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Osteoporosis Intervention Following Distal Forearm Fractures
A Missed Opportunity?
Maria-Teresa Cuddihy, MD, MPH;
Sherine E. Gabriel, MD, MS;
Cynthia S. Crowson, BS;
Elizabeth J. Atkinson, MS;
Claudia Tabini, BA;
W. Michael O'Fallon, PhD;
L. Joseph Melton III, MD
Arch Intern Med. 2002;162:421-426.
ABSTRACT
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Background Fractures are a manifestation of osteoporosis, but therapeutic interventions
to reduce the risk of recurrent fractures are not widespread.
Objective To identify predictors of osteoporosis treatment in postmenopausal women
following distal forearm fracture.
Methods This population-based retrospective cohort study included all postmenopausal
women, 45 years or older, residing in Olmsted County, Minnesota, who sustained
a distal forearm fracture due to minimal trauma (a fall from standing height
or under) in 1993 to 1997. Complete medical records were reviewed for each
subject and Cox proportional hazards regression was used to evaluate the relationship
of baseline demographic and clinical characteristics to therapeutic interventions
for osteoporosis within 12 months following the fracture.
Results A total of 343 women with a mean age of 70.5 years had a minimal trauma
distal forearm fracture. Within 12 months, 83% had seen a nonorthopedic physician.
Of these, 17% had a pharmacologic osteoporosis intervention and the 12-month
actuarially estimated cumulative incidence of any intervention was 18% (95%
confidence interval [CI], 14%-22%). In a multivariate analysis, treatment
was more likely to be offered to those with a prior diagnosis of osteoporosis
(relative risk [RR], 2.08; 95% CI, 1.21-3.58), previous distal forearm fracture
(RR, 2.38; 95% CI, 1.30-4.34), or history of cigarette smoking (RR, 1.86;
95% CI, 1.11-3.12).
Conclusions Effective osteoporosis interventions are underutilized among postmenopausal
women who experience an osteoporotic fracture. Further work is needed to overcome
barriers to optimal osteoporosis management in these women who are at high
risk for future complications of osteoporosis.
INTRODUCTION
OSTEOPOROTIC fractures represent a serious and growing threat to our
aging population.1 The cost of caring for individuals
with these fractures was $13.8 billion in 1995,2
but since the population at risk of osteoporosis is so large,3
the potential cost of preventing these fractures is also great. Consequently,
there is ongoing debate about the relative cost-effectiveness of various management
strategies.4 It seems clear, however, that
treatment of high-risk individuals is both cost-effective and socially important.5-7 Individuals who have
already sustained a fracture are in a particularly high-risk group.8 Thus, men and women with a distal forearm fracture
have a greatly increased likelihood of experiencing additional osteoporotic
fractures in the future,9-12
including hip fractures that are quite costly.1
Since forearm fractures typically occur earlier in life than do hip fractures,
it has been recommended for many years that interventions be targeted to this
group.13-15 Several
studies have confirmed that women younger than 65 years who sustain a distal
forearm fracture have reduced bone densitometry compared with same-aged women
without a fracture.16-17 Yet,
few postmenopausal women are treated for osteoporosis following a distal forearm
fracture12 despite the availability of antiresorptive
agents that have been shown to be effective in preventing future fractures
among those who have already experienced one.18-20
The objective of this study was to investigate the type of interventions for
osteoporosis offered to a population-based cohort of postmenopausal women
who had sustained a minimal trauma distal forearm fracture, placing them at
high risk for future fracture, and to identify predictors of the likelihood
of receiving such advice from physicians practicing in the community.
PATIENTS AND METHODS
Population-based epidemiologic research can be conducted in Olmsted
County, Minnesota, because medical care is virtually self-contained within
the community and there are relatively few providers. Through the resources
of the Mayo Clinic and the Rochester Epidemiology Project, the details of
almost all of the medical care provided to local residents are available for
study.21 Using this unique medical records
linkage system, we assembled a cohort composed of all postmenopausal women
residing in Olmsted County who sustained a distal forearm fracture in the
5-year period 1993 to 1997. Women were identified using methods previously
described.22 Following approval by the Mayo
Clinic's institutional review board, we reviewed the complete (inpatient and
outpatient) medical records held by community providers of patients with any
diagnosis coded to rubrics 813.4 and 813.5.23
Mayo Clinic records, for example, contain the details of every outpatient
office or clinic visit, all emergency department and nursing home care, and
all inpatient care at its 2 hospitals, as well as all laboratory results,
radiographic reports, and pathology reports, including autopsies, and all
correspondence with each patient.24 Record
review was restricted to postmenopausal women aged 45 years or older at the
time of fracture. Postmenopausal status was defined by the absence of menses
for greater than 6 months, new identification of hot flashes, or age older
than 55 years. We excluded women who were premenopausal at the time of their
fracture and women younger than 55 years whose postmenopausal status could
not be determined from the physician notes. We also restricted this analysis
to the distal forearm fractures that resulted from no more than minimal trauma
(by convention, a simple fall from standing height or under). All fractures
were radiographically confirmed at diagnosis.
