Douglas C. Bauer, MD

Disclosures

September 23, 2003

Question

I have a postmenopausal patient (64 years old, body mass index 28.5) with low bone mineral density (BMD; -1.0) who is recovering from a wrist fracture after a fall. She is currently taking a statin (40 mg/day) and a multivitamin that contains 400 IU vitamin D and 125 mg Ca. She also takes a 500-mg/day calcium tablet. She says her diet is typical Western fare. What are your recommendations for postfracture medical care?

Response From the Expert

Douglas C. Bauer, MD
Associate Professor of Medicine, Epidemiology & Biostatistics, University of California, San Francisco

 

Postfracture care has historically focused on the procedures needed to safely align and immobilize the acutely fractured bone. Far less attention has been given to the fact that most fractures represent a sentinel event that should trigger a thoughtful evaluation for osteoporosis and appropriate interventions to prevent additional fractures. Perhaps some of the confusion relates to the outdated concept that only "low trauma" fractures are associated with osteoporosis. In fact, fractures occur when trauma exceeds bone strength, and all but the most severely traumatic fractures (such as those that result from motor vehicle accidents) represent clinically important events that increase the risk of future fractures.

Numerous studies show that previous fractures are a potent risk factor for subsequent fractures. The risk of fractures after a hip or vertebral fracture is substantial, with relative risks of 3-5. Of note, the increased risk persists even after accounting for other risk factors, such as low BMD, family history, and low body weight.

The risk of additional fractures after a distal radium (Colles') fracture is less well studied, but several studies have addressed the issue. For example, a study from the Mayo Clinic[1] found that compared with expected fracture rates in the community, the risk of a hip fracture after an index forearm fracture was increased 1.4-fold in women (95% confidence interval [CI], 1.1-1.8) and 2.7-fold in men (95% CI, 0.98-5.8). Subsequent vertebral fractures after a distal radius fracture were also significantly increased, with a 5.2-fold increase (95% CI, 4.5-5.9) in risk among women and a 10.7-fold increase (95% CI, 6.7-16.3) among men.

Given the prognostic importance of a fracture, each postmenopausal woman presenting with a new fracture should be evaluated for osteoporosis. Such an evaluation might include a targeted medical history to detect insufficient calcium or vitamin D intake, medications or diseases associated with secondary osteoporosis (such an antiseizure, excess thyroid hormone, and even inhaled corticosteroids), health habits such as smoking or physical inactivity, and most important, axial BMD (particularly of the hip). Strong consideration should be given to obtaining a lateral spine film to detect vertebral fractures. Most experts agree that any woman with a documented spine and hip fracture should receive pharmacologic treatment, regardless of her BMD. There are much fewer data in men, but it is likely that the same relationships hold true.

The patient of this physician does not appear to have osteoporosis by BMD criteria. There is increasing evidence that among women without vertebral fractures, bisphosphonate treatments are most effective for those women with substantially reduced BMD (t-score < -2 to -2.5). Thus, pharmacologic treatment of such an individual would be considered optional, but counseling about treatment options and lifestyle issues should be the standard of care.

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