Position Statement

Recommendations for Enhancing the Care of Patients with Fragility Fractures

This Position Statement was developed as an educational tool based on the opinion of the authors. It is not a product of a systematic review. Readers are encouraged to consider the information presented and reach their own conclusions.

Fragility fracture care: Action is needed

Fragility fractures are defined as fractures resulting from a fall from a standing height or less, or presenting in the absence of obvious trauma. Fragility fractures affect up to one-half of women and one-third of men over age fifty, and are often associated with low bone density.^1,2,3,4,5,6 Such fractures occur most commonly in the hip, spine, and wrist.^1,7 The dual burdens of suffering and health care costs are enormous for all fracture patients, particularly those with hip fractures. Clinical trials have demonstrated that treatment of patients with fragility fractures can reduce the risk of future fractures by up to 50%.^8,9 Thus, it is important that these patients not only receive treatment for the presenting fracture, but also for prevention of future fractures.^10,11 Multiple associations with socioeconomic class have been reported showing lower classes have a higher risk of fragility types of fractures.¹² There has also been an increased report in patients with diabetes revealing that the incidence in these patients may be significantly underestimated.¹³ Spine related fractures of this type have also been associated with poor outcomes and high mortality rates.¹⁴

Fractures lead to more fractures and long term disability

One of the most compelling reasons to determine the etiology of a fracture and provide appropriate treatment is that a previous low-energy fracture is among the strongest risk factors for new fractures.^{1,15,16,17,18,19, 20,21,22} Specifically, patients with a low-energy fracture of the wrist, hip, proximal humerus or ankle have nearly a two to four-fold greater risk for future fractures than individuals who have never experienced a fracture.^15,22 Furthermore, up to half of patients with a prior vertebral fracture will experience additional vertebral fractures within three years, many within the first year.^16,18 Indeed, compared to individuals with no history of fracture, a patient with a prior vertebral fracture has nearly a five-fold increased risk of future vertebral fractures and up to a six-fold increased risk of hip and other nonvertebral fractures.^17,20,22 Those patients who sustain a vertebral body fragility fracture show a prolonged course that can lead to significant disability even one year later.¹⁴ Even with increased awareness of the need for treatment in elderly hip fracture patients, studies reveal that a low percentage of these patients ever receive treatment.²³ Taken together, these data indicate that patients with a history of any type of prior fracture have a two- to six-fold increased risk of subsequent fractures compared to those without a previous fracture and are at risk of a significant disability as a result.¹⁴

These findings emphasize that optimal care of fragility fracture patients includes not only management of the presenting fracture, but also evaluation, diagnosis and treatment of the underlying cause(s) of the fracture, including low bone density or other medical conditions.²⁴ In this regard, supplementation with calcium and vitamin D has been shown to lower fracture risk in the elderly.^25,26 In addition, several pharmacologic agents have been demonstrated to reduce the risk of future fracture by as much as 50% in patients with existing fractures and to be safe in the elderly population.^{8,9,27,28,29,30,31} Non-pharmacologic interventions, such as fall prevention programs and individually-tailored exercise programs, have been shown to reduce falls among the elderly,^32,33,34 which may decrease the incidence of fractures. In addition, trochanteric padding has been shown to dramatically reduce hip fractures among those at highest risk.³⁵ Thus, initiating interventions soon after a fragility fracture occurs may significantly reduce the incidence and severity of subsequent fractures.

A unique opportunity

Orthopaedic surgeons manage most fragility fractures. Indeed, the orthopaedic surgeon usually is the first, and often the only physician seen by the fracture patient. Thus, orthopaedic surgeons have a unique opportunity to educate the fracture patient about the need to decrease the risk for future fractures and to advocate for improved fracture care in their communities.^10,11,24,36

The American Academy of Orthopaedic Surgeons (AAOS) encourages the orthopaedic surgeon to:

1. Consider the likelihood that osteoporosis is a predisposing factor when a patient presents with a fragility fracture and keep associated risk factors in mind when identifying these patients.
2. Advise patients with fragility fractures that an osteoporosis evaluation may lead to treatment which can reduce the risk of future fractures.
3. Initiate an investigation of whether osteoporosis is an underlying cause in patients with fragility fractures. The orthopaedic surgeon may conduct this evaluation or may refer the patient to another medical provider as long as direct communication is provided.
4. Establish partnerships within the medical and nursing community that facilitate the evaluation and treatment of patients with fragility fractures.
5. Urge their hospitals and office practices to establish clinical coordinator and pathways that ensure optimal care is provided for patients with fragility fractures.

