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PubMed2002

Proximal femur geometry to detect and distinguish femoral neck fractures from trochanteric fractures in postmenopausal women.

Some proximal femur geometry (PFG) parameters, measured by dual-energy X-ray absorptiometry (DXA), have been reported to discriminate subjects with hip fracture. Relatively few studies have tested their ability to discriminate femoral neck fractures from those of the trochanter. To this end we performed a cross-sectional study in a population of 547 menopausal women over 69 years of age with femoral neck fractures (n = 88), trochanteric fractures (n = 93) or controls (n = 366). Hip axis length (HAL), neck-shaft angle (NSA), femoral neck diameter (FND) and femoral shaft diameter (FSD) were measured by DXA, as well as the bone mineral density (BMD) of the nonfractured hip at the femoral neck, trochanter and Ward's triangle. In fractured subjects, BMD was lower at each measurement site. HAL was longer and NSA wider in those with femoral neck fractures. With logistic regression the age-adjusted odds ratio (OR) for a 1 standard deviation (SD) decrease in BMD was significantly associated at each measurement site with femoral neck fracture (femoral neck BMD: OR 1.9, 95% confidence interval (95% CI): 1.4-2.5; trochanter BMD: OR 1.6, 95% CI 1.2-2.0; Ward's triangle BMD: OR 1.7, 95% CI 1.3-2.2) and trochanteric fracture (femoral neck BMD: OR 2.6, 95% CI 1.9-3.6; trochanter BMD: OR 3.0, 95% CI 2.2-4.1; Ward's triangle BMD: OR 1.8, 95% CI 1.4-2.3). Age-adjusted OR for 1 SD increases in NSA (OR 2.2, 95% CI 1.7-2.8) and HAL (OR 1.3, 95% CI 1.1-1.6) was significantly associated with the fracture risk only for femoral neck fracture. In the best predictive model the strongest predictors were site-matched BMD for both fracture types and NSA for neck fracture. Trochanteric BMD had the greatest area (0.78, standard error (SE) 0.02) under the receiver operating characteristic curve in trochanteric fractures, whereas for NSA (0.72, SE 0.03) this area was greatest in femoral neck fractures. These results confirm the association of BMD with proximal femur fracture and support the evidence that PFG plays a significant role only in neck fracture prediction, since NSA is the best predictive parameter among those tested.

Absorptiometry, Photon↗
PubMed1977

Condylar fractures of the mandible. I. Classification and relation to age, occlusion, and concomitant injuries of teeth and teeth-supporting structures, and fractures of the mandibular body.

In 123 individuals, 138 fractures of the mandibular condyle were classified with respect to fracture level, dislocation at the fracture level, and condylar head relation to the articular fossa. The age of the patient and the location of the most distal occlusal contact were recorded as well as teeth injuries and concomitant fractures of the mandibular body. The position of the most distal occlusal contact did not influence the dislocation of the condylar fragment. Teeth injuries such as fractures and luxation were found to be associated with condylar head or neck fractures, whereas the concomitant fractures of the mandibular body were mostly seen with the subcondylar fractures. Teeth injuries as well as concomitant fractures of the mandibular body were found more frequently in patients with bilateral than unilateral condylar fractures. Fractures of teeth in the molar and bicuspid regions were most frequent on the condylar fracture side, while the concomitant fractures of the mandibular body were located to the contralateral side. Medial angulation of the condylar fragment with lateral override at the fracture level was the typical fracture in adults, and angulation without override the characteristic fracture in growing individuals. Medical override occurred both in children and in adults and seemed to be the result of more severe trauma to the chin.

Accidents↗
PubMed2002

Fractures between the ages of 20 and 50 years increase women's risk of subsequent fractures.

