With the emergency resident doctors and consultant orthopaedic surgeons Dr Jesus Ramon and Dr Ignacio Casillas Cortes
Between June 3, 2024, and June 28, 2024 I undertook an international medical elective in the emergency and the trauma & orthopaedic departments of Zapopan Cruz Verde Hospital in Guadalajara, Mexico. Supervised by Dr Arturo Padilla Ledezma and Dr Jesus Ramon Delgado (trauma & orthopaedic surgeons). I split my time over four weeks between the emergency room and orthopaedic theatres. In the UK, I attended the acute frailty unit at Chesterfield Royal hospital, Chesterfield under the supervision of Dr Kavanagh (consultant geriatrician).
I chose to write a comparison report relating to fragility fractures, as because of our ageing population in the UK14, this is a very important and relevant topic. For example, a recent study in Scotland found that from 2017 to 2021, the number of annual hip fractures increased by 15%, with a forecasted rise of 32% from 2021 to 202914. They estimated this may cost a minimum of an additional £25 million per year, putting significant strain on our healthcare and social services14. To help prevent this one must investigate how to limit risk factors for fragility fracture as a prevention method. We can look to another country with lower rates of osteoporosis, such as Mexico2,4,5.
The FRAX (fracture risk assessment tool) score was developed by Sheffield University in 2008 for evaluation of fracture risk in patients1. It is an algorithm that generates a FRAX score determining the percentage risk of a major osteoporotic fracture within the next 10 years6. It is comprised of 12 questions testing for the presence of predetermined risk factors for osteoporosis of which have been detailed in figure 2. This tool is used alongside national osteoporosis guidelines (NOGG)3 to determine whether the patient should receive treatment for osteoporosis.
FRAX scores can be categorised into low risk, intermediate risk, high risk and very high risk of a major osteoporotic fracture in the next 10 years3 according to NOGG guidelines3. There is a designated threshold for intervention, when reached, the patient is commenced on treatment that consists of pharmacological and non-pharmacological interventions3. The threshold varies dependant on the age of the patient and FRAX score as displayed in figure 13 The FRAX score has a continuing impact on the management of osteoporosis in healthcare systems around the world6. The tool is located on a website where it is translated into 35 different languages and available in 84 countries1.
FRAX score incorporates variables that influence the risk of fragility fractures. These risk factors are listed below in figure 2 with a brief explanation, taken from the official FRAX tool website1.
Aims
In this report, the aim is to investigate the relationship of fragility fractures and FRAX scores in both Mexican and British populations. The hypothesis of the report is that the average FRAX scores differ between these two patient groups. To do this, an analysis was performed on FRAX scores between the two populations, and different factors that could explain variations amongst the two samples. This report will investigate risk factors relating to FRAX scores to identify any correlations that emerge.
In addition, this report would document if patient’s received orthopaedic surgical interventions and discuss whether there is an association with their FRAX score. Furthermore, due to differing geographical climates between these two samples this report will aim to assess the levels of vitamin D of the sample, subject to availability which can only be discovered upon start of the elective.
Before scrubbing to observe a knee replacement
Methodology
The FRAX score tool was used on the two samples of patients (Mexican and British) arriving in the emergency department. To minimise bias, the patient groups were selected from emergency departments in state-run hospitals. The participants were between the ages of 40 and 90 years as required for a FRAX score1. As each country has a specific dataset for the FRAX score2, I used the Mexican FRAX calculator and the British FRAX calculator for each sample group.
Firstly, information was collected by obtaining 50 patient FRAX scores per sample group (n=50), with an equal gender split (25 male and 25 females). These patients were selected opportunistically, with consent. FRAX scores were calculated from a combination of history- taking and existing medical records. Additionally, surgical orthopaedic outcomes, vitamin D levels and supplementation (vitamin D and/or calcium) were noted where applicable.
After calculating FRAX scores, both samples were assessed for statistical significance in variation using an independent T-test. Then, by using tables and the NOGG guidance3 FRAX scores were categorised into risk categories from low to very high risk (see figure 1). It was also noted whether the scores were either above or below the threshold for intervention as per NOGG guidance.
Results
The results of the independent T-test to assess for significance in variation were a P value of 0, T-test score of 5.6421 and 98 degrees of freedom. As the P value is less than 0.05, the variance in data can be said to be statistically significant.
Comparing the information from the UK and Mexico, regarding intervention thresholds as defined by NOGG guidance3, 21 out of 50 British patients and 2 out of 50 Mexican patients were above the threshold for intervention.
In the low-risk category, there were 10 British patients and 34 Mexican patients. In the intermediate risk category, there were 22 British patients and 14 Mexican patients. In the high- risk category, there were 7 British patients and 1 Mexican patient. In the very high-risk category, there were 11 British patients and 1 Mexican patient. Within these categories the division between genders were examined, which can be viewed below in the table 1.
Conclusion
Learning how to use a manual defibrillator with paddles
Overall, there has been a significant difference in FRAX scores highlighted here, British patients displaying increased risk of fragility fractures within the next 10 years. This highlights the need for tailored healthcare strategies to manage osteoporosis effectively in different demographics. The higher FRAX scores in the British sample suggest a greater need for intervention and preventive measures in the UK to mitigate the rising costs and healthcare burden associated with osteoporotic fractures.
Future studies should consider larger sample sizes, incorporate additional biochemical markers, such as vitamin D levels, and consider investigating how duration of physical activity affects a FRAX score to provide a more comprehensive understanding of the factors influencing osteoporosis risk.
Research into implementing targeted prevention programmes, improved screening practices and addressing lifestyle factors will help shape future ideas and standards of treatment for osteoporosis, while reducing incidence of fragility fractures.
Acknowledgments
I was well supported on both my placements for my elective and would like to express my deep gratitude to the team at Cruz Verde Norte Hospital in Guadalajara. They helped me and inducted me in the orthopaedic emergency clinics and emergency department. I learnt a lot from all members of the team but also had the opportunity to take join in other parts of the hospital comings and goings. I spent 1 week with the paramedic team learning their trade in the field where I attended emergency calls and helped transport the patients back to the hospital. I also worked with the resuscitation team in the emergency department. I observed many orthopaedic injuries that I have never encountered in the UK and may not again, for example gunshot injuries.
In addition, I learnt a lot of new medical Spanish and am very grateful to the team for their patience in helping to teach me. I would also like to thank Dr Kavanagh for his continued support and help in shaping the project and staff at Chesterfield Royal hospital.