By taking an active role in managing or referring patients with fragility fractures, orthopaedic surgeons can substantially improve the long-term outcome of these patients, reduce the risk of subsequent fracture, and thereby help mitigate the downward spiral in health and quality of life that often follows fractures.

References:

1. Cummings SR, Melton LJ: Epidemiology and outcomes of osteoporotic fractures. Lancet 2002;359(9319):1761-7.
2. Riggs BL, Melton LJ: The worldwide problem of osteoporosis: insights afforded by epidemiology. Bone 3rd 1995;17(5 Suppl):505S-511S.
3. Ross PD: Osteoporosis. Frequency, consequences, and risk factors. Arch Intern Med 1996;156(13):1399-411.
4. Jones G, Nguyen T, Sambrook PN, Kelly PJ, Gilbert C, Eisman JA: Symptomatic fracture incidence in elderly men and women: the Dubbo Osteoporosis Epidemiology Study (DOES). Osteoporos Int 1994;4(5):277-82.
5. Nguyen TV, Eisman JA, Kelly PJ, Sambrook PN: Risk factors for osteoporotic fractures in elderly men. Am J Epidemiol 1996;144(3):255-63.
6. Kanis JA, Johnell O, Oden A, Sembo I, Redlund-Johnell I, Dawson A, De Laet C, Jonsson B: Long-term risk of osteoporotic fracture in Malmo. Osteoporos Int 2000;11(8):669-74.
7. Tosteson AN, Gabriel SE, Grove MR, Moncur MM, Kneeland TS, Melton LJ: Impact of hip and vertebral fractures on quality-adjusted life years. Osteoporos Int 3rd 2001;12(12):1042-9.
8. Delmas PD: Treatment of postmenopausal osteoporosis. Lancet 2002;359(9322):2018-26.
9. Hochberg M: Preventing fractures in postmenopausal women with osteoporosis. A review of recent controlled trials of antiresorptive agents. Drugs Aging 2000;17(4):317-30.
10. Tosi LL, Lane JM: Osteoporosis prevention and the orthopaedic surgeon: when fracture care is not enough. J Bone Joint Surg Am 1998;80(11):1567-9.
11. Rosier RN: Expanding the role of the orthopaedic surgeon in the treatment of osteoporosis. Clin Orthop 2001;(385):57-67.
12. Navarro MC, Sosa M, Saavedra P, Lainez P, Marrero M, Torres M, Medina CD: Poverty is a risk factor for osteoporotic fractures. Osteoporos Int 2009;Mar;20(3):393-8.
13. Epstein S, Leroith D: Diabetes and fragility fractures - a burgeoning epidemic? Bone 2008;Jul;43(1):3-6.
14. Suzuki N, Ogikubo O, Hansson T: The course of the acute vertebral body fragility fracture: its effect on pain, disability and quality of life during 12 months. Eur Spine J 2008;Oct;17(10):1380-90.
15. Nevitt MC, Ross PD, Palermo L, Musliner T, Genant HK, Thompson DE: Association of prevalent vertebral fractures, bone density, and alendronate treatment with incident vertebral fractures: effect of number and spinal location of fractures. The Fracture Intervention Trial Research Group. Bone 1999;25(5):613-9.
16. Robinson CM, Royds M, Abraham A, McQueen MM, Court-Brown CM, Christie J: Refractures in patients at least forty-five years old: a prospective analysis of twenty-two thousand and sixty patients. J Bone Joint Surg Am 2002;84-A(9):1528-33.
17. Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA, Berger M: Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res 2000;15(4):721-39.
18. Lindsay R, Silverman SL, Cooper C, Hanley DA, Barton I, Broy SB, Licata A, Benhamou L, Geusens P, Flowers K, Stracke H, Seeman E: Risk of new vertebral fracture in the year following a fracture. JAMA 2001;285(3):320-3.
19. Johnell O, Oden A, Caulin F, Kanis JA: Acute and long-term increase in fracture risk after hospitalization for vertebral fracture. Osteoporos Int 2001;12(3):207-14.
20. Gunnes M, Mellstrom D, Johnell O: How well can a previous fracture indicate a new fracture? A questionnaire study of 29,802 postmenopausal women. Acta Orthop Scand 1998; 69(5):508-12.
