Assessing Fracture Risk

QFracture®-2016 risk calculator:

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.

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

http://qfracture.org

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

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)

Relationship Between BMD and Fracture Risk

T–score

–1SD

2 x

SD – Standard deviation1. Watts NB. Oral Presentation at ASBMR 2001.

%

patien

ts with

vertebral

fractures

0

5

10

15

20

25

30

35

-5 -4 -3 -2 -1 0

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

Rel

ativ

e R

isk

Presence of Previous Vertebral Fracture Increases the Risk of

Future Vertebral Fracture

Case 1

45 year old lady - No risk FactorsRequests a bone density scan

1. Send for DXA2. Fracture risk assessment3. Do Nothing

Case 2

79 year old lady who had fallen-No other risk factors

1. DXA2. Fracture Risk3. Do nothing

Case 3

• 54 year old lady

• Fractured wrist

• BMI 21

• Maternal hip fracture

1. DXA2. Fracture Risk3. Do nothing

T-Score Total hip -2.4

Case 4 61 year old lady Primary prevention

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)

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

Case 5

Case 664 year old lady

Fractured wrist

Compression fractures several lumbar and thoracic vertebrae most severe at T10 & T12

Intolerant of bisphosphonates

Case 6