Current Osteoporosis Reports

, Volume 10, Issue 1, pp 22–27 | Cite as

Secondary Fracture Prevention

  • Robert A. Adler
Current Therapeutics (SL Silverman, Section Editor)


Osteoporosis causes no symptoms until there is a fracture. Although screening for osteoporosis is recommended for some populations, patients may present with a fragility fracture. Such patients are at high risk for subsequent fractures. Despite this high risk and the presence of generally safe and effective osteoporosis therapy, only a minority of low trauma fracture patients have evaluation and treatment of underlying osteoporosis. A brief summary of the evaluation and medical treatment of the post-fracture patient is provided. Several institutions, integrated health systems, and countries have instituted programs to identify, evaluate, and treat fragility fracture patients. Such programs have had variable success. This article describes some of the programs that work, their cost-effectiveness, and the applicability to the generally non-integrated US health care system. It is clear that better management of the post-fracture patient (and other high-risk patients) will lead to fewer fractures, decreased morbidity and mortality, and long-term cost savings.


Osteoporosis Fracture Secondary prevention Dual energy x-ray absorptiometry Bisphosphonates 



Conflicts of interest: R.A. Adler: has been a consultant for Eli Lilly; and has received grant support from Genentech, Novartis, Merck, Amgen, and Eli Lilly.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Lim LS, Hoeksema LJ, Sherin KM. ACPM Prevention Practice Committee, Screening for osteoporosis in the adult U.S. population: ACPM position statement on preventive practice. Am J Prev Med. 2009;36:366–75.PubMedCrossRefGoogle Scholar
  2. 2.
    National Osteoporosis Foundation, Clinician’s guide to prevention and treatment of osteoporosis. Washington, DC 2008.Google Scholar
  3. 3.
    Preventive Services US. Task Force, Screening for osteoporosis: U.S. preventive services task force recommendation statement. Ann Intern Med. 2011;154:356–64.Google Scholar
  4. 4.
    Kanis JA, Johansson H, Oden A, et al. The effects of a FRAX revision for the USA. Osteoporos Int. 2010;21:35–40.PubMedCrossRefGoogle Scholar
  5. 5.
    Nguyen ND, Frost SA, Center JR, et al. Development of a nomogram for individualizing hip fracture risk in men and women. Osteoporos Int. 2008;18:1109–17.CrossRefGoogle Scholar
  6. 6.
    Compston J, Cooper A, Cooper C, et al. Guidelines for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK. Maturitas. 2009;62:105–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Andrade SF, Majumdar SR, Chan A, et al. Low frequency of treatment of osteoporosis among postmenopausal women following a fracture. Arch Intern Med. 2003;163:2052–7.PubMedCrossRefGoogle Scholar
  8. 8.
    Kamel HK, Hussain MS, Tariq ST, et al. Failure to diagnose and treat osteoporosis in elderly patients hospitalized with hip fracture. Am J Med. 2000;109:326–8.PubMedCrossRefGoogle Scholar
  9. 9.
    Elliot-Gibson V, Bogoch ER, Jamal SA, et al. Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: a systematic review. Osteoporos Int. 2004;15:767–78.PubMedCrossRefGoogle Scholar
  10. 10.
    Torgerson DJ, Dolan P. Prescribing by general practitioners after an osteoporotic fracture. Ann Rheum Dis. 1998;57:378–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Lyles KW, Colon-Emeric CS, Magaziner JS, et al. Zoledronic acid in reducing clinical fractures and mortality after hip fracture. N Engl J Med. 2007;357:1799–809.PubMedCrossRefGoogle Scholar
  12. 12.
    Van Staa TP, Leufkens HG, Cooper C. Does a fracture at one site predict later fractures at other sites? A British cohort study. Osteoporos Int. 2002;13:624–9.PubMedCrossRefGoogle Scholar
  13. 13.
    Bone HG, Hosking D, Devogelaer JP, et al. Ten years’ experience with alendronate for osteoporosis in postmenopausal women. N Engl J Med. 2004;350:1189–99.PubMedCrossRefGoogle Scholar
  14. 14.
    Watts NB, Josse RG, Hamdy RC, et al. Risedronate prevents new vertebral fractures in postmenopausal women at high risk. J Clin Endocrinol Metab. 2003;88:542–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Black DM, Delmas PD, Eastell R, et al. Once-yearly zoledronic acid for treatment of osteoporosis. N Engl J Med. 2007;356:1809–22.PubMedCrossRefGoogle Scholar
  16. 16.
    Leslie WD, Lix LM. Manitoba bone density program, simplified 10-year absolute fracture risk assessment: a comparison of men and women. J Clin Densitom. 2010;13:141–6.PubMedCrossRefGoogle Scholar
  17. 17.
    Fitzpatrick LA. Secondary causes of osteoporosis. Mayo Clin Proc. 2002;77:453–68.PubMedGoogle Scholar
  18. 18.
    Tannenbaum C, Clark J, Schwartzman K, et al. Yield of laboratory testing to identify secondary contributors to osteoporosis in otherwise healthy women. J Clin Endocrinol Metab. 2002;87:4431–7.PubMedCrossRefGoogle Scholar
  19. 19.
    Ryan CS, Petkov VI, Adler RA. Osteoporosis in men: the value of laboratory testing. Osteoporos Int. 2011;22:1845–53.PubMedCrossRefGoogle Scholar
  20. 20.
    • Ross AC, Manson JE, Abrams SA, et al. The 2011 report of dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. J Clin Endocrinol. 2011;96:53–8. This is the short version of the IOM report on calcium and vitamin D intake. It is based on a thorough review of the literature on the effects of dietary/supplemental calcium and vitamin D on bone health. CrossRefGoogle Scholar