21. Ross P, Davis J, Epstein R, Wasnich R: Pre-existing fractures and bone mass predict vertebral fracture incidence in women. Ann Int Med 1991;114:919-923.
22. van Staa TP, Leufkens HG, Cooper C: Does a fracture at one site predict later fractures at other sites? A British cohort study. Osteoporos Int 2002;13(8):624-9.
23. Rabenda V, Vanoverloop J, Febri V, Mertens R, Sumkay F, Vannecke C, Deswaef A, Verpooten G, Reginster J: Low incidence of anti-osteoporosis treatment after hip. J Bone Joint Surg Am 2008;Oct;90(10):2142-8.
24. Johnell O, Kannus P, Obrant KJ, Jarvinen M, Parkkari J: Management of the patient after an osteoporotic fracture: Guidelines for orthopedic surgeons--consensus conference on Treatment of Osteoporosis for Orthopedic Surgeons, Nordic Orthopedic Federation, Tampere, Finland 2000. Acta Orthop Scand 2001;72(4):325-30.
25. Chapuy MC, Arlot ME, Duboeuf F, Brun J, Crouzet B, Arnaud S, Delmas PD, Meunier PJ: Vitamin D3 and calcium to prevent hip fractures in the elderly women. N Engl J Med 1992;327(23):1637-42.
26. Dawson-Hughes B, Harris SS, Krall EA, Dallal GE: Effect of calcium and vitamin D supplementation on bone density in men and women 65 years of age or older. N Engl J Med 1997;337(10):670-6.
27. Inderjeeth C, Foo A, Lai M, Glendenning P: Efficacy and safety of pharmacological agents in managing osteoporosis in the old: Review of the evidence. Bone 2008;Dec 16 (EPub).
28. Black DM, Cummings SR, Karpf DB, Cauley JA, Thompson DE, Nevitt MC, Bauer DC, Genant HK, Haskell WL, Marcus R, Ott SM, Torner JC, Quandt SA, Reiss TF, Ensrud KE: Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group [see comments]. Lancet 1996;348(9041):1535-41.
29. McClung MR, Geusens P, Miller PD, Zippel H, Bensen WG, Roux C, Adami S, Fogelman I, Diamond T, Eastell R, Meunier PJ, Reginster JY: Effect of risedronate on the risk of hip fracture in elderly women. Hip Intervention Program Study Group. N Engl J Med 2001;344(5):333-40.
30. Reginster J, Minne HW, Sorensen OH, Hooper M, Roux C, Brandi ML, Lund B, Ethgen D, Pack S, Roumagnac I, Eastell R: Randomized trial of the effects of risedronate on vertebral fractures in women with established postmenopausal osteoporosis. Vertebral Efficacy with Risedronate Therapy (VERT) Study Group. Osteoporos Int 2000;11(1):83-91.
31. Neer RM, Arnaud CD, Zanchetta JR, Prince R, Gaich GA, Reginster JY, Hodsman AB, Eriksen EF, Ish-Shalom S, Genant HK, Wang O, Mitlak BH: Effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis. N Engl J Med 2001;344(19):1434-41.
32. Province MA, Hadley EC, Hornbrook MC, Lipsitz LA, Miller JP, Mulrow CD, Ory MG, Sattin RW, Tinetti ME, Wolf SL: The effects of exercise on falls in elderly patients. A preplanned meta-analysis of the FICSIT Trials. Frailty and Injuries: Cooperative Studies of Intervention Techniques. JAMA 1995;273(17):1341-7.
33. Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH: Interventions for preventing falls in elderly people. Cochrane Database Syst Rev 2001;(3):CD000340.
34. Carter ND, Kannus P, Khan KM: Exercise in the prevention of falls in older people: a systematic literature review examining the rationale and the evidence. Sports Med 2001;31(6):427-38.
35. Kannus P, Parkkari J, Niemi S, Pasanen M, Palvanen M, Jarvinen M, Vuori I: Prevention of hip fracture in elderly people with use of a hip protector. N Engl J Med 2000;343(21):1506-13.
36. Bauer DC: Osteoporotic fractures: ignorance is bliss? Am J Med 2000;109(4):338-9.

June 2003 American Academy of Orthopaedic Surgeons.
Revised December 2009.

This material may not be modified without the express written permission of the American Academy of Orthopaedic Surgeons.

Position Statement 1159

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