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Osteoporosis Follow-up After Wrist Fractures Following Minor Trauma
Sophia A. Khan, MD;
Carolyn de Geus, MD;
Brian Holroyd, MD;
Anthony S. Russell, FRCP
Arch Intern Med. 2001;161:1309-1312.
ABSTRACT
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Background Patients presenting with low-trauma wrist fractures are an ideal target
population for early case finding of osteoporosis. We decided to investigate
whether this early detection occurred in practice.
Methods This study was conducted at a single center in Edmonton, Alberta. A
structured interview format was used to contact 112 (72%) of 156 patients
older than 40 years who were diagnosed as having an atraumatic fracture of
the distal radius/ulna from April 1997 to March 1998 and from January 1999
to February 1999. Information on osteoporosis follow-up and drug therapy was
obtained from the patient.
Results The time between fracture and telephone interview ranged from 6 months
to 3 years, with the majority of the sample being interviewed at least 1 year
after fracture. Of the 112 patients in this study, 44 had sustained previous
fractures, 17 of which had occurred at the wrist, vertebrae, or hip. Sixteen
patients in the sample had already sustained a subsequent clinical fracture
before our telephone contact. Thirty-two patients had received treatment for
osteoporosis before fracture. A further 24 patients (21%) had undergone osteoporosis
follow-up after fracture. After fracture, 42 (38%) of all patients were receiving
either hormone replacement therapy or using a bisphosphonate.
Conclusions Only 50% of the study population had received osteoporosis follow-up
after fracture. Few patients had any change in their medication use after
fracture. The findings in this study population suggest that recognition of
the potential for osteoporosis in such patients is inadequate. Given the magnitude
of this public health care problem, it is clear that attention to case finding
and treatment of osteoporosis should be increased.
INTRODUCTION
THE MAJOR consequences of osteoporosis are fractures, especially of
the wrists, vertebrae, and hips. These fragility fractures confer a significant
morbidity, mortality, and cost to the Canadian public.1-3
Strategies to prevent such fractures are important both to the individual
and from a public health care perspective.
Adults who sustain wrist fractures as a result minor trauma are an ideal
target group for early case finding of osteoporosis. This group has a high
probability for having osteoporosis1, 4-9
and are at an increased risk for sustaining hip fractures.10-14
Also, wrist fractures generally precede hip fractures by about 15 years.1, 10, 15 By identifying patients
with wrist fractures who have low bone mass, there is a window of opportunity
to prevent subsequent and potentially more serious fractures.
An unrestricted MEDLINE search from 1966 to the present was conducted
using the key words: wrist fractures, osteoporosis, and follow-up studies. No published
studies were found that determined the rate of follow-up or treatment of osteoporosis
for patients who sustain a wrist fracture. The primary objective of the study
was to determine the percentage of patients who receive any formal osteoporosis
follow-up after sustaining a low-trauma wrist fracture. The second objective
was to compare the percentage of patients who receive protective drug therapy
before and after fracture.
SUBJECTS AND METHODS
SUBJECTS
This study was conducted at a single tertiary care center in Edmonton,
Alberta, and had received approval from the Faculty of Medicine Ethics Review
Board. Two groups of patients were studied. The first group consisted of 34
patients with wrist fractures who had been seen at the orthopedic plaster
clinic. This group of patients was used to pilot the development of a survey
instrument on osteoporosis follow-up.
The second group consisted of 181 patients treated in the emergency
department for wrist injuries from April 1997 to March 1998 and from January
1999 to February 1999 (14 months). Patients had to be older than 40 years
and had to have sustained a closed fracture of the distal radius/ulna (International Classification of Diseases, Ninth Revision, Clinical
Modification codes 813.4 and 813.5) to be included in the study. Patients
were identified via a medical records review of discharge diagnoses.
Patients were excluded if there was a history of significant trauma
as determined through diagnostic codes or through telephone interview. Significant
trauma was defined as a fall from 1.2 cm or more, a fall from a ladder, being
in a motorized vehicle crash, or being struck by an object. Compound fractures
were excluded.
