Factors related to occurrence of hip fracture during a fall on the hip

Associations between weight-adjusted waist index and fractures: a population-based study

INTRODUCTION

The weight-adjusted waist circumference index (WWI) is a novel obesity evaluation indicator that appears to be superior to body mass index (BMI) and waist circumference (WC) in evaluating muscle and fat mass. The purpose of this study was to investigate the association between WWI and fractures among adults.

METHODS

In this cross-sectional study, multivariate logistic regression and smoothed curve fitting were used to investigate linear and nonlinear associations between WWI and fractures, based on data from 28,679 adult participants in the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2018.

RESULTS

After adjusting for all covariates, the prevalence of hip/wrist/spine fractures among all participants was 1.09%, 8.87%, and 1.97%, respectively. A 1-unit increase in WWI was associated with a 5% increase in the odds of hip fractures [1.05 (1.01, 1.10)], and a 9% increase in the odds of spine fractures [1.09 (1.06, 1.13)], but not with the prevalence of wrist fractures [0.97 (0.94, 1.06)].

CONCLUSIONS

Higher WWI was associated with an increased prevalence of hip fracture and spine fracture, but not wrist fracture.

Systematic causality mapping of factors leading to accidental falls of older adults

Introduction

According to WHO’s statistical evidence, accidental falls are the second leading causes of death worldwide. This systematic literature review and meta-analysis aims to provide a holistic view of risk factors and unfold the missing or less addressed but crucial factors that lead to accidental falls of the older adults. It also intends to profile the risk factors at different levels, which helps exhibit the level of consistency relationship between various risk factors and falls.

Study design

Systematic literature review.

Methods

A systematic review on the risk factors leading to accidental falls of older adults by retrieving English journal papers published starting from 1980 was conducted on April 2018. A method of literature synthesis and causal mapping was adopted to aggregate those fall-leading factors into macro variables and a coherent causal tracing network was thereby built, which can reflect not only the causal relationship of various macro variables but also the “consistency of agreement” between macro variables and falls of the older adults.

Results

A hypothesized causal relationship diagram of 19 aggregated macro variables and their 31 causal relationship suggested by the observational evidences is demonstrated. The consistency relationship between macro variables and elderly accidental fall are summarized and demonstrated. Our analysis reveals that “Time”, “Season” and “Weather” are three less-studied factors in the literature. In our comprehensive analysis, our study also indicates neglected countries and senior populations such as Africa and Oceania, which requires more attention from the research community and global funding agencies. It is found that major quantitative tools focus on the traditional statistical analysis.

Conclusion

With the accelerated aging and increase of longevity worldwide, national and regional policies, and public health programs to provide adequate care services for the older people are crucially needed in both industrialized and developing countries. Evidences identified in the research are valuable inputs for policy design and decision makers of different stakeholders and prevention design of risk factors for falls in the older adults. The categorization of research methods in different literature also suggests that more quantitative approaches including simulation, optimization in operational research, and maybe machine learning are needed to enrich the research paradigm. We suggest researchers to consider using our presented causal map and the way of building it and explore the possibility of extending this framework to uncover more research topics in health-related research.

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Find less addressed but important fall-leading factors for the older adults.

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Apply a systematic causal mapping method for synthetizing known factors.

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Profile fall-leading factors in the older adults at different levels.

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Identify the level of consistency for those relationships of risk factors to fall.

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Build a framework containing all causal relationships of key fall-causing factors.

Assessment of fracture risk tools in care home residents: a multi-centre observational pilot study

BACKGROUND

Fragility fractures are common in care home residents but established tools have not been tested in this population.

AIM

To identify the most practicable tool for use.

METHODS

DESIGN: Multicentre prospective observational cohort pilot study.

SETTING

18 care homes in Boston, UK.

ASSESSMENTS

fragility risk score at baseline with FRAX, QFractureScore, Garvan nomogram, body mass index and TUGT for each participant.

OUTCOMES

falls, fractures, combined falls & fractures. Follow-up; 12 months.

