Fragility fractures

Fragility fractures are responsible for significant morbidity and mortality, and their prevention and management require multidisciplinary collaboration.

What is a fragility fracture?

Fragility fractures are fractures that result from mechanical forces that would not ordinarily result in fracture, known as low-level (or 'low-energy') trauma, quantified by The World Health Organization (WHO) as forces equivalent to a fall from a standing height or less.¹ Vertebral fractures may occur without a fall.

An osteoporotic fracture is a fragility fracture which has occurred as a consequence of osteoporosis.

Osteoporosis is a major risk factor for fragility fractures; however, other causes include:

• Advancing age.

• Other conditions affecting bone strength, such as acromegaly or osteogenesis imperfecta.

• Predisposition to falls due to loss of balance or poor muscle strength.

Osteoporosis is defined by reduced bone mineral density (BMD) as measured by dual energy X-ray absorptiometry (DXA), but due to its low sensitivity, most osteoporotic fractures will occur in people who do not have osteoporosis as defined by T score.²

See also the separate articles on Osteoporosis (Causes, Symptoms, and Treatment) and Osteoporosis Risk Assessment and Primary Prevention.

How common are fragility fractures?²

• Approximately 1 in 2 adult women and 1 in 5 men will sustain one or more fragility fractures (a low trauma fracture sustained from a fall from standing height or less) in their lifetime.

• Common sites of fragility fracture include the vertebral bodies, hip, distal radius, proximal humerus and pelvis.

• In the UK, the prevalence of femoral neck BMD T-Score ≤-2.5, in those aged 50 years and older, is 6.8% in men and 21.8% in women. However, the majority of people who sustain a fragility fracture will have a femoral neck BMD T-Score above -2.5, reflecting the contribution of many other factors, besides bone mineral density, to fracture risk.

• Currently in the UK, approximately 549,000 new fragility fractures occur each year, including 105,000 hip fractures, 86,000 vertebral fractures, and 358,000 other fractures (pelvis, ribs, humerus, forearm, tibia, fibula, clavicle, scapula, sternum, and other femoral fractures). 33% are sustained by men.

Causes of fragility fractures

Fragility fractures may result from minor falls or minor trauma. Vertebral fractures often occur without a causative fall and may follow normal activity such as bending or lifting or sneezing.

Risk factors³

Identify high-risk groups of people to assess fragility fracture risk. These groups should include:

All women aged 65 years and over, and all men aged 75 years and over.
All women aged 50–64 years and all men aged 50–74 years who have any of the following risk factors:

• A previous osteoporotic fragility fracture.

• Current use or frequent recent use of oral corticosteroids.

• History of falls.

• Low body mass index (less than 18.5 kg/m2).

• Smoker.

• Alcohol intake of more than 14 units per week.

• A secondary cause of osteoporosis, including:

  • Hypogonadism in either sex, including untreated premature menopause (menopause before 40 years of age), treatment with aromatase inhibitors (such as exemestane) or gonadotrophin-releasing hormone agonists (such as goserelin).

  • Endocrine conditions, including diabetes mellitus, Cushing's disease, hyperthyroidism, hyperparathyroidism, and hyperprolactinaemia.

  • Conditions associated with malabsorption, including inflammatory bowel disease, coeliac disease, and chronic pancreatitis.

  • Rheumatoid arthritis and other inflammatory arthropathies.

  • Haematological conditions such as multiple myeloma and haemoglobinopathies.

  • Chronic obstructive pulmonary disease.

  • Chronic liver failure.

  • Chronic kidney disease.

  • Immobility.

People younger than 50 years of age with any of the following risk factors:

• Current or frequent use of oral corticosteroids.

• Untreated premature menopause.

• A previous fragility fracture.

People younger than 40 years of age with any of the following risk factors:

• Current or recent use of high-dose oral corticosteroids equivalent to, or more than, 7.5 mg prednisolone daily for three months or more.

