The document summarizes a meeting of the FLS Champions' Summit in 2016. It discusses updates on the implementation of Fracture Liaison Services (FLS) across the UK, priorities for improving osteoporosis services, and new developments for 2016 including best practices for identifying vertebral fractures. The National Osteoporosis Society's plans for 2016 aim to increase coverage of FLS and improve their quality. The meeting provided information on tools and support available to help establish and improve FLS, including implementation workshops, clinical standards, and a cost and workforce calculator. An audit presented at the meeting found some gaps in investigating patients and shortfalls in the numbers being seen by FLS compared to expected fractures.

1. FLS Champions’
Summit 2016
5th February 2016

2. FLS Implementation
Update
Hilary Arden, Head of Service Delivery
5th February 2016

3. National Osteoporosis Society
Priorities and Plans for 2016
Aim 1:
Every person aged over 50 who breaks a
bone is assessed for osteoporosis and
managed appropriately.
Priority 1:
Extend coverage of Fracture Liaison Services
Priority 2:
Improve quality of Fracture Liaison Services
and osteoporosis services

4. New for 2016…
Develop and implement best
practice for identification and
management of vertebral
fractures

5. • FLS Implementation Group
• FLS Implementation Toolkit
• FLS Implementation Workshops
• UK FLS Clinical Standards
• Fracture Prevention Practitioner (FPP) Training
• Peer Review
• Service Delivery Team support
A National Approach to FLS

6. Service Delivery Team
Sonya Stephenson
Service Development
Project Manager
Will Carr
Service Development
Project Manager
Hilary Arden
Head of
Service Delivery
Tim Jones
Commissioning
Advisor
Mayrine Fraser
Service Development
Project Manager
Debbie Stone
Service Development
Project Manager
Fiona Gardner
Operation Projects
Officer
Henry Mace
Professional
Development Lead
Jo Sayer
Service Development
Project Manager

7. • Facilitate stakeholder engagement
• Help establish patient/care pathway
• Project manage commissioning/funding:
o The economic and business case
o Service specification
o Resource and capacity planning
• Work with commissioners to ensure services
are sustained.
How We Help

10. FLS Cost & Workforce Calculator
• Additional resource within the FLS-IT
• Designed for use by clinicians and Health
Boards to help develop an FLS
• Provides the ‘cost’ side of a cost/benefit table
for the FLS business case
• Uses estimates of fracture numbers either
from local audit or from using the FLS
Benefits Calculator
• Outputs: the numbers of staff, DXA, follow-
ups etc. required, bespoke to the service.

11. FLS Implementation Workshops
2 workshops planned for 2016:
South Central & NE London
Rebecca Gear, Osteoporosis specialist
nurse practitioner, Care UK: “I feel
confident in going forward and have a plan
in mind. A must have workshop when
wanting to start an FLS.”
Dr Madhavi Vindlacheruvu, Consultant
Orthogeriatrician, Cambridge
University Hospitals: “Excellent to be
able to present 1st draft of business case.
Great expertise and support, really well
organised.”

12. • Provide input to support the development of
an FLS to meet the Clinical Standards
• Identify gaps in service provision, put in place
improvement plans and monitor against
agreed actions
• Help establish data collection, analysis,
evaluation and reporting
• Peer review.
How We Help

