Kenneth J. Koval, MD Laura Tosi, MDAOA Committee for theOwn the Bone Pilot Project Created February 2007; Revised March 2011

Fragility Fractures

PrevalenceMore than 34 million Americans suffer from osteoporosis or low bone mass80% are women1 in 2 women over 50 years old1 in 4 men over 50 years old

Source: National Osteoporosis FoundationOsteoporosis-fracture Occurrences vs Other Diseases0500,0001,000,0001,500,0002,000,000Osteoporotic fracturesStrokeBreast Cancer250,000 hip184,300750,000 vertebral250,000 other sites228,000Annual incidence of common diseases1,500,000

Wrist Fractures:200,000+Hip Fractures:300,000+Vertebral Fractures:700,000+Other Fractures:300,000+Source: National Osteoporosis Foundation, 20001.5 Million Fractures Annually

$14 billion annuallyBurden of DiseaseApproximately $38 million dailyCongestive heart failure costs $8 billion annuallyAsthma costs $9.8 billion annually

Burden of Disease1 out of 4 osteoporotic hip fractures result in long-term nursing home careOne half of these are unable to walk without assistance24% greater risk of dying within one year

Whats the link?

Fragility fractures Fractures of the distal radius, proximal humerus, vertebrae and proximal femur that result from minimal trauma, such as a fall from a standing height.

Up to 95% of hospitalized fracture inpatients over 75 years of age, and 80%-90% of fractures in patients between 60 and 74 years of age can be attributed to osteoporosis.

- Fragility Fractures & Osteoporosis -Only 23% of hip fracture patients received the care recommended on the basis of good practice standards.! Source: RAND Report

40% of postmenopausal women and ~25-33% of men will eventually experience osteoporotic fractures. ~20 percent of senior citizens who suffer a hip fracture die within a yearRisk of mortality is 2.8-4 times greater among hip fracture patients during the first 3 months after the fractureNearly 1 in 5 hip fracture patients ends up in a nursing home within a year

Alarming Fracture Statistics Source: Surgeon Generals Report, 2004, Jrnl of Bone and Mineral Research

Fractures cost $18 billion/yearand expected to increase if actionis not taken.

The Costs Continue to Grow

Risk Factors for OsteoporosisFemaleThin or small frameLow body weightSmoker

Risk Factors for OsteoporosisAdvanced ageHistory of fragility fractureFamily history- primary relative with osteoporosis or fragility fracture

Risk Factors for OsteoporosisPost MenopausalHormonal imbalances can result in rapid bone lossWomen can lose up to 20% of their bone mass in 5-7 years

Risk Factors for OsteoporosisAmenorrhea, Anorexia & BulimiaDiet low in calciumCertain medicationsLow testosterone in men

Risk Factors for OsteoporosisInactive lifestyleExcessive alcohol consumption

Ethnicity & Osteoporosis 13-16% with osteoporosis now 36-49% of Mexican American women 50+ have experienced significant bone loss Hispanic women at highest risk

Ethnicity & OsteoporosisCaucasian & Asian-American women also high risk

Ethnicity & Osteoporosis10% of African-American women 50+ have osteoporosis30% more have low bone density

Ethnicity & Osteoporosis300,000 African-American women have osteoporosis80-95% of all fractures sustained by African-Americans 64+ are osteoporoticAfrican-American women more likely to die from hip fractures than White women

Underdiagnosed Unrecognized Underreported Inadequately researched Men & Osteoporosis

Men & Osteoporosis2 million American men have osteoporosis3 million more are at risk1/3 of male hip fractures related to osteoporosis1/3 of these men will not survive 1 year after fracture

Risk Factors for Fragility FracturesImpaired vision despite correctionEstrogen deficiency at an early age (

Fractures beget FracturesRisk of future fractures increases 1.5-9.5 fold following initial fractureHistory of fragility fracture is more predictive of future fracture than bone density

Diagnosis: Bone DensitometryRecommendations for bone densityAnyone with a fragility fractureAll women age 65 and olderPostmenopausal younger than 65 with risk factorsMen over 50 with risk factors

GoalsPrevent future fractures Treat osteoporosisDecrease the risk of mortality after fracturesTreatment

Calcium and Vitamin D All patients with bone loss or the potential for bone loss should be educated on the appropriate intake of calcium and vitamin D+=Stronger Bones!Treatment

There is a high prevalence of vitamin D insufficiency in:Nursing home residentsHospitalized patientsAdults with hip fracturesTreatment

