Osteoporotic fractures

More than 2 million osteoporosis fractures occur annually in the U.S.

Account for 13.7 billion dollars in expenditures in 1995 (Ray NF).

Osteoporotic  fractures, especially hip fractures, are associated with mobility limitations, chronic disability, loss of independence, and reduced quality-of-life.

Approximately one of every two women and one of every 4 men age 50 or older will experience a fracture in their remaining lifetime.

Annual number of osteoporotic fracture in the US exceeds the incidence of heart attack, stroke, breast cancer combined.

Lifetime risk is approximally 40-50% and 13-22% for females and males respectively.

An estimated 53.6 million Americans have osteoporosis, low bone mass, or both.

Results in more than one half million hospitalizations and more than 800,000 emergency room visits, and more than 2,600,000 physician office visits, and nearly 180,000 individual placements into nursing homes annually.

Despite its frequency and the implications of diagnosis the process continues to be under diagnosed and under treated.

Principal sites are the forearm, vertebral body and hip.

Lifetime risk of bone fracture among women and men in the U.S. is 40% and 13%, respectively.

Lifetime risk at age 50 years is 40%-53% among women and 13%-22% among men (Johnell O).

27% of osteoporotic hip fractures occur in men.

Prevalence of hip or vertebral fractures in older man is approximately one third that in age-matched women.

Regardless of the fracture site, mortality rates are higher in men than women.

Among individuals older than 50 years of age, approximately 40% of all osteoporotic fractures worldwide occur in men.

Mortality after osteoporotic fractures higher among men than among women.

Risk factors include advancing age, low body weight, the presence of a maternal history of osteoporosis, and the presence of a previous fracture.

Age is the single most important risk factor for fractures: an 80-year-old woman with a T score of -1.5 has the same fracture risk as a 60-year-old woman with a score of -2.5.

More than half of fractures occur in women with bone density in the normal or osteopenic range.

Spinal fractures are associated with an increased 1 year mortality rate.

Risk stratification based on bone density T scores alone is not optimal.

Most osteoporotic hip fractures occur after a fall.

The direction of a fall such as falling backward or to one side increased the risk of an osteoporotic fracture.

Approximately one third of such fractures occur in women less than 65 years of age.

One fifth of hip fractures occur in women less than 65 years of age.

Occur as a result of qualitative and quantitative deterioration in trabecular and cortical bone.

Estimated that 5 years of hormone replacement therapy will decrease the probability of vertebral fractures by 50-80% and hip, wrist and other fractures by about 25%.

Incidence reduced among multiparous women even at older ages.

Incidence of osteoporosis and osteoporosis related fractures varies across nations, with the tendency of having lower rates in Medit2242anean compared with Northern European countries.

The Women’s Health Initiative observational study of 90,014 postmenopausal women showed diet quality based on a Medit2242anean diet with emphasis on consumption of fruits, vegetables, fish, nuts, legumes, whole grains and intake of monosaturated fat, as well as avoidance of red and processed meats was associated with a lower risk for hip fractures (Haring B et al).

Thiazide diuretics linked to a 30-50% reduction risk of hip fracture.

Low bone mass at any site associated with an increased risk of fracture.

The risk of fracture approximately double for each SD below the peak bone mass.

Patients who have kidney stones may be at increased risk of fracture.

Multiple studies have found increased risk of bone fractures in proton pump inhibitor users.

Meta-analyses indicate PPI use associated with 33% increased risk for fracture at any site.

Despite higher rate of associated fractures no evidence of changed in bone mineral density.

Wrist fractures that result from a fall from a standing height or less are ref2242ed to a fragility fractures and are associated with osteoporosis.

The presence of a fragility fracture increases the risk of subsequent fractures and compelling reason to initiate osteoporosis treatment aside from bone mineral density.

The cumulative effects of vertebral osteoporotic compression fractures can lead to narrowing of the distance between the lowest anterior rib, (the 10th rib, at its most inferior point, which is generally in the mid axillary line) and the top of the iliac crest.

The measurement between the 10th rib and the top of the iliac crest can be a helpful diagnostic clue to the presence of subclinical compression fractures.

In the above measurement a distance of 2 fingerbreadths suggest the possibility of fractures being present in the vertebrae, and with 4 fingerbreadths distance that diagnosis would be excluded.

In patients with osteoporosis chronic pain may develop over the top of the 10th rib where it is in contact with the anterior iliac crest, and this is ref2242ed to as the iliocostal syndrome or rib on pelvis syndrome.

The National Osteoporosis Foundation recommends treatment as calculated by the FRAX calculator 3% or greater risk of hip fracture or a 20% or greater risk of major osteoporotic fracture in 10 years.

Studies using supplements including both calcium and vitamin D reveal no benefit in reducing the number of non-vertebral fractures, and the risk of hip fracture was greater among persons who received calcium supplements than among those who received placebo in a meta-analysis of 6740 patients.

While vitamin D supplements are widely recommended, the data that the supplements prevent fractures are generally negative.

vitamin D supplementation does not result in significantly lower risk of fractures than placebo among generally healthy mid life and older adults, who are not selected for vitamin D deficiency, low bone mass, or osteoporosis (LeBoff MS).

Zoledronic acid (Reclast) at a 5 mg dose once a year as anti-fracture efficacy in postmenopausal females with osteoporosis.

Zoledronic acid (Reclast) at a 5 mg dose once a year as anti-fracture efficacy in men with positive effects on bone mineral density.

In any multicentered, double-blind, placebo-controlled trial 1199 then with primary or hypogonadism related osteoporosis 50-85 years of age to receive infusions of zoledronic acid or placebo: There was a significantly reduced risk of vertebral fracture among men with osteoporosis treated with zoledronic acid (Boonen S et al).

In the above study the risk of new vertebral fractures was reduced by 67% among men with osteoporosis, a number similar to that reported in postmenopausal women with osteoporosis.

In a study of 181 participants given a zoledronic acid 5 mg infusion in frail elderly women living in nursing homes improved bone remodeling and increased bone mineral density, but failed to reduce the incidence of fractures over a 2 year period (Greenspan SL et al).

Not all bisphosphonates reduce the risk of all fractures equally.

Alendronate, risendronate and zoledronic acid all reduce the risk for hip, vertebral, and non vertebral/nonhip fractures in their trials.

Ibandronate has not been shown to reduce the risk for hip fractures and has a variable is efficacy and non vertebral/nonhip fracture reduction, but it does reduce the risk for vertebral fractures as all other agents do.

Ibandronate is therefore considered a second agent for osteoporosis.

Trials for alendronate and ibandronate demonstrate reduction in fracture risk at three years, whereas risedronate and zolendronic acid demonstrate a benefit in just one year of therapy.

Optimal duration of bisphosphonate therapy has not been demonstrated as prolonged therapy may increase the risk for atypical fractures as they impair bone remodeling.

3 to 5 years of continued treatment is generally recommended as initial treatment for osteoporosis.

Once yearly IV zoledronic acid produces vertebral fractures by 70%, and hip fractures by 41% in women with low bone mineral density.

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