13. UK FLS Clinical Standards
Summary of Standards
CRITERIA RATIONALE MEASURES OUTCOMES
Identification
1 All patients aged 50 years and over with a new fragility
fracture or a newly reported vertebral fracture, whether
managed as inpatients or outpatients, will be systematically
and proactively identified.
Patients who have sustained a
fracture are at higher relative risk of
fracture than those who have not.
Targeted interventions in this
population will have most impact on
reducing future fracture burden.
Proportion of fracture patients aged
over 50 years identified by the FLS.
Denominator for all fragility fractures
can be best estimated by multiplying
total hip fractures in over 50 year
olds by 5 (1).
Systematic identification of at
risk patient population who
would benefit from investigation.
Investigation
2 Patients will have a bone health assessment and their need
for a comprehensive falls risk assessment will be evaluated
within 3 months of the incident fracture.
Assessments need to be conducted
promptly as the risk of having a further
fracture is increased in the first year.
% of identified patients who have a
bone health assessment within 3
months of incident fracture.
% of identified patients who have
their need for a falls risk assessment
evaluated within 3 months of
incident fracture.
Improved identification of the
population who will benefit from
interventions leading to
appropriate targeting of
resources.
Information
3 All patients identified will be offered written information about
bone health, lifestyle, nutrition and bone-protection
treatments.
Anyone aged over 50 years who has
had a fracture needs to be aware of
the steps they can take to maintain
healthy bones.
% of identified patients given
information.
Improved patient understanding
leading to confident self-
management and engagement
with recommended
interventions.
Intervention
4 Patients at risk of further fracture will be offered appropriate
bone-protection treatments.
Appropriately targeted interventions
reduce future fracture risk.
% of assessed patients offered
bone-protection treatment.
The right people receive the
right interventions for bone
health and falls leading to
reduced fracture risk and fewer
fractures.
Patient mobility and
independence is maintained.
5 Patients at risk of further falls will be offered appropriate
assessment or interventions to reduce future falls.
Evidence-based falls interventions are
effective at reducing falls risk.
% of assessed patients offered
referral for assessment or an
intervention.

14. Gap Analysis

15. Fracture Prevention Practitioner
(FPP) Training
• Officially launched April 2015 @ BSR
• 420 healthcare professionals registered
• 98 accredited FPPs
• Accessed by 91 different hospital trusts and
GP practices
• Endorsed by 10 leading educational and
professional bodies
• Accessed from across 15 different countries
(US, AUS, NZ, SA, CA, ROI, FR)

16. 16
Peer Review
• A means of assessing clinical care against agreed
standards
• Addresses agendas of clinical governance, practitioner
revalidation, and service development
• Facilitates a quality assured level of care for patients
with osteoporosis and metabolic bone diseases.

17. 17
FLS Coverage England NI/IOM Scotland Wales UK
2015
FLS Coverage
47/141
(33%)
4/6
(80%)
7/14
(50%)
6/11
(55%)
64/171
(37%)
Supporting new
service
development
38 0 2 4 44
Supporting
quality
improvement
40 6 12 6 64
Number of
additional sites
in contact
31 3 2 6 42
Total/Potential
number of FLS
109/141
(77%)
9/9
(100%)
16/16
(100%)
16/16
(100%)
150/182
(82%)
No. of services
commissioned
7 0 0 0 7
FLS Implementation
To Date

18. 18
FLS Mapping

19. FLS Benefits
Area Population Cohort
(50+)
Hip
fractures
prevented*
Total benefits
(of hip fractures
prevented)*
Bradford 459,142 129,011 119 £1,960,644
East Sussex 374,801 167,905 188 £3,097,488
Epsom 405,456 119,974 115 £1,894,740
Rotherham 258,751 96,591 66 £1,111,902
Salisbury 144,835 59,786 59 £972,084
Stoke-on-Trent 214,991 88,334 88 £1,449,888
Vale of York 348,363 131,411 128 £2,108,928
Total 2,206,339 793,012 763 £12,595,674
*Over a 5 year period

20. 20

21. FLS Cost & Workforce
Calculator
Tim Jones
Commissioning Advisor
5th February 2016

22. FLS Cost & Workforce Calculator
This tool has been designed for use by NHS hospitals,
community services and commissioning organisations
to help develop a local FLS. The calculator will enable
you to estimate the costs required to implement or
improving an FLS…

23. Commissioning a Fracture
Liaison Service
Salisbury District Hospital
Dr Zoe Cole
5th February 2016

24. History
2002 Heel ultrasound
2007 DXA machine
2007 First business case for FLS
2011 3rd business case rejected (QOF)
2013 New Consultant started

25. Performance against
Best Practice Tariff
2009-2010
(£445 per patient)
1.5%(2)
Ranked 98th out of
100 hospitals.
Income: £890
2010-2011
(£890)
58%(131)
Ranked 12th out of
the 176 hospitals.
Income: £116,590
2011-2012
(£890)
84.7% (205/242)
Ranked 1st in the
Southwest
Region, Ranked
4th Nationally
(out of more than
200 NHS Trusts)
Income: £187,790