RESULTS

217/618 (35%) residents in the 18 care homes were enrolled. 147 (68%) had mental capacity,70 (32%) did not. There were 325 falls and 10 fractures in participants during the study. At the same time there were 1671 falls and 103 fractures in residents not participating in the study. Multiple regression analyses showed that only age had a statistically significant association with falls (χ²(1) = 5.7775, p = 0.0162), fractures (χ²(1) = 4.7269, p = 0.0297) and combined falls & fractures (χ²(1) = 4.7269, p = 0.0297). C-statistics were: falls; FRAX 0.544, BMI 0.610, QFractureScore 0.554, Garvan nomogram 0.579, TUGT 0.656, fractures; FRAX 0.655, BMI 0.708, QFractureScore 0.736, Garvan nomogram 0.712, TUGT 0.590, combined falls and fractures, c-statistics were same as for fractures. Fifty-four participants (25%) died during follow-up. Charlson comorbidity index predicted mortality, R² = 0.021 (p = 0.034).

CONCLUSIONS

QFractureScore, BMI and Garvan nomogram were good predictors of fractures and combined falls and fractures Only age had statistically significant association with the outcomes. No tool was good predictor of falls.

A study on bone mass density using dual energy X-ray absorptiometry: Does high body mass index have protective effect on bone density in obese patients?

Background:

Osteoporosis is known as reduction of bone density, which is diagnosed using dual-energy X-ray absorptiometry. Although some studies have shown high body mass index (BMI) as a protective factor for osteoporosis and fracture risks, some other studies demonstrated obesity as a risk factor for osteoporosis. The aim of this study is to evaluate the relationship between BMI and bone mineral density (BMD) in premenopausal and postmenopausal females. Furthermore, we determined the correlation between BMI and fracture risk in postmenopausal females.

Materials and Methods:

In this study, we evaluated the relationship between the age and BMI with 10-year probability fracture risk (estimated using fracture risk assessment tool) and BMD in the L1–L4 spine and femoral neck. Data were collected from BMD center, Askariye Hospital, Isfahan, Iran, from May 2016 to July 2017.

Results:

The study consisted of 1361 individuals, including 305 premenopausal females and 1056 postmenopausal females. The results showed a statistically significant increase of BMD (P < 0.001) and a decrease of fracture risk (β = −0.158, R² = 0.518) with an increase of BMI in postmenopausal females. Moreover, lumbar spine and femoral neck BMD were significantly higher in individuals with BMI ≥30 than in those with BMI <25 in both premenopausal and postmenopausal females (P < 0.001). In addition, older postmenopausal females indicated significantly lower L1–L4 BMD (r = −0.280, P < 0.05) and femoral neck BMD (r = −0.358, P < 0.05).

Conclusion:

The results showed a positive correlation between BMI and BMD of the spine and femoral neck which did not differ by menopausal status. However, there was a correlation between BMI and fracture risk in postmenopausal females.

Obesity, Bariatric Surgery, and Fractures

CONTEXT

Obesity and its associated comorbidities are a recognized and growing public health problem. For a long time, obesity-associated effects on bone were considered to strengthen the bone, mainly because of the known relationship between body weight and bone mass and the long-term weight-bearing load effect on bone. However, recent epidemiologic studies have shown that obesity may not have a fully protective effect on the occurrence of fragility fractures. The goal of this article is to review updated information on the link between obesity, bariatric surgery, and fractures.

METHODS

The primary source literature for this review was acquired by searching a published database for reviews and articles up to January 2018. Additional references were selected through the in-depth analysis of the relevant studies.

RESULTS

We present data showing that overweight and obesity are often encountered in fracture cases. We also analyzed possible reasons and risk factors for fractures associated with overweight and patients with obesity. In addition, this review focuses on the complex effects of dramatic changes in body composition when interpreting dual-energy X-ray absorptiometry readings and findings. Finally, we review the data on the effects and consequences of bariatric surgery on bone metabolism and the risk of fractures in patients undergoing these procedures.

