The Fracture Liaison Service helps patients prevent a second hip fracture or bone fracture by encouraging medication use, exercise and safety.

Nancy Hurley-Claflin’s hip fracture occurred one summer day after the 65-year-old lost her balance as she carried heavy water jugs up some stairs on her way to tend to plants at her home in Winthrop, Massachusetts.

“A fragility fracture is a warning that there will be more,” says Marcy Bolster, MD, a Mass General rheumatologist.

During her hospital stay for hip surgery at Massachusetts General Hospital, the retired nurse enrolled in a new Mass General program called the Fracture Liaison Service. It aims to help patients prevent a second fracture.

Known as “fragility fractures,” injuries like Nancy’s are common. They occur when a person falls from a height that would not usually fracture a healthy bone.

Preventing the Second Hip Fracture

The presence of a fragility fracture indicates that a patient has osteoporosis, a disease of weakened bones. Sometimes, the fracture is how patients learn they have the disease.

“A fragility fracture is a warning that there will be more,” says Marcy Bolster, MD, a Mass General rheumatologist. After a fragility fracture, a patient has an increased risk for a second fracture, which could be at the hip, spine, shoulder, wrist or lower leg.

Marcy Bolster, MD
Marcy Bolster, MD

Providing treatment for preventive care after a patient has surgery to repair such an injury can be a challenge. Patients can benefit from osteoporosis medications and physical therapy. But those messages can get lost when patients leave the hospital.

Coordinating to Improve Care

Dr. Bolster led the effort to create the Fracture Liaison Service and is its medical leader. The goal is to prevent additional fractures, educate patients and physicians about osteoporosis and collect data to enhance patient care. Its team includes specialists in endocrinology, rheumatology, orthopedics and geriatrics.

“We know if a patient has a heart attack that he or she should be treated with a beta-blocker,” Dr. Bolster says. “National treatment rates for prescribing beta-blockers after a heart attack are upwards of 90 percent, but treatment for osteoporosis with medications after a hip fracture range from 5 to 20 percent.”

Statistics tell a different story. Within one year of a hip fragility fracture, about 20 percent of patients will die.

Dr. Bolster says patients mistakenly believe once their bone is fixed, the problem is solved.

Statistics tell a different story. Within one year of a hip fragility fracture, about 20 percent of patients will die. The effects of not getting around as well, or at all, can lead to blood clots, pneumonia and increasing frailty, Dr. Bolster says.

Benjamin Leder, MD, medical director of MGH Endocrine Associates and a member of the Fracture Liaison Service, is concerned about the increase in fractures since 2011. For decades fracture rates had declined because patients used osteoporosis medications to strengthen their bones. But following reports of serious, but rare, side effects, fewer patients are being treated.

“The risk-benefit ratio for a patient who has already experienced a fracture or who has low bone density far favors treatment with osteoporosis medications, which are generally safe and well-tolerated drugs,” Dr. Leder says. These medications can reduce the risk of spine fractures by up to 80 percent and hip fractures by about half, he adds.

Benjamin Leder, MD
Benjamin Leder, MD

Addressing Risk Factors for Osteoporosis

Women are at an increased risk for osteoporosis after menopause because the female body makes less estrogen, a hormone that protects bones. Significant bone loss can continue for at least five years after menopause, Dr. Leder explains.

Then, as women age, they have a more gradual decline of bone density. Older men are also at risk for osteoporosis.

Another cause of bone loss is vitamin D deficiency, which is common in New England, due to the lack of sunlight and compounded by the use of sunblock. Dr. Leder says endocrinologists and physicians can treat vitamin D deficiency and other hormonal disorders to improve skeletal health.

Guiding Patients Through Recovery

When patients are hospitalized at Mass General with a fragility fracture, physician assistant Lisa Beyer, from the Fracture Liaison Service, educates them about their injury and the recovery process. She then contacts their primary care physician.

“I feel grateful because I wouldn’t have been in this program if I hadn’t had my hip fracture.”

After Nancy Hurley-Claflin suffered her hip fracture, Ms. Beyer talked to her about nutritional supplements and bone-strengthening exercises. Ms. Beyer told Nancy that the backless sandals she was wearing may have contributed to her fall. They talked about home safety issues such as good lighting and secure rugs. And they discussed the importance of physical therapy and osteoporosis medication treatment.

Determined to travel to Disney World with her family, Nancy is following the advice she has received through the Fracture Liaison Service. Physical therapy has improved her walking and she plans to get yearly infusions of an osteoporosis medication.

“I feel grateful because I wouldn’t have been in this program if I hadn’t had my hip fracture,” she says. “I know it’s going to change my future because my bones will be stronger.”

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