26. Outcomes
• BEST PRACTICE TARIFF % for 2012-2013: 85.7%
(220/257)
• Length of stay reduced by 7.82 days from 27.6
days to 20.09 days (April 2012-March 2013)
• £509,960 saved: 2,549 bed days at £200 per day
• Mortality reduced from 10.1% to 7.4%
• Re-admissions reduced from 4 (2010/11) to 2
(2011/12)
• Positive Feedback from patients, families and staff.
(Real time feedback and very few complaints)

27. Bone protection on
admission
Area %
Slough 22.2
Oxford 21.4
Basingstoke 14.8
Southampton 14.4
IOW 10
Milton Keynes 9.4
Stoke Mandeville 9.1
Reading 8.3
Salisbury 3.2
Portsmouth 5.2

29. Salisbury experience
pre and post QOF
2011 Audit
• 56% not investigated
• 24% on treatment
• 6% re-fractured (2 hip)
2013 Audit
• 56% not investigated
• 12% treatment
• 6% re-fractured
50 patients who presented with colles fractures followed up
at 6 months with telephone call to assess what treatment
they were on.

30. 2013
New business case put together
 Help from business writing course
 Health economist
 HES data
 Dr Foster data
 Previous local and national audit
 DoH FLS economic case

31. 2014
• Case presented to Primary care forum
• Presented at Sarum CCG meeting
Full support
• Refused at Wiltshire CCG executive meeting
Economic benefits not great enough

32. Public Health
• Wiltshire Falls and Bone health group
External report by NHS England
First priority FLS
£30,000 promised 2015/16 only

33. NOS Dec 2014
• Discussed case with Tim Jones
Strong case
NOS writing new economic model
Salisbury test case

34. 2015
• Jan-Feb: Met with CCG
Decided case fitted with Better Care Fund
Whole new case written (new templates)
Year
2015 2016 2017 2018 2019 All years
Net benefit
(NHS
only)
-£25,634 £77,751 £183,081 £270,574 £346,759 £852,531
Net benefit
(NHS
and
social
care)
£61,833 £238,523 £419,539 £570,903 £703,858 £1,994,655

35. Progress to date
• March: Presented to Better Care
Pilot funding given for 2 years (verbal)
• August: written confirmation
• Nov: FLS nurse started
• Jan 2016: FLS live

36. McLellan et al. Osteporos Int 2003;14:1028–1034 36

37. Thank you
Tim Jones
Hilary Arden
Fizz Thompson
Sonya Stephenson
Kassim Javaid
Friscy
Lynn Talbot
Stuart Eastman
All colleagues at SDH

38. FLS Champions’: FLS DB audit
MK Javaid
Academic Rheumatologist
University of Oxford

39. Important confidentiality notice
• Data shared is for this meeting only
• No photography
• Information being shared is not for publication on
social media or in other form
• No handouts or post meeting slides
• Release date for audit is 10th May 2016

40. FLS-DB Work-stream
Clinical Lead: Dr M Kassim Javaid
RCP Leads: Naomi Vasilakis (project manager), Rowena Schoo (project co-ordinator),
Sunil Rai (data coordinator), Roz Stanley (programme coordinator)
Constituency
RCGP -Jonathan Bailey, David Stephens
BGS – Frances Dockery, Rachael Bradley
Orthogeriatrics - Celia Gregson
BOA – Xavier Griffin
BES - Neil Gittoes
BSR - Gavin Clunie
NOS - Anne Thurston/ Sonya Stephenson
RCN - Debbie Janaway
RCS - David Cromwell, Carmen Tsang
Patients – Susie, Iona
Crowne - Jonathan Roberts

41. Process
• FLS-DB Facilities audit
• The FLS-DB audit – patient centred

42. FLS Breakpoint Audit
Opportunities for improving the
quality and efficiency of patient care
to prevent recurrent fragility fractures

43. Identification (52/85 had FLS)

44. Identification: case mix
England
FLS n
England
FLS %
Wales
FLS n
Wales
FLS %
Outpatient Clinic 45 93.8 4 100.0
+Non-hip inpatients 24 50.0 3 75.0
+Hip inpatients 23 47.9 2 50.0
+Clinical vertebral 19 39.6 2 50.0
+ Incidental vertebral 10 20.8 2 50.0

