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Barriers to the identification of fragility fractures for secondary fracture prevention in an orthopaedic clinic-based fracture liaison service

a prospective cohort study

Senay, Andréa, MSca,b; Delisle, Josée, BScN, MScb,c; Banica, Andreea, BScNb,c; Laflamme, G. Yves, MDb,c; Leduc, Stéphane, MDb,c; Mac-Thiong, Jean-Marc, MDb; Ranger, Pierre, MDb,c; Rouleau, Dominique, MDb,c; Fernandes, Julio C., PhDa,b,c

doi: 10.1097/BCO.0000000000000691

Background: The goal of this study was to determine the identification and participation rates of fragility fracture patients in a Fracture Liaison Service (FLS). We also identified factors affecting performance in patient identification.

Methods: Surgeons, staff, and FLS nurses of an outpatient orthopaedic clinic from a hospital (Montreal, Canada) identified patients 50 yr of age or older with a fragility fracture eligible to join an FLS from January 2014 to March 2015. The list of orthopaedic referrals for the same period was retrieved and compared to our list of patients in the FLS to determine the participation rate. An in-house questionnaire was dispensed to volunteer staff to identify gaps in fragility fracture identification.

Results: We identified 1011 patients with fractures from the orthopaedic referral list. Two hundred forty-nine patients (24.6%) were not identified because of nonreferral by surgeons or staff. Of the 762 remaining patients, 288 were excluded for high-energy trauma (n = 126), fracture of the face, skull, foot, or hand (n = 87), and other reasons (n = 75). Out of 474 patients with fragility fracture, 295 (62.2%) joined the FLS (178 refusals (37.6%). FLS managers only accessed 46.9% (474/1011) of eligible patients. The highest difficulty reported by the staff was about the time allocated to patient identification considering their workload.

Conclusions: Major barriers to diagnosis and treatment of underlying osteoporosis in fragility fractures are nonreferral from orthopaedic surgeons or staff, and patient refusal. Challenges reside in implementing an institutional policy for optimal screening, better surgeon, staff, and patient education combined with improved systematic clinical management programs.

aUniversité de Montréal, Montreal, Qc, Canada

bCIUSSS Nord de l’Ile de Montréal, Hôpital du Sacré-Coeur de Montréal, Montreal, Qc, Canada

cCIUSS Nord de L’Ile de Montréal, Hôpital Jean-Talon, Montreal, Qc, Canada

Sources of Funding: Orthopaedic funds from the research center of the healthcare institution where the study took place were used to finance this research project.

Financial Disclosure: Dr. Leduc reports financial relationships outside this work with Eli Lily, Stryker, Smith and Nephew, Zimmer, J&J, Medacta Wright; Dr. MacThiong with Medtronic, and Spinologics; and Dr. Ranger with Sanofi Canada, Bioventus, Horizon Pharma, J& J, and Smith and Nephew. The other authors have no disclosures. The authors report no conflicts of interest in regard to this work. Source of Funding: Hôpital du Sacré-Coeur de Montréal.

Correspondence to Julio C. Fernandes, PhD, Research Center, office K3045, Hôpital du Sacré-Cœur de Montréal, 5400 bl. Gouin oust, Montreal, Quebec, Canada, H4J 1C5 Tel: +1-514-338-2222; fax: +1-514-338-3661; e-mail:

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