Are All Types of Fractures Predictive of Osteoporosis?
Any kind of fracture was predictive of more fractures in postmenopausal women, new data suggested. In a prospective, observational study of over 66,000 women from the Women's Health Initiative (WHI), there was a 49% increased risk for another fracture following an initial fracture (adjusted HR 1.49, 95% CI 1.38-1.61, P<0.001), reported Carolyn Crandall, MD, MS, of David Geffen School of Medicine at the University of California, Los Angeles, and colleagues. The increased risk was seen regardless of which type of initial fracture the women had, the researchers noted in the study online in JAMA Internal Medicine. Specifically, women who initially had a traumatic fracture had a 25% increased risk for a subsequent fracture (aHR 1.25, 95% CI 1.06-1.48), and those who initially had a nontraumatic fracture had a 52% increased risk of a subsequent fracture (aHR 1.52, 95% CI 1.37-1.68). "One in two postmenopausal women will have an osteoporosis-related fracture during their remaining lifetimes," Crandall's group said, adding that nontraumatic fractures -- also known as fragility fractures -- are the strongest risk factor for future fracture. However, current clinical practice guidelines for osteoporosis tend to leave out traumatic fractures, the researchers noted. "To our knowledge, clinical guidelines recommend considering pharmacologic therapy for postmenopausal women and men 50 years or older who have experienced fragility fractures or certain types of fragility fractures (i.e., vertebral or hip fragility fractures), but do not provide guidance regarding traumatic fractures." Crandall and co-authors said the findings are "clinically important," because traumatic fractures often do not trigger counseling or evaluation for osteoporosis like nontraumatic fractures do. As a result, certain at-risk women may be missed when it comes to evaluation and treatment. This point was echoed in an accompanying commentary by Anne Schafer, MD, of San Francisco Veterans Affairs Health Care System, and Dolores Shoback, MD, of the University of California, San Francisco. "What is lost when traumatic fractures are overlooked is that patients do not receive attention to their bone health." "This oversight may contribute to the widening osteoporosis treatment gap, with missed opportunities for case-finding and targeted nonpharmacologic and pharmacologic secondary fracture prevention efforts," Schafer and Shoback wrote. They added that the findings may also hold clinical implications for men as well, as older men are even more likely to sustain a fracture due to trauma than women are. The analysis drew on women in the WHI study, which included women between the ages of 50 and 79 from 40 U.S. clinical sites. The vast majority of the cohort were white, and the cohort was also generally split into thirds for women of normal weight, overweight, and those who had obesity. Fractures were self-reported by the women and confirmed by medical records. Only fractures of the hip, upper leg (not hip), pelvis, knee, lower leg or ankle, foot (not toe), coccyx, spine or back (vertebra), lower arm or wrist, hand (not finger), elbow, upper arm, or shoulder were included in the analysis, while fractures of the jaw, nose, face, skull, finger, toe, ribs, and sternum were excluded. The average follow-up time between an initial and a subsequent fracture was 8.1 years. About 11% of the total cohort had an initial fracture during the study period, and 10% of that group had a second fracture. "The idea that nontraumatic vs traumatic is a distinction without a difference will likely be welcomed by busy clinicians," Schafer and Shoback concluded. "What clinician would not appreciate being relieved of the tedium of trying to accurately interrogate a patient about the energy and impact of the fall, the step from which they fell, the softness or hardness of the surface for landing, the rung of the ladder on which they had been standing, or the speed the car had been moving?" Kristen Monaco is a staff writer, focusing on endocrinology, psychiatry, and dermatology news. Based out of the New York City office, shes worked at the company for nearly five years.