45. Investigation: evidence of chaos?
England
FLS n
England
FLS %
England
non FLS
n
England
non FLS
%
Wales
FLS n
Wales
FLS %
Wales
non FLS
n
Wales
non FLS
%
Renal function tests 41 85.4 19 73.1 4 100.0 1 25.0
Serum Calcium 40 83.3 18 69.2 4 100.0 1 25.0
Liver function tests 38 79.2 18 69.2 4 100.0 1 25.0
Full blood count 37 77.1 19 73.1 2 50.0 1 25.0
Serum alkaline phosphate 37 77.1 17 65.4 4 100.0 1 25.0
Serum phosphate 37 77.1 15 57.7 4 100.0 1 25.0
Thyroid function 37 77.1 16 61.5 4 100.0 1 25.0
Serum 25OH vitamin D 36 75.0 16 61.5 3 75.0 1 25.0
Erythrocyte sedimentation rate /
ESR Liver function
29 60.4 9 34.6 1 25.0 1 25.0
Coeliac disease screen 28 58.3 6 23.1 3 75.0 1 25.0
Serum Electrophoresis for
myeloma screen
27 56.3 15 57.7 4 100.0 1 25.0
Serum Parathyroid hormone 26 54.2 12 46.2 3 75.0 1 25.0
Testosterone/ Sex hormone
binding globulin
24 50.0 9 34.6 4 100.0 1 25.0
C-reactive protein 20 41.7 11 42.3 2 50.0 0 0.0
Other 16 33.3 6 23.1 0 0.0 1 25.0
Missing 6 12.5 6 23.1 0 0.0 2 50.0
24 hour urinary calcium 3 6.3 2 7.7 0 0.0 0 0.0
Spot urinary calcium 3 6.3 1 3.8 0 0.0 0 0.0

46. Identification: Observed vs
Expected

47. Service structure: FLS nurse time and
Estimated fragility fractures

48. Overview
• Shortfall in numbers being seen
• Shortfall in FLS size to meet the demand
• Variation in
– Case mix
– Investigations
– Reporting
– Monitoring

49. Service review
to close any
care gap
Identification
Investigation
Initiation
Information
Monitoring
Site specific report
ON KEY indicators
RCP
FLS site
CCG/ LHB
In patients
Hip fracture
Clinical spine
Incidental spine
Blood panel
Falls questions
2nd line bone drugs
Strength and balance class
Standard report
Data management / upload to FLSDB audit
Scope
Timing

50. Process
• FLS-DB Facilities audit
• The FLS-DB audit – patient centred

51. FLS-DB audit: overview
• Identification
• Investigation
• Initiation
• Monitoring for prescribing
• Re-fracture/ re-falls
AIM: Ensure the FLS works for its patients
Objective: To describe the pathway of patients
Method: Monthly patient audit upload vs. direct data entry

52. FLS-DB audit: update
• Clinical dataset approved and online
• Direct Web entry on Monday
• NOS supporting – excel spreadsheet
• First upload in March 2016
• Final upload in October 2016

53. Assessed, 2+ falls, fear, At risk drugs
pre fracture mobility, vision
continence, abnormal cardiovascular
cognitive, Referrals
Age, gender
Post code, Care home status
Fracture – hip, spine, nonhip/spine
Dates
Fracture diagnosed
FLS identified, assessedHeight & weight
Previous fragility fractures
Family history
Smoking
On anti-osteoporosis therapy
FLS-DB Audit:
Patient identifiers
Bone risk factors
Ordered, Date
Lowest T score, Frax
/ QFracture
Bone therapy
Calcium and D
Initiation
DXA
Falls

54. FLS-DB Audit
Date
Started bone / CaD
Started strength and balance
4 month
Date
On bone / CaD
Refracture
Re-falls
12 month

55. Get the data to RCP
1. Direct web entry
2. Upload monthly

56. www.fffap.org

60. •

61. Uploaders
• Initial effort
– Updating data collection tools
– Updating database
• Medium long term benefits
– Standardized core assessment
– Comparability with other services
– No duplicate data entry