• Previous fragility fracture of the spine, hip, forearm, or proximal humerus.

• History of multiple fragility fractures.

Consider assessing fracture risk for people taking the following medication, especially in the presence of other risk factors:

• Selective serotonin reuptake inhibitors.

• Antiepileptic medication - particularly enzyme-inducing drugs, such as carbamazepine.

• Aromatase inhibitors, such as exemestane.

• Gonadotropin-releasing hormone agonists, such as goserelin.

• Proton pump inhibitors.

• Thiazolidinediones, such as pioglitazone.

Fragility fracture symptoms¹

The most common sites for fragility fracture are the vertebrae, hip (proximal femur) and wrist (distal radius). Other sites affected include the pelvis, ribs, arm and shoulder. Presentation is commonly to an emergency department with acute pain after an injury; however, vertebral compression fractures may go unrecognised as a cause of worsening back pain. Up to two thirds of these vertebral fractures are said to be unrecognised at the time of occurrence.⁴

Following a fracture, mobility and independence may be affected, in some cases resulting in drastic life changes, and there is potential for loss of confidence, anxiety, depression and reduced quality of life.

Compression fractures can cause:⁵

• Pain and morbidity associated with high doses of analgesia.

• Loss of height.

• Difficulty breathing.

• Loss of mobility.

• Gastrointestinal symptoms.

• Difficulty sleeping.

• Symptoms of depression.

The National Osteoporosis Society guidelines for the Effective Identification of Vertebral Fractures highlights the underdiagnosis of vertebral fracture. This occurs for a number of reasons:²

• Unlike other fragility fractures, only a minority of vertebral fractures result from a fall.

• Symptoms from a vertebral fracture are often attributed to another cause by both patient and healthcare professionals.

• The need for spine imaging in a patient with risk factors for osteoporosis presenting with new back pain is often not recognised.

• When imaging is undertaken for indications other than back pain, the spine may not be systematically scrutinised during the reporting process.

• Vertebral fractures may be reported using ambiguous and confusing terminology.

• The referring clinician may regard the finding of a vertebral fracture as incidental to the reason for the original referral, and fail to recognise its clinical importance.

Fragility fracture treatment⁶

Management of fragility fractures requires collaboration and multidisciplinary care. Management of the acute injury may require orthopaedic intervention, but elderly fragile people may require medical care as inpatients during and after surgery, physiotherapy and occupational therapy as part of rehabilitation during admission and following discharge. General practitioners have a crucial role in identifying fractures as fragility fractures and managing secondary prevention, and before fractures occur, identifying those at risk and considering primary preventative measures. Rheumatologists and endocrinologists are often also involved in primary and secondary prevention.

Components of management include the following:

Management of the acute injury

Pain relief, management of associated chronic disease, fluid management, fracture stabilisation and surgery may be involved. Decisions regarding surgical management should take into account comorbidity and pre-fracture condition. Where surgery is required, pre-operative investigations to prevent complications or exacerbation of existing conditions would usually include:

• Chest X-ray.

• ECG.

• FBC, blood group and clotting studies.

• Renal function.

• Glucose.

• Assessment of cognitive function.

See the separate Wrist Fractures and Femoral Fractures articles for specific information about management of these injuries. Most vertebral fractures are managed in the community with pain relief and physiotherapy and do not require admission. Vertebroplasty and kyphoplasty are surgical options for those who do not respond to conservative measures.⁵ Percutaneous vertebroplasty was not found to be of value in a 2015 Cochrane review.⁷

Liaison with medical team

For the elderly person admitted with a fragility fracture, an assessment by a geriatrician is advisable to reduce morbidity and mortality associated with the injury and any subsequent surgery. Components to postoperative care should include:

• Pain control.

• Antibiotic prophylaxis where appropriate.

• Monitoring of FBC and correction of postoperative anaemia where required.

• Routine systems examinations to detect complications early or exacerbation of existing comorbid conditions.

• Regular assessment of cognitive function.