CONCLUSION

Because of various adiposity-induced effects, patients with obesity are at risk for fracture in certain sites. Bariatric surgery increases the risk of fractures in patients undergoing malabsorptive procedures.

Temporal trends in hip fracture incidence, mortality, and morbidity in Denmark from 1999 to 2012

Background and purpose - While development in hip fracture incidence and mortality is well examined, none has yet looked at the temporal trends regarding prevalence of co-morbidities. Therefore we investigated changes in incidence of first hip fracture, co-morbidity prevalence, 30 day- and 1-year mortality in hip fracture patients in the Danish population during the period 1999 to 2012. Patients and methods - Patients >18 years admitted with a fractured hip in Denmark between 1996 and 2012 were identified with data for the period 1999-2012 being analyzed regarding prevalence of co-morbidities, incidence, and mortality. Results - 122,923 patients were identified. Incidence in the whole population declined but sex-specific analysis showed no changes for men. For the whole study population, 30-day and 1-year mortality remained unchanged. Age at time of first hip fracture also remained unchanged. Of the included co-morbidities a decrease in prevalence of malignancy and dementia in women was found while there was an increase in the prevalence of all remaining co-morbidities, except hemi- or paraplegia for both sexes, rheumatic diseases for women, and for men diabetes with complications, myocardial infarction, AIDS/HIV, and malignancy. Interpretation - While hip fracture incidence declined for women it was unchanged for men; likewise, 30-day and 1-year mortality rates together with age at first fracture remained unchanged. When these results are compared with the relatively large increase in the prevalence of co-morbidities, it does not seem likely that the increased disease burden is affecting either the incidence or the mortality.

Pediatric short-distance household falls: biomechanics and associated injury severity

OBJECTIVES

Short-distance household falls are a common occurrence in young children, but are also a common false history given by caretakers to conceal abusive trauma. The purpose of this study was to determine the severity of injuries that result from accidental short-distance household falls in children, and to investigate the association of fall environment and biomechanical measures with injury outcomes.

METHODS

Children aged 0-4 years who presented to the Emergency Department with a history of a short furniture fall were included in the study. Detailed case-based biomechanical assessments were performed using data collected through medical records, interviews, and fall scene investigations. Injuries were rated using the Abbreviated Injury Scale (AIS). Each case was reviewed by a child abuse expert; cases with a vague or inconsistent history and cases being actively investigated for child abuse were excluded.

RESULTS

79 subjects were enrolled in the study; 15 had no injuries, 45 had minor (AIS 1) injuries, 17 had moderate (AIS 2) injuries, and 2 had serious (AIS 3) injuries. No subjects had injuries classified as AIS 4 or higher, and there were no fatalities. Children with moderate or serious injuries resulting from a short-distance household fall tended to have fallen from greater heights, have greater impact velocities, and have a lower body mass index than those with minor or no injuries.

CONCLUSION

Children aged 0-4 years involved in a short-distance household fall did not sustain severe or life-threatening injuries, and no children in this study had moderate or serious injuries to multiple body regions. Biomechanical measures were found to be associated with injury severity outcomes in short-distance household falls. Knowledge of relationships between biomechanical measures and injury outcomes can aid clinicians when assessing whether a child's injuries were the result of a short-distance fall or some other cause.

Relationship of body mass index with main limb fragility fractures in postmenopausal women

