To discover whether orthopaedic surgeons follow the BOA guidelines for secondary prevention of fragility fractures, a retrospective audit on neck of femur fractures treated in our hospital in October/November 2003 was carried out. There were 27 patients. Twenty-six patients (96%) had full blood count measured. LFT and bone-profile were measured in 18 patients (66%). Only nine patients (30%) had treatment for osteoporosis (calcium and vitamin D). Only one patient was referred for DEXA scan. Steps were taken to create better awareness of the BOA guidelines among junior doctors and nurse practitioners. In patients above 80 years of age it was decided to use abbreviated mental score above 7 as a clinical criterion for DEXA referral. A hospital protocol based on BOA guidelines was made. A re-audit was conducted during the period August-October 2004, with 37 patients. All of them had their full blood count and renal profile checked (100%). The bone-profile was measured in 28 (75.7%) and LFT in 34 (91.9%) patients. Twenty-four patients (65%) received treatment in the form of calcium + Vit D (20) and bisphosphonate (4). DEXA scan referral was not indicated in 14 patients as 4 of them were already on bisphosphonates and 10 patients had an abbreviated mental score of less than 7. Among the remaining 23 patients, nine (40%) were referred for DEXA scan. This improvement is statistically significant (p=0.03, chi square test). The re-audit shows that, although there is an improvement in the situation, we are still below the standards of secondary prevention of fragility fractures with 60% of femoral fragility fracture patients not being referred for DEXA scan. A pathway lead by a fracture liaison nurse dedicated to osteoporotic fracture patients should improve the situation

Osteoporosis is common and the health and financial cost of fragility fractures is considerable. The burden of cardiovascular disease has been reduced dramatically by identifying and targeting those most at risk. A similar approach is potentially possible in the context of fragility fractures. The World Health Organization created and endorsed the use of FRAX, a fracture risk assessment tool, which uses selected risk factors to calculate a quantitative, patient-specific, ten-year risk of sustaining a fragility fracture. Treatment can thus be based on this as well as on measured bone mineral density. It may also be used to determine at-risk individuals, who should undergo bone densitometry. FRAX has been incorporated into the national osteoporosis guidelines of countries in the Americas, Europe, the Far East and Australasia. The United Kingdom National Institute for Health and Clinical Excellence also advocates its use in their guidance on the assessment of the risk of fragility fracture, and it may become an important tool to combat the health challenges posed by fragility fractures.

Introduction. The purpose of this study was to establish whether men and women with a fragility hip fracture were equally investigated and treated for osteoporosis. Methods. A retrospective review was carried out including 91 patients (48 females, 43 males) who were admitted with a fragility hip fracture between March 2003 and April 2004. Data about age, sex, investigations and medication were collected from the case notes, GP surgeries and the bone densitometry database. Investigations and treatment were compared with current guideline recommendations (SIGN 2003, NICE 2005). Data were analysed using SPSS Version 13.0. Results. According to the guidelines patients < 75 years of age should be investigated and patients > 75 years should be treated for osteoporosis. In our review 33% of women and only 8% of men < 75 years were investigated with a DEXA scan following their hip fracture (Fishers Exact Test, p = 0.32). In patients > 75 years 25% of women and only 6% of men were treated with bisphosphonates (Chi-square = 4.18, p < 0.05). There was also a statistically significant difference in overall treatment including bisphosphonates and calcium/vitamin D between the sexes (Chi-square = 6.81, p < 0.05). Conclusion. This study shows that there is clearly a need for improvement in secondary prevention of fragility fractures in both sexes, but men are significantly less likely to be investigated and treated than women. It is important to include recommendations for men in future guidelines and increase the awareness of male osteoporosis. This is of particular importance as men have a higher morbidity and mortality following hip fractures than women. Orthopaedic surgeons should therefore take on responsibility for these fracture patients and ensure that the process of secondary prevention is initiated

Most people experience low back pain (LBP) at least once in their lifetime. A minority goes on to develop persistent LBP causing significant socioeconomic costs. Aim of this study was to identify factors that influence the progression of acute to persistent LBP at an early stage (Hilfiker et al. 2007). Prospective inception cohort study of patients attending a health practitioner for their first episode of acute LBP or recurrent LBP after a pain free period of at least six months. Patients were assessed at baseline addressing occupational and psychological factors as well as pain, disability, quality of life and physical activity, and followed up over six months. Baseline and follow-up questionnaires were based on the recommendations of the Multinational Musculoskeletal Inception Cohort Study (MMICS) Statement (Pincus et al. 2008). Variables were combined to the three indices ‘working condition’, ‘depression and maladaptive cognitions’ and ‘pain and quality of life’. The index ‘depression and maladaptive cognitions’ comprising of depression, somatisation, a resigned attitude towards the job, fear-avoidance, catastrophizing and negative expectations on return to work was found to be a significant baseline predictor for persistent LBP up to six months (OR 5.1; 95%CI 1.04–25.1). The diagnostic accuracy of the predictor model had a sensitivity of 0.54 and a specificity of 0.90. Positive likelihood ratio was moderate with 5.3, negative likelihood ratio 0.5. Overall predictive accuracy of the model was 81%. The area under the curve in receiver operating characteristic (ROC) analysis of the index was 0.78 (CI95% 0.65–0.92), demonstrating a satisfactory quality of discrimination. Psychological factors in patients with acute LBP in a primary care setting correlated with a progression to persistent LBP up to six months. The benefit of including factors such as ‘depression and maladaptive cognition’ in screening tools is that these factors can be addressed in primary and secondary prevention

There were 70000 people admitted to hospital with fractured hips in 2007 and the incidence is rising by 2% each year. Hip fractures represent significant morbidity and mortality to patients and cost the NHS £1.8 billion annually. In 2008 the British Orthopaedic Association Standards for Trauma (BOAST) issued a 14-point guideline to be followed for the management of hip fractures. The aim was to improve secondary prevention of osteoporosis, reduce the falls risk and further fractures. This aimed to provide better care to improve the outcomes for patients and reduce the burden of hip fractures on society. The aim of the audit was to see if the BOAST guidelines are met before and after the transition to a level 1 MTC (Major Trauma Centre) and to measure any impact the change had. Methods: Prospective data was collected for three months in 2010, 2011 and 2012. 94 case notes were reviewed and compared to the outcomes laid out in the BOAST guidelines to see if standards were met. Overall adherence to the guideline's recommendations was high throughout the 3 sample months. For each of the 3 sample months 100% adherence was seen in all of the following criteria: further imaging if x-rays unclear, appropriate analgesia, pre-op assessment, seniority of surgeon, orthogeriatrician involvement, seniority of surgeons and submission to the National Hip Fracture Database. The main common area where adherence was less than 100% was with A and E breaches (i.e. greater than 4 hours referral to the ward). Despite relocation and transition to a level 1 MTC, the management of fractured neck of femur patients compared to the BOAST guidelines remained of a high standard. Further improvements have also been made since moving to the new hospital site where shortcomings in management have been identified. Improvements from year one to three include prophylactic antibiotics and warfarin reversal; there is now a new trust protocol in place for warfarin reversal in the case of hip fractures. Elsewhere adherence to the guidelines remains high across the sample months. Confirming that despite moving to a level 1 status the trauma team continues to be performing well and managing this group appropriately. In January 2012 BOAST published a second version of the hip fracture guidelines: A and E breaches were removed from the guidelines. There have also been several new additions to the guidelines, which prompt a further re-audit in the future