Seniors with High-Trauma Fractures Should be Checked for Osteoporosis

Nov. 28, 2007 – It may mostly be a matter of semantics for research statisticians, but the common practice of not associating major trauma factures in older people to osteoporosis is challenged by a new study. Although clinicians often recognize fractures resulting from minimal trauma as osteoporotic, those related to more substantial injury – such as auto accidents - are rarely given the same consideration.

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People with osteoporosis, a condition of low bone mineral density that is closely associated with aging, do experience fractures from a level of force that would not break a healthy bone. (More about osteoporosis below news story.)

It is argued that the determination of cause is important, because it can help these victims and others to possibly avoid such injuries in the future.

The study by researchers at the California Pacific Medical Center (CPMC) Research Institute is published today in the Journal of the American Medical Association.

It was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), and the National Institute on Aging (NIA). NIAMS and NIA are components of the National Institutes of Health.

"We know that too many clinicians pass on any follow-up of many fracture patients because, in their minds, the patient ‘earned’ their fracture," says Joan A. McGowan, Ph.D., director of the Division of Musculoskeletal Diseases at NIAMS.

"These missed opportunities can have a devastating impact on these men and women, who, without proper management, are at increased risk for subsequent fracture."

The study authors note that current practice says “high-trauma fractures (those resulting from motor vehicle crashes or falls from greater than standing height) are not related to low bone mineral density (BMD) or subsequent fracture risk and therefore are presumed not to be manifestations of osteoporosis.”

They add that these beliefs have several consequences, including the clinical opinions that an older adult who has a high-trauma fracture does not require evaluation for osteoporosis, and that high-trauma fractures cannot be prevented by osteoporosis treatments that increase BMD and bone strength.

CPMC’s Steven R. Cummings, M.D., and his colleagues analyzed data from two large prospective cohort studies: the Study of Osteoporotic Fractures (SOF) in women and the Osteoporotic Fractures in Men Study (Mr. OS). The SOF followed 8,022 women for nine years and Mr. OS tracked 5,995 men for five years. Bone mineral density (BMD) was assessed by dual-energy X-ray absorptiometry (DXA). Study participants were contacted every four months to determine whether they experienced a fracture in the previous four-month period.

When a fracture was reported, clinical staff interviewed the participant to learn how it occurred. Without knowledge of the participant’s BMD, staff classified each fracture as high-trauma or low-trauma.
● High-trauma fractures were defined as those caused by motor vehicle crashes and falls from greater than standing height.
● Low-trauma fractures were defined as those resulting from falls from standing height and less severe trauma.

Cummings and his team discovered that the relationship between BMD and fracture risk was similar for high-trauma and low-trauma fractures.

They also found that women who experienced a high-trauma fracture were at increased risk for future fractures. (A similar analysis was not conducted in men because of the shorter follow-up time.)

"It is becoming increasingly clear that any fracture experienced by an older individual is worthy of an osteoporosis evaluation," says Sheryl S. Sherman, Ph.D., Geriatrics and Clinical Gerontology Branch, NIA.

"We believe that this study changes the definition of osteoporotic fracture and expands the number of fractures that should be considered as such," Cummings says.

"Moreover, it is critical that fractures that occur as a result of high trauma be included as outcomes in future studies, so that we may fully understand the impact of these fractures and develop strategies to prevent them."

An editorial in the journal says the study “clearly demonstrates that the current definition of high-trauma fracture is not particularly useful.

“Until a better definition of fractures unrelated to BMD is developed, older patients sustaining high-trauma fractures cannot be ignored in terms of their skeletal status, and they should be evaluated more thoroughly for underlying osteoporosis.

In addition, these fractures should be included as end points in clinical trials involving prevention or treatment of osteoporosis.”

The editorial was written by Sundeep Khosla, M.D., of Mayo Clinic, Rochester, Minn.

Editor’s Notes:

The mission of the National Institute of Arthritis and Musculoskeletal and Skin Diseases, a part of the Department of Health and Human Services’ National Institutes of Health, is to support research into the causes, treatment and prevention of arthritis and musculoskeletal and skin diseases; the training of basic and clinical scientists to carry out this research; and the dissemination of information on research progress in these diseases. For more information about NIAMS, call the information clearinghouse at (301) 495-4484 or (877) 22-NIAMS (free call) or visit the NIAMS Web site at http://www.niams.nih.gov. Information on osteoporosis and other bone disorders is available from the NIH Osteoporosis and Related Bone Diseases~National Resource Center; phone toll-free 800-624-BONE (2663), or visit www.niams.nih.gov/bone .

NIA leads the federal effort supporting and conducting research on aging and the medical, social and behavioral issues of older people, including Alzheimer’s disease and age-related cognitive change. For information on dementia and aging, please visit NIA’s Alzheimer’s Disease Education and Referral Center at www.nia.nih.gov/alzheimers, or call 1-800-438-4380. For more general information on research and aging, go to www.nia.nih.gov. Please visit the Web sites to sign up for e-mail notification of new information and publications about aging and about age-related cognitive change.

The National Institutes of Health (NIH) — The Nation's Medical Research Agency — includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. It is the primary federal agency for conducting and supporting basic, clinical and translational medical research, and it investigates the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.

References:
Mackey D, et al. High-trauma fractures and low bone mineral density in older women and men. JAMA 2007;298(20):2381-2388

More About Osteoporosis

Osteoporosis makes your bones weak and more likely to break. Anyone can develop osteoporosis, but it is common in older women. As many as half of all women and a quarter of men older than 50 will break a bone due to osteoporosis.

Risk factors include:

>> Getting older

>> Being small and thin

>> Having a family history of osteoporosis

>> Taking certain medicines

>> Being a white or Asian woman

>> Having osteopenia, which is low bone mass

Osteoporosis is a silent disease. You might not know you have it until you break a bone. A bone mineral density test is the best way to check your bone health. To keep bones strong, eat a diet rich in calcium and vitamin D, exercise and do not smoke. If needed, medicines can also help.

by National Institute of Arthritis and Musculoskeletal and Skin Diseases

More Information:

>> Osteoporosis(National Institute of Arthritis and Musculoskeletal and Skin Diseases)
>> Osteoporosis(Patient Education Institute) - Requires Flash Player - Also available in Spanish
>> Osteoporosis Overview(National Institute of Arthritis and Musculoskeletal and Skin Diseases)
>> What Is Osteoporosis?(National Institute of Arthritis and Musculoskeletal and Skin Diseases)

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