COMMENTARY

Don't Be so Cavalier About That Non-Hip Fracture

Richard M. Plotzker, MD

Disclosures

November 09, 2018

Not long after the warranty on my 40-year-old parts expired, I was sprinting from my office to pick up my daughter a block away when my left ankle slipped off the curb, leaving me in sudden pain.

I hobbled the rest of the way to my daughter, limped back to the car, and then drove home, where my daughter innocently pushed the injured ankle into the kitchen table leg, bringing about another quick shriek.

My ankle was massively swollen, so it was off to the emergency department. An x-ray showed that the distal process of the fibula had snapped, as well as a fracture of the fourth metacarpal.

Some fractures reflect an underlying disease and may be the first clue to other health problems to follow.

Not long after, I was the owner of a brand-new cast, crutches, and my first Tylenol #3 ever. My injuries healed uneventfully with a few office visits, and there was no concern whatsoever of fracture-related mortality appearing in the next 10 years.

Fracture Outcomes: What Do We Know?

A recent report[1] from a population study in Denmark, however, suggests that had I been a few years older when the orthopedic misadventure occurred—above the age of 50—my surgeon and I should not have been quite as cavalier about my 10-year survival. Some of these fractures reflect an underlying disease expressed in the skeleton and may be the first clue to other health problems to follow.

The casts and hip replacements go to the orthopedic surgeons, but the bone itself seems to be more of an endocrine organ with hormonal control points such as parathyroid hormone, metabolites of vitamin D, and perhaps calcitonin—that vestigial hormone that doesn't seem to have a clear physiologic purpose.

People have known of ominous outcomes from hip and pelvic fractures for decades, and great strides have been made to improve long-term survival and minimize disability associated with hip fractures. Vertebral fractures have long been known to cause disability, respiratory compromise from deformity or immobility, and some excess mortality.

Medicines introduced over the past 20 years have reduced but not eliminated the risks for these often devastating events.

Less is known about the long-term sequelae of distal fractures, which are seen with hyperparathyroidism, celiac disease, and alcoholism, where rib fractures from minor trauma are prevalent. Sometimes aging weekend athletes who do not have any apparent medical illness will need their tennis partners to drive them to the ER.

Tracking Survival

Figuring out who fractured what and how they fared subsequently cannot be assessed just anywhere. The fractures have to be identified and there has to be a registry of global clinical outcomes.

Denmark has a registry and a single payer, so all treatment for fractures can be isolated from a database and stratified by age, bone, and gender. Then, using centralized mortality data, these individuals can be matched against a mortality base for the general population to determine excess mortality.

The study investigators tracked all people in Denmark who had a first fracture in 2001 (with a few exclusions, such as those from auto accidents) for survival in the next 10 years.[1]

A fragility fracture may serve as a marker for a disease already present but not appreciated for its potential seriousness.

About half of the fractures were in the forearm, humerus, or hip, and they tended to occur in older people than did more distal fractures. Those who died within 10 years were more likely to have had a chronic disease at the time of fracture than those who healed and survived. Men seemed to do less well than women.

The distal-most fractures—ankle, foot, hand, and wrist—seemed to have little impact on relative longevity; proximal and central fractures—such as those in the humerus, rib, leg (not ankle), and clavicle—did.

The excess mortality within 1 year of fracture was found to be mostly associated with malignancy, whereas late mortality beyond 5 years appeared to be associated with respiratory events.

Greater Awareness Needed

These findings suggest that a fragility fracture may serve as a marker for a disease already present but not appreciated for its potential seriousness. Some of these diseases can be managed more aggressively and lead to better outcomes later.

Although clinicians have long been trained to recognize those with osteoporotic hip and vertebral fractures as being at serious medical risk, that awareness should perhaps be expanded to some of the more proximal and central fractures that invariably get treated orthopedically but perhaps underestimated medically.

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