A fracture isn’t just a broken bone—it’s often a wake‑up call. Especially in adults over 50, what appears as an isolated accident may signal underlying osteoporosis. If untreated, there’s a high risk of another fracture—sometimes within a year.
This makes secondary fracture prevention not just beneficial, but essential. And at the heart of this strategy? You, the GP.
1. When Should GPs Start Treatment?
- Immediately after any fragility fracture in adults ≥ 50. All such patients—especially those with hip or vertebral injuries—should be assessed for osteoporosis and started on treatment if indicated.
- Within the first 12 months. The highest risk of refracture is in the year post‑fracture; early medication significantly reduces the chance of recurrence.
- Based on DXA results or FRAX scores. A T‑score ≤ −2.5, plus FRAX hip‑fracture risk > 3%, or presence of a minimal‑trauma fracture, should prompt initiation of antiosteoporosis therapy, typically a bisphosphonate.
Key takeaway: Don’t delay—investigate promptly and treat early.
2. GP Screening Guidelines in Practice
a) Who needs screening?
- Patients aged ≥ 50 with a fragility fracture.
- Those with risk factors like corticosteroid use, family history, early menopause, or low bone density.
b) Recommended tools & tests:
- DXA scan for BMD assessment.
- FRAX to evaluate 10‑year fracture risk.
- Blood tests: calcium, vitamin D, renal function, thyroid, and sometimes bone turnover markers.
c) Interpreting results:
- DXA T‑score ≤ −2.5 OR high FRAX risk: Start therapy.
- Borderline BMD (T between −1.0 and −2.5): Consider individual risk; discuss treatment options.
- Normal BMD but prior fracture: Treat anyway—the fracture itself is high‑risk.
3. Coordinated Care: GP + Orthopaedics (and FLS)
Improving outcomes requires seamless teamwork:
a) Fracture Liaison Services (FLS):
Run by hospitals or orthogeriatric teams, FLS identify fracture patients and coordinate care—educating, ordering tests, and recommending treatment.
b) Integrated care pathways:
- Type A FLS: Initiate treatment within the FLS.
- Type B FLS: Refer result and recommendations to GP to start treatment, easing pressure off hospital services.
c) Challenges at transition:
Studies highlight common barriers:
- Overloaded GPs;
- Information gaps or miscommunication;
- Confusion over roles between FLS and GP.
d) What works in real‑world models:
- Education plus reminders: Combined GP education and patient follow‑up significantly boost ongoing care.
- Co‑ordinated multidisciplinary teams: Nurse‑led services working alongside primary care improve DXA uptake, treatment initiation, and medication persistence.
4. GPs: Best Practice Action Plan
- Identify: Ask about falls or fractures ≥ 50 years, even minor ones.
- Educate: Explain that a fragility fracture signals bone weakness and risk of another, and that treatment helps.
- Investigate: Order DXA, FRAX score, and relevant blood tests promptly.
- Start treatment: If indicated, begin bisphosphonate + calcium and vitamin D.
- Coordinate: Engage with FLS/orthopaedics—clarify roles, refer as needed.
- Follow‑up: Check adherence at 3, 6, and 12 months; encourage persistence—drop‑off often happens early.
- Long‑term monitoring: Repeat DXA every 2 years or as clinically indicated, adjust treatment plan if necessary.
5. Overcoming Barriers
Delegate follow‑up or reviews to a nurse or GP registrar.
- Knowledge gaps in osteoporosis?
Attend short accredited training or use FLS/FN guidelines.
- Poor communication channels?
Ask FLS to send clear, written care plans—electronic summaries work best.
- Medication concerns/adverse effects?
Address them early—explain risk vs benefit. Many issues (e.g., GI side effects) can be managed or mitigated.
6. Why It Matters
- Refracture rates drop significantly—up to 50% with early treatment.
- Quality of life improves, survival increases, and healthcare costs for hip fractures decrease.
- Thanks to regular monitoring, patients stay on therapy longer—fewer medication drops post-FLS when primary care continues the follow‑up.
Dr Oliver Khoo’s Insight
“Many patients and even some GPs see a fracture as a one‑off injury. But in my experience, it’s often a red flag—something deeper. If we miss that, we’re missing our best chance to prevent the next fracture.”
Dr Khoo advocates for a shared‑care model: hospital‑based FLS teams initiate treatment and educate, while GPs provide ongoing monitoring, adherence support, and long-term care.
Frequently Asked Questions
Q: Isn’t it just older people?
Not always—frequent medications, chronic illness, early menopause, or low body weight can all increase risk, even at younger ages.
Q: How long should treatment continue?
Most patients stay on bisphosphonates for 5 years, then have a “drug holiday” or switch therapy depending on risk.
Q: Are there non-surgical options?
Yes! Weight‑bearing exercise, fall‑risk reduction, healthy diet, smoking cessation, and limiting alcohol all help bone health.
