Wrist fracture as a predictor of future fractures in younger versus older postmenopausal women: results from the National Osteoporosis Risk Assessment (NORA)

Association between a history of major osteoporotic fractures and subsequent hip fracture: a systematic review and meta-analysis

PURPOSE

A history of fractures involving the distal radius, proximal humerus, spine, and hip may be associated with the incidence of subsequent hip fractures in older people. However, a comprehensive summary of this association using a rigorous methodology is lacking. Our objective was to systematically review the literature and examine the association between four major osteoporotic fractures and subsequent hip fractures in individuals aged ≥ 50 years.

METHODS

We searched MEDLINE, Embase, CENTRAL, ICTRP, and ClinicalTrials.gov on February 15, 2023. The search included cohort or case-control studies investigating the association between these four types of osteoporotic fractures and subsequent hip fractures. We pooled the hazard ratios (HRs) with 95% confidence intervals (CI) using the random-effects model. We used the Quality In Prognosis Studies tool to assess the risk of bias in the included studies, and the grading of recommendations assessment, development, and evaluation approach to determine the certainty of evidence.

RESULTS

The selection process identified 48 studies for qualitative synthesis and 23 studies (2,239,217 participants) for meta-analysis. The overall methodological quality had a low risk of bias in 65% of the included studies. The association between a history of major osteoporotic fractures and subsequent hip fracture varied, with a high certainty of evidence for a history of proximal humerus and hip fractures (HR 2.02, 95% CI 1.75-2.33 and 2.86, 95% CI 1.92-4.25, respectively), moderate certainty for distal radius fractures (HR 1.66, 95% CI 1.53-1.81), and low certainty for spine fractures (HR 1.53, 95% CI 1.38-1.69).

CONCLUSIONS

In conclusion, a history of major osteoporotic fractures, particularly distal radius, proximal humerus, and hip fractures, is associated with subsequent hip fractures in older adults. Further research is needed to verify the association between a history of spine fracture and subsequent hip fractures.

PROTOCOL REGISTRATION

Open Science Framework ( https://osf.io/7fjuc ).

Osteoporosis Prediction Using Machine-Learned Optical Bone Densitometry Data

Optical bone densitometry (OBD) has been developed for the early detection of osteoporosis. In recent years, machine learning (ML) techniques have been actively implemented for the areas of medical diagnosis and screening with the goal of improving diagnostic accuracy. The purpose of this study was to verify the feasibility of using the combination of OBD and ML techniques as a screening tool for osteoporosis. Dual energy X-ray absorptiometry (DXA) and OBD measurements were performed on 203 Thai subjects. From the OBD measurements and readily available demographic data, machine learning techniques were used to predict the T-score measured by the DXA. The T-score predicted using the Ridge regressor had a correlation of r = 0.512 with respect to the reference value. The predicted T-score also showed an AUC of 0.853 for discriminating individuals with osteoporosis. The results obtained suggest that the developed model is reliable enough to be used for screening for osteoporosis.

Preoperative Anemia as a Risk Factor for Postoperative Complications After Open Reduction Internal Fixation of Distal Radius Fractures

Purpose

The incidence of distal radius fractures (DRFs) in the United States is more than 640,000 cases per year and is projected to increase. The overall prevalence of anemia in the United States increased from 5.71% in 2005 to 6.86% in 2018. Therefore, preoperative anemia may be an important risk factor to consider before surgical fixation of a distal radius fracture. The purpose of this study was to investigate preoperative anemia and its association with short-term complications after surgical treatment of DRFs.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent open reduction internal fixation (ORIF) of DRFs between 2015 and 2020. The initial pool of patients was divided into cohorts based on preoperative hematocrit. Multivariate logistic regression, adjusted for all significantly associated patient demographics and comorbidities, was used to identify associations between preoperative anemia and postoperative complications after ORIF of DRFs.

Results

A total of 22,923 patients who underwent ORIF of DRFs were identified in National Surgical Quality Improvement Program from 2015 to 2020. Of the 12,068 patients remaining after exclusion criteria, 9,616 (79.7%) patients were included in the normal cohort, 2,238 (18.5%) patients were included in the mild anemia cohort, and 214 (1.8%) patients were included in the severe anemia cohort. Compared with the reference cohort, patients with any anemia were independently associated with higher rates of reintubation (odds ratio [OR], 6.51; 95% confidence interval [CI], 1.29-32.80; P = .023), blood transfusion (OR, 11.83; 95% CI, 3.95-35.45; P < .001), septic shock (OR, 10.76; 95% CI, 1.19-97.02; P = .034), readmission (OR, 2.10; 95% CI, 1.60-2.76; P < .001), nonhome discharge (OR, 2.22; 95% CI, 1.84-2.68; P < .001), and mortality (OR, 2.70; 1.03-7.07; P = .043).

Conclusions

Preoperative anemia, both mild and severe, were clinically significant predictors for postoperative complications within 30-day after ORIF of DRFs. Severe anemia was associated with higher rates of blood transfusion, nonhome discharge, and mortality compared with mild anemia.

Type of study/level of evidence

Prognostic III.

Lower limb muscle strength and balance in older adults with a distal radius fracture: a systematic review

BACKGROUND

Distal radius fractures are common fractures in older adults and associated with increased risk of future functional decline and hip fracture. Whether lower limb muscle strength and balance are impaired in this patient population is uncertain. To help inform rehabilitation requirements, this systematic review aimed to compare lower limb muscle strength and balance between older adults with a distal radius fracture with matched controls, and to synthesise lower limb muscle strength and balance outcomes in older adults with a distal radius fracture.

METHODS

We searched Embase, MEDLINE, and CINAHL (1990 to 25 May 2022) for randomised and non-randomised controlled clinical trials and observational studies that measured lower limb muscle strength and/or balance using instrumented measurements or validated tests, in adults aged ≥ 50 years enrolled within one year after distal radius fracture. We appraised included observational studies using a modified Newcastle-Ottawa Scale and included randomised controlled trials using the Cochrane risk-of-bias tool. Due to the clinical and methodological heterogeneity in included studies, we synthesised results narratively in tables and text.

RESULTS

Nineteen studies (10 case-control studies, five case series, and four randomised controlled trials) of variable methodological quality and including 1835 participants (96% women, mean age 55-73 years, median sample size 82) were included. Twelve included studies (63%) assessed strength using 10 different methods with knee extension strength most commonly assessed (6/12 (50%) studies). Five included case-control studies (50%) assessed lower limb strength. Cases demonstrated impaired strength during functional tests (two studies), but knee extension strength assessment findings were conflicting (three studies). Eighteen included studies (95%) assessed balance using 14 different methods. Single leg balance was most commonly assessed (6/18 (33%) studies). All case-control studies assessed balance with inconsistent findings.

CONCLUSION

Compared to controls, there is some evidence that older adults with a distal radius fracture have impaired lower limb muscle strength and balance. A cautious interpretation is required due to inconsistent findings across studies and/or outcome measures. Heterogeneity in control participants' characteristics, study design, study quality, and assessment methods limited synthesis of results. Robust case-control and/or prospective observational studies are needed.

REGISTRATION

International prospective register of systematic reviews (date of registration: 02 July 2020, registration identifier: CRD42020196274).

Dietary Inflammatory Index and Fractures in Midlife Women: Study of Women's Health Across the Nation

CONTEXT

While evidence suggests that chronic, low-grade inflammation is a risk factor for bone loss and fractures, the potential relation between an inflammatory dietary profile and greater fracture risk is uncertain.

OBJECTIVE

We examined whether a more inflammatory diet, consumed during pre- and early perimenopause, is associated with more incident fractures starting in the menopause transition (MT) and continuing into postmenopause.

METHODS

Dietary inflammatory potential was quantified using 2 energy-adjusted dietary inflammatory index scores: one for diet only (E-DII), and one for diet plus supplements (E-DII-S). We included 1559 women from the Study of Women's Health Across the Nation, with E-DII and E-DII-S scores from the baseline visit (during pre- or early perimenopausal), and up to 20 years of follow-up. We excluded women using bone-beneficial medications at baseline; subsequent initiators were censored at first use. The associations of E-DII or E-DII-S (each tested as separate exposures) with incident fracture were examined using Cox proportional hazards regression.

RESULTS

Adjusted for age, BMI, cigarette use, diabetes, MT stage, race/ethnicity, prior fracture, bone-detrimental medication use, aspirin or nonsteroidal anti-inflammatory drug use, and study site, greater E-DII and E-DII-S (tested separately) were associated with more future fractures. Each SD increment in E-DII and E-DII-S predicted 28% (P = .005) and 21% (P = .02) greater fracture hazard, respectively. Associations were essentially unchanged after controlling for bone mineral density.

CONCLUSION

A more pro-inflammatory diet in pre- and early perimenopause is a risk factor for incident fracture. Future studies should consider whether reducing dietary inflammation in midlife diminishes fracture risk.

Prediabetes and Fracture Risk Among Midlife Women in the Study of Women's Health Across the Nation

Importance

Whether prediabetes is associated with fracture is uncertain.

Objective

To evaluate whether prediabetes before the menopause transition (MT) is associated with incident fracture during and after the MT.

Design, Setting, and Participants

This cohort study used data collected between January 6, 1996, and February 28, 2018, in the Study of Women's Health Across the Nation cohort study, an ongoing, US-based, multicenter, longitudinal study of the MT in diverse ambulatory women. The study included 1690 midlife women in premenopause or early perimenopause at study inception (who have since transitioned to postmenopause) who did not have type 2 diabetes before the MT and who did not take bone-beneficial medications before the MT. Start of the MT was defined as the first visit in late perimenopause (or first postmenopausal visit if participants transitioned directly from premenopause or early perimenopause to postmenopause). Mean (SD) follow-up was 12 (6) years. Statistical analysis was conducted from January to May 2022.