• Prevention and management of pressure sores.

• Monitoring of nutritional status and renal function.

• Monitoring of bowel and bladder function, and management of problems as required.

• Wound care.

• Early mobilisation.

Rehabilitation and education

Early physiotherapy and muscle-strengthening exercises, fall prevention measures, balance training, etc all have a role following fragility fractures. A medication review may identify pharmacological factors predisposing to falls. Education about modifiable risk factors (smoking, weight, alcohol, diet, exercise, etc) is important, as well as education about treatment, duration of treatment, and follow-up.

Assessment for risk of future fragility fractures

This should involve assessing risk factors, and considering DXA where appropriate. European guidelines advise DXA scan of the lumbar spine and X-rays of the spine should be considered after all fragility fractures. UK osteoporosis guidelines differ on whether fragility fractures should trigger a DXA scan, or initiation of treatment without further investigation. Guidelines from the Scottish Intercollegiate Guidelines Network (SIGN) advise DXA scan following a fragility fracture and treat if osteoporosis is confirmed, whereas the National Institute for Health and Care Excellence (NICE) guidelines suggest that over the age of 75 years, it is reasonable to assume a diagnosis of osteoporosis if there has been a fragility fracture, and start treatment accordingly.^{1 8} Fracture risk tools, such as the FRAX® score and QFracture® score may be helpful in evaluating risk of fracture and guiding management decisions.⁹ Ideally this would happen after treatment in hospital but in reality, this assessment is often made by the GP.

Treatment of low bone density

Ensure adequate calcium intake and vitamin D status, prescribing supplements if required. Dietary calcium may be assessed by one of a number of online tools.¹⁰ Elderly people who are housebound or living in a nursing home may be assumed to require vitamin D supplementation. If there is adequate dietary calcium intake of more than 1000 mg/day but a lack of vitamin D, consider prescribing 10 micrograms (400 units) of vitamin D without a full replacement dose of calcium. For people who have a dietary calcium intake of less than 1000 mg/day, prescribe 10 micrograms (400 units) of vitamin D with at least 1000 mg of calcium daily (eg, as two Calcichew D3® tablets - calcium 500 mg, colecalciferol 5 micrograms). There is ongoing research into the safety of calcium supplementation but no risk has been found where calcium is combined with vitamin D and, thus far, evidence suggests combined calcium and vitamin D is safe and more effective than vitamin D alone in preventing fractures.¹¹

Where a high risk of future fracture is identified by a risk calculator combining BMD measurement with clinical risk factors, consider treatment aimed at improving BMD. Current options are:²

• Bisphosphonates. Alendronate and risedronate can be given orally daily or weekly. Ibandronate is given orally each month or by IV injection three-monthly. Zoledronic acid is given by IV infusion annually.

• Denosumab is a monoclonal antibody that reduces osteoclast activity (and hence bone breakdown) which is given by six-monthly subcutaneous injections. NICE has approved it for secondary prevention for postmenopausal women with increased risk of fractures who cannot comply with the special instructions for administering alendronate or risedronate, or have an intolerance or a contra-indication to those treatments.¹²

• Strontium ranelate should only be used to treat severe osteoporosis in postmenopausal women and men at high risk of fracture, for whom treatment with other approved options are not possible, due to an increase in the risk of myocardial infarction. It cannot be used in patients with current or past history of coronary heart disease, uncontrolled hypertension, peripheral arterial disease and/or cerebrovascular disease.

• Raloxifene is a selective oestrogen receptor modulator and inhibits bone resorption. It is approved for the treatment and prevention of osteoporosis in postmenopausal women, in a daily oral dose. It has been shown to reduce vertebral fracture risk but not other types of fractures.

• Teriparatide is a recombinant fragment of parathyroid hormone prescribed in secondary care. It may be considered for those with very severe osteoporosis or very high fracture risk who are unable to use bisphosphonates, or in whom bisphosphonates have not been effective.

