A woman, aged 58 years, suffered a fragility fracture when she slipped and fell on the ice, breaking her distal radius. By definition, this fracture classifies her as having osteoporosis. However, the results of a dual-energy x-ray absorptiometry are quite good. The woman’s femoral neck T-score is 1.0, and her L1-L4 T-score is -0.7. Is treatment with a bisphosphonate advised?—Michelle Spencer, NP, Salt Lake City
A fragility fracture is defined as a fracture resulting from a fall from a standing height or less. The Fracture Risk Assessment Tool (FRAX) (www.shef.ac.uk/FRAX) from the World Health Organization (WHO) may be useful in this case.
This tool considers all risk factors for osteoporosis, such as smoking status, age, sex, family history, and previous fracture. FRAX also considers nationality and ethnicity when calculating risk. Using the FRAX tool and based on the above information—with the fracture and postmenopausal status as the woman’s only risks—and assuming Caucasian ethnicity, nonsmoking status, no family history of osteoporosis, no history of steroid use, no excessive alcohol intake, and average height and weight, this patient’s 10-year risk of a major osteoporosis-related fracture is 8.8% and risk of hip fracture is 0.1%.
The WHO recommendations are to start treatment in cases of hip or vertebral fracture, T-score <-2.5 at the femoral neck or spine after excluding secondary causes, and a 10-year probability of hip fracture >3% or 10-year probability of major osteoporosis-related fracture >20%. Based on these results, I would not recommend bisphosphonate treatment for this patient.
I would assure adequate nutrition and caloric intake, maintenance of normal calcium and vitamin D levels, regular exercise, and rescreen bone density in one to two years.—Kathy Pereira, MSN, FNP-BC, assistant professor, co-coordinator, family nurse practitioner program, Duke University School of Nursing, Durham, N.C. (183-1)
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