Exposure

Proportion of visits before the MT that women had prediabetes (fasting glucose, 100-125 mg/dL [to convert to millimoles per liter, multiply by 0.0555]), with values ranging from 0 (prediabetes at no visits) to 1 (prediabetes at all visits).

Main Outcomes and Measures

Time to first fracture after the start of the MT, with censoring at first diagnosis of type 2 diabetes, initiation of bone-beneficial medication, or last follow-up. Cox proportional hazards regression was used to examine the association (before and after adjustment for bone mineral density) of prediabetes before the MT with fracture during the MT and after menopause.

Results

This analysis included 1690 women (mean [SD] age, 49.7 [3.1] years; 437 Black women [25.9%], 197 Chinese women [11.7%], 215 Japanese women [12.7%], and 841 White women [49.8%]; mean [SD] body mass index [BMI] at the start of the MT, 27.6 [6.6]). A total of 225 women (13.3%) had prediabetes at 1 or more study visits before the MT, and 1465 women (86.7%) did not have prediabetes before the MT. Of the 225 women with prediabetes, 25 (11.1%) sustained a fracture, while 111 of the 1465 women without prediabetes (7.6%) sustained a fracture. After adjustment for age, BMI, and cigarette use at the start of the MT; fracture before the MT; use of bone-detrimental medications; race and ethnicity; and study site, prediabetes before the MT was associated with more subsequent fractures (hazard ratio for fracture with prediabetes at all vs no pre-MT visits, 2.20 [95% CI, 1.11-4.37]; P = .02). This association was essentially unchanged after controlling for BMD at the start of the MT.

Conclusions and Relevance

This cohort study of midlife women suggests that prediabetes was associated with risk of fracture. Future research should determine whether treating prediabetes reduces fracture risk.

The clinical necessity of a distal forearm DEXA scan for predicting distal radius fracture in elderly females: a retrospective case-control study

BACKGROUND

Recent studies have demonstrated that the distal forearm dual-energy X-ray absorptiometry (DEXA) scan might be a better method for screening bone mineral density (BMD) and the risk of a distal forearm fracture, compared with a central DEXA scan. Therefore, the purpose of this study was to determine the effectiveness of a distal forearm DEXA scan for predicting the occurrence of a distal radius fracture (DRF) in elderly females who were not initially diagnosed with osteoporosis after a central DEXA scan.

METHODS

Among the female patients who visited our institutes and who were over 50 years old and underwent DEXA scans at 3 sites (lumbar spine, proximal femur, and distal forearm), 228 patients with DRF (group 1) and 228 propensity score-matched patients without fractures (group 2) were included in this study. The patients' general characteristics, BMD, and T-scores were compared. The odds ratios (OR) of each measurement and correlation ratio among BMD values of the different sites were evaluated.

RESULTS

The distal forearm T-score of the elderly females with DRF (group 1) was significantly lower than that of the control group (group 2) (p < 0.001 for the one-third radius and ultradistal radius measurements). BMD measured during the distal forearm DEXA scan was a better predictor of DRF risk than BMD measured during the central DEXA (OR = 2.33; p = 0.031 for the one-third radius, and OR = 3.98; p < 0.001 for the ultradistal radius). The distal one-third radius BMD was correlated with hip BMD, rather than lumbar BMD (p < 0.05 in each group).

CONCLUSION

Performing a distal forearm DEXA scan in addition to a central DEXA scan appears to be clinically significant for detecting the low BMD in the distal radius, which is associated with osteoporotic DRF in elderly females.

LEVEL OF EVIDENCE

III; case-control study.

Menopause-Related Changes in Body Composition Are Associated With Subsequent Bone Mineral Density and Fractures: Study of Women's Health Across the Nation

During the menopause transition (MT), lean mass decreases and fat mass increases. We examined the associations of these body composition changes during the MT (2 years before to 2 years after the final menstrual period) with bone mineral density (BMD) at the end of the MT and fracture after the MT. We included 539 participants from the Study of Women's Health Across the Nation who were not taking bone-beneficial or bone-detrimental medications before or during the MT. Using multivariable linear regression, we assessed the independent associations of % lean mass loss and % fat mass gain during the MT (mutually adjusted) with femoral neck (FN) and lumbar spine (LS) BMD at the end of the MT, adjusted for pre-MT BMD, pre-MT lean and fat mass, race/ethnicity, Study of Women's Health Across the Nation (SWAN) study site, age, and cigarette use. We used Cox proportional hazards regression to quantify the relations of % lean loss and % fat gain during the MT with fracture after the MT. The Cox model was adjusted for the covariates above plus post-MT use of bone-detrimental medications, and censored at the first use of bone-beneficial medications; we further controlled for FN or LS BMD at the end of the MT. Adjusted for covariates, each standard deviation (SD) (6.9%) increment in lean mass loss was associated with 0.010 g/cm2 lower FN BMD (p < 0.0001); each SD (19.9%) increment in fat mass gain was related to 0.026 g/cm2 greater FN (p = 0.009) and LS (p = 0.03) BMD. Each SD increment in lean mass loss and fat mass gain was associated with 63% (p = 0.001) and 28% (p = 0.05) greater fracture hazard after the MT; associations were essentially unchanged by BMD adjustment. MT-related lean mass loss and fat mass gain were associated differentially with BMD; both were independently related to more fractures. Mitigating MT-related body composition changes may reduce fracture risk. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Potential of Health Insurance Claims Data to Predict Fractures in Older Adults: A Prospective Cohort Study

Purpose

In older adults, fractures are associated with mortality, disability, loss of independence and high costs. Knowledge on their predictors can help to identify persons at high risk who may benefit from measures to prevent fractures. We aimed to assess the potential of German claims data to predict fractures in older adults.

Patients and Methods

Using the German Pharmacoepidemiological Research Database (short GePaRD; claims data from ~20% of the German population), we included persons aged ≥65 years with at least one year of continuous insurance coverage and no fractures prior to January 1, 2017 (baseline). We randomly divided the study population into a training (80%) and a test sample (20%) and used logistic regression and random forest models to predict the risk of fractures within one year after baseline based on different combinations of potential predictors.

Results

Among 2,997,872 persons (56% female), the incidence per 10,000 person years of any fracture in women increased from 133 in age group 65–74 years (men: 71) to 583 in age group 85+ (men: 332). The maximum predictive performance as measured by the area under the curve (AUC) across models was 0.63 in men and 0.60 in women and was achieved by combining information on drugs and morbidities. AUCs were lowest in age group 85+.

Conclusion

Our study showed that the performance of models using German claims data to predict the risk of fractures in older adults is moderate. Given that the models used data readily available to health insurance providers in Germany, it may still be worthwhile to explore the cost–benefit ratio of interventions aiming to reduce the risk of fractures based on such prediction models in certain risk groups.

Associations of Age at Menopause With Postmenopausal Bone Mineral Density and Fracture Risk in Women

CONTEXT

Menopause before age 45 is a risk factor for fractures, but menopause occurs at age ≥45 in ~90% of women.

OBJECTIVE

To determine, in women with menopause at age ≥45, whether (1) years since the final menstrual period (FMP) is more strongly associated with postmenopausal bone mineral density (BMD) than chronological age and (2) lower age at FMP is related to more fractures.

DESIGN AND SETTING

The Study of Women's Health Across the Nation, a longitudinal cohort study of the menopause transition (MT).

PARTICIPANTS

A diverse cohort of ambulatory women (pre- or early perimenopausal at baseline, with 15 near-annual follow-up assessments).

MAIN OUTCOME MEASURES

Postmenopausal lumbar spine (LS) or femoral neck (FN) BMD (n = 1038) and time to fracture (n = 1554).

RESULTS

Adjusted for age, body mass index (BMI), cigarette use, alcohol intake, baseline LS or FN BMD, baseline MT stage, and study site using multivariable linear regression, each additional year after the FMP was associated with 0.006 g/cm2 (P < 0.0001) and 0.004 g/cm2 (P < 0.0001) lower postmenopausal LS and FN BMD, respectively. Age was not related to FN BMD independent of years since FMP. In Cox proportional hazards regression, accounting for race/ethnicity, BMI, cigarette use, alcohol intake, prior fracture, diabetes status, exposure to bone-modifying medications/supplements, and study site, the hazard for incident fracture was 5% greater for each 1-year decrement in age at FMP (P = 0.02).

CONCLUSIONS

Years since the FMP is more strongly associated with postmenopausal BMD than chronological age, and earlier menopause is associated with more fractures.

Longitudinal Analysis of Circulating Markers of Bone Turnover Across Multiple Decades in Osteoporotic Women

PURPOSE

The objective of this study was to analyze changes in serum markers of bone turnover across multiple decades in osteoporotic women compared with nonosteoporotic controls, to determine their utility as potential predictors for osteoporosis. Early prediction of those at risk for osteoporosis can enable early intervention before the irreversible loss of critical bone mass.

METHODS

Serum samples were obtained from 20 women given the diagnosis of osteoporosis after age 46 years and 20 age-matched women with normal bone mineral density from 4 time points in their life (ages 25-31, 32-38, 39-45, and 46-60 years). Serum levels of bone turnover markers (propeptide of type I collagen, parathyroid hormone, bone-specific alkaline phosphatase, osteocalcin, C-terminal telopeptide of type I collagen, sclerostin, osteoprotegerin, osteopontin, and 25-OH vitamin D) were measured using commercially available arrays and kits. We used logistic regression to assess these individual serum markers as potential predictors of osteoporosis, and mixed-effects modeling to assess the change in bone turnover markers between osteoporotic and control groups over time, then performed fivefold cross-validation to assess the classification ability of the models.