2. ExercisePhysical activity makes bones and muscles stronger and helps prevent bone loss.

All types of physical activity can contribute to bone health

High impact exercise programs may be the most effective at preventing fragility fracturesTreatment

3. Fall PreventionEach year, more than 1.6 million older U.S. adults go to emergency departments for fall-related injuries. Among older adults, falls are the number one cause of: Fractures Hospital admissions for trauma Loss of independence Injury deathsSource: National Institute of Health/National Institute on Aging

Fall3 factorsthat contributeto fracturesForceFragilityTreatment

4. BMD/DXA TestingSingle most important diagnostic test to predict whether a person will have a fracture in the future. It helps diagnose osteoporosis and predict the risk for having a fracture by comparing bone density to the bones of an average healthy young adultTreatment

5. Cessation of smokingSmoking can reduce bone mass, increase fracture risk and should be avoided for a variety of health reasonsTreatment

6. Pharmacotherapy Treatment & preventionBisphosphonates are approved by the FDA and can help stop or slow bone loss, or help form new bone, and reduce the risk of fracturesTreatment

TypeBrand NameAlendronateFosamaxIbandronateBonivaRisedronateActonelRaloxifeneEvistaZoledronic AcidReclast

Bisphosphonates Bisphosphonates are bone-building drugs that prevent bone resorption and remain important treatment options for patients at risk of debilitating fractures.

But, where does the impact on dental health figure into the equation? What is the true incidence of osteonecrosis of the jaw (ONJ)?

Source: Bamias A. Osteonecrosis of the jaw in cancer after treatment with bisphosphonates: incidence and risk factors. J Clin Oncol 2005;23(34):8580-7. Approximately 125 cases of osteonecrosis have been linked to bisphosphonate usage. The majority of these cases have been administered through an IV to cancer patients The Facts

A man with a hip fracture has a 1:3 chance of dying within a year A woman with a hip fracture has a 1:4 chance of dying within a yearThe risk for ONJ among patients taking oral bisphosphonates is likely to be 1:100,000Bisphosphonates

Bisphosphonate Associated FractureMay occur with long term bisphosphonate useRelatively rare occurrence compared to fragility fracturesRisk/benefit analysis still favors bisphosphonate use Source: Bisphosphonate use and the risk of subtrochanteric or femoral shaft fractures in older women. Park-Wyllie LY, Mamdani MM, Juurlink DN, Hawker GA, Gunraj N, Austin PC, Whelan DB, Weiler PJ, Laupacis A. JAMA. 2011 Feb 23;305(8):783-9.

7. Patient NoteProvide the patient with written information regarding fragility fractures and preventive measures that can be taken. Encourage them to speak with their primary care physicians for additional follow-up after the fracture has healedTreatment

8. Physician ReferralA letter sent to the primary care physician can provide information regarding the patients fracture and recommend appropriate measures be takenTreatment

Use handrails on stairs, bathroomKeep rooms free of clutterKeep floors clean but not slipperyWear supportive, low-heeled shoes. Dont walk in socks; floppy slippersUse 100 watt bulbs in all roomsInstall ceiling lighting in bedroomsUse rubber matt in shower/tub Keep a flashlight at bedside Check posture in mirror oftenFall Prevention in the Home

BibliographyBisphosphonate use and the risk of subtrochanteric or femoral shaft fractures in older women. Park-Wyllie LY, Mamdani MM, Juurlink DN, Hawker GA, Gunraj N, Austin PC, Whelan DB, Weiler PJ, Laupacis A. JAMA. 2011 Feb 23;305(8):783-9.The American Orthopaedic Association's "own the bone" initiative to prevent secondary fractures. Tosi LL, Gliklich R, Kannan K, Koval KJ. J Bone Joint Surg Am. 2008 Jan;90(1):163-73.Primary care-relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force. Michael YL, Whitlock EP, Lin JS, Fu R, O'Connor EA, Gold R; US Preventive Services Task Force. Ann Intern Med. 2010 Dec 21;153(12):815-25. Review.Bisphosphonates for osteoporosis. Favus MJ. N Engl J Med. 2010 Nov 18;363(21):2027-35.

Keep floors free from clutterUse portable phone; keep phone and electrical wires out of walkwaysSkid-proof backing on carpets / scatter rugsKeep weeks supply of prescription medications on handDaily contact with family member / neighborContract with monitoring company for 24 hour response time in emergencyMore Home Fall Prevention Return to General/Principles IndexE-mail OTA about Questions/CommentsIf you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please