Title : The silent fracture crisis: Secondary prevention following upper limb fragility fractures
Abstract:
Background: Fragility fractures of the distal radius and proximal humerus are sentinel events indicating significant osteoporosis risk. Without appropriate secondary prevention, patients face a two- to fivefold increase in baseline fracture risk within the first year. Despite clear national guidance from the Royal Osteoporosis Society Fracture Liaison Service (FLS) - mandating DEXA scanning in 80% of eligible patients within 90 days - and NICE CG146 recommending bone health assessment following all fragility fractures, a substantial proportion of patients fail to receive secondary prevention.
Aim: To determine the proportion of patients aged ≥65 years sustaining distal radius or proximal humerus fragility fractures who received DEXA scanning following their injury, and to benchmark performance against national FLS standards at BHRUT.
Methods: A retrospective cohort study was conducted over a 24-month period (March 2024 – February 2026) at BHRUT. A total of 173 patients were included. Inclusion criteria: age ≥65 years with confirmed distal radius or proximal humerus fracture. Exclusion criteria: high-energy trauma and pathological fractures. Post-fracture DEXA uptake, timing, and compliance with FLS and NICE CG146 standards were assessed.
Results: 173 patients were identified (mean age 80.5 years): 69 distal radius (39.9%) and 104 proximal humerus (60.1%) fractures. Only 11% (n=19) received post-fracture DEXA scanning, representing a 69% shortfall against the 80% FLS standard (122 patients missed). Of the 19 who received scans, 84% were completed within 90 days; however, overall, 90-day compliance across the full cohort was 9.2% (16/173). No significant difference in DEXA uptake was identified between fracture types (distal radius 11.6% vs proximal humerus 10.6%; p>0.05), suggesting a systemic rather than fracture-specific failure. A total of 8,558 DEXA scans were performed at BHRUT over the same period, confirming adequate imaging capacity.
Conclusions: Secondary prevention following upper limb fragility fractures at BHRUT is critically inadequate: only 11% of eligible patients received post-fracture DEXA scanning against a national standard of 80%. Over the 24-month study period, an estimated 154 high-risk patients missed secondary prevention, representing significant preventable morbidity, mortality, and economic cost (estimated £420,000 annually). The findings indicate a systemic absence of referral infrastructure rather than a capacity issue. Urgent implementation of a Fracture Liaison Service, electronic referral pathways flagging ICD-10 codes S52 and S42, and structured bone health discharge protocols is required to meet national standards and prevent subsequent fractures.