RESULTS

Markers of bone turnover, bone-specific alkaline phosphatase, C-terminal telopeptide of type I collagen, sclerostin, and osteocalcin were all independent predictors at multiple time points; osteopontin was an independent predictor in the 39- to 45-year age group. Receiver operating characteristic analyses demonstrated moderately strong classification ability at all time points. Sclerostin levels among groups diverged over time and were higher in the control group than the osteoporotic group, with significant differences observed at time points 3 and 4.

CONCLUSIONS

Serum markers of bone turnover may be used to estimate the likelihood of osteoporosis development in individuals over time. Although prospective validation is necessary before recommending widespread clinical use, this information may be used to identify patients at risk for developing low bone mineral density long before traditional screening would ostensibly take place.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Effective communication regarding risk of fracture for individuals at risk of fragility fracture: a scoping review

Two scoping reviews were conducted to review recommendations and guidelines for communication regarding general health risk, and to investigate communication strategies regarding risk of fracture. Healthcare professionals are invited to apply these recommendations to optimize a patient-centered approach to reducing risk of fracture.

INTRODUCTION

To conduct a scoping review of the medical literature regarding recommendations and tools for effective communication between healthcare professionals and patients regarding general health risk and risk of fracture.

METHODS

The scoping review was divided into two parts to search for (1) studies presenting recommendations and guidelines for communication regarding general health risk; (2) studies investigating communication regarding risk of fracture for individuals at risk for fractures. Medline was searched in April 2020 to identify relevant studies.

RESULTS

The scoping review included 43 studies on communication with regard to general health risk and 25 studies about communication regarding risk of fracture. Recommendations for effective communication with regard to risk are presented. Communication of numeric data on risk should be adapted to the literacy and numeracy levels of the individual patient. Patient understanding of numerical data can be enhanced with appropriate use of visual aids (e.g., pie charts, icon arrays, bar charts, pictograms). The FRAX® tool is the most recommended and most used tool for assessing risk of fracture. Communication sent as individualized letters to patients following DXA scans has been studied, although patient understanding of their risk of fracture is often reported as low using this technique. Use of visual aids may improve patient understanding.

CONCLUSION

Healthcare professionals are encouraged to apply recommendations presented in this scoping review in their clinical practice. Patient understanding of risk of fracture should be confirmed by making sure that patients feel free to ask questions and express their concerns. This will contribute to an optimal patient-centered approach. Developing online tools to convert the probability of fracture into patient-friendly visual presentations could facilitate communication between healthcare professionals and patients about risk of fracture.

High Risk of Hip and Spinal Fractures after Distal Radius Fracture: A Longitudinal Follow-Up Study Using a National Sample Cohort

The purpose of the present study was to estimate the risk of hip and spinal fracture after distal radius fracture. Data from the Korean National Health Insurance Service—National Sample Cohort were collected between 2002 and 2013. A total of 8013 distal radius fracture participants who were 50 years of age or older were selected. The distal radius fracture participants were matched for age, sex, income, region of residence, and past medical history in a 1:4 ratio with control participants. In the subgroup analysis, participants were stratified according to age group (50–59, 60–69, or ≥70 years) and sex (male or female). Distal radius fracture patients had a 1.51-fold and 1.40-fold higher incidence of hip fracture and spinal fracture in the adjusted models, respectively. Among males, patients of all ages had a significantly higher incidence of hip fracture, and those who were 50 to 69 years of age had a significantly higher incidence of spinal fracture. Among females, those older than 70 years had a significantly higher incidence of hip fracture, and patients of all ages had a significantly higher incidence of spinal fracture. Previous distal radius fracture has a significant impact on the risk of subsequent hip and spinal fractures.

Rates of Osteoporosis Management and Secondary Preventative Treatment After Primary Fragility Fractures

Fragility fractures are often sentinel events in documenting new cases of osteoporosis. Numerous analyses have demonstrated low rates of adequate osteoporosis evaluation and treatment following primary fragility fractures. The purpose of this study was to quantify the incidence of primary fragility fractures in America and the rates of osteoporosis screening and management before and after fracture.

The Characteristics of Women with Subsequent Distal Radius Fracture after Initial Distal Radius Fracture

BACKGROUND

The purpose of this study was to investigate the characteristics of women with subsequent distal radius fracture (DRF) and to compare bone fragility variables in women with initial and subsequent DRF.

METHODS

We enrolled 227 women who experienced DRF (203 women with initial DRF and 24 women with subsequent DRF) between September 2016 and April 2019. We compared demographic characteristics and bone fragility variables, including bone mineral density, trabecular bone score, hip geometry, bicortical thickness of the distal radius, and fracture risk assessment tool (FRAX) scores between the 2 groups. To reduce bias, patients with subsequent DRF were propensity score-matched in a 1:2 manner with patients affected by initial DRF, and additional comparisons were performed.

RESULTS

Patients in the subsequent DRF group were older than those in the initial DRF group, but this difference was not significant (P=0.091). The proportion of patients receiving treatment with osteoporosis medication was significantly higher in the subsequent DRF group (41.7% vs. 19.2%, P=0.011). Bone fragility variables did not differ significantly between the 2 groups. However, the ten-year probability of major osteoporotic fractures based on FRAX scores was significantly higher in patients with subsequent DRF (7.5% vs. 10.8%, P<0.001). Similar results were observed when comparing the propensity score-matched initial and subsequent DRF groups.

CONCLUSIONS

These findings suggest that the occurrence of subsequent DRF after initial DRF can be attributed to multiple factors rather than bone fragility alone. Systematic and multidisciplinary management would be helpful in preventing the occurrence of subsequent DRF after the initial DRF.

Development of the Home Fall Hazard Checklist

Objective

Home hazard assessment is particularly important following a fracture as a means of preventing subsequent fractures. The purpose of this study was to evaluate current checklists and evidence on home hazard to develop a usable self-administered checklist that could be used by adults to assess home hazards.

Design

Review and observational, prospective study. Setting. Community dwelling. Participants. Nine adults (4 men, 5 women) were asked to review the checklist and provide feedback on whether items were relevant, comprehensive, and easy to understand. Intervention. A search for literature examining the causes of falls that focused on home hazards or behaviours was conducted, and causes were extracted. Using the combined list of home hazards, a draft checklist was created. The participants were asked to pilot the checklist through their home. Primary and Secondary Outcome. An initial iteration of the checklist was modified to reduce redundancy (by grouping certain items together), improve usability (by adding a “not applicable category”), and improve readability (by removing double-barrelled questions or rewriting certain items).

Results

This process resulted in 74 items in 10 areas. On average, it took 10 minutes for the participants to complete the home walk-through while filling out the checklist.

Conclusion

The fall hazard-home checklist is a new checklist designed to identify home fall hazards with the intended use of being either administered by self-report through memory or supported by a walk-about, and that could potentially be completed by a patient who has incurred a fall, fracture, a family member, or caregiver. Given the expense of home hazard assessments that involve a home visit, the validity of this method of detection warrants further investigation.

After the initial fracture in postmenopausal women, where do subsequent fractures occur?

BACKGROUND

The locations of subsequent fractures after initial fracture in postmenopausal women are poorly characterized.

METHODS

We conducted a prospective analysis of subsequent fractures after initial fracture in Women's Health Initiative (1993-2018) participants who provided follow-up (mean 15.4 years, SD 6.2 years) data (n = 157,282 participants; baseline age 50-79; 47,458 participants with incident fracture). Cox proportional hazards models were adjusted for age, race/ethnicity, body mass index, and other covariates.

FINDINGS

The risk of each type of subsequent fracture was increased after each type of initial fracture. Incident lower arm/wrist fracture was associated with significantly elevated risks of subsequent fractures at the upper arm/shoulder, upper leg, knee, lower leg/ankle, hip/pelvis, and spine (adjusted hazard ratios [aHRs] ranging 2·63-5·68). The risk of hip fracture was increased after initial lower arm or wrist fracture (aHR 4·80, 95% CI 4·29-5·36), initial upper arm or shoulder fracture (aHR 5·06, 95% CI 4·39-5·82), initial upper leg fracture (aHR 5·11, 95% CI 3·91-6·67), initial knee fracture (aHR 5·03, 95% CI 4·20-6·03), initial lower leg/ankle fracture (aHR 4·10, 95% CI 3·58-4·68), and initial spine fracture (aHR 6·69, 95% CI 5·95-7·53). Associations were significant in all age groups, even women aged 50-59 years. Risks of subsequent fracture were more pronounced among non-Hispanic Black, Hispanic/Latina, and Asian/Pacific Islander than among non-Hispanic White women.

INTERPRETATION

Increased risk of subsequent fracture is observed for all fracture types across all ages. Women who experience any of these fractures should be targeted for interventions to prevent subsequent fractures.

FUNDING

National Institutes of Health HHSN268201600018C,HHSN268201600001C, HHSN268201600002C, HHSN268201600003C, and HHSN268201600004C.

