Fragility fractures are responsible for significant morbidity and mortality, and their prevention and management require multidisciplinary collaboration.
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. 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.
- In the UK, osteoporosis causes over 200,000 fractures per year, costing the NHS over £1.7 billion.
- The National Osteoporosis Guideline Group (NOGG) estimates that, due to the ageing of the population, if changes are not made in current practice, there will be a doubling of osteoporotic fractures over the next 50 years.
- Women are more affected than men, as they have a higher incidence of osteoporosis.
- More than 1 in 3 women and 1 in 5 men will have one or more osteoporotic fractures in their lifetime.
- Following hip fracture, about half of those admitted can no longer live independently on discharge from hospital, and 20% die within a year.
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.
Reduced BMD is a major risk factor for fragility fracture.
As well as reduced BMD, a number of other risk factors increase fracture risk. Some do this by increasing the risk of osteoporosis, some are independent risk factors and some work in more than one way.
- Increasing age (risk increase partly independent of reducing BMD).
- Female gender.
- Low body mass (<20 kg/m2) and anorexia nervosa.
- Parental history of hip fracture.
- Past history of fragility fracture (especially hip, wrist and spinal fracture).
- Corticosteroid therapy (current treatment at any dose orally for three months or more).
- Cushing's syndrome.
- Alcohol intake of three or more units per day.
- Ethnicity. Caucasian men and women are at higher risk than other ethnic groups.
- Other causes of abnormal bone - eg, osteogenesis imperfecta and acromegaly[4, 5].
- Falls and conditions increasing the risk of falls, such as:
- Visual impairment.
- Lack of neuromuscular co-ordination or strength.
- Cognitive impairment.
- Sedative medication and alcohol.
- Secondary causes of osteoporosis, such as:
- Rheumatoid arthritis and other inflammatory arthropathies. (Rheumatoid arthritis also increases risk of fracture independently of BMD and use of steroids.)
- Prolonged immobilisation or a very sedentary lifestyle.
- Primary hypogonadism (men and women).
- Primary hyperparathyroidism.
- Chronic kidney disease.
- Gastrointestinal disease such as Crohn's disease, ulcerative colitis and coeliac disease.
- Untreated premature menopause (<45 years) or prolonged secondary amenorrhoea.
- Type 1 and type 2 diabetes mellitus.
- Chronic liver disease.
- Chronic obstructive pulmonary disease.
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.
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:
- Pain and morbidity associated with high doses of analgesia.
- Loss of height.
- Difficulty breathing.
- Loss of mobility.
- Gastrointestinal symptoms.
- Difficulty sleeping.
- Symptoms of depression.
May 2018 - Dr Hayley Willacy draws your attention to the recently published National Osteoporosis Society guidelines for the Effective Identification of Vertebral Fractures. This guidance highlights the underdiagnosis of vertebral fracture. This occurs for a number of reasons:
- 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.
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.
- FBC, blood group and clotting studies.
- Renal function.
- Assessment of cognitive function.
See 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. Percutaneous vertebroplasty was not found to be of value in a 2015 Cochrane review.
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 fracture. 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 fracture
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, 3]. Fracture risk tools, such as the FRAX® score and QFracture® score may be helpful in evaluating risk of fracture and guiding management decisions. 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. 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.
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:
- 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.
- 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 separate Osteoporosis article for further information about the individual treatment options and the duration of treatment.
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.
The key to preventing fragility fractures and the enormous morbidity and mortality associated with them is the identification of those at risk and then consideration of treatment.
There is no national screening protocol for osteoporosis. Guidelines from NOGG, NICE, SIGN and the International Osteoporosis Foundation (IOF) differ, making it difficult for the clinician to choose whom to carry out risk assessments or BMD measurement upon. Broadly, consider a risk assessment in:
- Those with a history of fragility fracture. Some guidelines suggest this should trigger BMD measurement; others suggest these should be considered for treatment without the need for further assessment.
- Postmenopausal women with risk factors.
- Women or men with significant risk factors.
- Women or men on oral corticosteroid treatment. (Any dose taken continuously over three months or frequent courses. 7.5 mg prednisolone or equivalent per day over three months continuously is considered high dose by NICE and confers higher risk.)
- All women aged over 65 and all men aged over 75 (NICE only).
Furthermore, there is debate in some circles about whether the evidence for the benefits of assessing risk with a view to subsequent treatment is strong enough to justify this approach, or whether it represents overdiagnosis. Evidence that treatment reduces fractures in the population over the age of 80 is not available, and the risk of adverse reaction significant.
Further reading and references
Falls: assessment and prevention of falls in older people; NICE Clinical Guideline (June 2013)
The Care of Patients with Fragility Fractures; British Orthopaedic Association (September 2007)
Osteoporosis: assessing the risk of fragility fracture; NICE Clinical Guideline (August 2012, updated February 2017)
Osteoporosis - Clinical Guideline for prevention and treatment; National Osteoporosis Guideline Group (NOGG), updated January 2016
Management of osteoporosis and the prevention of fragility fractures - A national clinical guideline; Scottish Intercollegiate Guidelines Network - SIGN, (March 2015)
Marini J, Smith SM; Osteogenesis Imperfecta.
Anthony JR, Ioachimescu AG; Acromegaly and bone disease. Curr Opin Endocrinol Diabetes Obes. 2014 Dec21(6):476-82. doi: 10.1097/MED.0000000000000109.
Yamamoto M; Insights into bone fragility in diabetes: the crucial role of bone quality on skeletal strength. Endocr J. 201562(4):299-308. doi: 10.1507/endocrj.EJ15-0129. Epub 2015 Mar 21.
Schousboe JT; Epidemiology of Vertebral Fractures. J Clin Densitom. 2016 Jan-Mar19(1):8-22. doi: 10.1016/j.jocd.2015.08.004. Epub 2015 Sep 5.
Percutaneous vertebroplasty and percutaneous balloon kyphoplasty for treating osteoporotic vertebral compression fractures; NICE Technology Appraisal Guidance, April 2013
Clinical Guidance for the Effective Identification of Vertebral Fractures; National Osteoporosis Society (2018)
EULAR/EFORT recommendations for management of patients older than 50 years with a fragility fracture and prevention of subsequent fractures; European League against Rheumatism (2017)
Buchbinder R, Golmohammadi K, Johnston RV, et al; Percutaneous vertebroplasty for osteoporotic vertebral compression fracture. Cochrane Database Syst Rev. 2015 Apr 304:CD006349. doi: 10.1002/14651858.CD006349.pub2.
Rheumatological diseases unit: Calcium Calculator; Institute of Genetics and Molecular Medicine (IGMM), University of Edinburgh
Avenell A, Mak JC, O'Connell D; Vitamin D and vitamin D analogues for preventing fractures in post-menopausal women and older men. Cochrane Database Syst Rev. 2014 Apr 144:CD000227. doi: 10.1002/14651858.CD000227.pub4.
Denosumab for the prevention of osteoporotic fractures in postmenopausal women; NICE Technology Appraisal Guidance, October 2010
Osteoporosis - Prevention of fragility fractures; NICE CKS, March 2016 (UK access only)
Jarvinen TL, Michaelsson K, Jokihaara J, et al; Overdiagnosis of bone fragility in the quest to prevent hip fracture. BMJ. 2015 May 26350:h2088. doi: 10.1136/bmj.h2088.
Jarvinen TL, Michaelsson K, Aspenberg P, et al; Osteoporosis: the emperor has no clothes. J Intern Med. 2015 Jun277(6):662-73. doi: 10.1111/joim.12366.
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