Hand fragility fractures as a missed opportunity for secondary prevention: A retrospective cohort study and assessment of the Second Metacarpal Cortical Index.

Abstract

Hand fragility fractures are often excluded from routine osteoporosis screening, yet they may represent a sentinel event for future morbidity. This study aimed to assess the fracture risk profile of older adults presenting with hand fragility fractures, quantify the 'treatment gap' in current practice, and evaluate the utility of the Second Metacarpal Cortical Index (2MCI) as a pragmatic triage tool. A retrospective cohort study was conducted across three seasonal timepoints at a UK Major Trauma Centre. Patients aged ≥50 presenting with low-energy hand fractures were included. Fracture risk was stratified using the Fracture Risk Assessment Tool (FRAX) calculated retrospectively from primary care records. Care pathways were audited for DEXA referral and treatment initiation. 2MCI was measured on standard radiographs and correlated with FRAX and hip T-scores. 134 patients were included (median age 71; 56% female). FRAX scoring classified 88% as intermediate, high or very high risk. Despite this, only 8% (11/134) of the total cohort underwent a DEXA scan. Of those scanned, 64% had osteopenia or osteoporosis. Eleven patients (8%) sustained subsequent fractures. 2MCI demonstrated excellent inter-rater reliability (ICC=0.81) and strong correlation with hip T-scores (r = 0.64). A 2MCI threshold of <45% yielded 100% specificity for detecting low bone mass, though sensitivity was limited. Patients with hand fragility fractures represent a high-risk cohort that is currently underserved by osteoporosis screening pathways. While 2MCI shows promise as an adjunctive triage tool, the primary finding is a significant missed opportunity for secondary prevention. Hand surgeons should routinely consider fracture risk assessment in this population.