Fractures are painful and debilitating. Some people are more vulnerable to fractures than others. 

Young kids and adolescents have growing bones, which reach peak mass at about 25 years of age. Bone mass and strength remain more or less stable till 50 to 60 years of age, after which a decline starts. This decline in bone mass and strength and resultant increase in fracture risk is especially marked in women after menopause. 

Scientific research has increased our understanding on cellular and molecular activities happening in our bones necessary for maintaining strong, resilient bones. As a result new drugs are available which can reduce the risk of fractures.

However all this knowledge is a waste if more and more elderly women, unaware of this bookish knowledge, slip in their bathrooms fracturing their hip bones. The most tragic part of this story is that once someone has a wrist, spine or hip fracture with trivial trauma (i.e. just from falling from a standing height), we already know she has “fragile bone” or “osteoporosis”. We have lots of data that show that someone who already had a fracture has a very high risk of fracturing again. Second fractures can and MUST be prevented. Despite knowing all this, only 20% people with fragility fractures are offered treatment globally, the figures being more dismal in India.

One reason for this is that osteoporosis is a misunderstood word. Someone having bony pains is NOT osteoporosis. Unfortunately though, bone pains and even joint pains are the most common reasons for prescribing anti-osteoporosis medicines in practice.

Bone density as measured by dual ray absorptiometry (DXA) is one measure for osteoporosis and helps in fracture risk prediction. It is however an expensive test and not available everywhere. Many doctors hesitate initiating anti-osteoporosis medicines without bone density report.

As we discussed already someone who already had a ‘fragility’ fracture in past SHOULD be prescribed anti-osteoporosis medicines irrespective of bone density results. Similarly a history of hip fracture in parents is a risk factor for fracture; low body weight and weight loss, smoking and alcohol, steroid therapy, thyroid diseases, diabetes and rheumatoid arthritis increase fracture risk independent of bone density. The risk conferred is different for each risk factor and varies from country to country. Mathematical formulae have been created to calculate absolute risk of fracture, FRAX score being one of them. Since we do not have epidemiological data in our country fro calculating FRAX, data from Singapore Indians have been used to calculate FRAX score in India, the validity of which is unclear.

Anyone can calculate their FRAX scores free of cost-the calculations are available online at the site: https://www.sheffield.ac.uk/FRAX/tool.aspx?country=51

We hypothesized that in most people we can avoid an expensive bone density test by applying FRAX scores and figuring out the risk. If the risk is very high, we treat and if it is very low, we do not investigate further. For those with intermediate risk, we offer bone density test.

We applied FRAX scores for hip fracture (FRAX-HF) and for major osteoporotic fracture (FRAX-MOF) in patients admitted in orthopedic ward at Medanta and studies the differences in patients with and without fragility fractures. Our study showed that there was a lot of overlap between these two groups, but overall, FRAX scores were higher in patients with fragility fractures as compared to those without fractures.

For FRAX-MOF, a cutoff of 2 had 90% sensitivity. This means that FRAX-MOF scores less than 2 can reasonably assure that a fracture risk is low enough to avoid DXA-BMD. For FRAX-MOF a cutoff of 10.5 had a specificity of 90% to differentiate those with and without current fractures.

The interpretation of this is that FRAX-MOF score greater than 10.5 has a risk of fracture high enough to initiate treatment without resorting to DXA-BMD in such patients.

For FRAX-HF, a cutoff of 0.3 had about 90% sensitivity. Therefore, if FRAX-HF is less than 0.3, fracture risk is very low and DXA-BMD need not be done. A FRAX-HF cutoff of 3.5 had 90% specificity to differentiate those with and without current fractures. This suggests that if FRAX-HF score is greater than 3.5, treatment can be initiated even without a DXA-BMD.

We suggest a simple algorithm for elderly men and women (figure 1): 

1. Open this link https://www.sheffield.ac.uk/FRAX/tool.aspx?country=51
2. Calculate your FRAX score
   1. If FRAX-MOF is less than 2 and FRAX-HF is less than 0.3: You have a low risk for fractures. However, take care of this gift by taking recommended amounts of calcium and protein in diet, vitamin D as supplement and walk everyday. Avoid smoking and alcohol.
   2. If your FRAX-MOF is greater than 10.5 or FRAX-HF is greater than 3.5: You have a high risk for fracture. Meet an endocrinologist to discuss about various anti-osteoporosis medications that will reduce your risk for fractures. Please take care not to fall. Most fractures happen at home especially bathrooms, bedside and stairs. Please take recommended calcium and protein in diet, vitamin D as supplement and walk daily. Avoid smoking and alcohol. 
   3. If your FRAX-MOF is between 2 and 10.5; FRAX-HF is between 0.3 and 3.5: Get a bone density using DXA scan. Recalculate your FRAX scores with DXA-BMD and find out if you are in the treatment zone or safe zone (figure 2). Please take care not to fall. Most fractures happen at home especially bathrooms, bedside and stairs. Please take recommended calcium and protein in diet, vitamin D as supplement and walk daily. Avoid smoking and alcohol.