Body mass index (BMI) has been found to be related to the risk of osteoporotic hip fractures in women, regardless of bone mineral density (BMD). The same relationship is under debate for other limb fragility fractures. Very few studies have investigated the comparison of fracture risk among BMI categories, classified according to the WHO criteria, despite the potential usefulness of such information for clinical purposes. To address these issues we studied 2,235 postmenopausal women including those with fragility fractures of the hip (187), ankle (108), wrist (226) and humerus (85). Statistical analyses were performed by logistic regression by treating the fracture status as the dependent variable and age, age at menopause, femoral neck BMD and BMI as covariates. BMI was tested as a continuous or categorical variable. As a continuous variable, increased BMI had a protective effect against hip fracture: OR 0.949 (95% CI, 0.900-0.999), but carried a higher risk of humerus fracture: OR 1.077 (95% CI, 1.017-1.141). Among the BMI categories, only leanness: OR 3.819 (95% CI, 2.035-7.168) and obesity: OR 3.481 (95% CI, 1.815-6.678) showed a significantly higher fracture risk for hip and humerus fractures, respectively. There was no relationship between ankle and wrist fractures and BMI. In conclusion, decreasing BMI increases the risk for hip fracture, whereas increasing BMI increases the risk for humerus fractures. Leanness-related low BMD and obesity-related body instability might explain the different BMI relationships with these two types of fracture.

Body weight is a strong predictor of postural stability

Proper balance control is a key aspect of acitivities of daily living. The aim of this study was to determine the contribution of body weight to predict balance stability. The balance stability of 59 male subjects with BMI ranging from 17.4 to 63.8kg/m(2) was assessed using a force platform. The subjects were tested with and without vision. A stepwise multiple regression analysis was used to determine the independent effect of body weight, age, body height and foot length on balance stability (i.e., mean speed of the center of foot pressure). With vision, the stepwise multiple regression revealed that body weight accounted for 52% of the variance of balance stability. The addition of age contributed a further 3% to explain balance control. Without vision, body weight accounted for 54% of the variance and the addition of age and body height added a further 8% and 1% to explain the total variance, respectively. The final model explained 63% of the variance. A decrease in balance stability is strongly correlated to an increase in body weight. This suggests that body weight may be an important risk factor for falling. Future studies should examine more closely the combined effect of aging and obesity on falling and injuries and the impact of obesity on the diverse range of activities of daily living.

Facteurs prédictifs de la chute chez l'hémiplégique vasculaire en centre de médecine physique

OBJECTIVES

To determine factors predicting falls by patients with vascular hemiplegia to establish a program aimed at preventing falls in this population.

METHODS

A comparative prospective study performed over 19 months with 44 patients older than 16 years who had had a cerebral vascular accident (CVA, stroke) and were consequently admitted to the Centre Richelie. The exclusion criteria were represented by CVA history, evidence of another form of encephalic lesion, and subsequent admission to hospital after hemiplegia or for follow-up. Assessment consisted of taking note of the mechanism of the fall, possible lesions, and number of falls and analyzing follow-up after the return home. Also included for all patients was information on 20 variables that could be risk factors for fall.

RESULTS

The patients' average age was 60.43+/-13.43 years and 20 had had at least one fall (mean 2.2), which allowed us to determine a "falling" group and a control group. Statistical analysis revealed the following factors considered to predict falls: large amount of time prior to hospitalization and lengthy hospitalization, low functional independence measure for entering and leaving, the existence of sensitivity disorders, spatial neglect, failed seated and standing equilibrium, and sedative treatment. In most cases, whatever their nature, falls occurred during transfers (68% of cases). Most often, the post-fall lesions were minor. However, in one case, a femur neck fracture necessitated osteosynthesis. One-third of the patients had a fall at home (as opposed to 5% of the control group).

CONCLUSION

Our results confirm those in the literature. The predictive factors for falls in patients with hemiplegia are therefore well established and essentially correlate with the CVA. This consideration must lead to implementation of a prevention program including material-based as well as human measures.

