Download - Fragility Fractures

Kenneth J. Koval, MD Laura Tosi, MD

AOA Committee for theOwn the Bone Pilot Project

Created February 2007; Revised March 2011

Fragility Fractures

Prevalence

•More than 34 million Americans suffer from osteoporosis or low bone mass

•80% are women•1 in 2 women over 50 years old•1 in 4 men over 50 years old

Source: National Osteoporosis Foundation

Osteoporosis-fracture Occurrences vs Other

Diseases

0

500,000

1,000,000

1,500,000

2,000,000

Osteoporoticfractures

513,000

Heart Attack

Stroke

†

Breast Cancer

250,000 hip

184,300750,000 vertebral

250,000 other sites

228,000

An

nu

al i

nci

den

ce o

f co

mm

on

dis

ease

s

1,500,000

Wrist Fractures:200,000+

Hip Fractures:300,000+

Vertebral Fractures:700,000+

Other Fractures:300,000+

Source: National Osteoporosis Foundation, 2000

1.5 Million Fractures Annually

$14 billion annually

Burden of Disease

• Approximately $38 million daily

• Congestive heart failure costs $8 billion annually

• Asthma costs $9.8 billion annually

Burden of Disease

•1 out of 4 osteoporotic hip fractures result in long-term nursing home care

•One half of these are unable to walk without assistance

•24% greater risk of dying within one year

What’s 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 year

• Risk of mortality is 2.8-4 times greater among hip fracture patients during the first 3 months after the fracture

• Nearly 1 in 5 hip fracture patients ends up in a nursing home within a year

Alarming Fracture Statistics

Source: Surgeon General’s Report, 2004, Jrnl of Bone and Mineral Research

Fractures cost

$18 billion/year

and expected to

increase if action

is not taken.

The Costs Continue to Grow

Risk Factors for Osteoporosis

•Female•Thin or small frame•Low body weight•Smoker


•Advanced age•History of fragility fracture

•Family history- primary relative with osteoporosis or fragility fracture


• Post Menopausal

–Hormonal imbalances can result in rapid bone loss

–Women can lose up to 20% of their bone mass in 5-7 years


•Amenorrhea, Anorexia & Bulimia

•Diet low in calcium•Certain medications•Low testosterone in men


•Inactive lifestyle•Excessive 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


Caucasian & Asian-American women also high risk


• 10% of African-American women 50+ have osteoporosis

• 30% more have low bone density


• 300,000 African-American women have osteoporosis

• 80-95% of all fractures sustained by African-Americans 64+ are osteoporotic

• African-American women more likely to die from hip fractures than White women

Underdiagnosed

Unrecognized Underreported

Inadequately researched

Men & Osteoporosis

Men & Osteoporosis

• 2 million American men have osteoporosis

• 3 million more are at risk

• 1/3 of male hip fractures related to osteoporosis

• 1/3 of these men will not survive 1 year after fracture

Risk Factors for Fragility Fractures• Impaired vision despite correction• Estrogen deficiency at an early age (<45 yrs)

• Dementia• Poor health / frailty• Recent falls• Lifelong low calcium intake• Low physical activity

Fractures beget Fractures

• Risk of future fractures increases 1.5-9.5 fold following initial fracture

• History of fragility fracture is more predictive of future fracture than bone density

Diagnosis: Bone Densitometry

Recommendations for bone density

•Anyone with a fragility fracture

•All women age 65 and older•Postmenopausal younger than 65 with risk factors

•Men over 50 with risk factors

Goals

• Prevent future fractures

• Treat osteoporosis

• Decrease the risk of mortality after fractures

Treatment

1. Calcium and Vitamin DAll patients with bone loss or the potential for bone loss should be educated on the appropriate intake of calcium and vitamin D

+ =

Stronger Bones!

Stronger Bones!

Treatment

There is a high prevalence of

vitamin D insufficiency in:• Nursing home residents• Hospitalized patients• Adults with hip fractures

Treatment

2. Exercise

Physical 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 fractures

Treatment

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 deaths

Source: National Institute of Health/National Institute on Aging

Fall

3 factors

that contributeto fractures

Force Fragility

Treatment

4. BMD/DXA Testing

Single 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 adult

Treatment

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

Treatment

6. Pharmacotherapy – Treatment & prevention

Bisphosphonates are approved by the FDA and can help stop or slow bone loss, or help form new bone, and reduce the risk of fractures

Type Brand Name

Alendronate Fosamax

Ibandronate Boniva

Risedronate Actonel

Raloxifene Evista

Zoledronic Acid Reclast

Treatment

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 year

• The risk for ONJ among patients taking oral bisphosphonates is likely to be 1:100,000

Bisphosphonates

Bisphosphonate Associated Fracture

• May occur with long term bisphosphonate use

• Relatively rare occurrence compared to fragility fractures

• Risk/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 healed

Treatment

8. Physician Referral

A letter sent to the primary care physician can provide information regarding the patient’s fracture and recommend appropriate measures be taken

Treatment

• Use handrails on stairs, bathroom

• Keep rooms free of clutter

• Keep floors clean but not slippery

• Wear supportive, low-heeled shoes. Don’t walk in socks; floppy slippers

• Use 100 watt bulbs in all rooms

• Install ceiling lighting in bedrooms

• Use rubber matt in shower/tub

• Keep a flashlight at bedside

• Check posture in mirror often

Fall Prevention in the Home

Bibliography

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.

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 clutter• Use portable phone; keep phone and electrical wires out of walkways

• Skid-proof backing on carpets / scatter rugs

• Keep week’s supply of prescription medications on hand

• Daily contact with family member / neighbor

Contract with monitoring company for 24 hour response time in emergency

More … Home Fall Prevention

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