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few medical comorbidities that pose challenges to delivering efficient and timely care." The key to overcoming these challenges is promptly identifying fragility fractures in the emergency room. Orthopedic specia lists at Winthrop-Universit y Hospital have educated providers in the emergency room to quickly identify fragility fractures and notify orthopedic surgeons for prompt evaluation. "In medicine, it comes down to pattern recognition," Dr. Barzideh says. "If you've seen something before, you can act on it faster. Our experienced orthopedic spe- cialists and senior Emergency Department staff communicate the knowledge they have to more junior members so they develop good habits early. We constantly educate Emergency Department staff as to which patients are indicated for the Fragility Fracture Service and which would be better served by care from other specialists. The entire endeavor provides more personalized care." The first thing Emergency Department providers learn is how to identify fractures and dislocations. When they identify a patient who fits the criteria, they initiate a patient-specific protocol, which may include X-rays, notifying appropriate specialists and lab work. These protocols are designed to reduce the amount of time patients spend in the emergency room and move them into a more clinical environment, according to Dr. Barzideh. These cases are often complex and present various diagnostic challenges. For example, patients may have experienced a fall but not feel the need to visit the emergency room until weeks later because of mobility difficulties. X-rays and clinical exams might not reveal a fracture, but the circumstances indicate a possible fragility fracture. "In my mind, anyone over 60 years old who has a history of a fall preceding the emergency room visit and has problems ambulating properly likely has a fragility fracture, and we should act as though this is the case until proven otherwise," Dr. Barzideh says. "We've found that pro- viders who aren't experienced in treating elderly patients often default to ordering CT scans of the pelvis or hip. But this patient population is unique because non- displaced fractures that don't show up on X-rays will most likely not show up on CT scans either; it's difficult to visualize a fracture in extremely osteopenic patients. To exclude fractures, we often order MRI exams, which are more sensitive for frac- tures in elderly patients." The Emergency, Orthopedic Surgery and Radiology departments devised a limited, 20-minute MRI exam into Emergency Department protocols before the Fragility Fracture Service even existed to make the transition between Emergency Department and specialist care more efficient. When providers suspect a fragility fracture despite no X-ray evidence, they enlist specialists from the Department of Radiology to coordinate advanced imaging options. But other challenges can crop up in geriatric patients, requiring providers to use alternative imaging methods. Many have pacemakers or implantable cardioverter defibrillators, which make MRI exams impossible. Such patients require bone scans, which, though extremely sensitive to frac- tures, are time-consuming. Identification protocols are geared to detect patients with these fractures — which commonly present in the hip, knee, ankle, shoulder, elbow, Hip fractures are one of the most debilitating — and common — injuries suffered by elderly patients, notes Dr. Barzideh. Just some of the members of Winthrop's multidisciplinary Fragility Fracture Service team SPECIAL CLINICAL SECTION: ORTHOPEDICS 1 6 | Long Island MD NEWS n M D N E W S . CO M