highlighted to their general practitioner for onward referral to local falls services
There is a strong evidence base for multi-factorial falls prevention interventions in reducing the risk of future falls and of reducing fear of falling whilst increasing independence and self-efficacy of fallers. The fracture clinic should have a pathway agreed with local primary care services for referring on for appropriate falls assessment and interventions. A typical evidence-based falls prevention exercise programme will last at least 4-6 months and involve participation of at least 50 hours to be effective6.
Fracture Liaison Services
Fracture Liaison services are co-ordinator based clinical systems developed to ensure appropriate management of patients following fracture. Fracture liaison usually involves a dedicated co-ordinator to liaise between the orthopaedic team, patient and other specialities, usually arranging for BMD testing, treatment recommendation and/ or initiation and follow up. Some programmes also address falls assessments and onwards referral.
The development of effective Fracture Liaison Services in the UK is being encouraged by a national quality initiative – the Fracture Liaison Service Database (FLS-DB)7, a new national audit commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the Falls and Fragility Fracture Audit Programme (FFFAP)8.
A Fracture Liaison Service should submit data to the new database. Eligibility requires a service that systematically identifies eligible patients aged over 50 years who have suffered a fragility fracture and treats or refers them to appropriate services with the aim of reducing their risk of subsequent fractures. i.e. meeting the description of a Fracture Liaison Service.
- Kanis JA, Oden A, Johnell O, Jonsson B, De LC, Dawson A. The burden of osteoporotic fractures: a method for setting intervention thresholds. Osteoporos Int. 2001; 12(5):417-427.
- Crandall CJ, Hovey KM, Cauley JA. Wrist fracture and risk of subsequent fracture: findings from the Women's Health Initiative Study. Journal of Bone and Mineral Research. 2015;30(11):2086-95
- Distal radius fracture risk reduction with a comprehensive osteoporosis management program. Harness NGet al. J Hand Surg Am. 2012 Aug;37(8):1543-9.
- http://www.nice.org.uk/guidance/cg146/evidence/osteoporosis-fragility-fracture-full-guideline-186818365[accessed 3/3/2016]https://www.nice.org.uk/guidance/cg161/chapter/1-recommendations#preventing-falls-in-older-people-2[accessed 3/3/2016]
- Sherringtonetal. 2011 Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations.’ NewSouth Wales Public Health Bulletin
- https://www.rcplondon.ac.uk/projects/fracture-liaison-service-database-fls-db[accessed 3/3/2016]
- https://www.rcplondon.ac.uk/projects/falls-and-fragility-fracture-audit-programme-fffap [ accessed 3/3/2016]