Fragility fractures, which result from low energy trauma, such as a fall from standing height or less, are a sign of underlying osteoporosis. A patient who has sustained one fragility fracture is at high risk of experiencing secondary fractures, especially in the first two years following the initial fracture.
A fracture arises when the load-bearing capacity of a bone is exceeded by forces applied to it, for example during trauma. This capacity is influenced by bone mineral density, but also by bone geometry, microstructure and quality.
Fragility fractures are the clinical outcome of osteoporosis. These fractures arise following an event which would otherwise not be expected to result in a fracture. Fractures occurring in a setting of low-level or low-energy trauma, defined as falling from standing height or less, are usually considered as osteoporotic [1]National Institute for Health and Care Excellence NICE: Clinical Guideline [CG146] - Osteoporosis: assessing the risk of fragility fracture. 2012 [Accessed 22.02.2019];
See link. However, individuals with osteoporosis compared to healthy individuals, suffer fractures from high-energy trauma at a greater frequency [2]Sanders, K.M., et al., The exclusion of high trauma fractures may underestimate the prevalence of bone fragility fractures in the community: the Geelong Osteoporosis Study. J Bone Miner Res, 1998. 13(8): p. 1337-42.
. As such, osteoporosis fracture sites are now more and more characterised by their association with low bone mineral density (BMD) and increasing incidence with age, after the age of 50 years [3]Kanis, J.A., et al., The burden of osteoporotic fractures: a method for setting intervention thresholds. Osteoporos Int, 2001. 12(5): p. 417-27.
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With this definition of fragility fractures, the most frequent fractures occur at the hip, spine and forearm. This, however, does not exclude other sites, including fracture of the humerus, ribs, tibia (excluding the ankle), pelvis and other femoral fractures, where osteoporosis fractures can occur partly due to low BMD, especially after the age of 50 years.
All of these fractures have major consequences on patients’ quality of life as they cause substantial pain and disability, which results in a loss of independence, and increased risk of morbidity and mortality [4]Cooper, C., et al., Population-based study of survival after osteoporotic fractures. Am J Epidemiol, 1993. 137(9): p. 1001-5.
[5]Kannus, P., et al., Epidemiology of osteoporotic ankle fractures in elderly persons in Finland. Ann Intern Med, 1996. 125(12): p. 975-8.
[6]Leibson, C.L., et al., Mortality, disability, and nursing home use for persons with and without hip fracture: a population-based study. J Am Geriatr Soc, 2002. 50(10): p. 1644-50.
[7]Magaziner, J., et al., Excess mortality attributable to hip fracture in white women aged 70 years and older. Am J Public Health, 1997. 87(10): p. 1630-6.
[8]Magaziner, J., et al., Predictors of functional recovery one year following hospital discharge for hip fracture: a prospective study. J Gerontol, 1990. 45(3): p. M101-7.
[9]Riggs, B.L. and L.J. Melton, 3rd, The worldwide problem of osteoporosis: insights afforded by epidemiology. Bone, 1995. 17(5 Suppl): p. 505S-511S.
[10]Cooper, C., The crippling consequences of fractures and their impact on quality of life. Am J Med, 1997. 103(2A): p. 12S-17S; discussion 17S-19S.
[11]McKercher, H.G., R.G. Crilly, and M. Kloseck, Osteoporosis management in long-term care. Survey of Ontario physicians. Can Fam Physician, 2000. 46: p. 2228-35.
[12]Adachi, J.D., et al., The impact of incident vertebral and non-vertebral fractures on health related quality of life in postmenopausal women. BMC Musculoskelet Disord, 2002. 3: p
[13]Gold, D.T., The nonskeletal consequences of osteoporotic fractures. Psychologic and social outcomes. Rheum Dis Clin North Am, 2001. 27(1): p. 255-62.
[14]Hall, S.E., et al., A case-control study of quality of life and functional impairment in women with long-standing vertebral osteoporotic fracture. Osteoporos Int, 1999. 9(6): p. 508-15.
[15]Lips, P., et al., Quality of life in patients with vertebral fractures: validation of the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO). Working Party for Quality of Life of the European Foundation for Osteoporosis. Osteoporos Int, 1999. 10(2): p. 150-60.
