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Women with low energy fracture: Case for investigation?
Linköping University, Department of Biomedicine and Surgery, Clinical Chemistry. Linköping University, Department of Medicine and Care, Internal Medicine. Östergötlands Läns Landsting, Centre for Public Health Sciences, Centre for Public Health Sciences. Linköping University, Faculty of Health Sciences.
Linköping University, Department of Medicine and Care, Internal Medicine. Linköping University, Faculty of Health Sciences.
Community Medicine, County Council of Uppsala, Uppsala, Sweden.
Linköping University, Department of Clinical and Experimental Medicine, Orthopaedics. Linköping University, Faculty of Health Sciences.
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: The combined use of bone mineral density, fracture history and other risk markers for fracture is advocated for identifying subjects with high fracture risk. An incident fracture is suggested as an accurate indication for osteoporosis investigation, but there are still insufficient data for grading the priority between ages and types of fractures. We therefore decided to examine a consecutive series of 55-75 year old women with an incident fracture for evaluating a standardized clinical routine program and for studying the covariance between fracture history, bone mineral density and other risk markers.

Materila and methods: We invited 600 consecutive women 55-75 years old with an incident newly diagnosed fracture in distal radius forearm, proximal humerus, vertebra or hip. External drop-out was 33%. Of the 400 responders 31 had a high-energy trauma, 62 were on treatment against osteoporosis and 4 were living in other counties and were therefore excluded. The remaining 303 subjects entered the study. A questionnaire on previous fractures and risk factors was enclosed with the invitation to the osteoporosis unit. At a single visit a short history was assessed and physical examination performed as well as a few laboratory investigations. Bone mineral density was measured at the hip, lumbar spine and forearm by DXA (Hologic QDR 4500A).

Results: The fracture spectrum was: distal radius 56.4 %, proximal humerus 12.2%, vertebra 18.2% and hip 13.2%. 49% had had at least one previous fracture, 19% at least two previous and 6.3% three or more previous fractures before the recent one. As few spine X-rays were performed, the true prevalence of vertebral fracture is unknown. Patients with fracture in vertebra or hip had lower BMD and more previous fractures than patients with forearm or humerus fracture. The number of previous fractures was inversely correlated to BMD of the hip and forearm, while BMD of the spine had a biphasic relationship.

The Odds ratio of having either osteopenia and osteoporosis were >20 for patients with hip fracture and 75 for the spine (mean values), whereas the OR of the forearm fracture group was slightly above 10, table 6. The OR were as expected dependent of cut-off limit used. Mean value for the OR was in the hip fracture group 8.2 and 9.2 for !-score -2.5 and -2.0 respectively at the lower end of the confidence interval. For the spine and the forearm, the corresponding odds ratios were 16-17 and 7-9 respectively.

Conclussion: Vertebral fracture was the strongest and distal radius the weakest predictor of low BMD. The number of previous fractures is a helpful information for finding the most osteoporotic patients. Only 15 % had been treated for osteoporosis before the index fracture. Osteoporosis investigation therefore seems warranted in every woman 55-75 years old with a recent low-energy fracture in distal radius, proximal humerus, spine or hip, with highest priority to those in spine or hip and those with multiple previous fractures.

National Category
Medical and Health Sciences
URN: urn:nbn:se:liu:diva-81343OAI: diva2:551748
Available from: 2012-09-12 Created: 2012-09-12 Last updated: 2012-09-12Bibliographically approved
In thesis
1. Osteoporosis in women: Epidemiological and diagnostic perspectives
Open this publication in new window or tab >>Osteoporosis in women: Epidemiological and diagnostic perspectives
2002 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

An epidemiological study of 15.462 hip fractures in Östergötland 1940-86 showed a large incidence increase mainly due to an increase in age-specific incidence of trochanteric fractures. A trendforecast assuming the same increase in incidence as over the study period and a population forecast according to the official prognosis, predicted 70% more hip fractures in the year 2000 compared to 1985. The different forecasts models were validated for the year 1995 and showed a good correlation between estimated and observed number of fractures, but varied dependent on which fracture and prognosis model that were evaluated.

A follow-up investigation of 11.517 hip fractures 1982-96 showed a downturn in incidence of female fractures and a continous increase for males, particularly of trochanteric fractures. A trend brake was thus seen and this continues up to 2010 according to our trendforecasts but may be counteracted by the increasing number of elderly after 2020. Gender ratio changed over time with increasing number of male fractures, more trochanteric fractures relative to cervical (c/t-ratio) and an increasing mean age of the fracture patient.

Age specific reference values were established for bone mineral density (BMD) in forearm, lumbar spine and hip after investigation of 429 women 20-80 years, randomly sampled from the general population. Bone density was assessed from cross-sectional data for the various skeletal sites over an almost complete adult life period and these were then compared to values obtained from other studies, densitometry technologies and reference materials. Large discordances were found between the different technologies and reference materials.

The outcome of using the T-score proposed by a WHO study group 1994 as a diagnostic cutoff principle for the diagnosis of osteoporosis (T<-2.5) and osteopenia (T<-1 - -2.5) was evaluated by calculating the resulting prevalence in a cohort of 210 women, 70 years of age. The use of different approaches in calculation of T -score and different reference samples, yielded unacceptable disparities in disease prevalence of between 9 and 72%. The differences were also heavely dependent of which and how many sites that were included in the diagnostic decision.

We studied biochemical markers of bone turnover (alkaline phosphatase, osteocalcin, hydroxyproline and calcium excretion in the urine) in relation to age, menopause and BMD, and their ability to predict bone loss in a 5-year follow-up perspective. Markers varied inversely to BMD, increased markedly at menopause and predicted bone loss over the next 5 years up to 75% at individual level, (AUC of an ROC analysis).

A case. finding strategy using low-energy index fractures in forearm, spine, hip or humerus was performed to detect subjects with osteoporosis. 303 consecutive women 55-75 years with a recent fracture were examined with densitometry and a risk profile questionnaire. The lowest BMD was found in spine and hip fracture patients. Odds ratio for osteoporosis was at least 8 for a patient with a prior hip fracture. The number of previous fractures correlated inversely with bone density (Z-score). Despite 92% of the fracture patients (many with a multiple fracture history) had a low bone mass (t-score<1), only 15% had been treated for osteoporosis before the index fracture.

Place, publisher, year, edition, pages
Linköping: Linköpings universitet, 2002. 129 p.
Linköping University Medical Dissertations, ISSN 0345-0082 ; 737
National Category
Medical and Health Sciences
urn:nbn:se:liu:diva-25686 (URN)10062 (Local ID)91-7373-531-0 (ISBN)10062 (Archive number)10062 (OAI)
Public defence
2002-06-05, Folkhälsovetenskapligt Centrums Aula, Universitetssjukhuset, Linköping, 09:00 (Swedish)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2012-09-12Bibliographically approved

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Löfman, OweHallberg, IngerWahlström, OlaLarsson, LasseToss, Göran
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