  21. 21.
    • Holick MF, Binkley NC, Bischoff-Ferrari HA, et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011;96:1911–30. This review of vitamin D provides recommendations for vitamin D that are somewhat different from those of the IOM. For the patient with osteoporosis and/or fracture, the authors provide a rationale for a higher vitamin D target. PubMedCrossRefGoogle Scholar
  22. 22.
    Saag KG, Zanchetta JR, Devogealer J-P, et al. Effects of teriparatide versus alendronate for treating glucocorticoid-induced osteoporosis: thirty-six month results of a randomized, double-blind, controlled trial. Arthritis Rheum. 2009;60:3346–55.PubMedCrossRefGoogle Scholar
  23. 23.
    Adler RA, Gill RS. Clinical utility of denosumab for treatment of bone loss in men and women. Clin Interven Aging. 2011;6:1–6.Google Scholar
  24. 24.
    • Jennings LA, Auerbach AD, Maselli J, et al. Missed opportunities for osteoporosis treatment in patients hospitalized for hip fracture. J Am Geriatr Soc. 2010;58:650–7. This review demonstrates just how few hospitalized fracture patients receive treatment for underlying osteoporosis. PubMedCrossRefGoogle Scholar
  25. 25.
    •• Majumdar SR. A T-2 translational research perspective on interventions to improve post-fracture osteoporosis care. Osteoporos Int. 2011;22 Suppl 3:S471–6. This recent review provides information on programs to improve post-fracture management in Canada. CrossRefGoogle Scholar
  26. 26.
    Streeten EA, Mohamed A, Gandhi A, et al. The inpatient consultation approach to osteoporosis treatment in patients with a fracture. Is automatic consultation needed? J Bone Joint Surg Am. 2006;88:1968–74.PubMedCrossRefGoogle Scholar
  27. 27.
    Glowacki J, Harris MB, Simon J, et al, Brigham fracture intervention team initiatives for hospital patients with hip fractures: a paradigm shift. Int J Endocrinol 2010, 590751.Google Scholar
  28. 28.
    •• Newman ED. Perspectives on pre-fracture intervention strategies: the Geisinger Health System osteoporosis program. Osteoporos Int. 2011;22(Suppl3):S451–5. The Geisinger Clinic has instituted a screening program to prevent fractures and to evaluate and treat those who have already fractured. They show the positive consequences of such a program. CrossRefGoogle Scholar
  29. 29.
    •• Dell R. Fracture prevention in Kaiser Permanente Southern California. Osteoporos Int. 2011;22 Suppl 3:S457–60. Southern California Kaiser Permanente has been in the forefront in providing programs to identify patients at risk for fracture or having had an osteoporotic fracture. This review demonstrates the many benefits of such a program. CrossRefGoogle Scholar
  30. 30.
    Rosen CJ, Khosla S. Placebo-controlled trials in osteoporosis – proceeding with caution. N Engl J Med. 2010;363:1365–7.PubMedCrossRefGoogle Scholar
  31. 31.
    Majumdar SR, Johnson JA, Bellerose D, et al. Nurse case manager vs. multifaceted intervention to improve quality of osteoporosis care after wrist fracture: randomized controlled pilot study. Osteoporos Int. 2011;22:223–30.PubMedCrossRefGoogle Scholar
  32. 32.
    •• McLellan AR, Wolowacz SE, Zimovetz EA, et al. Fracture liaison services for the evaluation and management of patients with osteoporotic fracture: a cost-effectiveness evaluation based on data collected over 8 years of service provision. Osteoporos Int. 2011;22:2083–98. The FLS instituted in many UK hospitals has been proven to be a cost-effective method to decrease further fractures, prevent suffering, and save money. PubMedCrossRefGoogle Scholar
  33. 33.
    Kannegaard PN, van der Mark S, Eiken P, Abrahamsen B. Excess mortality in men compared with women following a hip fracture: national analysis of co-medications, co-morbidity, and survival. Age Ageing. 2010;39:203–9.PubMedCrossRefGoogle Scholar
  34. 34.
    Beaupre LA, Morrish DW, Hanley DA, et al. Oral bisphosphonates are associated with reduced mortality after hip fracture. Osteoporos Int. 2011;22:983–91.PubMedCrossRefGoogle Scholar
  35. 35.
    •• Center JR, Bliuc D, Nguyen ND, et al. Osteoporosis medication and reduced mortality risk in elderly women and men. J Clin Endocrinol Metab. 2011;96:1006–14. Amid all the many reports of side effects of bisphosphonates, this review demonstrates that overall mortality is lower in people taking bisphosphonates. PubMedCrossRefGoogle Scholar
  36. 36.
    Sambrook PN, Cameron ID, Chen JS, et al. Oral bisphosphonates are associated with reduced mortality in frail older people: a prospective five-year study. Osteoporos Int. 2011;22:2551–6.PubMedCrossRefGoogle Scholar
  37. 37.
    Bunta AD. It is time for everyone to own the bone. Osteoporos Int. 2011;22 Suppl 3:S477–82.CrossRefGoogle Scholar
  38. 38.
    Adler RA, Semla T, Cunningham F, Pogach L, The VHA male osteoporosis program – a national model for bone health, submitted for publication.Google Scholar

Copyright information

© Springer 2012

Authors and Affiliations

  1. 1.Endocrinology and Metabolism Section, McGuire Veterans Affairs Medical CenterRichmondUSA
  2. 2.Departments of Internal Medicine and of Epidemiology and Community HealthVirginia Commonwealth University School of MedicineRichmondUSA

Personalised recommendations