Information was then gathered on each patient with respect to their
index fracture and potential predictors of osteoporosis treatment. We collected
demographic data (age, race, and educational history), behavioral data (cigarette
smoking and alcohol use), and a variety of clinical information including
premature menopause (before age 40 years), type of menopause (natural or surgical)
including hysterectomy status, use of hormone replacement therapy (HRT), height
loss (>5.08 cm since age 18 years), history of osteoporotic fractures (defined
as distal forearm, proximal humerus, vertebral, pelvis, proximal femur, and
distal tibia/fibula fractures25), family history
of osteoporosis or other relevant family history (cancer, gynecologic malignancy,
and coronary artery disease), and personal medical history (including coexisting
comorbidities that might influence decisions about HRT such as coronary artery
disease, dementia, or history of thromboembolic disease or malignancy), as
well as other relevant exposures such as diabetes mellitus, peripheral vascular
disease, and corticosteroid use. We reviewed all physician encounters following
the index fracture, gathering information on physician specialty and sex as
well as specific recommendations for osteoporosis interventions including
medications and referral for bone mineral density testing. Bone densitometry
measurements were made using dual-energy x-ray absorptiometry. We categorized
treatment recommendations as follows: (1) new therapeutic advice, (2) documented
review of existing therapies, or (3) ongoing use of osteoporosis medication,
such as HRT, without documentation of any consideration of the fracture event
or mention of osteoporosis intervention.
We used  2 statistics for discrete comparisons. The cumulative
incidence of intervention (1 minus survival-free-of-intervention) and of nonorthopedist
physician visits were projected for 12 months following the distal forearm
fracture using product-limit life-table methods.26
Cox proportional hazards regression models were used to assess the influence
of various risk factors (or predictors) on the review or advice to begin a
pharmacologic intervention for osteoporosis within 12 months of fracture.
A multivariate model was developed using the stepwise process, and interactions
among the significant main effects were assessed.
RESULTS
Over the 5-year period (1993-1997), 409 Olmsted County women 45 years
or older experienced a distal forearm fracture. Of these, 17 women were premenopausal
at the time of their fracture and menopausal status could not be established
for 4 others who were younger than 55 years. In addition, 42 women whose distal
forearm fracture was caused by significant trauma (usually motor vehicle crashes,
falls from greater than 0.9 m, or sports-related trauma) and 3 for whom the
cause could not be determined with certainty, were excluded. This left 343
women for study whose fracture resulted from only minimal trauma, ie, a fall
from standing height or under without a speed greater than walking. The mean
age of the cohort was 70.5 years (range, 45-99 years) and the majority of
fractures (66%) occurred in women older than 65 years. We found that 98% of
the subjects were white, in keeping with the demographics of the county (95%
white in 1990). Medical record documentation prior to fracture averaged 39.6
± 19.8 years (median, 39.7 years; range, 0-82 years). These patients
were subsequently followed up through their medical records in the community
for 1031 person-years (mean ± SD, 3.0 ± 1.7 years; median, 3.0
years; range, 1 day to 6.7 years). However, only the first 12 months of follow-up,
after the index forearm fracture, were considered in this analysis (303 of
the 343 women were followed up for a full 12 months after fracture).
Within the first 6 months, most women (68%) were attended by a physician
other than the treating orthopedist and an additional 15% were seen 6 to12
months after the fracture. The timing of the nonorthopedic physician visits
is shown in Figure 1. Altogether,
236 women were attended by a general internist or family practitioner, 14
by some other specialist (eg, gynecologist or endocrinologist), and 8 by both
types of physicians, while 85 (25%) saw only an orthopedist in the 12 months
following the fracture. Only 29% of treating community physicians were female.
