What workup is recommended for osteoporosis in patients with femoral neck, intertrochanteric (IT) or femoral shaft fractures after open reduction and internal fixation?

Osteoporosis Workup After Femoral Fracture Fixation

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

Recommended Diagnostic Workup

• Dual-energy X-ray absorptiometry (DXA) of the spine and hip to assess bone mineral density (BMD) 1

• Vertebral imaging to identify existing vertebral fractures that may be clinically silent but would indicate higher fracture risk 1

• Clinical risk factor assessment including:

  • Age, sex, prior fractures, prior falls 1, 2
  • Low body weight 1, 2
  • Family history of hip fracture 2
  • Smoking and alcohol consumption 1
  • Glucocorticoid use 1, 2
  • Comorbidities (inflammatory bowel disease, rheumatoid arthritis, chronic liver/kidney disease) 1, 2

• Laboratory testing to identify secondary causes of osteoporosis 1:

  • Complete blood count
  • Comprehensive metabolic panel (calcium, phosphorus, liver function, kidney function)
  • 25-hydroxyvitamin D levels
  • Thyroid-stimulating hormone
  • Parathyroid hormone levels
  • 24-hour urinary calcium
  • Testosterone levels (in men)
  • Consider additional testing based on clinical suspicion

• Falls risk assessment to identify modifiable risk factors for falls 1

Fracture Risk Assessment

• Calculate the 10-year probability of fracture using the WHO Fracture Risk Assessment Tool (FRAX) 1, 2
  • Treatment threshold: ≥20% risk for major osteoporotic fracture or ≥3% risk for hip fracture 1

Implementation Strategy

• Establish a Fracture Liaison Service (FLS) with a dedicated coordinator (often a nurse) who works under supervision of an orthopedic surgeon, endocrinologist, or rheumatologist 1
  • The coordinator identifies patients with fractures, organizes diagnostic investigations, initiates interventions, and communicates with primary care physicians 1
  • FLS has been shown to significantly improve implementation of osteoporosis treatment after fragility fractures 1, 2

Common Pitfalls to Avoid

• Delaying evaluation: The risk of subsequent fracture is highest immediately after the initial fracture, making prompt assessment critical 1

• Focusing only on BMD: Comprehensive assessment should include clinical risk factors and vertebral imaging, not just BMD measurement 1, 2

• Overlooking secondary causes: Up to 30% of women and 50% of men with osteoporosis have underlying secondary causes that require specific treatment 1

• Neglecting men: While osteoporosis is more common in women, men with hip fractures have higher mortality rates and should receive thorough evaluation 2, 3

By implementing this systematic approach to osteoporosis evaluation after femoral fractures, you can significantly reduce the risk of subsequent fractures and improve patient outcomes.