Osteoporosis going largely undiagnosed in trauma patients

One-third of trauma patients found to have osteoporosis, with only one in five previously diagnosed and just 5% receiving treatment.

A preliminary study finds osteoporosis underdiagnosed and undertreated in orthopedic trauma patients — a shortfall resolvable with a solid osteoporosis protocol.

Researchers in Fort Worth, Texas, and Shreveport, La., found that without an protocol, 98% of patients were likely to have gone without osteoporosis treatment. Once they implemented this protocol, they found 66 trauma patients with osteoporosis — out of a group of 200 — of which only 18% had previous diagnosis and 5% were being treated. The researchers found osteopenia in another 22 patients.

“To date, incidence of osteoporosis in trauma patients has not been known,” said Cory A. Collinge, MD, of Harris Methodist Hospital/John Peter Smith Orthopaedic Surgery Residency in Fort Worth. He presented the study results at the Orthopaedic Trauma Association 21st Annual Meeting. “And so far, until this study, there have been no protocols to evaluate and/or treat osteoporosis in trauma patients.”

Establishing a protocol

Collinge and his colleagues used a prospectively designed orthopedics trauma database to identify all patients treated for acute injury by a fellowship-trained orthopedic trauma surgeon. The IRB-approved study enrolled 200 consecutive adult patients with an average age of 46 and >500 skeletal injuries, treated over a six-month period with the osteoporosis protocol.

Early in the hospital stay, researchers did bone mineral density tests using Achilles Insight from General Electric, a quantitative heel ultrasound. From that, they obtained a T-score for the quantitative ultrasound, with a definition of –1.6 for osteoporosis.

“We found that almost half of the patients had low bone mineral density, as defined by osteopenia or osteoporosis, and that one-third of the patients met the criteria for osteoporosis,” Collinge said. “The average T-score was almost osteopenic by definition at –0.5.”

Patients found to have osteoporosis were placed on Os-Cal or a Vitamin D supplement. They also received a 20- to 25-minute education session with a nurse clinician and a one-page osteoporosis brochure with information about diagnosis, treatment options and the importance of follow-up. Upon discharge, surgeons gave the patients Os-Cal prescriptions and referred them to primary care physicians with the bone mineral density information.

Before the protocol

To evaluate performance before the established protocol, researchers designated a 100-patient retrospective control group. In this group, 18 had osteoporosis designated on their charts, eight of which had diagnosis on their admission and 10 with a new diagnosis documented on their charts.

“Of that 100 patients, none had in-hospital bone mineral density testing, only one had osteoporosis education documented, and only three left the hospital on the calcium or Vitamin D supplement,” Collinge said. “We weren’t doing a very good job.”

Collinge’s co-author Laura Gehrig, MD, of Louisiana State University, told Orthopedics Today that, in the past, when orthopedic surgeons treated traumas, the focus was on the immediate trauma at hand. “Nobody was thinking of bone quality or quantity,” she said. “The emphasis was always on saving the life or the limb.”

The American Academy of Orthopedic Surgeons (AAOS) has issued several position statements urging orthopedic surgeons to better predict osteoporosis in trauma patients by paying attention to bone quality and quantity.

Collinge said the researchers will next investigate shared risk factors between osteoporosis and trauma patients, including: nutrition, smoking, alcohol use, psychotropic medication use, anticonvulsant use and prior fracture.

They will also conduct a follow-up on how many patients visited their primary care physicians as directed. Gehrig said she predicts that half of study patients met with primary care physicians to discuss the bone mineral density and osteoporosis information.

For more information:
Collinge C, Gehrig L, Draper T. Osteoporosis in hospitalized orthopaedic trauma patients: an opportunity to intervene? #8. Presented at the Orthopaedic Trauma Association 21st Annual Meeting. Oct. 19-22, 2005. Ottawa.