Bone health assessment via digital wrist tomosynthesis in the mammography setting

Bone fractures attributable to osteoporosis are a significant problem. Though preventative treatment options are available for individuals who are at risk of a fracture, a substantial number of these individuals are not identified due to lack of adherence to bone screening recommendations. The issue is further complicated as standard diagnosis of osteoporosis is based on bone mineral density (BMD) derived from dual energy x-ray absorptiometry (DXA), which, while helpful in identifying many at risk, is limited in fully predicting risk of fracture. It is reasonable to expect that bone screening would become more prevalent and efficacious if offered in coordination with digital breast tomosynthesis (DBT) exams, provided that osteoporosis can be assessed using a DBT modality. Therefore, the objective of the current study was to explore the feasibility of using digital tomosynthesis imaging in a mammography setting. To this end, we measured density, cortical thickness and microstructural properties of the wrist bone, correlated these to reference measurements from microcomputed tomography and DXA, demonstrated the application in vivo in a small group of participants, and determined the repeatability of the measurements. We found that measurements from digital wrist tomosynthesis (DWT) imaging with a DBT scanner were highly repeatable ex vivo (error = 0.05%-9.62%) and in vivo (error = 0.06%-10.2%). In ex vivo trials, DWT derived BMDs were strongly correlated with reference measurements (R = 0.841-0.980), as were cortical thickness measured at lateral and medial cortices (R = 0.991 and R = 0.959, respectively) and the majority of microstructural measures (R = 0.736-0.991). The measurements were quick and tolerated by human patients with no discomfort, and appeared to be different between young and old participants in a preliminary comparison. In conclusion, DWT is feasible in a mammography setting, and informative on bone mass, cortical thickness, and microstructural qualities that are known to deteriorate in osteoporosis. To our knowledge, this study represents the first application of DBT for imaging bone. Future clinical studies are needed to further establish the efficacy for diagnosing osteoporosis and predicting risk of fragility fracture using DWT.

Effects of β-Cryptoxanthin on Improvement in Osteoporosis Risk: A Systematic Review and Meta-Analysis of Observational Studies

Many studies have analyzed the effects of β-cryptoxanthin (BCX) on osteoporosis and bone health. This systematic review and meta-analysis aimed at providing quantitative evidence for the effects of BCX on osteoporosis. Publications were selected and retrieved from three databases and carefully screened to evaluate their eligibility. Data from the final 15 eligible studies were extracted and uniformly summarized. Among the 15 studies, seven including 100,496 individuals provided information for the meta-analysis. A random effects model was applied to integrate the odds ratio (OR) to compare the risk of osteoporosis and osteoporosis-related complications between the groups with high and low intake of BCX. A high intake of BCX was significantly correlated with a reduced risk of osteoporosis (OR = 0.79, 95% confidence interval (CI) 0.70–0.90, p = 0.0002). The results remained significant when patients were stratified into male and female subgroups as well as Western and Asian cohorts. A high intake of BCX was also negatively associated with the incidence of hip fracture (OR = 0.71, 95% CI 0.54–0.94, p = 0.02). The results indicate that BCX intake potentially reduces the risk of osteoporosis and hip fracture. Further longitudinal studies are needed to validate the causality of current findings.

Incidence of subsequent osteoporotic fractures after distal radius fractures and mortality of the subsequent distal radius fractures: a retrospective analysis of claims data of the Korea National Health Insurance Service

A better understanding of the features of subsequent fractures after distal radius fracture (DRF) is important for the prevention of further osteoporotic fractures. This study found that the cumulative incidence of subsequent osteoporotic fractures in South Korea increased over time and that the mortality rates of subsequent DRFs were lower than those of first-time DRFs.

INTRODUCTION

We examined the incidence of osteoporotic fractures following distal radius fractures (DRFs) and the mortality rate after subsequent DRFs using claims data from the Korea National Health Insurance (KNHI) Service.

METHODS

We identified records for 41,417 patients with first-time DRFs in 2012. The occurrence of osteoporotic fractures of the spine, hip, wrist, and humerus at least 6 months after the index DRF was tracked through 2016. All fractures were identified by specific diagnosis and procedure codes. One-year mortality rates and standardized mortality ratios (SMRs) for initial and subsequent DRFs were calculated for all patients.

RESULTS

The 4-year cumulative incidence of all subsequent osteoporotic fractures was 14.74% (6105/41,417; 9.47% in men, 15.9% in women). The number of associated subsequent fractures was 2850 for the spine (46.68%), 2271 for the wrist (37.2%), 708 for the hip (11.6%), and 276 for the humerus (4.52%). The cumulative mortality rate 1 year after the first-time and subsequent DRF was 1.47% and 0.71%, respectively, and the overall SMR was 1.48 (95% CI: 1.37-1.61) and 0.71 (95% CI: 0.42-1.21), respectively.

CONCLUSION

The cumulative incidence of osteoporotic fractures following DRFs increased over the study period and was higher among women. The cumulative mortality rates and SMRs of subsequent DRFs were lower than those of first-time DRFs at the 1-year follow-up. Given the increasing incidence rate of DRFs, the incidence of subsequent osteoporotic fractures may also increase.

Osteoporosis care after distal radius fracture reduces subsequent hip or spine fractures: a 4-year longitudinal study

We evaluated whether active osteoporosis care in patients experiencing their first distal radius fracture (DRF) reduces subsequent hip or spine fractures by comparing two cohorts. The incidence of subsequent fractures was significantly lower in the active care cohort than the other cohort in 4-year follow-up.

PURPOSE

Studies show that osteoporosis care in patients with osteoporotic fracture reduces subsequent fractures, but the impact of such active care in patients with distal radius fracture (DRF) has not been well studied. We evaluated how much osteoporosis care in patients experiencing their first DRF can reduce subsequent hip or spine fractures at 4-year follow-up.

METHODS

Active osteoporosis care by orthopedic surgeons for patients with DRF started from September 2009 at our institution, thus we had a unique opportunity to compare the two cohorts: pre-involvement (PreI) group (DRF before September 2009) and post-involvement (PostI) group (DRF from September 2009). We compared the two cohorts for subsequent hip or spine fracture incidence in the 4 years following DRF.

RESULTS

Overall, 1057 patients with a DRF (85% women; mean age, 70 years) were studied, of whom 205 patients were in PreI group and 852 in PostI group. Subsequent fractures occurred in 27 patients (2.6%), with a mean interval of 29 months after DRF. The incidence was significantly lower in the PostI group than in the PreI group (1.9% vs. 5.4%, p = 0.004), especially in hip fractures (0.4% vs. 2.9%, p = 0.002). The relative risk reduction was 65% for all subsequent fractures and 86% for hip fractures.

CONCLUSION

This study demonstrates that active osteoporosis care in patients with DRF significantly reduces subsequent fracture incidence even for the 4-year follow-up period. These findings add an evidence for the current proactive osteoporosis care programs such as fracture liaison services.

LEVEL OF EVIDENCE

Therapeutic level III.

The Risk of Osteoporotic Forearm Fractures in Postmenopausal Women in a Siberian Population Sample

The reduction in bone and muscle mass increases in menopausal women and poses a threat to the loss of self-dependence in the elderly. The aim of the study was to assess the frequency of osteoporotic forearm fractures (OFF) in postmenopausal women and to study their association with risk factors for chronic non-communicable diseases (NCD). The study was based on the Russian arm of the Health, Alcohol and Psychosocial Factors In Eastern Europe (HAPIEE) project (Novosibirsk). In a subsample of postmenopausal women aged 55–84 years old (n = 2005), we assessed the history of OFF during the last 3 years and risk factors for fracture and common NCD/. Cross-sectional associations between OFF history and potential determinants were analyzed using multivariable-adjusted logistic regression. A history of OFF in the last 3 years was found in 3.9% women. In a multivariable-adjusted model, the risk of OFF was directly associated with smoking in the past (OR = 2.23; 95% Cl 1.10–4.55), total cholesterol level higher than 200 mg/dL (OR = 1.98; 95% Cl 1.19–3.29), and it was inversely associated with body mass index (OR = 0.91; 95% Cl 0.86–0.96). In studied population sample of postmenopausal women the cross-sectional determinants of osteoporotic forearm fractures were smoking in the past and high total cholesterol value; body mass index protectively related to the risk of osteoporotic fractures. These findings might have implications for fracture prevention in postmenopausal women.

Therapist's practice patterns for subsequent fall/osteoporotic fracture prevention for patients with a distal radius fracture

STUDY DESIGN

Cross-sectional survey.

INTRODUCTION

Multifactorial risk factor screening and treatment is needed for subsequent falls/osteoporotic fractures prevention (SFOFP), given the elevated risk among patients with distal radius fracture (DRF).

PURPOSE OF THE STUDY

The primary objective was to describe hand therapists' knowledge and clinical practice patterns for assessment, treatment, referral, and education with respect to SFOFP for patients with DRF older than 45 years. Secondary objective was to explore therapist's preferences in content and delivery of knowledge translation tools that would support implementation of SFOFP.

METHODS

A cross-sectional multinational (Canada, the United States, and India) survey was conducted among 272 therapists from August to October 2014. Completed surveys were analyzed descriptively.

RESULTS

Surveys were completed by 157 therapists. Most respondents were from the United States (59%), certified hand therapists (54%), and females (87%). Although 65%-90% believed that they had knowledge about SFOFP assessment, treatment, and referral options, 55% did not include it in their routine practice for patients with DRF. Most assessed medication history (82%) and never used a Fracture Risk Assessment Tool (90%) or lower extremity muscle strength testing (54%) to identify those at risk of secondary fractures. With respect to treatment, approximately 33% always used upper extremity muscle strengthening exercises. Most reported rarely (sometimes to never) using balance (79%), lower extremity muscle strengthening (85%), bone strengthening (54%), or community-based physical activity (72%) programs. Similarly, when surveyed about patient education, therapists rarely (sometimes to never) advised patients about web-based resources (94%), regular vision testing (92%), diet for good bone health (87%), bone density evaluation (86%), footwear correction (73%), and hazard identification (67%). Most hand therapists were interested to receive more information on SFOFP for patients with DRF. Nearly one-half preferred to have Web sites for patients, and two-fifth were in favor of pamphlets for patients.

