Two Fracture Studies
One fracture is enough! Acta Orthopaedica 2006; 77(1):3-8, Astrand J and others. PMID: 16534695. This study was based on the hypothesis that fracture patients have lower bone mineral density (BMD) than the population in general. The authors tested whether a screening routine to verify whether fracture patients are at high risk for further fracture can be done with limited resources in an orthopedic practice. The study population was all patients between 50 to 75 years of age presenting to the practice with a low-energy distal radius, vertebra or hip fracture during a one-year period. The total was 256 patients with 54 of them being males. Follow up dual-energy X-ray absorptiometry (DXA) was done on consenting individuals. This was a total of 239 patients with only 13% having normal BMD. Additionally 45% had osteopenia and 42% had osteoporosis. Only 13 patients had DXA and pharmacological treatment for osteoporosis at the time of fracture. The authors note that a DXA can't determine bone architecture and strength, but that a fracture can be considered an indicator of suboptimal bone architecture. They suggest that the first fracture should be the impetus to perform DXA to verify whether medical therapy for osteoporosis is indicated to help prevent future fractures. Note that the first fracture might be of the wrist, which is much more treatable, and with less morbidity and mortality, than the hip or spine. So diagnosis and treatment after such a first fracture may be lifesaving for an individual. Editor's comments: This study points out important issues for patients and physicians. Endocrinologists and rheumatologists are often the medical specialists that diagnosis and treat osteoporosis. Orthopedic surgeons are often the specialists who first see people who have fractures. But they are treating the fracture, not the medical condition that may have caused it. Having this screening routine at the orthopedic office is an important step toward getting osteoporosis patients proper diagnosis and treatment. The authors rightly point out that they can then only refer the fracture patient for further therapy. So this can be a weak link in the chain if the patients don't follow up with a visit for the osteoporosis treatment referral. Bottom line: If you are older than 50 and have a low-trauma fracture, figure you have osteoporosis until proven otherwise. Have a DXA done, and see the osteoporosis specialist if your BMD is low. Don't risk a second or third fracture.
A study of male patients with forearm fracture in Northern Ireland. Clin Rheumatol. 2006 Mar 22; [Epub ahead of print], Wright S and others. PMID: 16552462. This study involved male patients aged 30-75 years who had a distal forearm fracture in 2000-2001 in Northern Ireland. 37 patients agreed to have further DXA and further diagnostic studies done. The results showed 27% of the men had osteoporosis, 49% had vitamin D insufficiency or deficiency, 27% had low serum testosterone, 14% had abnormal liver functions tests, and 14% had raised parathyroid hormone. The authors note that some individuals suggest that men should be diagnosed with osteoporosis if their T-score is -2..0, whereas in women -2.5 would be needed. If this group of men were to fall under that diagnostic scheme, 51% would have had osteoporosis. Indeed the median spine T-score was -1.081, the hip was -1.391, and the forearm was -0.981. The osteoporosis risk factors in this group of men appeared to be excessive alcohol consumption, positive celiac serology and insufficient vitamin D status. Editor's comments: This study, like the other one in the Update, shows that more than fracture treatment should be going on when an individual presents at an orthopedic office with a low-impact fracture. Diagnostic testing, and then medical therapy, if warranted by the tests, should be done. It isn't enough to just treat the fracture without some kind of follow up to look for a medical cause of the fracture.