After a Broken Bone, the Risk of a Second Fracture

Older adults who break a bone face a serious yet potentially preventable risk of breaking another, often within the next two years. This is especially true for the more than 340,000 people 65 and older who break a hip and the nearly 700,000 who develop a spinal fracture each year.

Unlike lightning, which almost never strikes the same place twice, “the person at highest risk of a fracture is the one who’s just had a fracture,” Dr. Ethel S. Siris, endocrinologist and director of the Toni Stabile Osteoporosis Center at the Columbia University Medical Center, told me.

These second fractures can result in life-limiting disability and a permanent loss of independence. One in five patients dies within a year of surgery for a hip fracture.

Yet those at risk of a repeat fracture often fall between the cracks. After their broken bones have healed, far too few patients are referred for treatment that could stave off another costly, debilitating and sometimes deadly fracture.

Neither patients nor most physicians realize that if the fracture is not the result of a major trauma, like a car accident, older people who fall and break a hip or who lift something heavy and fracture their spine should be treated to diminish the risk of further fractures. Even if a bone density test suggests otherwise, by definition, older people who have broken a bone this way have osteoporosis and are at high risk of breaking more bones.

“We’ve become so wedded to the concept of bone density that we ignore the simple fact that fracture is itself the definition of the disease,” Dr. Sundeep Khosla, endocrinologist at the Mayo Clinic in Rochester, Minn., said in an interview.

In a 2015 study of about two million Medicare patients hospitalized after a fracture, 307,000 had a second fracture during the following two to three years at an additional cost of $6.3 billion.

Yet within six months of the first fracture, only 9 percent had been tested for bone loss and, if needed, offered bone-protecting drugs that could have prevented at least 20 percent of the second fractures and saved more than a billion dollars as well as immeasurable pain and suffering among those afflicted.

“No one says to the patient ‘you just broke your hip, you’ve got osteoporosis, and it should be treated’,” Dr. Siris said. “The problem is that the fracture fixers — the orthopedic surgeons whose job is to get patients back on their feet — are not the fracture preventers who can avert the next fracture. There’s no one connecting the dots between the orthopedic surgeons, who are really good at what they do, and the medical service that can prescribe preventive treatment.”

She outlined three critical measures that too often are not taken:

1. Assuring that patients’ blood levels of calcium and vitamin D are adequate, because “if they’re deficient, it sets off mechanisms that are bad for bones.”

2. Prescribing medication that can strengthen bones so that they’re less likely to break when a person falls from a standing height or picks up something heavy or even turns the wrong way in bed.

3. Taking various steps to prevent falls, like exercises to strengthen supporting muscles and improve balance and mobility, and eliminating fall risks in and around the home.

At the very least, following a hip or vertebral fracture, experts say patients should be referred to a physical or occupational therapist or a physiatrist (a specialist in rehabilitation medicine) for advice and exercises to help prevent more broken bones.

Last year, a very large group of experts assembled by the American Society for Bone and Mineral Research published a consensus statement recommending steps clinical medicine should take to prevent second fractures among people aged 65 and older with a hip or vertebral fracture.

These are people, the experts from diverse fields of medicine and several countries wrote, for whom “the benefits of treatment almost always outweighed the risk.”

Dr. Khosla of the Mayo Clinic, who was a member of this illustrious task force, said the current disconnect is “puzzling, a head scratcher. For some diseases we do everything we can to prevent the next event. If a patient comes in with a heart attack, it’s malpractice if the person is not put on a full preventive program. But the effort to prevent second fractures is dismal. The majority of patients leave the hospital without any preventive measures.”

In other countries, and within some medical networks in the United States, including the Kaiser Permanente system in California, there are coordinated services to assure appropriate post-fracture follow-up. In 2013, the International Osteoporosis Foundation introduced a campaign called Capture the Fracture to assure that “fragility fracture sufferers receive appropriate assessment and intervention to reduce future fracture risk,” but such organized preventive measures have remained rare in the United States.

Establishing fracture liaison services, as they are called, faces a major stumbling block in this country. There’s no mechanism to pay the person who coordinates care between the orthopedic surgeon and the practicing physician. Medicare doesn’t cover the cost of a coordinator, Dr. Siris said, “so there’s no incentive to get a post-fracture patient into medical hands. Many primary care doctors don’t even know that their patients broke a hip.”

Given the astronomical costs to Medicare of hip fractures, Dr. Khosla called the failure to cover the cost of coordinating services to prevent a second fracture “penny-wise and pound-foolish.” (Of course, this is but one of many economically questionable limitations of Medicare. Consider, for example, its failure to cover hearing aids, the lack of which increases the risk of dementia, falls and a host of other expensive medical problems that Medicare does pay for.)

The consensus group’s 13 recommendations for preventing fractures include advice to not smoke or use tobacco, to limit alcohol consumption to two drinks a day for men and one for women, and to exercise regularly, at least three times a week, including weight-bearing, muscle-strengthening and balance and postural exercises. Doctors are urged to discuss both the benefits and possible risks of medications that can help prevent fractures.

Many patients have been unduly frightened, Dr. Khosla said, by the amount of attention given to the rare risks of an atypical femur fracture or jaw decay when taking bisphosphonates like Fosamax that can help maintain bone strength.

“When the drugs are used correctly for three to five years, followed by a drug holiday, and attention is paid to warning symptoms like leg or dental pain, the benefits of treatment way outweigh the risks,” he said.

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