CONCLUSION

Current practice patterns reveal care gaps and limited implementation with respect to SFOFP for patients with DRF. Future research should focus on web-based educational/knowledge translation strategies to promote implementation of multifactorial fall risk screening and hand therapist's engagement in SFOFP for patients with DRF.

Utility of Distal Forearm DXA as a Screening Tool for Primary Osteoporotic Fragility Fractures of the Distal Radius: A Case-Control Study

BACKGROUND

Osteoporotic fragility fractures frequently occur at the distal part of the radius. This suggests that initial osteoporosis evaluation at this site may inform screening and treatment to prevent additional fractures. The purpose of this study was to investigate the utility of distal forearm dual x-ray absorptiometry (DXA) as a screening tool to assess the risk of fragility fractures at the distal part of the radius.

METHODS

This retrospective, case-control study included postmenopausal women who had sustained a distal radial fracture (fracture group, n = 110) and postmenopausal women with no history of fracture (control group, n = 95). DXA measurements at the spine, hip, and distal part of the forearm (ultra-distal, mid-distal, and one-third distal sections) were compared between the groups on the basis of bone mineral density (BMD), T-score, and the proportion of patients with a T-score of ≤-2.5 standard deviations (SD). We also investigated the regional differences on the basis of T-score among the skeletal sites. Furthermore, the reliability of distal forearm DXA measurements was validated by assessing the statistical correlation (r) with volumetric BMD by computed tomography (CT).

RESULTS

Compared with the control group, the fracture group showed significantly lower BMD and T-scores and higher proportions of patients with a T-score of ≤-2.5 SD at the ultra-distal, mid-distal, and one-third distal forearm; however, the spine and hip measurements did not differ significantly between the 2 groups. With respect to regional differences, in the fracture group, T-scores were significantly lower and the proportions of patients with a T-score of ≤-2.5 SD were significantly higher for the 3 distal forearm sites compared with the spine and hip. DXA measurements at all 3 of the distal forearm regions exhibited high correlation with volumetric BMD by CT (r = 0.83 to 0.92).

CONCLUSIONS

Some postmenopausal women were found to exhibit bone loss preferentially at the distal part of the radius, which may render them vulnerable to fragility fractures. Forearm DXA for the assessment of local bone loss may demonstrate benefit in screening for those at risk for distal radial fractures and facilitate the early identification of patients who require intervention for osteoporosis.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Recovery patterns over 4 years after distal radius fracture: Descriptive changes in fracture-specific pain/disability, fall risk factors, bone mineral density, and general health status

STUDY DESIGN

Descriptive/Longitudinal cohort.

INTRODUCTION

Distal radius fracture (DRF) is a common fall related fragility fracture that is known to be an early and independent predictor of secondary osteoporotic (OP) fractures. Changes in falls risk status, bone status and general health has not been evaluated prospectively in a population that has sustained a DRF.

PURPOSE OF THE STUDY

The purpose of our study was to describe the status of fracture-specific pain/disability, fall risk factors such as physical activity (PA) and fear of falling (FOF), bone mineral density (BMD) and general health status (HS) in people with a DRF and how these variables change over four years with respect to sex, age, incidence of secondary falls and secondary OP fractures.

METHODS

Patients (n = 94) self-reported their fracture-specific pain and disability (Patient-Rated Wrist Evaluation), PA (Rapid Assessment of Physical Activity), FOF (Modified Fall Efficacy Scale), HS (12-item Short Form Health Survey) and completed dual-energy X-ray absorptiometry scan based BMD assessment (lumbar spine and total hip) at baseline (1-2 weeks post-fracture), six months and four years after DRF. Descriptive statistics and general linear models were used to describe changes in recovery patterns over four years.

RESULTS

There was significant (p<0.001) improvement in fracture-specific pain/disability (60 points), FOF (1 point) and physical HS (11 points) between baseline and 4 year follow-up. There were no significant changes in PA and BMD. When stratified with respect to age, sex, presence of subsequent falls and OP fractures, there were no significant differences in fracture-specific pain/disability, PA, FOF, and BMD at baseline, six months or four years after DRF. The physical HS was significantly (p<0.05) less/poorer among those with secondary falls (lower by 2-6 points) and fractures (lower by 5-6 points) compared to those without. Similarly, mental HS was significantly (p<0.05) poorer among people with secondary falls (lower by 2-6 points) and in 50-64 year age group (lower by 3-5 points) than those without secondary falls and in 65-80 year age group, respectively.

CONCLUSION

Post DRF, the majority of the improvement in fracture-specific pain/disability, FOF and HS was completed at six months and very small changes were observed between the six month and four year follow-up.

LEVEL OF EVIDENCE

NA.

[10-year risk of fractures (FRAX) in people with diabetes type 2]

AIM

To study indicators of bone mineral densit (BMD) and trabecular bone score (TBS) and to reveal the 10-year fracture risk (FRAX®) taking into account the data obtained in persons with type 2 diabetes (DM2).

MATERIALS AND METHODS

A clinical study of the type of case - control. The study included 122 people with and without DM2. All persons were: questionnaires, anthropometry, densitometry, determination of TBS and fracture risk on the FRAX®.

RESULTS AND DISCUSSION

Persons with DM2 who underwent a fracture had lower T-score values in all areas except the spine, unlike those with DM2, but without fracture. However, persons with DM2 had a fracture at high values of T-score in vertebrae and hips in comparison with persons without DM. Using the TBS, we did not get a significant difference in any of the examined groups. We also found no differences in the risk of recurrent fractures among women with and without DM2 using FRAX® without densitometry and FRAX® adjusted for TBS. The values of FRAX® by T-score in the group of persons with DM with fractures were significantly lower (p=0.029 for major fractures, p=0.024 for hip fractures) than in persons without DM with fractures.

CONCLUSION

Persons with DM2 and fractures have higher BMD values, lower than the FRAX fracture risk values adjusted for the T-score, do not differ significantly in TBS, which determines the difficulties in diagnosis, the need to find additional methods for early diagnosis of increased fracture risk in patients with DM2.

Abaloparatide effect on forearm bone mineral density and wrist fracture risk in postmenopausal women with osteoporosis

PURPOSE

Wrist fractures are common, contribute significantly to morbidity in women with postmenopausal osteoporosis, and occur predominantly at the ultradistal radius, a site rich in trabecular bone. This exploratory analysis of the phase 3 ACTIVE study evaluated effects of abaloparatide versus placebo and teriparatide on forearm bone mineral density (BMD) and risk of wrist fracture.

METHODS

Forearm BMD was measured by dual energy X-ray absorptiometry in a subset of 982 women from ACTIVE, evenly distributed across the three treatment groups. Wrist fractures were ascertained in the total cohort (N = 2463).

RESULTS

After 18 months, ultradistal radius BMD changes from baseline were 2.25 percentage points greater for abaloparatide compared with placebo (95% confidence interval (CI) 1.38, 3.12, p < 0.001) and 1.54 percentage points greater for abaloparatide compared with teriparatide (95% CI 0.64, 2.45, p < 0.001). At 18 months, 1/3 radius BMD losses (versus baseline) were similar for abaloparatide compared with placebo (-0.42; 95% CI -1.03, 0.20; p = 0.19) but losses with teriparatide exceeded those of placebo (-1.66%; 95% CI -2.27, -1.06; p < 0.001). The decline with abaloparatide was less than that seen with teriparatide (group difference 1.22%; 95% CI 0.57, 1.87; p < 0.001). The radius BMD findings, at both ultradistal and 1/3 sites, are consistent with the numerically lower incidence of wrist fractures observed in women treated with abaloparatide compared with teriparatide (HR = 0.43; 95% CI 0.18, 1.03; p = 0.052) and placebo (HR = 0.49, 95% CI 0.20, 1.19, p = 0.11).

CONCLUSIONS

Compared with teriparatide, abaloparatide increased BMD at the ultradistal radius (primarily trabecular bone) and decreased BMD to a lesser extent at the 1/3 radius (primarily cortical bone), likely contributing to the numerically lower wrist fracture incidence observed with abaloparatide.

Association of Modifiable Risk Factors with Bone Mineral Density among People with Distal Radius Fracture: A Cross-Sectional Study

Purpose: This study determined the extent to which modifiable risk factors (balance, muscle strength, and physical activity [PA]) explained variability in bone mineral density (BMD) among people with a recent distal radius fracture (DRF). Method: This cross-sectional study included 190 patients, aged 50-80 years, with a DRF. Participants were assessed for balance, muscle strength, PA, fracture-specific pain, and disability. Areal BMD at the femoral neck (BMD-FN) and total hip (BMD-TH) was assessed. Correlation and multiple linear regression was used to determine the contribution of modifiable risk factors to BMD. Results: Balance, handgrip strength, knee extension strength, and plantar-flexion strength had significant bivariate associations with BMD-FN. There was a weak to moderate correlation (r = 0.25-0.40; p < 0.05) of balance and grip strength with BMD. Grip strength independently (p < 0.05) explained 17% and 12% of the variability in BMD-FN (n = 81) and BMD-TH (n = 82), respectively. Stratified by age, balance (R ² = 0.10; p = 0.04) and grip strength (R ² = 0.32; p = 0.003) were independent significant predictors of BMD-FN among women aged 50-64 years and 65-80 years, respectively. Conclusions: Grip strength of the unaffected hand is independently associated with BMD-FN and BMD-TH in people with recent DRF. It may act as a surrogate for general bone health, frailty, or overall muscle strength rather than as a direct target for intervention.

