Fractures

APFFA's primary clinical focus

Acute fracture management

  • Older people who are admitted to hospital as a result of fracture should be managed by a multidisciplinary team which includes orthopaedic surgeons, geriatricians or internal medicine specialists, anaesthetists, rehabilitation medicine physicians, osteoporosis specialists, nurses, and physiotherapists.1

  • These “Orthogeriatric Services” will:1

    • Minimise the incidence of delirium (confusion)
    • Ensure appropriate pain management
    • Guarantee adequate and efficient preoperative assessment and preparation for surgery, and expedite that surgery
    • Coordinate post-acute management with the outpatient care team

  • The joint model of care co-led by a senior orthopaedic surgeon and senior geriatrician on a dedicated orthogeriatric ward has been shown to drive shorter time to surgery, shorter length of in-patient hospital stay and achieve the lowest inpatient and 1-year mortality rate.2

  • Secondary fracture prevention is a critical component of acute fracture management (refer to the section on secondary fracture prevention below).

  • Establishment of a national hip fracture registry enables hospitals to benchmark their provision of care against quality standards and guidelines, to help drive local and national quality improvement initiatives.

  • APFFA supports the implementation of national hip fracture registries across Asia Pacific to identify the economic burden, promote multidisciplinary management and advocate for organisational initiatives that improve the care and outcomes for people following a hip fracture.

Secondary fracture prevention

  • Because half of people who fracture their hip have broken another bone prior to their hip fracture, healthcare professionals and patients must be educated that every fracture in a person aged 50 years or older is an opportunity to prevent subsequent fractures that should NEVER be missed.

  • During the first five years after sustaining a fracture, approximately one fifth of patients will sustain a subsequent fracture, with the highest risk being during the two years after the initial fracture.4,5

  • Patients must be educated that low trauma fractures are the culmination of a chronic disease process, and that their risk of future fracture can be mitigated with treatment.6, 7

  • A hip or vertebral fracture in those aged 65 years or over is indicative of an osteoporosis diagnosis in the absence of another metabolic bone disease, regardless of bone mineral density (BMD), and is one of the strongest risk factors for subsequent fragility fractures.6

  • Currently, the vast majority of older adults who sustain fractures do not receive subsequent interventions to identify and treat underlying modifiable fracture risk factors.8

  • Given nine in 10 hip fractures result from a simple fall from standing height or less, falls prevention is a critical intervention.6

  • The risk of sustaining a further fracture can be reduced by up to 30 to 40 per cent if the underlying osteoporosis and falls risk are managed by a secondary fracture prevention program.7

  • APFFA promotes the widespread implementation of the Fracture Liaison Service (FLS) model of care to reliably deliver secondary fracture prevention and ensure the best transition of care from hospital to community.

Rehabilitation

  • A significant proportion of individuals who sustain hip fractures will not recover their pre-fracture ability to walk and carry out routine activities of daily living which are required to remain autonomous.3

  • Multidisciplinary rehabilitation teams are required to deliver strategies for the long-term restoration of musculoskeletal function beyond the acute recovery period.

  • Key objectives of rehabilitation include:

    • Improve early mobility after fragility fracture.
    • Improve physical and psychological functions after fragility fracture.
    • Provide exercise prescriptions to improve muscle strength and balance.
    • Provide falls prevention program.
    • Prescribe proper assistive devices, orthosis, and mobility aids.
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Epidemiology

  • By 2050, an estimated 1.3 billion people in Asia will be aged 60 years or above.9
  • Concerningly, by 2050, between 4.5 to 6.3 million hip fractures are predicted to occur worldwide, half of which will occur in Asia.10

