Assessing Fracture Risk Dr Damien Gormley

1. Assessing Fracture Risk
QFracture®
-2016 risk calculator:

2. NICE-CG 146 Osteoporosis: assessing the risk of
fragility fracture Feb 2017
Targeting risk assessment
o In all women aged 65 years and over and all men aged 75 years and over
o in women aged under 65 years and men aged under 75 years in the
presence of risk factors, for example:
 previous fragility fracture
 current use or frequent recent use of oral or systemic glucocorticoids
 history of falls
 family history of hip fracture
 other causes of secondary osteoporosis[7]
 low body mass index (BMI) (less than 18.5 kg/m2
)
 smoking
 alcohol intake of more than 14 units per week for women and more than 21 units
per week for men.

3. SIGN 142 Management of osteoporosis and prevention of
fragility fractures March 2015

4. http://qfracture.org

5. FRAX: (www.shef.ac.uk/FRAX)

6. FRAX - cautions
• Underestimates fracture risk for dose dependant variables e.g.
 smoking,
 alcohol,
 multiple fractures,
 glucocorticoids
• Underestimates risk if
 previous clinical vertebral fracture
 vertebral fracture risk if lumbar BMD low
 Very elderly
• Not accurate for patients on treatment
• Does not include falls risk (qfracture.org.uk includes falls)

7. Relationship Between BMD and
Fracture Risk
T–score
–1SD
2 x
SD – Standard deviation
1. Watts NB. Oral Presentation at ASBMR 2001.
%patientswithvertebral
fractures
0
5
10
15
20
25
30
35
-5 -4 -3 -2 -1 0

9. 1. Black DM, et al. J Bone Miner Res 1999; 14(5):821–828. 2. McClung M, et al. JAMA 1999; 282(7):687–
689. 3. Ross PD, et al. Osteoporos Int 1993; 3:120–126.
5.4
4.5
7.4
0
1
2
3
4
5
6
7
8
Study of
Osteoporotic
Fractures1
MORE2 Ross et al, 19933
RelativeRisk
Presence of Previous Vertebral
Fracture Increases the Risk of
Future Vertebral Fracture

10. Case 1
45 year old lady - No risk Factors
Requests a bone density scan
1. Send for DXA
2. Fracture risk assessment
3. Do Nothing

13. Case 2
79 year old lady who had fallen-No other risk factors
1. DXA
2. Fracture Risk
3. Do nothing

14. Case 3
• 54 year old lady
• Fractured wrist
• BMI 21
• Maternal hip fracture
1. DXA
2. Fracture Risk
3. Do nothing

15. T-Score Total hip -2.4

16. Case 4
61 year old lady Primary prevention

17. Treatment Benefit Depends on Absolute Risk
Treatment X is associated with a 50% RRR in event rate
Treat 100 patients at 10 % risk over 10 years
90 don’t have an event
– Of 10 who would have an event
– 5 still do
– 5 events prevented
(1 in 20 chance of benefit)

18. Case 5
•A 78 year old lady
•Fractured distal radius
•PMR on steroids several years now 2.5mg
daily
•Wedge fractures noted on thoracic
radiographs 2016
•Treatment not previously prescribed

19. Case 5

20. Case 6
64 year old lady
Fractured wrist
Compression fractures several lumbar and thoracic
vertebrae most severe at T10 & T12
Intolerant of bisphosphonates

21. Case 6