METHODS
After consent for the interview was obtained from each subject, we collected
information on demographics, follow-up, and drug therapy using a structured
telephone interview format and a single interviewer. Follow-up was defined
as a discussion with a physician on osteoporosis or as a referral for bone
mineral density. Protective drug therapy was defined as including calcium
or vitamin D supplementation, but requiring either hormone replacement therapy
or bisphosphonate use.16-26
Nasal calcitonin and selective estrogen-receptor modulators were not available
in Canada at that time. This study was a retrospective observational study.
In addition, information was obtained to calculate the SCORE index.27 The SCORE index is a well-validated method that uses
6 variables: age, weight, race, history of estrogen use, rheumatoid arthritis,
and fracture to estimate a woman's risk of osteoporosis. Lydick et al27 developed this index in a cohort of more than 1200
women and validated it in a separate cohort of 259 women. They recommended
a score of 6 (likelihood ratio, 1.78) to be used as a lower cutoff for referral
to bone mineral density testing.
Information was obtained through telephone interviews between August
1999 to February 2000. All data were entered into a spreadsheet (Excel; Microsoft,
Seattle, Wash), and relevant rates were calculated.
RESULTS
One hundred fifty-six patients were eligible after the exclusion criteria
were applied. Of the 25 patients excluded, 17 had fallen from a height of
1.2 cm or more or from a ladder, and 8 had been in a motorized vehicle crash
or struck by an object. Follow-up was complete for 112 (72%) of the 156 patients.
Of the 44 patients whose survey information was not collected, 4 were unwilling
to participate, 4 were unable to answer questions, 11 were dead, and 25 were
not traceable. The time between fracture and telephone interview ranged from
6 months to 3 years, with the majority of the sample being interviewed at
least 1 year after fracture.
The mean age of the subjects was 64 years (age range, 42-91 years).
Eighty-three percent of the patients were female. Ninety-two percent of women
had a SCORE index of 6 or more, with a mean value of 14 (Table 1). Forty-four patients had a history of fracture, and 17
(almost 40%) of those fractures had occurred at a typical osteoporotic site
(wrist, vertebra, or hip). Sixteen patients (14% of the sample) had sustained
another fracture before our telephone contact. Seven (44%) of those fractures
had occurred at a typical osteoporotic site (Table 1).
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Table 1. Characteristics of the 112 Study Participants
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Twenty-nine percent (n = 39) of the sample underwent treatment for osteoporosis
before fracture. Fifty percent (n = 56) of the sample received osteoporosis
follow-up after fracture (Table 2). Fifty percent (n = 56) of the patients also were taking calcium or vitamin
D supplements before fracture. After fracture, 69 patients were taking one
of these medications. Thirty percent (n = 34) of the patients were receiving
either hormone replacement therapy or using a bisphosphonate. After fracture,
38% (n = 42) of the patients were taking one of these medications (Table 2).
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Table 2. Osteoporosis Management and Drug Therapy for 112 Study Patients*
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COMMENT
This study allows several observations. The first is that the majority
of fractures in this study occurred in women. This observation confirms the
results of large epidemiological studies and supports the idea that wrist
fractures are associated with osteoporosis.1, 4-9
The vulnerability of women to wrist fractures is likely due to a declining
bone mass during the postmenopausal years.15
It must be emphasized not only that fractures relate to a propensity for falls,
but also that aspects of bone structure not reflected in bone mineral density
are of importance as well.28-30
Thus, 1 fracture significantly increases the risk for subsequent fractures,
even in patients with similar bone densities.
In men, bone mass does not decline at the same rate, and there is no
comparable rise in fracture incidence in men during what would be the postmenopausal
years in women. Nevertheless, men with wrist fractures as a result of minor
trauma may still be an appropriate target group for case finding of osteoporosis.
Fractures due to minor trauma may indicate a secondary cause of osteoporosis.
Also, wrist fractures in men are a powerful predictor of subsequent hip fracture
risk. A study conducted by Owen et al15 demonstrated
a relative risk for hip fracture of 6.4, and one performed by Mallmin et al14 revealed a hazard ratio of 2.27 for hip fracture
in men with a history of Colles fracture. These studies indicate that men
with Colles fractures are susceptible to further fractures. For these reasons,
men were not excluded.
