Why 66,000 hip fractures a year is too many

According to new data released by National Hip Fracture Database (NHFD),¹ 66,313 people presented with a hip fracture at one of the 175 trauma units across England, Wales and Northern Ireland throughout 2018.

The latest figures show a progressive improvement in mortality in the month after a hip fracture, with 564 fewer people dying within a month of breaking their hip compared to 2017. Meaning the overall mortality rate, of 4,007, is now half of what it was when the NHFD was first established in 2007.

Although this is a tremendous achievement, as is the NHFD finding that 69% of patients are now operated on the same day, or the day following first presentation with a hip fracture, the fact remains that hip fractures continue to devastate lives and far too many people are having hip fractures in the first place. 

The cost of not protecting hips

The impact of a hip fracture on the individual is not to be underestimated. At best, the pain is devastating, preventing those affected from lifting their grandchildren and causing them to have to give up sports and hobbies they loved. At worst many individuals will never make it back to their own home, which has a significant impact on them and the social care system.

According to the latest NHFD findings, three months after suffering a hip fracture only 71% of people will have returned to their original residence. Not least because during the first year after hip fracture, half of people who were able to walk unaided prior to their fracture will no longer be able to walk independently.²

Also, although hip fractures only make up one fifth of all fractures, they are estimated to generate 58% of all fracture-related costs.³

How to prevent hip fractures?

Fortunately, hip fractures are typically preceded by less devastating fractures, such as wrist fractures, and can be prevented if these primary fractures are recognised as the common warning sign for osteoporosis that they often are. Instead, a survey by the Royal Osteoporosis Society shows that a fifth of women who have broken a bone will break three or more before being diagnosed.⁴

The charity has also found, in audit findings due to be released in the spring, that many vertebral fractures go unreported when picked up on scans for other conditions, such as cancer or lung conditions, even though women who have had a spinal fracture are twice as likely to break their hip and four times as likely to have another vertebral fracture.⁵

Most worrying of all, even though 12% of people who have had a hip fracture will go onto fracture their other hip within the same year,⁶ this year’s NHFD report shows a worrying decline in bone protection medication. Just 8.2% of people admitted for a hip fracture were already on treatment to reduce the risk of further fracture and one in four people (24.7%) were not prescribed anything to protect their bones going forward.

Identifying people at risk

With any fragility fracture doubling the risk of another fracture and a secondary fracture most likely to occur within the two years following the initial fracture,⁷ the case for early intervention is clear.

Over half a million fragility fractures taking place every year in the UK, that’s one every minute,⁸ so there are extensive opportunities to consider whether someone who has just broken a bone, in particular a wrist, might have osteoporosis and therefore be at greater risk of going on to break a hip. Especially if that break was as a result of a minor bump or fall, from a height that would have normally resulted in a soft-tissue injury.

Healthcare professionals looking after the over 50s, have a particularly important role to play in taking patients through a fracture risk assessment survey, such as FRAX.⁹ This can predict the patient’s risk of osteoporosis, so they can be directed towards appropriate support, such as a Fracture Liaison Service (FLS), which can help them to understand the exercise and treatment options available to strengthen and protect their bones going forward.

The value of this approach for preventing hip fractures is proven, with the first FLS introduced in Glasgow found to have reduced the number of hip fractures by 7.3% over ten years, compared to just under a 17% increase across England¹⁰ over the same time.

Raising awareness of hip fracture prevention

Healthcare professionals working with the over 50s need to take the lead on encouraging individuals to consider whether they might have osteoporosis, is because it remains a relatively invisible condition.

Even though three million people in the UK are estimated to have osteoporosis and the risk of suffering a major osteoporotic fracture after the age of 50 is 35% for women and 17% for men,¹¹ two in three people (68%) aged 50-69 have not given the idea that they might have osteoporosis any thought.¹²

By encouraging the over 50s to think about what they can do to strengthen their bones and reduce the risk of falls, before they even have their first fracture, geriatricians have a vital role to play in making hip fractures and the devastation they cause a thing of the past.

Alison Doyle is head of clinical practice at the Royal Osteoporosis Society

1. National Hip Fracture Database (NHFD) annual report 2019, https://www.rcplondon.ac.uk/projects/outputs/national-hip-fracture-database-nhfd-annual-report-2019
2. Osnes EK, Lofthus CM, Meyer HE, Falch JA, Nordsletten L, Cappelen I, Kristiansen IS. (2004). Consequences of hip fracture on activities of daily life and residential needs. Osteoporos Int. 15(7):567-574
3. International Osteoporosis Foundation (2018) Broken Bones, Broken Lives€¯: A roadmap to solve the fragility fracture crisis in the United Kingdom. Available at: http://share.iofbonehealth.org/EU-6-Material/Reports/IOF_report_UK.pdf.
4. Royal Osteoporosis Society, Stop at One Survey, 2013 https://stopatone.theros.org.uk/
5. Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA 3rd, Berger M. (2000). Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res. 15(4):721-39. Figures in table 1 of paper
6. Royal Osteoporosis Society, hip fracture report highlights need to prevent secondary fractures, 2019 https://theros.org.uk/healthcare-professionals/healthcare-sector-news/2019/december/16/hip-fracture-report-highlights-need-to-prevent-secondary-fractures/
7. Kanis, et al (2004) €˜A meta-analysis of previous fracture and subsequent fracture risk.’, Bone. Elsevier, 35(2), pp. 375€“82. quoted in FLS DB Commissioners Report 2018
8. Svedbom A, Hernlund E, Ivergård M, Compston J, Cooper C, Stenmark J, McCloskey EV, Jönsson B, Kanis JA, EU Review Panel of IOF. (2013). Osteoporosis in the European Union: a compendium of country-specific reports. Arch Osteoporos. 8(1-2):137.
9. FRAX^® Fracture Risk Assessment Tool, University of Sheffield, https://www.sheffield.ac.uk/FRAX/
10. Skelton D and Neil F. (2009). NHS Greater Glasgow and Clyde Strategy for Osteoporosis and Falls Prevention 2006-2010: An evaluation 2007-2009.
11. International Osteoporosis Foundation (2018) Broken Bones, Broken Lives€¯: A roadmap to solve the fragility fracture crisis in the United Kingdom. Available at: http://share.iofbonehealth.org/EU-6-Material/Reports/IOF_report_UK.pdf.
12. Echo €“ Global Research Protecting Brands and Reputation (2013). Brand Awareness & Audience Insights Study, Findings of Baseline Survey. [Internal report commissioned by National Osteoporosis Society], reported in National Osteoporosis Society Annual Review 2013