Importance of Recent Fracture as Predictor of Imminent Fracture Risk

PURPOSE OF REVIEW

To examine the importance of recent fracture as a predictor of imminent fracture risk, review the importance of prior fracture type and timing, and identify risk factors for recurrent osteoporotic fracture.

RECENT FINDINGS

Prior fracture type and timing impact risk of subsequent fracture that is largely independent of bone mineral density. Site of re-fracture is similar to original major osteoporotic fracture. Incidence of recurrent major osteoporotic fracture is greatest within the first year. Other risk factors include those that pertain to individual characteristics. Approved osteoporosis therapies reduce risk of recurrent fracture. Prior fracture timing, type, and individual characteristics are important components of predicting the risk of future fracture. Initiation of osteoporosis medication therapy should be started after initial fracture to reduce the risk of future fracture, though these medications typically take 6-12 months to have an effect, during which time is the highest rate of imminent re-fracture.

Osteoporosis and osteopenia in the distal forearm predict all-cause mortality independent of grip strength: 22-year follow-up in the population-based Tromsø Study

Low bone mineral density (BMD) gives an increased risk of fractures, which can lead to premature death. Can BMD of the wrist predict mortality? BMD consistent with osteopenia and osteoporosis gave a significantly increased risk of death for both men and women in a general population in Tromsø, Norway.

INTRODUCTION

To investigate if bone mineral density (BMD) levels of the distal forearm, consistent with osteopenia and osteoporosis, can predict mortality and if grip strength is an effect modifier.

METHODS

The study population constituted 6565 participants aged 50-79 years at baseline in the Tromsø Study wave 4 conducted in 1994-1995. Forearm BMD measured by SXA was categorized as "normal," "osteopenia," or "osteoporosis" following WHO's definition. Cox regression with all-cause mortality as the outcome over 22 years of follow-up was performed for men and women separately, adjusting for health-related factors, as well as BMD by grip strength interaction. A secondary analysis with a 15-year follow-up also adjusted for hip fractures and osteoporotic fractures.

RESULTS

During follow-up, 3176 of participants died (47%). Those categorized as osteoporotic had higher mortality hazard ratio (HR) compared to those with normal BMD; men HR = 1.37 (95% confidence interval (CI) 1.19, 1.58) and women HR = 1.32 (1.14, 1.53) were adjusted for age, body mass index, physical activity, smoking habits, education, health status, chronic diseases, and grip strength. Corresponding HRs for osteopenia were men HR = 1.13 (1.00, 1.27) and women HR = 1.17 (1.01, 1.35). Further adjustments for fractures did only marginally attenuate the results, and HRs were still significant. There was no grip strength by BMD interaction.

CONCLUSION

Men and women with low distal forearm BMD values, consistent with osteoporosis or osteopenia, had an increased mortality compared to normal BMD participants. High grip strength did not modify this association, and the association remained after adjustment for a range of health-related factors.

Evidence-Based Review of Distal Radius Fractures

Distal radius fractures are one of the most commonly treated fractures in the United States. The highest rates are seen among the elderly, second only to hip fractures. With the increasing aging population these numbers are projected to continue to increase. Distal radius fractures include a spectrum of injury patterns encountered by general practitioners and orthopedists alike. This evidence-based review of distal radius fractures incorporates current and available literature on the diagnosis, management, and treatment of fractures of the distal radius.

Risk factors predicting subsequent falls and osteoporotic fractures at 4 years after distal radius fracture-a prospective cohort study

In a prospective cohort of 113 patients followed 4 years after distal radius fracture (DRF), 24% of patients experienced a subsequent fall and 19% experienced a subsequent fracture. People with poor balance, greater fracture-specific pain/disability, low bone density, and prior falls had nearly a three times higher risk of subsequent falls.

PURPOSE

To determine the extent to which modifiable risk factors alone or in combination with bone mineral density (BMD) and non-modifiable risk factors predict subsequent falls and osteoporotic (OP) fractures after distal radius fracture (DRF).

METHODS

We assessed a cohort of patients (n = 191; mean age = 62 ± 8 years; female = 88%) shortly after DRF (baseline) and again at 4 years to identify subsequent falls or OP fractures. Baseline predictors included age, sex, prior falls, and modifiable risk factors such as balance, muscle strength, physical activity, fear of falling, BMD, fracture-specific pain/disability, and general health status. Univariate, multivariate, and stepwise logistic regression analyses were conducted to compute odds ratio (OR) with 95% CI to determine the extent of association between the risk factors and outcomes.

RESULTS

Among the 113 patients, who completed 4-year follow-up, 24% reported ≥ 1 subsequent fall and 19% reported ≥ 1 subsequent fracture. Significant predictors of subsequent falls included poor balance (OR = 3.3), low total hip BMD (OR = 3.3), high patient-rated wrist evaluation (PRWE) score (OR = 3.0), and prior falls (OR = 3.4). When adjusted for BMD, age, and sex; only prior falls (OR = 4.1) remained a significant independent predictor of future falls. None of the modifiable or non-modifiable risk factors were significantly associated with subsequent fractures.

CONCLUSION

Prior falls (≥ 2) is an independent predictor of subsequent falls in patients with DRF. In clinical practice, screening of patients for prior falls, balance, fracture-specific pain/disability, and BMD may identify those who might be at risk of subsequent falls after their first DRF.

Fragility Fractures & Their Impact on Older People

Osteoporotic fractures, in particular hip and vertebral, are a major health burden worldwide. The majority of these fractures occur in the elderly population, resulting in one of the most important causes of mortality and disability in older ages. Their cost for societies is enormous and is forecast to steadily increase over the coming decades globally. Low bone mineral density (BMD) remains a key preventable risk factor for fractures. Screening and treatment of individuals with high risk of fracture is cost-effective. Predictive tools including clinical risk factors, minimisation of falls risk and public authorities' support to create Fracture Liaison Services are paramount strategies.

Predictive Power of Distal Radial Metaphyseal Tenderness for Diagnosing Occult Fracture

PURPOSE

To correlate the physical examination finding of distal radial metaphyseal tenderness with plain radiographic and magnetic resonance imaging after acute wrist injury to diagnose occult distal radius fractures. We hypothesized that persistent distal radial metaphyseal tenderness 2 weeks after acute injuries is predictive of an occult fracture.

METHODS

Twenty-nine adult patients presented, after acute trauma, with distal radial metaphyseal tenderness and initial plain radiographs and/or fluoroscopic images that did not show a distal radius fracture. Patients were reevaluated clinically and radiographically at approximately 2 weeks after initial presentation. Patients with persistent distal radial tenderness and negative radiographs underwent magnetic resonance imaging to definitively diagnose an occult distal radius fracture. We calculated the sensitivity and positive predictive value for persistent distal radial metaphyseal tenderness using a 95% confidence interval and standard formulas. Both radiographs and magnetic resonance imaging were used as our endpoint diagnosis for a distal radius fracture.

RESULTS

We diagnosed 28 occult distal radius fractures, 8 by follow-up radiograph and 20 by magnetic resonance imaging. The positive predictive value for patients who completed the protocol was 96%. One patient who did not have an occult distal radius fracture had a fracture of the ulnar styloid.

CONCLUSIONS

Tenderness of the distal radial metaphysis after wrist injury is strongly suggestive of a distal radius fracture despite both normal plain radiographs and fluoroscopic images.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Post-fracture care: do we need to educate patients rather than doctors? The PREVOST randomized controlled trial

We conducted a multicenter, randomized controlled trial to evaluate the impact of a population-based patient-centered post-fracture care program with a dedicated case manager, PREVention of OSTeoporosis (PREVOST), on appropriate post-fracture osteoporosis management. We showed that, compared to usual care, BMD investigation post-fracture was significantly improved (+20%) by our intervention program.

INTRODUCTION

Our study aims to evaluate the impact of a population-based patient-centered post-fracture care program, PREVOST, on appropriate post-fracture care.

METHODS

Multicenter, randomized controlled trial enrolling 436 women aged 50 to 85 years and attending a French hospital, for a low-energy fracture of the wrist or humerus. Randomization was stratified by age, hospital department, and site of fracture. The intervention was performed by a trained case manager who interacted only with the patients, with repeated oral and written information about fragility fractures and osteoporosis management, and prompting them to visit their primary care physicians. Control group received usual care. The primary outcome was the initiation of an appropriate post-fracture care defined by Bone Mineral Density (BMD) and/or anti-osteoporotic treatment prescription at 6 months.

RESULTS

At 6 months, 53% of women in intervention group initiated a post-fracture care versus 33% for usual care (adjOR 2.35, 95%CI [1.58-3.50], p < 0.001). Post-fracture care was more frequent after wrist than humerus fracture (adjOR 1.93, 95%CI [1.14-3.30], p = 0.015) and decreased with age (adjOR for 10 years increase 0.76, 95%CI [0.61-0.96], p = 0.02). The intervention resulted in BMD prescription in 50% of patients (adjOR 2.10, 95%CI [1.41-3.11], p < 0.001) and in BMD performance in 41% of patients (adjOR 2.12, 95%CI [1.40-3.20], p < 0.001) versus 33 and 25% for usual care, respectively. Having performed a BMD increased treatment prescription; however, only 46% of women with a low BMD requiring a treatment according to the French guidelines received a prescription.

