Fragility Fractures: Introduction
Osteoporosis is a disease that is the most common bone disease in humans and is characterized by low bone mass and skeletal fragility, which results in an increased risk of fracture. Annually, two million fractures are attributed to osteoporosis, causing more than 432,000 hospital admissions, almost 2.5 million medical office visits, and about 180,000 nursing home admissions in the USA (1). Osteoporotic fractures, also known as fragility fractures, are those occurring from a fall from a standing height or less, without major trauma such as a motor vehicle accident. The most common areas affected are the spine, hip, wrist, humerus and pelvis. The geriatric hip fracture fracture ranks as the third most expensive musculoskeletal diagnosis for the US Centers for Medicare and Medicaid Services (CMS), following only hip and knee arthroplasty (2).
Bone strength is typically determined by bone mineral density (BMD), bone geometry, degree of mineralization, microarchitecture and bone turnover (5). The measurement of bone mineral density is vital in the detection of osteoporosis and fracture risk increased exponentially as BMD decreases (6). BMD measurements remain an integral component of all tools to assess an individual’s absolute risk of fragility fractures because it has been shown to be an excellent predictor of future fracture risk (6). This is usually done with using dual energy x-ray absorptiometry (DXA) and this is the gold standard for the diagnosis of osteoporosis and low bone mass. The
Screening , or primary prevention, for individuals at risk for osteoporosis can be done by many different providers including family practice, internal medicine, rheumatology and orthopedics (Figure 2). Any postmenopausal woman or man age 50 or older should be evaluated for osteoporosis risk in order to determine the need for BMD testing. Non-BMD factors that need to be factored in include age, previous fractures, falls, chronic glucocorticoid therapy, family history of hip fracture and smoking status. Some professional organizations, such as the American Association of Clinical Endocrinologists recommend screening individuals that have osteopenia radiographically.
QFracture was developed in the UK in 2009 and calculates 10 year hip and major fracture risk without BMD testing. It is applicable to people aged 30-85 and also includes clinical risk factors, similar to FRAX. The clinical risk factors included in the QFracture algorithm in men and women are: age, sex, BMI, smoking, alcohol intake, glucocorticoids, asthma, cardiovascular disease, history of falls, chronic liver disease, rheumatoid arthritis, type 2 diabetes and tricyclic antidepressants. Additional factors used in women only are: hormone replacement therapy, parental history of hip fracture, menopausal symptoms, gastrointestinal malabsorption and other endocrine disorders. The algorithm was undergone updates with the most recent in 2016 and is readily available online (https://qfracture.org/).
Another similar program that is gaining popularity is the Own the Bone (OTB) (https://www.ownthebone.org/OTB) program. After a successful pilot program involving 14 enrollment sites, OTB was designated by the AOA as a national quality improvement project in 2009 (9). OTB was a quality improvement initiative, which included an online, web-based registry of de- identified patient history and fracture data that encouraged orthopedic surgeons to include bone health education and treatment as a distinct part of comprehensive fracture care. As a secondary benefit, the OTB registry has evolved into a large and robust dataset, which thoroughly characterizes fragility fractures presenting for inpatient care in the USA. This data enables benchmarking of institutions involved in the OTB program to help define best practices and to identify those factors and practices associated with suboptimal outcomes.
In summary, It is widely accepted that bone health and osteoporosis have a significant impact on our current healthcare landscape. Roughly two million fractures attributed to osteoporosis occur each year in the United States and estimates show this problem will continue to grow (2). Bone strength for individuals at risk is typically determined by bone mineral density and determined by DXA. Tools, such as the FRAX and QFracture have been developed to determine 10 year risk of major fractures to help determine who needs treatments for either primary or secondary prevention. Programs such as Own the Bone and Capture the Fracture have also been started to document fractures and educate both providers and patients on fragility fractures.