Improving evaluation and treatment for osteoporosis following distal radial fractures

Background: Fragility fractures are associated with a significant increase in the risk of future fracture, but the rates of evaluation to identify osteoporosis after such injuries are low. The purpose of this study was to determine the rates of evaluation and treatment of osteoporosis following distal radial fractures and to test two interventions in the outpatient clinic to improve evaluation and treatment rates. Methods: In the first part of the study, the medical records of 298 consecutive patients treated for a fragility fracture of the distal part of the radius were reviewed. Primary outcome measures were a bone mineral density examination and treatment with osteoporosis medication within six months after the fracture. In the second part of the study, fifty patients with a fragility fracture of the distal part of the radius were prospectively randomized to receive one of two interventions. These consisted of (1) the orthopaedic surgeon ordering a bone mineral density examination and forwarding the results to the primary care physician or (2) the orthopaedic surgeon sending a letter to the primary care physician outlining guidelines for osteoporosis screening. Patients were contacted at six months after the fracture to determine the rates of evaluation and treatment for osteoporosis. Results: The first part of the study revealed that, following a distal radial fracture, 21.3% of 240 patients had a bone mineral density examination and 78.7% were never screened. Osteopenia was the most common diagnosis among those screened (57%). Most (72.5%) of the 240 patients received no medication, whereas 6.7% received calcium and vitamin D; 11.3%, bisphosphonates; 2.5%, hormone replacement therapy; and 7.1%, a combination regimen. The treatment rate for the patients who had undergone a bone mineral density examination was 2.5-fold higher than the rate for those who had not had bone mineral density testing (53% compared with 21%, p < 0.001). In the second part of the study, the patients randomized to Intervention I had two to threefold greater rates of bone mineral density testing (93% compared with 30%, p < 0.001), discussion of osteoporosis with their primary care physician (89% compared with 35%, p < 0.001), and initiation of osteoporosis therapy (74% compared with 26%, p < 0.001) compared with patients randomized to Intervention 2. Conclusions: Rates of evaluation and treatment for osteoporosis after fragility fractures remain low (21.3% and 27.5%, respectively). Patients who undergo a bone mineral density examination are more likely to receive treatment. Ordering a bone mineral density examination in the orthopaedic clinic can dramatically improve osteoporosis evaluation and treatment rates following fragility fractures of the distal part of the radius. Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.