CONCLUSION

A patient-centered care program with a dedicated case manager can significantly improve post-fracture BMD investigation.

Epidemiology of distal radius fractures and factors predicting risk and prognosis

STUDY DESIGN

Literature Review.

INTRODUCTION

For optimal Distal Radius Fracture (DRF) rehabilitation and fracture prevention, it is important to understand the epidemiology and factors predictive of injury, chronic pain, chronic disability, and subsequent fracture.

PURPOSE

To summarize the literature reporting on DRF epidemiology, risk factors, and prognostic factors.

METHODS

Literature synthesis.

RESULTS

Although incidence varies globally, DRFs are common across the lifespan and appear to be on the rise. Risk of DRF is determined by personal factors (age, sex/gender, lifestyle, health condition) and environmental factors (population density, climate). For example, age and sex influence risk such that DRF is most common in boys/young men and older women. The most common causes of DRF in the pediatric and young adult age groups include playing/sporting activities and motor vehicle accidents. In contrast, the most common mechanism of injury in older adults is a low-energy trauma because of a fall from a standing height. Poorer health outcomes are associated with older age, being female, poor bone healing (or having an associated fracture of the ulnar styloid), having a compensated injury, and a lower socioeconomic status.

CONCLUSIONS

Risk stratification according to predictors of chronic pain and disability enable therapists to identify those patients who will benefit from advocacy for more comprehensive assessment, targeted interventions, and tailored educational strategies. The unique opportunity for secondary prevention of osteoporotic fracture after DRF has yet to be realized by treating therapists in the orthopedic community.

LEVEL OF EVIDENCE

V.

Elevated Bone Turnover Markers Are Associated With Distal Radius Fractures in Premenopausal Women

PURPOSE

To examine whether premenopausal women with distal radius fractures (DRF) have lower levels of 25-hydroxyvitamin D (25[OH]D) and increased levels of serum bone turnover markers (BTM) compared with control subjects without fracture.

METHODS

Premenopausal women with DRF (n = 20) were prospectively enrolled and compared with age-matched individuals without a fracture (n = 20). Outcome measures included serum levels of 25(OH)D, parathyroid hormone (PTH), markers of bone formation (osteocalcin [OC], N-terminal extension propeptide of type I collagen [P1NP], and bone-specific alkaline phosphatase [BSAP]), and markers of bone resorption (C-terminal telopeptide of type I collagen [CTX]). We assessed associations between BTM and DRF with conditional logistic regression and the utility of markers for fracture prediction with a receiver operator characteristic analysis.

RESULTS

The fracture group and control group were comparable in terms of age at menarche and BMI. Patients who had fractures had significantly greater levels of OC and P1NP, and demonstrated a nonsignificant increase in CTX. Levels of 25(OH)D, PTH, and BSAP were similar between groups. Conditional logistic regression revealed independent associations between DRF and increased levels of OC and CTX. Levels of 25(OH)D and PTH were not associated with DRF. Receiver operator characteristic analyses demonstrated moderate performance for OC, P1NP, BSAP, and CTX in predicting DRF.

CONCLUSIONS

Levels of 25(OH)D were not associated with DRF in premenopausal women. However, patients with DRF had increased levels of BTM of formation and resorption. Bone turnover markers may be helpful in predicting future fragility fractures in premenopausal women.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Wrist Fracture and Risk of Subsequent Fracture: Findings from the Women's Health Initiative Study

Wrist fractures are common in postmenopausal women and are associated with functional decline. Fracture patterns after wrist fracture are unclear. The goal of this study was to determine the frequency and types of fractures that occur after a wrist fracture among postmenopausal women. We carried out a post hoc analysis of data from the Women's Health Initiative Observational Study and Clinical Trials (1993-2010) carried out at 40 US clinical centers. Participants were postmenopausal women aged 50 to 79 years at baseline. Mean follow-up duration was 11.8 years. Main measures included incident wrist, clinical spine, humerus, upper extremity, lower extremity, hip, and total non-wrist fractures and bone mineral density (BMD) in a subset. Among women who experienced wrist fracture, 15.5% subsequently experienced non-wrist fracture. The hazard for non-wrist fractures was higher among women who had experienced previous wrist fracture than among women who had not experienced wrist fracture: non-wrist fracture overall (hazard ratio [HR] = 1.40, 95% confidence interval [CI] 1.33-1.48), spine (HR = 1.48, 95% CI 1.32-1.66), humerus (HR = 1.78, 95% CI 1.57-2.02), upper extremity (non-wrist) (HR = 1.88, 95% CI 1.70-2.07), lower extremity (non-hip) (HR = 1.36, 95% CI 1.26-1.48), and hip (HR = 1.50, 95% CI 1.32-1.71) fracture. Associations persisted after adjustment for BMD, physical activity, and other risk factors. Risk of non-wrist fracture was higher in women who were younger when they experienced wrist fracture (interaction p value 0.02). Associations between incident wrist fracture and subsequent non-wrist fracture did not vary by baseline BMD category (normal, low bone density, osteoporosis). A wrist fracture is associated with increased risk of subsequent hip, vertebral, upper extremity, and lower extremity fractures. There may be substantial missed opportunity for intervention in the large number of women who present with wrist fractures.

Opportunistic Osteoporosis Screening - Gleaning Additional Information from Diagnostic Wrist CT Scans

BACKGROUND

Although screening for and treating osteoporosis can prevent subsequent fractures, the rates of such interventions are low following a distal radial fracture. One potential method for identifying metabolic bone disease is via Hounsfield unit (HU) measurements from diagnostic computed tomography (CT) scans. We hypothesized that HU values of the distal aspect of the radius could be used to assess local bone quality and would be predictive of distal radial fracture risk, thereby allowing the identification of patients in need of further management.

METHODS

Measurements of bone mineral density (BMD) were made for 100 patients on the basis of HU values of cancellous portions of the distal aspect of the radius, the ulnar head, and the capitate. The HU values in twenty-five male and twenty-five female patients with an acute distal radial fracture documented on CT were compared with those of age and sex-matched control patients who had a CT scan obtained for other indications.

RESULTS

Among the control patients, HU values decreased as age increased. When assessed on the basis of sex, both male and female patients with a distal radial fracture had significantly lower regional BMD compared with nonfracture control patients. A distal radial HU value of 218 for females and 246 for males optimized sensitivity and specificity; values below this threshold were associated with an increased risk of distal radial fracture.

CONCLUSIONS

HU measurements can be obtained from any diagnostic CT scan using modern software programs and can be obtained by physicians in the office setting with minimal effort and at no additional cost or radiation exposure to the patient. Regardless of imaging indications, we suggest that patients with HU values below the identified thresholds be considered for further metabolic bone disease work-up, such as additional imaging, laboratory assessments, the initiation of osteoporosis treatment, or appropriate referral.

A trans-ethnic genome-wide association study identifies gender-specific loci influencing pediatric aBMD and BMC at the distal radius

Childhood fractures are common, with the forearm being the most common site. Genome-wide association studies (GWAS) have identified more than 60 loci associated with bone mineral density (BMD) in adults but less is known about genetic influences specific to bone in childhood. To identify novel genetic factors that influence pediatric bone strength at a common site for childhood fractures, we performed a sex-stratified trans-ethnic genome-wide association study of areal BMD (aBMD) and bone mineral content (BMC) Z-scores measured by dual energy X-ray absorptiometry at the one-third distal radius, in a cohort of 1399 children without clinical abnormalities in bone health. We tested signals with P < 5 × 10(-6) for replication in an independent, same-age cohort of 486 Caucasian children. Two loci yielded a genome-wide significant combined P-value: rs7797976 within CPED1 in females [P = 2.4 × 10(-11), β =- 0.30 standard deviations (SD) per T allele; aBMD-Z] and rs7035284 at 9p21.3 in males (P = 1.2 × 10(-8), β = 0.28 SD per G allele; BMC-Z). Signals at the CPED1-WNT16-FAM3C locus have been previously associated with BMD at other skeletal sites in adults and children. Our result at the distal radius underscores the importance of this locus at multiple skeletal sites. The 9p21.3 locus is within a gene desert, with the nearest gene flanking each side being MIR31HG and MTAP, neither of which has been implicated in BMD or BMC previously. These findings suggest that genetic determinants of childhood bone accretion at the radius, a skeletal site that is primarily cortical bone, exist and also differ by sex.

Interaction between bone and muscle in older persons with mobility limitations

Aging is associated with a progressive loss of bone-muscle mass and strength. When the decline in mass and strength reaches critical thresholds associated with adverse health outcomes, they are operationally considered geriatric conditions and named, respectively, osteoporosis and sarcopenia. Osteoporosis and sarcopenia share many of the same risk factors and both directly or indirectly cause higher risk of mobility limitations, falls, fractures and disability in activities of daily living. This is not surprising since bones adapt their morphology and strength to the long-term loads exerted by muscle during anti-gravitational and physical activities. Non-mechanical systemic and local factors also modulate the mechanostat effect of muscle on bone by affecting the bidirectional osteocyte-muscle crosstalk, but the specific pathways that regulate these homeostatic mechanisms are not fully understood. More research is required to reach a consensus on cut points in bone and muscle parameters that identify individuals at high risk for adverse health outcomes, including falls, fractures and disability. A better understanding of the muscle-bone physiological interaction may help to develop preventive strategies that reduce the burden of musculoskeletal diseases, the consequent disability in older persons and to limit the financial burden associated with such conditions. In this review, we summarize age-related bone-muscle changes focusing on the biomechanical and homeostatic mechanisms that explain bone-muscle interaction and we speculate about possible pathological events that occur when these mechanisms become impaired. We also report some recent definitions of osteoporosis and sarcopenia that have emerged in the literature and their implications in clinical practice. Finally, we outline the current evidence for the efficacy of available anti-osteoporotic and proposed antisarcopenic interventions in older persons.