About osteoporosis and fractures

  • Osteoporosis is a chronic disease characterised by a deficiency of bone tissue and bone architecture, and is a major fracture risk factor.11, 12 It is asymptomatic until a fracture occurs.
  • The World Health Organization (WHO) defines osteoporosis as low bone mass (measured as bone mineral density—BMD) and micro architectural deterioration of bone tissue with a consequent increase in bone fragility and susceptibility to fractures involving the wrist, spine, hip, pelvis, ribs, or humerus.13
  • The WHO defines a fragility fracture as a fracture caused by injury, which would be insufficient to fracture normal bone: the result of reduced bone strength.14
  • Clinically, a fragility fracture can be defined as one, which occurs as a result of minimal trauma, such as a fall from a standing height or less, or no identifiable trauma.13
  • The diagnosis of an osteoporosis is by the presence of fragility fracture (clinical or radiological), in a person who has not yet suffered a qualifying fracture, by BMD (T-score - below or equal to -2.5).13
  • Many physicians fail to make the diagnosis of osteoporosis on clinical grounds following a low trauma fracture. This leads to striking underdiagnosis and underdiagnosis of patients who have already suffered fractures.6, 15
  • Hip and spinal (vertebral) fragility fractures carry the highest health burden,16 around three-quarters of which occur in those aged 65 years and above.16
  • Fragility fractures, particularly hip fractures, are associated with limitations in ambulation, chronic pain and disability, loss of independence, and decreased quality of life.
  • Concerningly, 21 to 30 per cent of patients who experience a hip fracture die within one year of fracture.17
  • Loss of function and independence among hip fracture survivors is profound, with 40 per cent unable to walk independently and 60 per cent requiring assistance a year later.18
  • One-third of all subsequent fractures occurred within the first year after initial fracture of the spine, shoulder or hip.19
  • In 2018, the estimated cost of hip fractures obtained from nine Asian countries or regions was USD7.5 billion. By 2050, projections suggest this will rise to approximately USD13 billion.10
  • A recent analysis of nine Asian countries from the Asian Federation of Osteoporosis Societies (AFOS) revealed the number of hip fractures will more than double from 1.13 million in 2018, to 2.54 million in 2050,10 primarily due to changing population demographics. Furthermore, projections suggest half of all hip fractures globally will occur in Asia-Pacific by 2050.20
  • The costs for treating a single hip fracture represents approximately 19 per cent of APAC’s regional per-head annual gross domestic product (GDP).21
  • Osteoporosis and fragility fractures compound the burden of APAC’s rapidly ageing population.22
  • Only 54 per cent of those admitted to hospital with a hip fracture will return home within 30 days.23
References
  1. Dreinhofer, K.E., et al., A global call to action to improve the care of people with fragility fractures. Injury, 2018. 49(8): p. 1393-1397.
  2. Prestmo, A., et al., Comprehensive geriatric care for patients with hip fractures: A prospective, randomised, controlled trial. The Lancet, 2015. 385.
  3. Bukata, S.V., et al., A guide to improving the care of patients with fragility fractures. Geriatric orthopaedic surgery & rehabilitation, 2011. 2(1): p. 5-37.
  4. Huntjens, K., et al., Risk of subsequent fracture and mortality within 5 years after a non-vertebral fracture. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA, 2010. 21: p. 2075-82.
  5. Söreskog, E., et al., Risk of major osteoporotic fracture after first, second and third fracture in Swedish women aged 50 years and older. Bone, 2020. 134: p. 115286.
  6. Conley, R.B., et al., Secondary Fracture Prevention: Consensus Clinical Recommendations from a Multistakeholder Coalition. Journal of Bone and Mineral Research, 2020. 35(1): p. 36-52.
  7. Nakayama, A., et al., Evidence of effectiveness of a fracture liaison service to reduce the re-fracture rate. Osteoporosis International, 2016. 27(3): p. 873-879.
  8. David, M., How to prevent the second fracture: systems for secondary prevention. Orthopaedic Proceedings, 2006. 88-B(SUPP_I): p. 11-11.
  9. Mitchell, P.J., et al., Quality Improvement Initiatives in Fragility Fracture Care and Prevention. Curr Osteoporos Rep, 2019. 17(6): p. 510-520.
  10. Cheung, C.L., et al., An updated hip fracture projection in Asia: The Asian Federation of Osteoporosis Societies study. Osteoporos Sarcopenia, 2018. 4(1): p. 16-21.
  11. World Health Organization, Assessment of fracture risk and its application to screening for postmenopausal osteoporosis : report of a WHO study group. 1994, World Health Organization: Geneva. p. 1-129.
  12. Osteoporosis Australia. About osteoporosis. What is it? [cited April, 2020]; Available from: https://www.osteoporosis.org.au/what-it.
  13. Meeta, M., Harinarayan, C.V., Marwaha, R.K., Sahay, R., Kalra, S., Babhulkar, S., . Clinical practice guidelines on postmenopausal osteoporosis: Clinical practice guidelines on postmenopausal osteoporosis: An executive summary and recommendations - Update 2019. 2019 [cited April, 2020 ]; Available from: https://indianmenopausesociety.org/wp-content/uploads/2020/03/Clinical-practice-guidelines-2020.pdf.
  14. Meeta, et al., Clinical practice guidelines on postmenopausal osteoporosis: An executive summary and recommendations. Journal of mid-life health, 2013. 4(2): p. 107-126.
  15. Siris, E.S., et al., What’s in a name? What constitutes the clinical diagnosis of osteoporosis? Osteoporosis International, 2012. 23(8): p. 2093-2097.
  16. Sanchez-Riera, L. and N. Wilson, Fragility Fractures & Their Impact on Older People. Best Pract Res Clin Rheumatol, 2017. 31(2): p. 169-191.
  17. Curry, S.J., Screening for Osteoporosis to Prevent Fractures. JAMA, 2018. 319(24): p. 2521-2531.
  18. International Osteoporosis Foundation. Facts and statistics. [cited Feb, 2020]; Available from: https://www.iofbonehealth.org/facts-statistics.
  19. Ebeling, P., et al., Secondary prevention of fragility fractures in Asia Pacific: an educational initiative. Osteoporosis International, 2019.
  20. Cooper, C., G. Campion, and L.J. Melton, 3rd, Hip fractures in the elderly: a world-wide projection. Osteoporos Int, 1992. 2(6): p. 285-9.
  21. The Economist Intelligence Unit, Demystifying ageing: Lifting the burden of fragility fractures and osteoporosis in Asia-Pacific. 2017.
  22. The Economist Intelligence Unit, Ageing with Strength: Adressing fragility fractures in Asia-Pacific. 2019.
  23. Neuburger, J., et al., The impact of a national clinician-led audit initiative on care and mortality after hip fracture in England: an external evaluation using time trends in non-audit data. Med Care, 2015. 53(8): p. 686-91.
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