BACKGROUND: Perimenopausal and postmenopausal fractures are well-recognized, strong, independent predictors of subsequent fractures. However, it is unknown whether premenopausal fractures are predictive of postmenopausal fractures. OBJECTIVE: To determine whether self-reported fractures sustained before the age of 50 years are associated with fractures after this age. SUBJECTS AND METHODS: Cross-sectional study of 1284 women (mean +/- SD age, 73 +/- 4 years) who were 10 or more years' postmenopausal and who were recruited from electoral rolls in Auckland, New Zealand. Detailed information on their fracture, medical, menstrual, alcohol, and smoking histories was obtained using a standardized questionnaire. RESULTS: Nine percent of the women reported fractures before the age of 20 years; 7%, between the ages of 20 and 50 years; and 29%,after the age of 50 years. Fractures sustained between the ages of 20 and 50 years were associated with a 74% increase in the risk of fractures after the age of 50 years (odds ratio, 1.74; 95% confidence interval, 1.12-2.70), while fractures occurring before the age of 20 years were not (odds ratio, 1.01; confidence interval, 0.66-1.56). Multivariate analysis showed that after bone density, age, maternal history of hip fractures, age at menopause, weight, history of hormone replacement therapy, and smoking and alcohol histories were adjusted for, a history of fractures between the ages of 20 and 50 years remained a significant independent predictor of risk of fractures after the age of 50 years (risk ratio, 1.83; confidence interval, 1.12-2.76). CONCLUSIONS: Any fracture (unrelated to motor vehicle accidents) sustained between the ages of 20 and 50 years is associated with increased risk of fractures after the age of 50 years. Therefore, this is an important clinical risk factor that points to the need for bone density measurement, consideration of lifestyle modification, and antiosteoporosis therapies in these women.

Age Factors↗
PubMed1993

Predicting vertebral fracture incidence from prevalent fractures and bone density among non-black, osteoporotic women.

We evaluated the ability of bone density and vertebral fractures at baseline to predict vertebral fracture incidence in a cohort of postmenopausal women with osteoporosis. The study population was 380 postmenopausal women (mean age 65 years) treated for osteoporosis in a randomized, placebo-controlled, clinical trial of the bisphosphonate etidronate at seven geographic centers in the United States. Baseline measurements of bone mineral density were obtained in 1986 by quantitative computed tomography at the spine and dual-photon absorptiometry at the lumbar spine and hip. Vertebral fractures were documented on serial spine radiographs. Proportional hazards models were used to evaluate the ability to predict the risk of subsequent fractures during an average of 2.9 years of follow-up. Presence of one or two fractures increased the rate of new vertebral fractures 7.4-fold (95% confidence interval = 1.0 to 55.9). Additional fractures at baseline further increased the fracture rate. A decrease of 2 standard deviations in spinal bone density by absorptiometry was associated with a 5.8-fold increase in fracture rate (95% confidence interval = 2.9 to 11.6). The lowest and highest quintiles of bone density had absolute fracture rates of 120 and 6 cases per 1000 patient-years, respectively. In general, the simultaneous use of two predictors (bone density and prevalent fractures or two bone density measurements) improved fracture prediction, compared with the use of a single predictor. We conclude that both bone density and prevalent vertebral fractures are strong, complementary predictors of vertebral fracture risk. The results suggest that physicians can use bone density and prevalent vertebral fractures, individually or in combination, as risk factors to identify patients at greatest risk of new fractures.

Aged↗
PubMed2003

Incidence and risk factors for a second hip fracture in elderly women. The Study of Osteoporotic Fractures.

Women with hip fracture have an increased risk of second hip fracture but other risk factors for a second hip fracture have not been established. We sought to determine the incidence and risk factors for second hip fracture, in a prospective cohort study of community-dwelling postmenopausal women over 65 years: the Study of Osteoporotic Fractures. From a cohort of 9,704 women, 632 women with a documented first hip fracture during the study were followed up until a second hip fracture or the end of follow-up. Clinical risk factors and bone mineral density were assessed at the beginning of the study. Fifty-three second hip fractures were validated by radiographs. Women with hip fracture had a 2.3% per year risk of second hip fracture. Women who walked for exercise at baseline were less likely to sustain a second hip fracture with a relative risk (RR) of 0.5 [0.3-0.9], as were those who had normal depth perception (RR=0.5 [0.3-0.9]). Women who lost weight since age 25 years had an increased risk of second incident hip fracture (RR = 2.7 [1.6-4.6]), as did those who had a low calcaneal bone mineral density (RR=1.5 [1.1-2.0] per standard deviation decrease in bone mineral density). Current use of estrogen replacement therapy at baseline was protective (RR=0.5 [0.3-0.9]) up to 2 years of follow-up. We conclude that community-dwelling women with a first hip fracture have a high risk of second hip fracture, and risk factors for this second fracture are similar to those of first hip fracture.

Aged↗
PubMed2002

Symptomatic fracture incidence in southern Tasmania: does living in the country reduce your fracture risk?