• Hormone replacement therapy may be an option in younger perimenopausal women who also need treatment for symptoms of menopause.

If oral bisphosphonates are not tolerated, or are not effective, it is likely that a referral to secondary care will be required to consider other options.

See the separate Osteoporosis article for further information about the individual treatment options and the duration of treatment.

Romosozumab for treating severe osteoporosis¹³

NICE has recommended romosozumab as an option for treating severe osteoporosis in women:

• Who are post menopausal; and

• Who have had an osteoporotic fracture (spine, hip, forearm or humerus fracture) within 24 months (so are at imminent risk of another fracture).

Clinical evidence has shown that romosozumab followed by alendronic acid is more effective at reducing the risk of fractures than alendronic acid alone.

Comparing romosozumab indirectly with other bisphosphonates and other medicines for this condition suggests that romosozumab is likely to be at least as effective at reducing the risk of fractures in people with osteoporosis after menopause.

Prognosis^{2 3}

Individual prognosis varies widely with age, comorbidity, fracture site, other risk factors and personal circumstances. Globally the burden in health and economic terms is huge. It is estimated that 50% of those who sustain a hip fracture cannot live independently afterwards, and 20% die within a year of the event. Vertebral fractures can cause long-lasting pain and disability as described above and are also associated with a reduced life expectancy.

Reduced quality of life, pain and disability may result from all fragility fractures. Having had one fragility fracture is a significant risk factor for having another.

Fragility fracture prevention³

• Lifestyle advice:

  • Take regular exercise. Encourage walking, especially outdoors, strength training of different muscle groups (eg, hip, wrist, and spine), and a combination of exercise types - eg, balance, flexibility, stretching, endurance, and progressive strengthening exercises.

  • Eat a balanced diet as this may improve bone health.

  • Stop smoking if applicable.

  • Drink alcohol only within recommended limits.

• For people whose fracture risk is above the recommended threshold (see 'Risk factors' above), offer a dual-energy X-ray absorptiometry (DXA) scan, then bone-sparing drug treatment if the T-score is -2.5 or lower.

• If the T-score is greater than -2.5, modify risk factors where possible, treat any underlying conditions, and repeat the DXA at an interval appropriate for the person based on their risk profile, using clinical judgement (but usually within two years).

• For people whose fracture risk is close to the recommended threshold and who have risk factors that may be underestimated by FRAX®, arrange a DXA scan to measure their bone mineral density (BMD) and offer drug treatment if the T-score is -2.5 or lower.

• For people whose fracture risk is below the recommended threshold, do not offer drug treatment, offer lifestyle advice, and follow up within five years.

If bone-sparing treatment is recommended, prescribe a bisphosphonate (alendronate 10 mg once daily or 70 mg once weekly, or risedronate 5 mg once daily or 35 mg once weekly) postmenopausal women and men over 50 years of age who have been confirmed by dual-energy X-ray absorptiometry (DXA) scan to have osteoporosis (bone mineral density [BMD] T-score of -2.5 or less).

• Consider prescribing to people who are taking high doses of oral corticosteroids (more than or equivalent to prednisolone 7.5 mg daily for three months or longer).

• If an oral bisphosphonate is not tolerated or is contra-indicated, consider specialist referral. Specialist treatment options include zoledronic acid, strontium ranelate, raloxifene, denosumab, and teriparatide.

• If the person's calcium intake is adequate (700 mg/day), prescribe 10 micrograms (400 international units) of vitamin D (without calcium) for people not exposed to much sunlight.

• If calcium intake is inadequate, prescribe 10 micrograms (400 international units) of vitamin D with at least 1000 mg of calcium daily. Prescribe 20 micrograms (800 international units) of vitamin D with at least 1000 mg of calcium daily for elderly people who are housebound or living in a nursing home.

• Consider prescribing hormone replacement therapy (HRT) to younger postmenopausal women to reduce the risk of fragility fractures and for the relief of menopausal symptoms.