Appropriate osteoporosis treatment by family physicians in response to FRAX vs CAROC reporting: results from a randomized controlled trial

Canadian guidelines recommend either the FRAX or the Canadian Association of Radiologists and Osteoporosis Canada (CAROC) fracture risk assessment tools to report 10-yr fracture risk as low (<10%), moderate (10%-20%) or high (>20%). It is unknown whether one reporting system is more effective in helping family physicians (FPs) identify individuals who require treatment. Individuals ≥50 yr old with a distal radius fracture and no previous osteoporosis diagnosis or treatment were recruited. Participants underwent a dual-energy x-ray absorptiometry scan and answered questions about fracture risk factors. Participants' FPs were randomized to receive either a FRAX report or the standard CAROC-derived bone mineral density report currently used by the institution. Only the FRAX report included statements regarding treatment recommendations. Within 3 mo, all participants were asked about follow-up care by their FP, and treatment recommendations were compared with an osteoporosis specialist. Sixty participants were enrolled (31 to FRAX and 29 to CAROC). Kappa statistics of agreement in treatment recommendation were 0.64 for FRAX and 0.32 for bone mineral density. The FRAX report was preferred by FPs and resulted in better postfracture follow-up and treatment that agreed more closely with a specialist. Either the clear statement of fracture risk or the specific statement of treatment recommendations on the FRAX report may have supported FPs to make better treatment decisions.

Relationship of bone mineral density of spine and femoral neck to distal radius fracture stability in patients over 65

PURPOSE

We hypothesized that an increasing degree of osteopenia in the femoral neck and lumbar spine would be associated with loss of reduction after closed manipulation and splinting of distal radius fractures in patients over 65 years of age.

METHODS

We performed a retrospective review, evaluating 78 patients with displaced distal radius fractures managed with closed reduction and splinting. T-scores from the lumbar spine and femoral neck were recorded from dual-energy x-ray absorptiometry scans performed either within 1 year before or after injury. Volar tilt, radial height, radial inclination, and ulnar variance were evaluated from the initial fracture, postreduction, and final follow-up radiographs. We calculated the percentage of reduction maintained regarding reduction variable. We correlated T-scores of the lumbar spine and femoral neck with the percentage of retained reduction.

RESULTS

We found no correlation between T-scores of the lumbar spine or femoral neck and the amount of reduction lost throughout the healing process of distal radius fractures with respect to volar tilt, radial height, radial inclination, or ulnar variance. Reduction was of no anatomical benefit in 53% to radial height, 44% to radial inclination, and 54% to ulnar variance.

CONCLUSIONS

There appears to be no relationship between bone mineral density, based on T-scores of the lumbar spine and femoral neck, and the ability to maintain reduction after closed manipulation and splinting of displaced distal radius fractures in patients over 65 years of age.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic III.

The clinical diagnosis of osteoporosis: a position statement from the National Bone Health Alliance Working Group

Osteoporosis causes an elevated fracture risk. We propose the continued use of T-scores as one means for diagnosis but recommend that, alternatively, hip fracture; osteopenia-associated vertebral, proximal humerus, pelvis, or some wrist fractures; or FRAX scores with ≥3% (hip) or 20% (major) 10-year fracture risk also confer an osteoporosis diagnosis.

INTRODUCTION

Osteoporosis is a common disorder of reduced bone strength that predisposes to an increased risk for fractures in older individuals. In the USA, the standard criterion for the diagnosis of osteoporosis in postmenopausal women and older men is a T-score of  ≤ -2.5 at the lumbar spine, femur neck, or total hip by bone mineral density testing.

METHODS

Under the direction of the National Bone Health Alliance, 17 clinicians and clinical scientists were appointed to a working group charged to determine the appropriate expansion of the criteria by which osteoporosis can be diagnosed.

RESULTS

The group recommends that postmenopausal women and men aged 50 years should be diagnosed with osteoporosis if they have a demonstrable elevated risk for future fractures. This includes having a T-score of less than or equal to -2.5 at the spine or hip as one method for diagnosis but also permits a diagnosis for individuals in this population who have experienced a hip fracture with or without bone mineral density (BMD) testing and for those who have osteopenia by BMD who sustain a vertebral, proximal humeral, pelvic, or, in some cases, distal forearm fracture. Finally, the term osteoporosis should be used to diagnose individuals with an elevated fracture risk based on the World Health Organization Fracture Risk Algorithm, FRAX.

CONCLUSIONS

As new ICD-10 codes become available, it is our hope that this new understanding of what osteoporosis represents will allow for an appropriate diagnosis when older individuals are recognized as being at an elevated risk for fracture.

Magnesium intake, bone mineral density, and fractures: results from the Women's Health Initiative Observational Study

BACKGROUND

Magnesium is a necessary component of bone, but its relation to osteoporotic fractures is unclear.

OBJECTIVE

We examined magnesium intake as a risk factor for osteoporotic fractures and altered bone mineral density (BMD).

DESIGN

This prospective cohort study included 73,684 postmenopausal women enrolled in the Women's Health Initiative Observational Study. Total daily magnesium intake was estimated from baseline food-frequency questionnaires plus supplements. Hip fractures were confirmed by a medical record review; other fractures were identified by self-report. A baseline BMD analysis was performed in 4778 participants.

RESULTS

Baseline hip BMD was 3% higher (P < 0.001), and whole-body BMD was 2% higher (P < 0.001), in women who consumed >422.5 compared with <206.5 mg Mg/d. However, the incidence and RR of hip and total fractures did not differ across quintiles of magnesium. In contrast, risk of lower-arm or wrist fractures increased with higher magnesium intake [multivariate-adjusted HRs of 1.15 (95% CI: 1.01, 1.32) and 1.23 (95% CI: 1.07, 1.42) for quintiles 4 and 5, respectively, compared with quintile 1; P-trend = 0.002]. In addition, women with the highest magnesium intakes were more physically active and at increased risk of falls [HR for quintile 4: 1.11 (95% CI: 1.06, 1.16); HR for quintile 5: 1.15 (95% CI: 1.10, 1.20); P-trend < 0.001].

CONCLUSIONS

Lower magnesium intake is associated with lower BMD of the hip and whole body, but this result does not translate into increased risk of fractures. A magnesium consumption slightly greater than the Recommended Dietary Allowance is associated with increased lower-arm and wrist fractures that are possibly related to more physical activity and falls.

The clinical significance of wrist fracture in osteoporosis

Wrist fracture is the most common fragility fracture in perimenopausal and young postmenopausal women in USA and Northern Europe. Recent studies based on high-resolution imaging have shown microarchitectural deterioration of trabecular bone even in premenopausal women presenting with a wrist fracture. These fractures increase the risk of subsequent fractures, especially in the first 7 years. So, wrist fracture female patients must be appropriately screened and treated for osteoporosis in order to preserve bone quality and prevent future, more severe, fractures.

Progressively increasing fracture risk with advancing age after initial incident fragility fracture: the Tromsø study

The risk of subsequent fracture is increased after initial fractures; however, proper understanding of its magnitude is lacking. This population-based study examines the subsequent fracture risk in women and men by age and type of initial incident fracture. All incident nonvertebral fractures between 1994 and 2009 were registered in 27,158 participants in the Tromsø Study, Norway. The analysis included 3108 subjects with an initial incident fracture after the age of 49 years. Subsequent fracture (n = 664) risk was expressed as rate ratios (RR) and absolute proportions irrespective of death. The rates of both initial and subsequent fractures increased with age, the latter with the steepest curve. Compared with initial incident fracture rate of 30.8 per 1000 in women and 12.9 per 1000 in men, the overall age-adjusted RR of subsequent fracture was 1.3 (95% CI, 1.2-1.5) in women, and 2.0 (95% CI, 1.6-2.4) in men. Although the RRs decreased with age, the absolute proportions of those with initial fracture who suffered a subsequent fracture increased with age; from 9% to 30% in women and from 10% to 26% in men, between the age groups 50-59 to 80+ years. The type of subsequent fracture varied by age from mostly minor fractures in the youngest to hip or other major fractures in the oldest age groups, irrespective of type and severity of initial fracture. In women and men, 45% and 38% of the subsequent hip or other major fractures, respectively, were preceded by initial minor fractures. The risk of subsequent fracture is high in all age groups. At older age, severe subsequent fracture types follow both clinically severe and minor initial incident fractures. Any fragility fracture in the elderly reflects the need for specific osteoporosis management to reduce further fracture risk.

Study of bone mass in young daughters of women with fracture of the distal end of the radius

The main aim was to assess whether young and healthy daughters of women with fractures of the distal end of the radius (DER) had less bone mass than the control group. In an observational study of cases and controls (1:1), the daughters of women with fractures of DER (96) were selected at the age of reaching the peak of bone mass and compared with a control group (91). All women underwent medical history, analytical determinations, and densitometry. In the case group, we found lower bone mass values at the spine and femoral neck than the control group. We also found a lower bone mass at the hips of daughters of women with 1 or more osteoporotic fractures associated with DER and at the lumbar spine in those whose mothers had densitometric osteoporosis. In conclusion, young daughters of women with fractures of DER had lower levels of bone mass density, with a possible "location-specific" occurrence based on the presence of 1 or more osteoporotic fractures associated with DER or on the presence of maternal densitometric osteoporosis.