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.

Endorsed by: American Academy of Orthopaedic Surgeons (AAOS); American Society for Bone and Mineral Research (ASBMR); International Osteoporosis Foundation (IOF); National Association of Orthopaedic Nurses (NAON); National Osteoporosis Foundation (NOF); Orthopaedic Research Society (ORS); and World Orthopaedic Osteoporosis Organization (WOOO).

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

Fractures lead to more fractures

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.^{1,12,13,14,15,16,17,18,19} 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.^12,19 Furthermore, up to half of patients with a prior vertebral fracture will experience additional vertebral fractures within three years, many within the first year.^13,15 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.^14,17,19 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.

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.²⁰ In this regard, supplementation with calcium and vitamin D has been shown to lower fracture risk in the elderly.^21,22 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.^{8,9,23,24,25,26} Non-pharmacologic interventions, such as fall prevention programs and individually-tailored exercise programs, have been shown to reduce falls among the elderly,_27,28,29 which may decrease the incidence of fractures. In addition, trochanteric padding has been shown to dramatically reduce hip fractures among those at highest risk.³⁰ 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.^10,11,20,31

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.
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.
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 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 2002 Epidemiology and outcomes of osteoporotic fractures. Lancet 359(9319):1761-7.
2. Riggs BL, Melton LJ, 3rd 1995 The worldwide problem of osteoporosis: insights afforded by epidemiology. Bone 17(5 Suppl):505S-511S.
3. Ross PD 1996 Osteoporosis. Frequency, consequences, and risk factors. Arch Intern Med 156(13):1399-411.
4. Jones G, Nguyen T, Sambrook PN, Kelly PJ, Gilbert C, Eisman JA 1994 Symptomatic fracture incidence in elderly men and women: the Dubbo Osteoporosis Epidemiology Study (DOES). Osteoporos Int 4(5):277-82.
5. Nguyen TV, Eisman JA, Kelly PJ, Sambrook PN 1996 Risk factors for osteoporotic fractures in elderly men. Am J Epidemiol 144(3):255-63.
6. Kanis JA, Johnell O, Oden A, Sembo I, Redlund-Johnell I, Dawson A, De Laet C, Jonsson B 2000 Long-term risk of osteoporotic fracture in Malmo. Osteoporos Int 11(8):669-74.
7. Tosteson AN, Gabriel SE, Grove MR, Moncur MM, Kneeland TS, Melton LJ, 3rd 2001 Impact of hip and vertebral fractures on quality-adjusted life years. Osteoporos Int 12(12):1042-9.
8. Delmas PD 2002 Treatment of postmenopausal osteoporosis. Lancet 359(9322):2018-26.
9. Hochberg M 2000 Preventing fractures in postmenopausal women with osteoporosis. A review of recent controlled trials of antiresorptive agents. Drugs Aging 17(4):317-30.
10. Tosi LL, Lane JM 1998 Osteoporosis prevention and the orthopaedic surgeon: when fracture care is not enough. J Bone Joint Surg Am 80(11):1567-9.
11. Rosier RN 2001 Expanding the role of the orthopaedic surgeon in the treatment of osteoporosis. Clin Orthop (385):57-67.
12. Nevitt MC, Ross PD, Palermo L, Musliner T, Genant HK, Thompson DE 1999 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 25(5):613-9.
13. Robinson CM, Royds M, Abraham A, McQueen MM, Court-Brown CM, Christie J 2002 Refractures in patients at least forty-five years old. a prospective analysis of twenty-two thousand and sixty patients. J Bone Joint Surg Am 84-A(9):1528-33.
14. Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA, 3rd, Berger M 2000 Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res 15(4):721-39.
15. Lindsay R, Silverman SL, Cooper C, Hanley DA, Barton I, Broy SB, Licata A, Benhamou L, Geusens P, Flowers K, Stracke H, Seeman E 2001 Risk of new vertebral fracture in the year following a fracture. JAMA 285(3):320-3.
16. Johnell O, Oden A, Caulin F, Kanis JA 2001 Acute and long-term increase in fracture risk after hospitalization for vertebral fracture. Osteoporos Int 12(3):207-14.
17. Gunnes M, Mellstrom D, Johnell O 1998 How well can a previous fracture indicate a new fracture? A questionnaire study of 29,802 postmenopausal women. Acta Orthop Scand 69(5):508-12.
18. Ross P, Davis J, Epstein R, Wasnich R 1991 Pre-existing fractures and bone mass predict vertebral fracture incidence in women. Ann Int Med 114:919-923.
19. van Staa TP, Leufkens HG, Cooper C 2002 Does a fracture at one site predict later fractures at other sites? A British cohort study. Osteoporos Int 13(8):624-9.
20. Johnell O, Kannus P, Obrant KJ, Jarvinen M, Parkkari J 2001 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 72(4):325-30.
21. Chapuy MC, Arlot ME, Duboeuf F, Brun J, Crouzet B, Arnaud S, Delmas PD, Meunier PJ 1992 Vitamin D3 and calcium to prevent hip fractures in the elderly women. N Engl J Med 327(23):1637-42.
22. Dawson-Hughes B, Harris SS, Krall EA, Dallal GE 1997 Effect of calcium and vitamin D supplementation on bone density in men and women 65 years of age or older. N Engl J Med 337(10):670-6.
23. 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 1996 Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group [see comments]. Lancet 348(9041):1535-41.
24. McClung MR, Geusens P, Miller PD, Zippel H, Bensen WG, Roux C, Adami S, Fogelman I, Diamond T, Eastell R, Meunier PJ, Reginster JY 2001 Effect of risedronate on the risk of hip fracture in elderly women. Hip Intervention Program Study Group. N Engl J Med 344(5):333-40.
25. Reginster J, Minne HW, Sorensen OH, Hooper M, Roux C, Brandi ML, Lund B, Ethgen D, Pack S, Roumagnac I, Eastell R 2000 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 11(1):83-91.
26. 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 2001 Effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis. N Engl J Med 344(19):1434-41.
27. Province MA, Hadley EC, Hornbrook MC, Lipsitz LA, Miller JP, Mulrow CD, Ory MG, Sattin RW, Tinetti ME, Wolf SL 1995 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 273(17):1341-7.
28. Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH 2001 Interventions for preventing falls in elderly people. Cochrane Database Syst Rev (3):CD000340.
29. Carter ND, Kannus P, Khan KM 2001 Exercise in the prevention of falls in older people: a systematic literature review examining the rationale and the evidence. Sports Med 31(6):427-38.
30. Kannus P, Parkkari J, Niemi S, Pasanen M, Palvanen M, Jarvinen M, Vuori I 2000 Prevention of hip fracture in elderly people with use of a hip protector. N Engl J Med 343(21):1506-13.
31. Bauer DC 2000 Osteoporotic fractures: ignorance is bliss? Am J Med 109(4):338-9.

© June 2003 American Academy of Orthopaedic Surgeons

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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