Do you refer patients with osteoporosis and compression fractures to orthopedic or endocrinology specialists?

Referral Strategy for Osteoporosis and Compression Fractures

Patients with osteoporosis and compression fractures should be managed through a coordinated multidisciplinary approach, with orthopedic surgery handling acute fracture care and either endocrinology or rheumatology managing long-term osteoporosis treatment, coordinated by a designated lead clinician or fracture liaison service. 1

Immediate Orthopedic Surgery Referral Required

Send to orthopedic surgery or neurosurgery immediately for:

• Any neurological deficits (weakness, numbness, bowel/bladder dysfunction) 2, 3
• Spinal instability on imaging 2, 3
• Hip fractures requiring surgical intervention 1
• Severe progressive kyphosis or spinal deformity 2, 3
• Suspected pathologic fracture from malignancy 2, 3

Conservative Management First (No Immediate Referral)

For neurologically intact patients with osteoporotic compression fractures, manage conservatively for the first 3 months: 1, 2, 3

• Calcitonin for first 4 weeks for pain control 2, 3
• Analgesics and activity modification 1
• MRI spine without contrast to characterize fracture and exclude pathologic causes 2, 3

Delayed Orthopedic Referral (After 3 Months)

Refer to orthopedic surgery or interventional radiology if: 2, 3

• Severe worsening pain despite 3 months of conservative management 2, 3
• Progressive spinal deformity 2, 3
• Pulmonary dysfunction from compression fractures 3
• Consider for percutaneous vertebral augmentation (kyphoplasty) 3

Endocrinology/Rheumatology Referral for Osteoporosis Management

All patients aged 50+ with fragility fractures require systematic evaluation for osteoporosis and future fracture risk. 1

Coordination Model

The EULAR/EFORT guidelines emphasize that a designated coordinator should liaise between surgeons, rheumatologists/endocrinologists, geriatricians, and primary care to ensure comprehensive secondary fracture prevention. 1

When to Refer to Endocrinology/Rheumatology:

• All patients with fragility fractures should have osteoporosis evaluation including DXA scan, clinical risk factors, vertebral imaging, falls assessment, and screening for secondary osteoporosis 1
• Endocrinology consultation significantly improves osteoporosis diagnosis, treatment initiation, and documentation compared to standard care 4
• Triggered endocrinology consultation for hip fracture patients increased proper evaluation from 3-21% to 55-97% across all parameters 4

Alternative: Fracture Liaison Service

Rather than individual referrals, implement a Fracture Liaison Service (FLS) that systematically captures all fragility fracture patients and coordinates care between orthopedics and endocrinology/rheumatology. 5

• FLS models improve diagnosis and treatment initiation rates 5
• Multidisciplinary interventions increase osteoporosis treatment from 18.8% (standard care) to 40-53% with systematic intervention 6

Geriatrics Co-Management

For elderly patients with hip fractures, orthogeriatric co-management on dedicated wards provides: 1

• Shortest time to surgery 1
• Shortest hospital stay 1
• Lowest inpatient and 1-year mortality 1
• Level IA evidence, Grade A recommendation 1

Common Pitfalls

• The treatment gap remains unacceptably large: Only 30-38% of patients with vertebral compression fractures receive active osteoporosis treatment, and rates are even lower in men 7, 8
• Failing to systematically evaluate all fragility fractures: Without systematic intervention, only 18.8% of untreated patients receive therapy 6
• Missing secondary osteoporosis causes: Always screen for secondary causes including malignancy, hyperparathyroidism, vitamin D deficiency 1
• Inadequate follow-up: Outpatient follow-up remains poor (6-15%) even with triggered consultations 4

Practical Algorithm

1. Acute presentation: Orthopedic surgery for fracture management if surgical intervention needed 1
2. Immediate: Rule out neurological deficits and pathologic fracture 2, 3
3. First 3 months: Conservative management with pain control 2, 3
4. Concurrent: Initiate systematic osteoporosis evaluation through endocrinology/rheumatology or FLS 1, 4, 5
5. After 3 months: Orthopedic/interventional radiology referral only if persistent severe pain or deformity 2, 3
6. Long-term: Endocrinology/rheumatology manages pharmacologic osteoporosis treatment to prevent subsequent fractures 1