[16]Lyles, K.W., Osteoporosis and depression: shedding more light upon a complex relationship. J Am Geriatr Soc, 2001. 49(6): p. 827-8.
[17]Nevitt, M.C., et al., The association of radiographically detected vertebral fractures with back pain and function: a prospective study. Ann Intern Med, 1998. 128(10): p. 793-800
[18]Robbins, J., et al., The association of bone mineral density and depression in an older population. J Am Geriatr Soc, 2001. 49(6): p. 732-6.
[19]Tosteson, A.N., et al., Impact of hip and vertebral fractures on quality-adjusted life years. Osteoporos Int, 2001. 12(12): p. 1042-9.
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Accounting for much of the fracture-related mortality and health care expenditures, the two most serious types of fractures are at the hip and vertebrae.
For these reasons it is important to prevent fractures. This can be achieved by changing lifestyle factors, such as nutrition and exercise, as well as pharmacological intervention to restore bone strength, and by preventing falls that are known to cause many fractures especially in the elderly. Different models of care also exist to help with preventing the initial fracture and subsequently preventing a second fracture from occurring.
Types of fragility fractures
Hip fractures are considered the most serious of fractures and are usually caused by a fall from a standing position, which almost always leads to hospitalisation. They are associated with subsequent chronic pain, reduced mobility, disability and an increasing degree of dependence [20]Keene, G.S., M.J. Parker, and G.A. Pryor, Mortality and morbidity after hip fractures. BMJ, 1993. 307(6914): p. 1248-50.
. A high rate of morbidity and mortality is also seen with hip fractures, where 20 % of patients die in the year after a hip fracture, often the result of other medical conditions, and less than half of the survivors regain their previous level of function [20]Keene, G.S., M.J. Parker, and G.A. Pryor, Mortality and morbidity after hip fractures. BMJ, 1993. 307(6914): p. 1248-50.
[21]Melton, L.J., 3rd, Adverse outcomes of osteoporotic fractures in the general population. J Bone Miner Res, 2003. 18(6): p. 1139-41.
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There are two main types of hip fracture, cervical or trochanteric, with the latter usually occurring in older patients. The way they are each treated differs, however, their incidence in many countries is quite similar [22]Pocket Reference to Osteoporosis, S. Ferrari, Roux, C., Editor 2019, Springer International Publishing.
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Overall, the incidence of hip fractures increases with increasing age for both sexes, with rates in women about double those in men from age 70 years [23]; the highest reported incidence of hip fracture worldwide was observed in Scandinavia [24]Kanis, J.A., et al., International variations in hip fracture probabilities: implications for risk assessment. J Bone Miner Res, 2002. 17(7): p. 1237-44.
. Read more about hip fracture epidemiology.
Most vertebral fractures are caused by moderate or minimal trauma that is associated with lifting or changing position, as opposed to falls. They are the hardest osteoporosis-related fractures to define as many are clinically silent and may not be not associated with densitometric osteoporosis. Diagnosis is based on an alteration in vertebral body shape (vertebral deformity) [22]Pocket Reference to Osteoporosis, S. Ferrari, Roux, C., Editor 2019, Springer International Publishing.
. When vertebral deformities do reach immediate clinical attention it is usually because of height loss and back pain among other functional impairments [25]Kanis, J.A., et al., The risk and burden of vertebral fractures in Sweden. Osteoporos Int, 2004. 15(1): p. 20-6.
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Vertebral deformities resulting from osteoporotic fractures are classified as:
- Wedge fractures: causing anterior height loss
- Biconcave fractures: causing central compression of the end-plate regions and maintenance of anterior and posterior heights
- Crush fractures: causing compression of the entire vertebral body
Read more about assessing vertebral fractures.
In Sweden, the incidence of clinical vertebral fractures is about 20-40 % of that of morphometric factures (that is, fractures detected on radiographs rather than clinical presentation), the incidence of which increases with age and is higher in women than in men at older ages [25]Kanis, J.A., et al., The risk and burden of vertebral fractures in Sweden. Osteoporos Int, 2004. 15(1): p. 20-6.
[26]O'Neill, T.W., et al., Back pain, disability, and radiographic vertebral fracture in European women: a prospective study. Osteoporos Int, 2004. 15(9): p. 760-5.
