Osteoporosis Evaluation and Management After Femoral Fracture

Diagnostic Workup

The American College of Rheumatology recommends that every patient aged 50 years and over with a femoral neck, intertrochanteric, or femoral shaft fracture should undergo systematic evaluation for osteoporosis to reduce the risk of subsequent fractures 1, 2
Dual-energy X-ray absorptiometry (DXA) of the spine and hip should be performed to assess bone mineral density (BMD) 1, 3, 4
Vertebral imaging should be used to identify existing vertebral fractures that may be clinically silent but would indicate higher fracture risk 4, 5
Clinical risk factor assessment, including age, sex, prior fractures, prior falls, low body weight, smoking and alcohol consumption, should be performed to evaluate the risk of osteoporosis 4, 5

The 10-year probability of fracture should be calculated using the WHO Fracture Risk Assessment Tool (FRAX) 5
Treatment threshold is defined as a ≥20% risk for major osteoporotic fracture or ≥3% risk for hip fracture 5

A Fracture Liaison Service (FLS) with a dedicated coordinator should be established to identify patients with fractures, organize diagnostic investigations, initiate interventions, and communicate with primary care physicians 1, 2
FLS has been shown to significantly improve implementation of osteoporosis treatment after fragility fractures 2

Delaying evaluation is a common pitfall, as the risk of subsequent fracture is highest immediately after the initial fracture 1
Focusing only on BMD is insufficient, as comprehensive assessment should include clinical risk factors and vertebral imaging 4
Overlooking secondary causes of osteoporosis is a common mistake, as up to 30% of women and 50% of men with osteoporosis have underlying secondary causes that require specific treatment 5