62. Uploaders
Download core dataset document and excel
Check against their local dataset
Amend and align dataset and collection
Select fracture data dates
Export as csv using filename OxfordFPS2016v1.0.csv
Upload using web-tool to RCP monthly

63. Why monthly upload?

64. Assessed, 2+ falls, fear, At risk drugs
pre fracture mobility, vision
continence, abnormal cardiovascular
cognitive, Referrals
Age, gender
Post code, Care home status
Fracture – hip, spine, nonhip/spine
Dates
Fracture diagnosed
FLS identified, assessed
Re-fracturesHeight & weight
Previous fragility fractures
Family history
Smoking
On anti-osteoporosis therapy
FLS-DB run charts
Patient identifiers
Bone risk factors
Ordered, Date
Lowest T score, Frax
/ QFracture
Bone therapy
Calcium and D
Initiation
DXA
Falls
Date
On bone / CaD
Refracture
Re-falls
Mortality
12 month
Date
Started bone / CaD
Started strength and balance
Mortality
4 month

65. Fracture diagnosis
FLS-DB run charts
DNA by age and genderTime interval
FLS contact
FLS Assessment
DXA date
4 month monitoring
FLS assessment
DXA
4 month monitoring

66. Patient
Effective
Care
pathway
Reduce
Avoidable
Fractures
+ =
✓
Data that the FLS has closed the care gap

67. FLS-DB run charts: suggestions
form launch meeting
Numbers and percentages of each of
1. Fracture details (type of fracture/re-fracture – particularly spinal (5), repeat
fractures (3), local v national re-fracture rates)
2. Treatment & assessment (FRAX, DXA (5), treatment recommended (4), still
compliant (2), not started (5) at 4 months (4), intolerant, followed up at 4m and
12m (2), mortality)
3. Time between
• Fracture to
– Diagnosis (2)
– DXA date (5)
– FLS assessment (5) within 4 weeks?
– FLS first contact
– Treatment (4)
• Identification by FLS to DXA date (2)
• First contact by FLS and assessment
• Referral to treatment
• Time to be seen from referral to FLS
4. Falls (S&B, risk assessment (2) , falls in past 12 months, referred to falls clinic (3))
5. Site adherence to each relevant FLS standards data being collected on in the
database

68. FLS-DB run charts: suggestions
form launch meeting (continued)
Numbers and percentages of each of
6. Patient info / FLS processes
– Informed decline (3)
– DNAs (3) - By age and gender
– No response to further contact
– Patients seen /inputted (3)
– Patients assessed at 8 weeks (2)
– Patients attended
– Residence (4)
– Admitted as outpatients
– Age (4)
• Average age
• Age at time of fracture (3)
– Gender (2)
– Family history
– Postcode

69. LUNCH
See you back here at 13.30

70. Vertebral fractures – missed
opportunities: The role of the
Radiology Department in correcting
this!
Andrew Pearson
NHS Borders, Scotland

71. Overview
• Significance of vertebral fractures
• Hip fracture audit
• Poor performance of Radiology
• Opportunities in Radiology to improve
fracture liaison
• Input from DEXA

72. Requirements for effective Secondary
Fracture prevention
• Effective mechanism for identification of
first fragility fracture
• Effective communication with clinicians
responsible for instigating treatment &
follow up

73. Why is a Radiologist so ‘enthusiastic’
about vertebral fractures?
• Highly predictive of future fracture risk
• Account for significant morbidity and mortality
• So common that they are often overlooked as
‘incidental’ findings
• Readily available golden opportunity to identify
patients requiring bone protecting medication
• Identification makes a real contribution to
reducing incidence of hip fractures
• Fragility fracture progression can be halted by
early identification, saving patient misery
• Represent a huge financial burden on NHS

74. Scottish Parliament. Written question
in 2012 asking number of Hip &
Vertebral Fractures, by health board
• Answered by Health Minister Nicola Sturgeon (now
first minister)
• Scottish Borders: 6 vertebral fractures per year!
• Real local experience: more like 6 a day!
• Most insufficiency vertebral fractures are not
included in collected data

