OrthoVirginia's Physician Assistant, Daniel Acevedo, located in the Lynchburg office writes about fragility fractures and the role of PA's in their management in the Orthopedics Today blog post.
BLOG: More can be done to educate providers, communities about osteoporosis, hip fractures
Fragility hip fractures are a devastating orthopedic injury. They incur significant health, economic and social consequences. Although some literature describes a downward trend in the incidence of hip fractures, these injuries are regularly seen in emergency departments, clinics and primary care offices across the nation and will continue to do so for the foreseeable future. As the population continues to age and life expectancy increases, patients will continue to sustain hip fractures. The physician assistant can play an integral role in any setting where these patients are diagnosed, treated and managed.
Hip fractures and other fragility type fractures are a passion of mine. This was not always the case. Plato’s proverb, “Necessity is mother of invention” comes to mind for me regarding this topic. For me, more accurately, “Necessity is the mother of necessity.” I realized the inadequacy of my knowledge regarding the gravity of this problem when I was tasked to “champion” the hospital management, discharge planning and follow-up care for some of our hip fracture patients.
A public concern
In 2015, our practice — located in a central Virginia town of around 80,000 people — treated nearly 600 hip fractures. Every day, my colleagues and I would see consult after consult involving patients older than 65 years who injured their hip from in ground-level fall. The orthopedic team would stabilize the fracture in the OR in a timely manner. Then, the waiting game began. Our results echoed those of the medical and orthopedic literature: Patients who were independent, community ambulators with few medical comorbidities improved quickly after surgery, while their frail, sedentary and sicker peers fared worse during the next 6 months to a year. It was demoralizing.
Our society has become aware of the dangers of smoking, the complications of obesity, the importance of screening for various cancers and even the diligent use of sunscreen to protect against melanoma. The emphasis of all these initiatives has been health promotion and preventative care. This is all great news. But, what about fragility fractures? We cannot prevent aging. Every second, we are getting older and for most Americans this means their bones are getting weaker. There must be something more to this problem — a proactive initiative that can be done to combat this public concern.
Osteoporosis and hip fractures are topics that are part of the core curriculum of physician assistant (PA) school. However, pathophysiology, diagnosis and management of chronic illnesses, like coronary artery disease and diabetes mellitus type 2, are at the forefront of education and this is rightly so. As a graduating primary care provider, I knew MONA (morphine, oxygen, sublingual nitro and aspirin) greeted every suspected heart attack patient in the ER. I was also comfortable with the pharmacokinetics and dosing of biguanides in a patient with type 2 diabetes to reduce blood glucose and improve long-term morbidity and mortality.
But what about hip fractures? We are taught that most of these fractures are unstable and need surgical fixation. Fractures can be intracapsular or extracapsular. Fixation can include arthroplasty or intramedullary nailing. The 1-year mortality for patients with hip fractures is equivalent to that of breast cancer. Osteoporosis contributes to most of these fractures and, therefore, women are affected more often than men.
More to this than we are taught
However, there is more to this than we are taught and even realize in our daily practice of treating these patients medically and surgically. Do you know that fewer than 25% of patients who are treated for a fragility type fracture are treated for their osteoporosis? How many of us are aware of the recommendations for DEXA screenings or that the American Academy of Orthopaedic Surgeons published guidelines for the management of these fractures? Do we understand the risks, benefits and indications of the plethora of drugs in our armamentarium to treat osteoporosis?
Low bone mass and osteoporosis affects more than 50 million Americans. Hip fractures due to osteoporosis and poor bone health are projected to climb to between 4.5 million to 6 million in the next 30 years. Outcomes of hip fractures can be devastating and include disability, chronic pain and death. Much can be done to educate providers, such as PAs, to engage their patients and to identify and treat osteoporosis. More so, much can be done to educate communities about the effects of poor bone health and to prevent fragility type fractures.
In the next few blog posts, I will review osteoporosis diagnosis, management and care and outline the ways PAs can engage their colleagues, patients and communities to highlight the importance of bone health.
Burgers PT, et al. Int Orthop. 2012;doi:10.1007/s00264-012-1569-7.
Coleman, et al. Osteoporosis Int. 2014;25:23599-2381.
Kessenich CR. Clin Interv Aging. 2007;2(2):263-266
Ning GZ, et al. Eur J Orth Surg Traumatol. 2014;doi:10.1007/s00590-012-1151-4.
Patel KV, et al. Clinc Orthop Relat Res. 2014;doi:10.1007/s11999-013-3334-7.
Zizic TM. Am Fam Physician. 2004;70(7):1293-1300.
Daniel J. Acevedo, PA-C