Despite contact with several physicians in the first year after fracture,
only 100 women had any documentation of osteoporosis intervention or treatment
advice during this time. The actuarially estimated cumulative incidence of
any pharmacologic intervention was 18% at 12 months (95% confidence interval
[CI], 14%-22%) (Figure 1). Altogether,
40 women (12%) were advised to initiate pharmacologic treatment, while 18
others (5%) were already being treated with an osteoporosis drug and this
therapy was reviewed in light of the fracture. Thirty-six other women (10%)
were taking pharmacologic therapy, principally estrogen (94%), prior to their
distal forearm fracture, but there was no documentation of any review of the
situation following the fracture. Finally, 6 women (2%) were offered only
nonpharmacologic advice (including calcium or vitamin D supplementation, or
weight-bearing exercise) for prevention of osteoporosis and 28 received both
nonpharmacologic and more potent pharmacologic therapeutic intervention. There
was no treatment or treatment advice for 72% of the 243 women whose forearm
fracture was the first that they had experienced nor for 67% of the 100 women
with a recurrent distal forearm fracture (Table 1).
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Timing of first nonorthopedist physician visit and cumulative incidence
of visits to nonorthopedists where advice on therapeutic interventions was
offered to Olmsted County, Minnesota, women following a minimal trauma distal
forearm fracture, 1993-1997.
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Table 1. Osteoporosis Treatment Advice Following a Minimal Trauma Distal
Forearm Fracture Among Women With and Without Prior Osteoporotic Fracture*
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Fifty-four women were already receiving therapy for osteoporosis treatment
or prevention prior to their forearm fracture (estrogen in 48, raloxifene
in 5, and alendronate in 1). Among the 48 women who were receiving HRT at
the time of their fracture, 35 (73%) were younger than 65 years and 13 (27%)
were 65 years old or older (P<.001). There was
no review of this therapy following fracture in 34 of these women; 8 had been
taking therapy for osteoporosis, while 26 had some other indication for treatment
(13 for menopause symptoms, 4 for prevention of heart disease, and 9 for unspecified
reasons). Of the 14 women who had their ongoing HRT reviewed in the 12 months
after fracture, 8 (57%) had their indication for use changed to osteoporosis
treatment from a prior reason for use and 6 had the osteoporosis indication
reinforced given the new fracture event. Despite the introduction of nonhormonal
therapies for osteoporosis between 1995 and 1997, HRT remained the most frequently
recommended therapy among the 40 women who received new treatment advice following
their distal forearm fracture (Table 2).
There were no significant differences in recommendations offered to women
of different ages (P = .41).
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Table 2. Pharmacologic Interventions for Osteoporosis Offered Within
12 Months Following a Minimal Trauma Distal Forearm by Age Group*
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We examined numerous factors that we believed might be related to the
treatment advice provided following a minimal trauma distal forearm fracture.
Since only 6 women received nonpharmacologic advice alone, and given the likelihood
that preventive advice might have been given but not necessarily documented
during the busy medical interaction, we restricted the proportional hazards
regression models to consideration of pharmacologic advice that was either
new or ongoing treatment that was specifically reviewed following the fracture.
A large number of variables were not significant predictors of a recommendation
for pharmacologic treatment as follows: age, ethnicity, loss of height (>5.08
cm since age 18 years), premature menopause (before 40 years of age), type
of menopause (natural or surgical), hysterectomy status, past HRT, family
history of osteoporosis, other family history (cancer, gynecologic malignancy,
or coronary artery disease), and personal medical history (diabetes mellitus,
coronary artery disease, peripheral vascular disease, history of thromboembolic
disease, dementia, history of malignancy, or corticosteroid use in the last
5 years) or alcohol consumption. Additional factors that were not significant
included treating physician specialty and sex. The factors that were significant
in univariate regression modeling were prior osteoporotic fracture, past distal
forearm fracture, previous diagnosis of osteoporosis, prior estrogen use,
greater than high school education, or ever cigarette smoker (Table 3). Women who had the diagnosis of osteoporosis (relative
risk [RR], 2.28; 95% CI, 1.34-3.88) or a prior osteoporotic fracture (RR,
1.95; 95% CI, 1.16-3.28) were twice as likely to receive a therapeutic intervention
after index fracture. Even more significantly, women who had a prior distal
forearm fracture were 2.5 times as likely (RR, 2.67; 95% CI, 1.48-4.81) to
receive an intervention after fracture. In addition, those who had a history
of estrogen use were more than 2 times (RR, 2.17; 95% CI, 1.28-3.66) as likely
to receive such an intervention. Women who had more education (greater than
high school) had a nearly 2-fold (RR, 1.84; 95% CI, 1.08-3.14) chance of receiving
osteoporosis advice, and ever smokers had nearly a 2-fold chance (RR, 1.73;
95% CI, 1.03-2.89). In a multivariate analysis, the only independent predictors
of new and reviewed pharmacologic treatment were prior diagnosis of osteoporosis
(RR, 2.08; 95% CI, 1.21-3.58), a previous distal forearm fracture (RR, 2.38;
95% CI, 1.30-4.34), and history of cigarette smoking (RR, 1.86; 95% CI, 1.11-3.12).