The second finding is that almost 40% of the sample had sustained a
fracture before the one in their wrist, and 39% of those fractures had occurred
at a typical osteoporotic site. Surprisingly, 14% of the sample at follow-up
had already sustained an additional fracture after the one in their wrist
by the time of our contact call. The large number of fractures in the study
group underscores the importance of case finding, as appropriate treatment
can clearly reduce the incidence of fractures.16-26,31
The rationale for case finding in patients with fracture is further
supported by the findings of a large cohort study of more than 800 women that
was conducted by Sanders et al32 in 1998. The
authors reported that patients with fracture were 3 times more likely to have
osteoporosis than were population-based controls, irrespective of the degree
of trauma.28-29,32
Studies that have focused on Colles fractures also report a high prevalence
of osteoporosis.4-6
In a prospective study of 106 women with Colles fracture, 50% of the patients
had osteoporosis and only 9% had normal bone mineral density.5
These results highlight the importance of fracture as a clinical indicator
for the possibility of osteoporosis.
More than 90% of the women in our study had a SCORE index of 6 or more.
The mean value was 14, with an SD of 6. In the study by Lydick et al,27 nearly all women with an index of 14 were in the
osteoporotic range (specificity, 93% for T score; 2.5 SD).The fact that the
SCORE index was so high in this study further validates the idea that this
index both emphasizes risk factors and provides a quantitative measure of
a need for osteoporosis screening that family physicians could use.
A liberal definition was used to define follow-up that included a physician
discussion on osteoporosis. This flexible definition allows a clinical diagnosis
of osteoporosis and limits bias against those patients who cannot access densitometry
testing or those who implement a preventive approach to osteoporosis, irrespective
of bone density testing.
Despite such a liberal definition, only 50% of the study population
received osteoporosis follow-up after fracture. If therapy is examined, few
patients had any change in their medication use, as evidenced by a small increase
in the rate of calcium or vitamin D supplement use and an even smaller increase
in the rate of bisphosphonate or hormone replacement therapy after fracture.
The findings in the study population suggest that recognition of the potential
for osteoporosis and further complications in such patients is inadequate.
These findings are comparable to those of other studies that have examined
the utilization rates of proven therapies. For example, a recent study on
the use of ß-blockers in the post–myocardial infarction period
reported that only 50% of infarct survivors actually receive this therapy.33 The authors concluded that ß-blockers are significantly
underused despite abundant scientific literature supporting their use.29 Whether osteoporosis or other diseases are examined,
it is clear that more than scientific evidence is required to instruct a change
in practice.
Interventions to improve osteoporosis follow-up of patients with wrist
fracture can include identifying these individuals in the emergency department,
providing them with literature on osteoporosis, and faxing an information
sheet to their family physician. Referral of these patients to a dedicated
clinic for prevention of osteoporosis is another option. Current studies to
assess some of these approaches are under way.
The most significant result of the present study is that 50% of the
sample population did not receive any osteoporosis follow-up after minor trauma
or fragility fracture. In Canada, the incidence of wrist fractures was 5 per
1000 women older than 50 years.1 Given the
magnitude of this public health care problem, quite apart from the costs relating
to subsequent hip fracture, more attention should be given to case finding
and treatment of osteoporosis.
AUTHOR INFORMATION
Accepted for publication December 6, 2000.
We would like to thank Proctor and Gamble Pharmaceuticals Canada for
partial funding for this study, as well as David Felson, MD, Samia Khan, MEd,
Nadia Khan, MD, and Waleed Khan, MBA, for their review of the manuscript.
Corresponding author: Anthony S. Russell, FRCP, 562 Heritage Medical
Research Centre, University of Alberta, Edmonton, Alberta, Canada T6G 2S2.
From the Departments of Medicine (Drs Khan, de Geus, and Russell) and
Emergency Medicine (Dr Holroyd), University of Alberta, Edmonton.
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