. Read more about vertebral fracture epidemiology.
Vertebral fractures lead to many adverse consequences for sufferers, including:
- Back pain, loss of height, deformity, immobility and increased number of hospital bed days [15]Lips, P., et al., Quality of life in patients with vertebral fractures: validation of the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO). Working Party for Quality of Life of the European Foundation for Osteoporosis. Osteoporos Int, 1999. 10(2): p. 150-60.
[17]Nevitt, M.C., et al., The association of radiographically detected vertebral fractures with back pain and function: a prospective study. Ann Intern Med, 1998. 128(10): p. 793-800 - Reduced quality of life resulting from loss of self-esteem, distorted body image and depression [13]Gold, D.T., The nonskeletal consequences of osteoporotic fractures. Psychologic and social outcomes. Rheum Dis Clin North Am, 2001. 27(1): p. 255-62.
[16]Lyles, K.W., Osteoporosis and depression: shedding more light upon a complex relationship. J Am Geriatr Soc, 2001. 49(6): p. 827-8.
[18]Robbins, J., et al., The association of bone mineral density and depression in an older population. J Am Geriatr Soc, 2001. 49(6): p. 732-6.
[19]Tosteson, A.N., et al., Impact of hip and vertebral fractures on quality-adjusted life years. Osteoporos Int, 2001. 12(12): p. 1042-9. - A significant negative impact on activities of daily living [12]Adachi, J.D., et al., The impact of incident vertebral and non-vertebral fractures on health related quality of life in postmenopausal women. BMC Musculoskelet Disord, 2002. 3: p
[14]Hall, S.E., et al., A case-control study of quality of life and functional impairment in women with long-standing vertebral osteoporotic fracture. Osteoporos Int, 1999. 9(6): p. 508-15.
Despite having less associated morbidity and mortality compared to hip fractures, as well as rarely requiring hospitalization, the outcome of wrist fractures is frequently underestimated as these fractures are painful, often necessitate one or more reductions and require a cast for 4-6 weeks.
Distal forearm fractures generally occur when trying to break a fall with an outstretched hand(s) and commonly result in a Colles’ fracture. This fracture type is defined by a dorsal angulation and displacement of the distal radial fragment and commonly accompanied by an ulna styloid process fracture [22]Pocket Reference to Osteoporosis, S. Ferrari, Roux, C., Editor 2019, Springer International Publishing.
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This fracture type is much more frequent in women compared to men and the incidence of wrist fractures in women usually increases gradually with age, which differs from the marked rise in the incidence of hip and vertebral fractures at older ages [22]Pocket Reference to Osteoporosis, S. Ferrari, Roux, C., Editor 2019, Springer International Publishing.
[27]Curtis, E.M., et al., Epidemiology of fractures in the United Kingdom 1988-2012: Variation with age, sex, geography, ethnicity and socioeconomic status. Bone, 2016. 87: p. 19-26.
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Compared to hip fractures, only about 1 % of individuals having suffered a wrist fracture become dependent. However, at 6 months almost 50 % report only recovering a poor to fair function [28]World Health Organization Collaborating Centre for Metabolic Bone Diseases University of Sheffield UK: FRAX® WHO Fracture Risk Assessment Tool. 2016 [Accessed 26.02.2019];
See Link [29]Kaukonen, J.P., et al., Functional recovery after fractures of the distal forearm. Analysis of radiographic and other factors affecting the outcome. Ann Chir Gynaecol, 1988. 77(1): p. 27-31.
. Read more about wrist fracture epidemiology.
In patients over 50 years of age, most fractures are osteoporosis-related. Overall, the fracture incidences at the pelvis, humerus and proximal tibia increase significantly with age and are more common in women than in men. In men fractures of the ribs and vertebrae and forearms are most common at age 50 compared to women where distal forearm, vertebral, rib and proximal humeral fractures are frequent.
Hip fractures, accounting for about 30% of all osteoporosis fractures, then become the most common fracture for both men and women from 85 years of age [3]Kanis, J.A., et al., The burden of osteoporotic fractures: a method for setting intervention thresholds. Osteoporos Int, 2001. 12(5): p. 417-27.
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