These results were unchanged when the analysis was confined to consideration
of HRT alone. In a multivariate model for women who were offered new advice
only, a previous distal forearm fracture was the only significant variable
(RR, 3.14; 95% CI, 1.60-6.18).
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Table 3. Predictors of Pharmacologic Interventions for Osteoporosis
Offered Following Minimal Trauma Distal Forearm Fracture*
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Diagnostic evaluations for osteoporosis were made infrequently in this
cohort, as only 17 women (5%) had their bone density measured within 12 months
of the fracture. Of the group tested, osteoporosis pharmacologic interventions
were provided to 76%. Of the individuals who did complete densitometry, 11
(65%) had T scores that were less than -1 at the femoral neck, while
12 (71%) had T scores less than -1 at the lumbar spine. Using a cutoff
of T scores less than -2.5 (ie, 2.5 SDs below peak adult bone mass)
to define osteoporosis, 6 women (43%) were below this threshold at the spine
and 2 (14%) at the hip.
COMMENT
These data demonstrate that evaluation of osteoporosis was not part
of routine follow-up care after a minimal trauma distal forearm fracture in
postmenopausal women. The actuarial cumulative incidence rate of any pharmacologic
therapeutic recommendation in the 12 months following the fracture was a modest
18%. This was a considerable improvement from earlier years, when only 12
of 1414 women in this community who had a distal forearm fracture in the 20-year
period (1975-1994) were started on HRT in the 12 months following fracture.12 The present study provides data from a 5-year population-based
sample, with correlation to medical record information in which barriers could
be identified. Other studies have reported similar results. In a study of
80 postmenopausal women who experienced a Colles fracture (the most common
type of distal forearm fracture) in 1995 to 1996, only 8% received a pharmacologic
intervention for osteoporosis.27 Pal et al28 surveyed 82 individuals (87% women) after a fracture
that occurred in 1996 and found that only 34 (41%) reported receiving information
about osteoporosis from their physician; 11% of the women received advice
regarding estrogen and 15% were advised to begin a treatment with bisphosphonate.
Similarly, Torgeson and Dolan29 studied 300
women, identified through the British General Practice Research Database,
who had osteoporotic fractures in 1995 (100 hip, 100 wrist, and 100 vertebral),
and found that only 5% who sustained a distal forearm fracture were receiving
osteoporosis treatment 12 months after the fracture. In their study, only
4% who sustained a hip fracture and 39% who sustained a vertebral fracture
received osteoporosis interventions after fracture. In a claims data study
of 1162 women older than 55 years sustaining a distal forearm fracture from
1994 to 1997, Freedman et al30 reported that
24% of this sample filled a prescription for an approved osteoporosis medication.
Kamel et al31 described very low rates of intervention
even after medical consultation in a study of 170 hip fracture patients (in
whom minimal trauma was the cause in more than 90%), in whom only 1% received
osteoporosis pharmacologic intervention.
The choice of therapeutic interventions in this cohort was predominantly
estrogen, whereas in other settings, the use of non-HRT agents has been more
prominent. Cole and Paushock32 found that non-HRT
treatment was more often used than estrogen for women with increased risk
of fracture. Torgeson and Dolan29 showed that
etidronate was the most commonly used treatment for individuals with vertebral
fractures in the United Kingdom. Unfortunately, the benefit of HRT, the preferred
choice among physicians and patients in this community, is lessened by the
traditionally poor long-term compliance with this therapy.32-33
Data from clinical trials suggest that adherence for treatment with bisphosphonates
and selective estrogen receptor modulators may be as high as 75%18, 20;
however, it remains to be seen whether compliance will be as high in routine
clinical practice.