75. What makes vertebral fractures
different?
• Most do not present acutely
• Many go undiagnosed (50-70%, ref. NICE TA161)
• Inrcremental process
• Often arise in absence of specific trauma
• Highly predictive of skeletal ‘fragility’
• Potentially the most important fractures to identify
• Account for chronic pain and morbidity
• Must be actively ‘looked for’

76. Vertebral Fractures Substantially
Increase
the Risk of New Fragility Fractures
A woman with one vertebral fracture has
a 4.4 times increased risk of another
vertebral fracture and 2.3 times
increased risk of hip fracture (NICE TA161)
One woman in five will suffer from
another vertebral fracture within a year
(Lindsay et al., JAMA, 2001)
Women with low BMD and one fracture
have a 25x risk of a women with normal
BMD and no fracture

77. Incidence Rates for Vertebral,
Wrist & Hip Fractures in Women
after Age 50
Wasnich RD, Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. 4th
edition, 1999
50 60 70 80
40
30
20
10
Vertebral
Hip
Wrist
Age (Years)
Annualincidenceper
1000women

78. Osteoporotic Fractures in
Women:
Comparison with Other
Diseases
Riggs BL, Melton LJ. Bone 1995
Heart and Stroke Facts, 1996, American Heart
Association
Cancer Facts & Figures, 1996, American Cancer
Society
1 500 000*
0
500
1000
1500
2000
Osteoporotic
Fractures
*annual incidence all ages
† annual estimate women 29+
‡annual estimate women 30+
§1996 new cases, all ages
513 000†
228 000‡
184 300§
750 000
vertebral
250 000
other sites
250 000
forearm
250 000
hip
Heart
Attack
Stroke Breast
Cancer
Annualincidencex1000

79. All Types of Vertebral Fractures
are Associated With Morbidity
Nevitt MC et al., Arch Intern Med.2000,
160:77
Limited Activity
Bed Rest
0
25
50
75
100
Patients(%)
No Incident
Fracture
Radiographic
Fracture
Clinical
Fracture
36.8
3.9
76.2
26.9
93.2
52.7
Due to back pain

80. NICE TA161
Vertebral fractures are associated with a
4.4% increased mortality (UK specific data)

81. Mortality Rates by
Number of Prevalent
Vertebral Fractures
Kado DM et al., Arch Intern Med 1999,159:1215
P for trend < 0.001
Mortality
(per1000person-years)
0
5
10
15
20
25
30
35
40
0 1 2 3 4 5+
Number of Vertebral Fractures
45

82. Vertebral fracture morbidity
• Chronic pain from multiple ‘incremental’
fractures
• Exaggerated kyphosis
• Cause reduced mobility, leading to further
bone loss
• Impact on respiratory reserve, especially in
COPD patients
• Significant increase in GP visits

83. Vertebral Fractures in
Summary
 are the most common osteoporotic fractures
 are associated with excess mortality
 are associated with significant morbidity, even if they do
not come to clinical attention
 increase the risk of subsequent vertebral fracture(s) by 5
fold and of other fragility fractures (including hip) by 2
fold
 highly predictive of future fracture risk due to the relative
absence of trauma in their causation

84. A Retrospective Study Suggests that
Vertebral Fractures are underdiagnosed
Gehlbach et al.,Osteoporos Int 2000,
11:577
934 hospitalised women with
a lateral chest x-ray
0
20
40
60
80
100
120
140
Patients(n)
132
65
23 25
Fracture
identified
by study
Radiologists
Fracture
noted in
Radiology
report
Fracture
noted in
medical
record
Received
Osteoporosis
treatment

85. Borders hip/vertebral fracture audit
• 202 hip fractures in 2010
• 56 (28%) had body CT in previous 5 years
• 22 (39%) CTs showed vertebral fractures
• 9 (40%) of 22 vert. fractures documented, 13
(60%) missed
• 13 potentially preventable hip fractures in 2010
(£520,000!)