Body mass index as a predictor of fracture risk: a meta-analysis

Low body mass index (BMI) is a well-documented risk factor for future fracture. The aim of this study was to quantify this effect and to explore the association of BMI with fracture risk in relation to age, gender and bone mineral density (BMD) from an international perspective using worldwide data. We studied individual participant data from almost 60,000 men and women from 12 prospective population-based cohorts comprising Rotterdam, EVOS/EPOS, CaMos, Rochester, Sheffield, Dubbo, EPIDOS, OFELY, Kuopio, Hiroshima, and two cohorts from Gothenburg, with a total follow-up of over 250,000 person years. The effects of BMI, BMD, age and gender on the risk of any fracture, any osteoporotic fracture, and hip fracture alone was examined using a Poisson regression model in each cohort separately. The results of the different studies were then merged. Without information on BMD, the age-adjusted risk for any type of fracture increased significantly with lower BMI. Overall, the risk ratio (RR) per unit higher BMI was 0.98 (95% confidence interval [CI], 0.97-0.99) for any fracture, 0.97 (95% CI, 0.96-0.98) for osteoporotic fracture and 0.93 (95% CI, 0.91-0.94) for hip fracture (all p <0.001). The RR per unit change in BMI was very similar in men and women ( p >0.30). After adjusting for BMD, these RR became 1 for any fracture or osteoporotic fracture and 0.98 for hip fracture (significant in women). The gradient of fracture risk without adjustment for BMD was not linearly distributed across values for BMI. Instead, the contribution to fracture risk was much more marked at low values of BMI than at values above the median. This nonlinear relation of risk with BMI was most evident for hip fracture risk. When compared with a BMI of 25 kg/m(2), a BMI of 20 kg/m(2) was associated with a nearly twofold increase in risk ratio (RR=1.95; 95% CI, 1.71-2.22) for hip fracture. In contrast, a BMI of 30 kg/m(2), when compared with a BMI of 25 kg/m(2), was associated with only a 17% reduction in hip fracture risk (RR=0.83; 95% CI, 0.69-0.99). We conclude that low BMI confers a risk of substantial importance for all fractures that is largely independent of age and sex, but dependent on BMD. The significance of BMI as a risk factor varies according to the level of BMI. Its validation on an international basis permits the use of this risk factor in case-finding strategies.

Role of chronic health disorders in perimenopausal fractures

Only a few studies have examined the risk of individual chronic health disorders on perimenopausal (i.e., around menopause) fractures in a single study. We evaluated the effect of chronic illnesses on fracture rate in a prospective cohort study of 3,078 women. These women were a stratified sample from the population base of 14,220 women aged 47-56 years and residing in the province of Kuopio in eastern Finland in 1989. Data on physician-diagnosed chronic diseases were collected by a baseline questionnaire in 1989. For certain diseases, questionnaire information of self-reported chronic disorders were compared with drug reimbursement data provided by the Social Insurance Institution of Finland. Axial bone mineral density (BMD) measurements from the femoral neck and lumbar spine were performed in 1989-91. Two hundred sixty-five (265) women experienced at least one fracture during the follow-up period of 3.6 years (SD+/-0.78). The first fracture during the follow-up period was taken to be the end-point event. The risk of follow-up fracture for an individual health disorder was estimated with the Cox's proportional hazards model. Several chronic health disorders increased the fracture risk in perimenopausal women. However, hypertension was a statistically significant (p=0.018) risk factor for fracture (adjusted hazard ratio [HR], 1.4; 95% confidence interval [CI], 1.1-1.9), especially in overweight and obese (body mass index > or =28) women (HR, 2.0; 95% CI, 1.4-3.0). In addition, coronary heart disease (adjusted HR, 1.76; 95% CI, 1.13-2.76), hyperthyroidism (adjusted HR, 1.7; 95% CI, 1.0-2.9), epilepsy (adjusted HR, 2.0; 95% CI, 1.1-3.6), alcoholism (adjusted HR, 3.5; 95% CI, 1.3-9.5) and chronic hepatic disease (adjusted HR, 5.2; 95% CI, 1.7-16.4) predicted fracture. BMD was either normal or even elevated in disease groups. However, women with a fracture during the follow-up usually had decreased bone density, although the difference was statistically significant only in women with hypertension and hyperthyroidism. We conclude that hypertension, coronary heart disease, alcoholism, epilepsy and hyperthyroidism can markedly increase the risk of fracture in perimenopausal women and should be taken into account when assessing the risk of future fracture in an individual patient. Furthermore, in contrast to previous data, obesity alone does not increase the risk of perimenopausal fracture, but in association with hypertension the risk seems to be markedly elevated.