There are limited data describing urban-rural differences in fracture incidence and the overall effect remains controversial. The aim of this study was to compare symptomatic fracture incidence occurring in geographically defined rural (n = 34619) and urban (n = 194974) populations of Southern Tasmania from July 1, 1997 to June 30, 1999. Fractures were ascertained by reviewing reports from all the radiology providers within the area. In the 2-year study time frame there were 3644 fractures in males and 2657 fractures in females. Fracture incidence was significantly higher in urban compared with rural populations in both sexes (male: RR 1.60, 95% CI 1.47-1.75; female: RR 1.77, 95% CI 1.58-1.98). This higher urban fracture incidence was present across all age groups and all fracture types with the exception of knee and pelvis fractures in males (although not all were statistically significant). In addition, urban men >50 years old had a higher fracture incidence than rural women >50 years old (RR 1.25, 95% CI 1.05-1.50), suggesting that in later life the factors responsible for the urban-rural difference are able to offset completely the effect of gender. While some of the reduced fracture incidence in the rural population may be explained by urban drift and underreporting of minor fractures such as foot fractures, the overall pattern of higher fracture risk was very consistent, suggesting a real difference in whole-of-life symptomatic fracture incidence. Further research at an individual level is required to determine what factors account for these large urban-rural differences, as they imply a substantial potential for fracture prevention.

Adult↗
PubMed2002

Does a fracture at one site predict later fractures at other sites? A British cohort study.

The extent to which a fracture at one skeletal site predicts further fractures at other sites remains uncertain. We addressed this issue using information from the UK General Practice Research Database, which contains the medical records of general practitioners; our study population consisted of all patients aged 20 years or older with an incident fracture during 1988 to 1998. We identified 222 369 subjects (119 317 women, 103 052 men) who had sustained at least one fracture during follow-up. There was a 2- to 3-fold increase in the risk of subsequent fractures at different skeletal sites. A patient with a radius/ulna fracture had a standardized incidence ratio (SIR) of 3.0 (95% confidence interval 2.9-3.1) for fractures at a different skeletal site; for initial vertebral fracture, this ratio was 2.9 (2.8-3.1) and for initial femur/hip fracture it was 2.6 (2.5-2.7). The SIRs were generally higher among men than women. Men aged 65-74 years with a radius/ulna fracture or vertebral fracture had substantially higher rates of subsequent femur/hip fractures than expected; SIRs were 6.0 (3.4-9.9) and 13.4 (7.3-22.5). Corresponding SIRs among women of similar age were 3.3 (2.8-3.9) and 5.8 (4.1-8.1), respectively. Men and women aged 65 years or older with a vertebral fracture had a 5-year risk of femur/hip fracture of 6.7% and 13.3%, respectively. Our results indicate that fractures at any site are strong risk factors for subsequent fractures, among both elderly men and women.

Adult↗
PubMed2004

A meta-analysis of previous fracture and subsequent fracture risk.

Previous fracture is a well-documented risk factor for future fracture. The aim of this study was to quantify this risk on an international basis and to explore the relationship of this risk with age, sex, and bone mineral density (BMD). We studied 15259 men and 44902 women from 11 cohorts comprising EVOS/EPOS, OFELY, CaMos, Rochester, Sheffield, Rotterdam, Kuopio, DOES, Hiroshima, and two cohorts from Gothenburg. Cohorts were followed for a total of 250000 person-years. The effect of a prior history of fracture on the risk of any fracture, any osteoporotic fracture, and hip fracture alone was examined using a Poisson model for each sex from each cohort. Covariates examined were age, sex, and BMD. The results of the different studies were merged by using the weighted beta-coefficients. A previous fracture history was associated with a significantly increased risk of any fracture compared with individuals without a prior fracture (RR = 1.86; 95% CI = 1.75-1.98). The risk ratio was similar for the outcome of osteoporotic fracture or for hip fracture. There was no significant difference in risk ratio between men and women. Risk ratio (RR) was marginally downward adjusted when account was taken of BMD. Low BMD explained a minority of the risk for any fracture (8%) and for hip fracture (22%). The risk ratio was stable with age except in the case of hip fracture outcome where the risk ratio decreased significantly with age. We conclude that previous history of fracture confers an increased risk of fracture of substantial importance beyond that explained by measurement of BMD. Its validation on an international basis permits the use of this risk factor in case finding strategies.

Adolescent↗
PubMed1997

Body size and hip fracture risk in older women: a prospective study. Study of Osteoporotic Fractures Research Group.

