Introduction: Osteoporosis is a skeletal disorder characterised by decreased bone mineral density (BMD) and a subsequent increased risk of fragility fractures. This disease is commonly associated with postmenopausal females with an increasing incidence into later life, over 50% of females over 80 have osteoporosis. At the opposite spectrum of life, decreased BMD is traditionally associated with the female athletic triad, with hormonal imbalance leading to skeletal insufficiency. Considered a “silent disease” until a fracture occurs, as orthopaedic surgeons we must be able to identify those at risk of osteoporosis and refer promptly for dual energy x-ray absorptiometry (DEXA) scanning to prevent future fragility fractures in this specific patient cohort.

Methods: We carried out an epidemiological analysis of all female patients under the age of 30 referred for DEXA scanning in a university teaching hospital over a 3 year period. We analysed mode of referral, risk factors, T-score and subsequent fractures with an aim to highlight an underestimated level of osteopenia/osteoporosis in the younger patient.

Results: We identified 102 patients eligible for our study, with a mean age of 25.34 (Range- 17–29). As per the World Health Organisation (WHO) osteopenia was defined as osteopenia as a T-Score between −1 and −2.5, with osteoporosis below −2.5. The mean T score of these patients was −1.037 (range −3.2 to 2.4). Medical teams initiated the majority of referrals (77%), followed by General Practitioners (17%), Gynaecologists (4%), Paediatricians (1%) and Surgeons(1%). Risk factors included excess steroid use for medical conditions (41%), decreased body mass index (BMI) (27%), ceoliac disease (12%) and radiological evidence of osteopenia (7%). 34% of these patients had suffered a fall with 12% of patients suffering from a fragility fracture.

Conclusion: We identified a definite cohort of young female patients who had a mean T-score within the levels for osteopenia. Over one third had suffered a fall and 12% had suffered a fragility fracture despite a young age. With ever increasing patient numbers in both fracture and orthopaedic clinics and increased pressure on resources, it is imperative that we still take thorough histories to identify those young female patients that are at risk of osteoporosis. With appropriate follow up and investigations, they can be started on necessary treatment and prevent subsequent fragility fractures, the incidence of which appears to be underestimated.

Background: Lumbar spinal stenosis (LSS) involves narrowing of the spinal, nerve root or intervertebral canals, producing compression of the intraspinal vascular and nervous structures. With an ageing population and advances in diagnostic accuracy, LSS is increasingly encountered and has become a major health care management issue.

Extended Scope Practitioners (ESPs) often assess and manage patients with LSS in orthopaedic and rheumatology clinics. Little is reported about how these patients are managed, variations in practice and the rationale for the clinical decision-making that occurs.

Methods: This quantitative, cross-sectional study used a questionnaire and vignettes to determine the factors affecting clinical decision-making in ESPs when managing patients with suspected LSS. The target population comprised all ESPs in the national Occupational Group of ‘Chartered Physiotherapists working as ESPs’ (n=288).

Results: The response rate to the questionnaire was 78.5% (n=226). The main factors affecting clinical decision-making (when deciding on referral to conservative or surgical management) were: accessibility of resources, including further investigations (MRI), consultants and surgery; severity of symptoms; and patient choice.

Discussion: The majority of participants reportedly considered patient choice an important factor in decision-making. When this principle was presented in the form of a real patient scenario (in the vignette) however, the trend in data showed that patient choice became less important in decision-making than the severity of signs and symptoms.

Conclusion: There are currently no national protocols or pathways to guide ESPs and facilitate standardisation of managing patients with LSS and wide variations in practice exist. Furthermore, whilst recognising the importance of respecting patients’ choice, in practice this remains a challenge to deliver.