Although hip and spine fractures are more commonly associated with the
diagnosis of osteoporosis, low bone mineral density also predisposes to distal
forearm fractures.34 In our cohort, only a
small number (5%) had bone densitometry testing, but the majority (65% at
the femur and 71% at the spine) of those tested had a T score below -1,
which is considered by many to be a therapeutic threshold following a low-impact
fracture.35 Indeed, 43% had a T score below -2.5
at the spine, which may actually underestimate the prevalence of osteoporosis
as osteoarthritis can falsely elevate spine density readings. Other studies
have similarly shown that women with distal forearm fractures have lower bone
density than age-matched controls.36-42
More important, there is strong epidemiologic evidence that distal forearm
fractures predispose to future fractures.9-12
In fact, pooled rates from several studies have shown a 3.3-fold increase
in future wrist fractures, a 1.7-fold increase in future vertebral fractures,
a 1.9-fold increase in future hip fractures, and a 2.4-fold increase for all
nonspine fractures together.8 In our population,
the risk of another distal forearm fracture was elevated 2.6-fold and the
risk of a subsequent vertebral fracture was increased more than 5-fold.12
In this study, the majority of clinical factors examined did not explain
barriers to osteoporosis intervention or at least assessment after low-impact
fracture. The factors that related to prior fracture, especially a prior distal
forearm fracture, and previous diagnosis of osteoporosis were independent
predictors. A higher level of education and history of cigarette smoking were
also associated with a higher likelihood of receiving advice about osteoporosis
after the minimal trauma index fracture.
In general, the occurrence of a distal forearm fracture did not appear
to be routinely recognized by physicians or patients as a manifestation of
osteoporosis and, therefore, did not commonly trigger a workup for osteoporosis.
Since the primary outcome in this study was whether a discussion about osteoporosis
took place after a low-impact trauma fracture, and some recommendations (such
as calcium and vitamin D supplementation and exercise) may not be consistently
recorded, we may have underestimated nonpharmacologic interventions. This
study suggests that there is a deficit, but it is not clear where the barrier
is, at the physician level or in the patient's willingness to accept this
type of preventive therapy. This is not unique to distal forearm fractures,
but is likely to be a problem with all postmenopausal women and elderly men
who sustain any low-impact fracture. Indeed, a survey of orthopedists in Britain
reported little attention to osteoporosis,28
and similar concerns have been raised by the American Society of Orthopedists
who are considering the timeliness of intervention after fracture.43 Likewise, in the Third National Health and Nutrition
Examination Survey, 17% of 2314 women had osteoporosis documented at the proximal
femur, yet only 5% of these reported having been told by a physician that
they had osteoporosis.44 Clearly, we need to
further explore barriers to osteoporosis prevention in patients who have already
sustained a low-impact fracture.
One way to lessen the impact of osteoporotic fractures on costs is to
target individuals who are at highest risk, but it has proven a challenge
to identify patients in whom the benefits of therapy are greatest and most
cost-effective. Based on existing evidence, a consensus panel of experts from
the National Osteoporosis Foundation developed treatment thresholds to facilitate
management of postmenopausal women, addressing the impact of risk factors,
including a previous low-impact fracture.7
Our aim is to improve awareness of the risk that a minimal trauma fracture
carries. Elderly women who sustain a fracture may be more receptive than nonfracture
patients to education about osteoporosis,45
and it is of utmost importance that these high-risk women receive appropriate
evaluation and treatment for osteoporosis. The responsibility should rest
with any physician caring for the postfracture patient, especially those who
are coordinating the care, managing the rest of the medical issues on a regular
basis, and educating patients with respect to their health risks. Effective
communication of therapeutic options is essential, since our patients may
be reluctant to accept therapy that may carry some risk. In addition, we need
further investigation into the nature of physician and patient barriers to
the provision of appropriate interventions following a minimal trauma fracture.
Strategies need to be developed to improve the care of postmenopausal women
after a fracture. Given the early opportunity when nearly 100% of patients
are treated by the orthopedist, these strategies should be multidisciplinary,
including diagnostic evaluations and close follow-up to assist patients to
accept and adhere to the best therapy over time.
AUTHOR INFORMATION
Accepted for publication June 6, 2001.
This work was supported by an unrestricted Junior Faculty Development
Award in Postmenopausal Women's Health provided by Eli Lilly and Company,
Indianapolis, Ind (Dr Cuddihy), and by research grant AG 04875 from the National
Institute on Aging, US Public Health Service, Bethesda, Md.
We wish to thank Michael O'Connor, MD, for reviewing and recalculating
the bone densitometry data to meet the T score criteria.
Corresponding author and reprints: Maria-Teresa Cuddihy, MD, MPH,
Division of Area General Internal Medicine, Department of Internal Medicine,
Mayo Clinic, 200 First St SW, Rochester, MN 55905.
From the Department of Internal Medicine, Division of Area General
Internal Medicine (Dr Cuddihy and Ms Tabini), and Department of Health Sciences
Research (Drs Gabriel, O'Fallon, and Melton and Mss Crowson and Atkinson),
Mayo Clinic and Mayo Foundation, Rochester, Minn.
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