PURPOSE: To determine the relationship between measures of body size and the risk of hip fracture in elderly women. PARTICIPANTS AND METHODS: The association between measures of body size and hip fracture risk was assessed in 8,011 ambulatory, nonblack women 65 years of age or older enrolled in the Study of Osteoporotic Fractures with measurements of total body weight, percent weight change since age 25, hip girth, lean mass, fat mass, percent body fat, body mass index, modified body mass index, and femoral neck bone mineral density (BMD) at the second examination. These 8,011 women were followed prospectively for incident hip fractures occurring after the second examination, which were confirmed by review of x-ray films. RESULTS: During an average of 5.2 years after the second examination, 236 (2.9%) women experienced hip fractures. Similar associations were observed between hip fracture risk and all measures of body size including total body weight, percent weight change since age 25, hip girth, lean mass, fat mass, percent body fat, body mass index, and modified body mass index. Women with smaller body size had a higher risk of subsequent hip fracture compared with those with larger body size, while women with average and larger body sizes shared similarly lower risks of subsequent hip fracture. For example, the incidence rate of hip fracture was 9.35 per 1000 woman-years in women in the lowest quartile of total weight compared with 4.63 per 1000 woman-years in women in the highest quartile of total weight (age-adjusted relative risk 1.93, 95% confidence interval (CI) 1.34 to 2.80), while rates of hip fracture among women in the second and third quartiles of total weight (5.22 and 4.32 per 1000 woman-years, respectively) were not significantly different from the rate among women in the highest quartile (P > 0.64). The increased risk of hip fracture among women of smaller body size remained after further adjustment for additional potential confounding factors including height at age 25, smoking status, physical activity, health status, estrogen use, and diuretic use. After further adjustment for femoral neck BMD, women with smaller body size were no longer at significantly increased risk of hip fracture compared with those with larger body size. For example, after adjustment for height at age 25, smoking status, physical activity, health status, estrogen use, and diuretic use, thin women had a 2.5-fold increase in the risk of hip fracture (multivariate relative risk 2.51, 95% CI 1.69 to 3.73) compared with the referent group composed of the heaviest women. After further adjustment for femoral neck BMD, the multivariate relative risk of hip fracture among thin women compared to heaviest women was 0.98 (95% CI, 0.64 to 1.50). CONCLUSION: Older women with smaller body size are at increased risk of hip fracture. This effect is because of lower hip BMD in women with smaller body size. Assessment of body size for prediction of hip fracture risk can be accomplished by measuring total body weight.

Aged↗
PubMed2003

Disability after clinical fracture in postmenopausal women with low bone density: the fracture intervention trial (FIT).

Relatively little is known about outcomes following clinical osteoporotic fractures at nonhip, nonvertebral skeletal sites. To address this issue, we prospectively assessed post-fracture disability at multiple skeletal sites in a population of 909 older (aged 55-81 years), community-dwelling women with low femoral neck bone mineral density who had experienced a fracture while enrolled in the Fracture Intervention Trial (FIT). FIT is a randomized, double-masked, placebo-controlled trial that was designed to determine the effect of alendronate on fracture incidence, and the current study was conducted as a secondary analysis of FIT data. Following incident clinical fractures, FIT participants were followed prospectively for assessment of site-specific, fracture-related disability. Measures of disability were self-reported days hospitalized or confined to bed because of the fracture ('bed days') and days of reduced usual activities because of the fracture ('limited activity days'). Of fracture types evaluated, those of the hip resulted in the highest percentage of subjects with any bed days or limited activity days after fracture (94% with any bed days and 100% with any limited activity days), though the mean number of bed days and limited activity days appeared highest after lumbar vertebral fractures (25.8 mean bed days and 158.5 mean limited activity days). Substantial disability also was reported after fractures of thoracic vertebrae, humerus, distal forearm, ankle and foot. Within fracture types, post-fracture disability was highly variable, ranging from none to more than 6 months.

Activities of Daily Living↗
PubMed2001

Basicervical fracture--a rare type of hip fracture.

Basicervical fracture is a controversial type of hip fracture, which can be regarded as either extracapsular or intracapsular. It is seldom mentioned in the authorized orthopaedic textbooks, and it lacks an exact definition in the most commonly used classifications. The aim of this study was to evaluate the rate of basicervical hip fractures and the methods of treating them in a prospective series of 1624 consecutive hip fractures. Standardized forms were used to collect information, including the classification of fracture types. Initially, 108 fractures were classified as basicervical, but a careful second-look check revealed that 51 were transcervical fractures, while 27 fractures had a trochanteric extension. Thus, 30 of the fractures fulfilled the criteria of basicervical fracture (rate 1.8%). The 14 fractures treated as extracapsular fractures (dynamic hip screw, DHS, or gamma nail) showed a better outcome than the 16 treated as intracapsular fractures (hemiarthroplasty or screw osteosynthesis). We conclude that basicervical fracture of the hip is a very uncommon entity, but it is worth considering and should be treated as a trochanteric fracture.

Aged↗