86. Missed vertebral fractures on whole body CT

87. Messages from audit
• High prevalence (39%) of all CTs showed
vertebral fractures
• 60% visible vertebral fractures were overlooked
• Radiologists need to do better at alerting these
fractures to the FLS team
• Increasing general use of CT will further increase
opportunities to identify vertebral fractures
• Same opportunities available in MRI
• This is opportunistic, without additional resource
requirement, using image data which is already
available
• Change in practice of Borders Radiologists has
contributed to 20% reduction in hip fractures
between 2010 & 2014

88. Opportunities in Radiology
• All clinical and many ‘occult’ vertebral fractures
pass through Radiology
• Radiology has instant access to previous fracture
history and previous DEXAs (including referral
forms)
• Easy imaging of spine (IVA, plain films, CSI)
• Computerised records for easy searching
• Opportunistic ‘cross sectional data’ : CT & MRI
• Identification of demineralisation on plain films
• Isotope Bone Scanning
• High fracture risk patients with cancer
treatment induced bone loss

89. CT & MRI data
• Large patient throughput
• High Osteoporosis risk patients
• No amendment to scanning protocol
• Instant reconstructions when reporting
• Access to previous records (fracture history,
DEXAs etc..)
• Smart code referral to FLS or straight to
DEXA

90. CTPAs

91. DEXA SCANNING
Importance of Vertebral
Morphometry

92. Lateral Vertebral
Assessment

93. Combining BMD & Vertebral Fracture
Assessment:
An Approach to Improve the Diagnosis
Rate of Vertebral Fractures
 Improves risk assessment
 Identification of occult fractures
 Identification of scoliosis
 Identification of artefacts

94. Poor quality IVA?
• Plain films (at same attendance)
• CT (baseline & follow up)

95. Differential diagnosis of vertebral
fractures
• Osteoporotic fragility fracture
• Myeloma
• Metastases
• Scheurmann’s disease
• Schmorl’s nodes
• Sickle cell disease, Gaucher’s disease

96. How can Radiology help
reduce Osteoporotic fractures?

97. Why in Radiology?
• Only location for identification of all vertebral
fractures
• Integration with non vertebral fractures keeps all
FLS data together
• Access to previous imaging & DEXA to assess
age and significance of fractures
• Assessment of alternative causes of insufficiency
fractures

98. Administrative process in Radiology,
NHS Borders
• Reporting Radiologist/Radiographer describes fracture
and dictates “insert fragility fracture”
• Text string inserted as suffix to report indicating that
patient may be at increased risk of further fractures and
will be assessed by the Osteoporosis team
• Radiology Office books these in as “Fracture Liaison”
examinations, with other fracture liaison cases
• Osteoporosis Radiologist/Clinician assesses case
(access to previous DEXA, fracture history, osteoporosis
clinic attendances, current drug treaments) and decides
on need to recall for DEXA or go straight to treatment
• Text string in report will automatically generate a DEXA
referral or standard text recommending treatment

99. Requirements for success:
1. Understanding amongst Radiology team members of
huge importance of identifying occult vertebral
fractures
2. Simple mechanism for reporting Radiologist or
Radiographer to identify and highlight presence of
vertebral fractures on cross sectional and other
imaging
3. Mechanism for ensuring that this information is passed
to the Fracture Liaison team for further action

100. Message for Radiologists
• 11% of hip fractures are dead within 30
days
• 40% of hip fracture patients who previously
lived independently in their own home end
up in institutional care
• Hip fractures cost £40,000 each
• Many hip fractures can be prevented

101. Why Radiology needs to act now!
• Nobody else is in such a good position to help
identify patients at risk of hip fracture
• Requires minimal time & effort
• 30 seconds to save a life!
• Failure to act when such obvious ‘incidental’
pathology is present on scan could be seen as a
clinical incident
• All you need to do is:
click of the mouse to show sagittal image
brief look at this image
dictate a few words (e.g.: there are several mid
thoracic vertebral fractures, “insert fragility
fracture”)

102. QUESTIONS

103. FLS Champions’ Summit
Management of Acute Vertebral
Fractures
Professor Opinder Sahota
Consultant Physician
QMC, Nottingham University Hospitals

104. Vertebral Fragility Fractures (VFF)
KyphoticNormal

105. Location of Vertebral Fractures
1. Nevitt MC et al. Bone. 1999;25:613–619.
2. Cooper C et al. J Bone Min Res. 1992;7:221–227.
Are most commonly located at the
midthoracic region (T7–T8) and the
thoracolumbar junction (T12–L1)1
– Midthoracic region–thoracic kyphosis is most
pronounced and loading (stress) during flexion
is increased
– Thoracolumbar junction–the relatively rigid
thoracic spine connects to the more freely
mobile lumbar segments2

