Clinical Opal #19 - ‘The thigh bone's connected to the hip bone’
Mary is a 69-year-old retired teacher discharged two weeks ago from the local public hospital after repair of a fractured neck of femur.
Mary’s post fracture care is progressing well, and it appears she is on the path back towards her previous active life. The fracture happened when she tripped on a gutter while walking her dog. She has no significant past medical history or medications.
Mary was commenced on vitamin D and told by the orthopaedic registrar to discuss osteoporosis treatment with her GP. As Mary is under 70 years of age, she is only eligible under the PBS for anti-resorptive agents if she has ‘established osteoporosis’.
Does Mary have osteoporosis? Does she need a DEXA scan?
Yes, Mary has osteoporosis.
Her diagnosis is confirmed by the fact that she has suffered a fracture after minimal trauma. A minimal trauma fracture is defined as ‘one that occurs after a fall from standing height or less, or from a minor force that would not normally cause a fracture in a healthy younger person’.1
While a DEXA scan may be useful to establish a baseline to assess future response to treatment, it is not required to confirm the diagnosis of osteoporosis and commence anti-resorptive treatment. It is important to note that BMD is only one of several factors that contribute to an person’s risk of fracture. Indeed, approximately 50% of minimal trauma fractures occur in people who have T-scores in the normal or osteopenic range.2
PBS subsidies for pharmacotherapy apply to people who:
- Have had a minimal trauma fracture
- Are aged over 70 years with low bone density
- Have low bone density and taking corticosteroids3,4
A previous minimal trauma fracture doubles a person’s risk of subsequent fracture. This makes it essential to manage patients who have suffered a minimal trauma fracture to prevent subsequent fractures.
References:
- RACGP Red Book. Guidelines for preventive activities in general practice: Osteoporosis. 2021
- RACGP and Osteoporosis Australia. Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age. 2nd edn. 2017.
- Australian Prescriber 2022. Treating osteoporosis: risks and management
- NPS Medicinewise. Preventing fractures in osteoporosis.
Gerard is a rural GP and GP Supervisor in Daylesford Victoria. Medical Educator and research academic focusing on vocational GP training.
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