106. Progressive Kyphosis & Spine
Compensation
• Impairs gait and mobility
• Para spinal muscle fatigue
• Increases strain on
posterior facet joints
Back Pain
Knee flexion and contraction
of the posterior muscles of
the lower back to tilt the hips

107. Long-term Consequences

108. Acute Fracture

109. Acute Fracture :
Optimise Pain Control
• Paracetamol
• Tramadol
• NSAIDs
• Fentenyl
• Buprenorphine

110. Acute Fracture :
Imaging

111. DXA

112. •
•
•
•
• •
Osteoporosis-Imaging
Lateral
Vertebral
Assessment
•
•

113. Vertebral Fragility Fractures
Genant HK et al. J Bone Miner Res. 1993;8:1137–1148.
Severe
(≥40%
height loss)
Normal Wedge Biconcave Crush
Moderate
(25-40%
height loss)
Mild
(20-25%
height loss)
Measurements used
for assessment:
Hp=posterior height;
Hm=middle height;
Ha=anterior height
Hp Hm Ha

114. Lateral
Vertebral
Assessment
Osteoporosis-Imaging

115. LVA Assessment
• 337 patients, presenting with low
trauma non-vertebral fractures
• LVA 83 (25%) vertebral fracture
confirmed
(37 (45%) more than one vertebral
fracture
• Of those with vertebral fractures, 75%
has deformities of grade 2 or 3
Gallacher SJ et al. Osteop Int . 2006; 18: 185-192

116. Acute Fracture :
Exclude Secondary Metabolic Causes
• FBC / ESR
• Biochemisty Profile
• TFTs, Coeliac Screen
• Calcium (PTH)
• Myeloma screen
• PSA

117. Acute Fracture :
Admission to Hospital

118. Acute Fracture :
Secondary Care
• Optimise Analgesia
• Regular bowel care
• Consider urgent MR
Imaging
• Discussion with spine
team

119. Acute Fracture :
Discussion with spine team
• On call
• HCOP Dedicated 4 PAs
• Spinal Osteoporosis Specialist Nurse

120. Vertebral Augmentation

121. Vertebral Augmentation

122. • Ms OG
• 82 Female, normally fit and well
• Acute back pain, following light gardening
• Presented to ED-log rolled
• X-ray spine confirmed L4#
• Plan transfer to medicine for analgesia and physio
Case Presentation 1

123. Case Presentation 1

124. Case Presentation 1

125. Case Presentation 1

126. Case Presentation 1

127. Case Presentation 1

128. Case
Presentation 1

129. • Ms KH
• 91 Female, normally fit and well, no aids
• Awoke with acute lower back pain
• Managed by GP regular analgesia, 48 hours
• Struggling to mobilise
• Admitted to hospital
Case Presentation 2

130. Case Presentation 2

131. Case Presentation 2

132. Case Presentation 2

133. Case Presentation 2

134. Case Presentation 2

135. Case Presentation 2

136. Acute Pelvic Fracture

137. Acute Pelvic Fracture

138. Acute Pelvic Fracture
Sacral
Fractures Pubic Rami
Fracture

139. Acute Pelvic Fracture

140. Pelvic Fractures
• CT
• MRI
• PARACEMATOL (IV)
• SACROPLASTY / SCREW FIXATION
• PARATHYROID HORMONE

141. Pelvic Fractures
• Teriparatide (1-34 parathyroid hormone)
• Parathyroid Hormone (1-84)
• 65 Patients with pubic / ischial rami fracture
• Fracture healing time reduced by 4.6 weeks (p<0.01)
• Improved pain scores and Timed Up and Go (p<0.01)
Peichl et al, JBJS, 2011; 93: 1-5

142. The Optimal Acute Pathway

144. Workshops
Workshop 1 – Euston Suite
FLS Standard 1: Vertebral Fracture Identification
Workshop 2 – Baker Suite
FLS Standard 7: Follow-up

145. FLS Champions’
Summit 2016
Thank you
5th February 2016