Osteoporotic Fracture

Educational Objectives

The goal of this program is to improve management of patients presenting with osteoporotic fracture. After hearing and assimilating this program, the clinician will be better able to:

1. Recognize patients at increased risk for fracture based on history and medications.
2. Identify patients with osteoporosis based on history of fracture.

Summary

Osteoporosis: an osteoporotic fracture from a fall from standing height is likely to occur in 50% of women and 20% of men over a lifetime; a second fracture is likely to occur if the first fracture is not discovered; osteoporosis may be diagnosed without a bone density scan if a fracture from a standing height occurs; height should be measured and an assessment for kyphosis done in the clinic; patients with osteoporosis may lose up to 4 inches of height; patients taking medications such as prednisone or aromatase inhibitors, or those who have undergone chemical castration for prostate cancer, are at very high risk for fractures; all patients must have their height measured and monitored beginning at 65 yr of age; the most frequent fractures are compression fractures, which may present as back pain and go undiagnosed; height loss is indicative of compression fracture; a study of men with prostate cancer treated with leuprolide reported that 20% died from fracture at 10 yr

Effects and risk factors: mortality at 1 yr after hip fracture is <22% for women and <30% for men; 50% of patients do not regain independence after a hip fracture and 50% do not regain their previous mobility; there is a severe decrease in quality of life; 90% of previously able patients cannot climb stairs, 30% cannot get out of bed, and 20% cannot put on pants without assistance after a hip fracture; hip fractures are easily preventable; a study found that 24% percent of patients had fractures on x-ray but only 7% were aware of the fracture; patients may have compression fractures but only osteopenia is detected on a bone density scan; patients with low bone density had a 1 yr fracture risk of 3% but patients with 1 compression fracture had a risk of 11% and those with 2 compression fractures had a risk of 24%

Bone density: patients who had fractures are at higher risk of refracture than those with a T-score of >-2.5; bone density is a good predictive measure, but fractures may occur in patients with normal bone density or osteopenia due to bone quality or other factors; trabecular bone score is helpful to assess bone quality; as bone density worsens, the risk for fracture goes up; most fractures occur in persons with osteopenia, because of the high prevalence of osteopenia; the Fracture Risk Assessment Tool (FRAX) gives a framework to manage these patients; 50% of fractures in the next year are likely to occur in the 16% of the general population who have prior fractures; the remaining 50% of fractures are likely to occur in the 84% of the general population who have not had fractures, but have risk factors

Types of fracture: the first fracture is often a Colles fracture, particularly in women; commonly occurs in persons >55 yr of age; compression fractures occur in three waves; the last fracture is frequently a hip fracture; morbidity and mortality is higher for hip fractures than other fractures; patients with healthy bone (ie, thick, healthy, connected vertical and horizontal struts) are less likely to fracture in comparison with patients with osteoporosis; horizontal struts are especially important for bone strength; a study of patients in the United States found 16% of patients with hip fractures were treated for osteoporosis at 1 yr and 4% of patients underwent a bone density scan; according to more recent data, 19% to 30% of patients are now treated for osteoporosis, and 15% to 22% of patients had a bone density scan by 1 yr; improvements to the system are needed to find these patients and provide care

Improving care: the most frequent fractures are spinal compression fractures (often missed), followed by hip fractures, according to data from the Bone Health and Osteoporosis Foundation (BHOF); 3 yr follow-up found that 30% of patients died (17% within 1 yr of hip fracture), and 24% had a subsequent fracture; Kaiser Permanente created a system showing the monthly number of patients presenting with fracture, number of women >65 yr needing bone density scan, and number of patients compliant with treatment; such systems are useful; the BHOF website contains helpful information for physicians and patients

Readings

GBD 2019 Fracture Collaborators Global, regional, and national burden of bone fractures in 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019. Lancet Healthy Longev. 2021;2:e580–e592; Griffith JF. Identifying osteoporotic vertebral fracture. Quant Imaging Med Surg. 2015;5(4):592-602. doi:10.3978/j.issn.2223-4292.2015.08.01; Hosseini HS, Dünki A, Fabech J, et al. Fast estimation of Colles' fracture load of the distal section of the radius by homogenized finite element analysis based on HR-pQCT. Bone. 2017;97:65-75. doi:10.1016/j.bone.2017.01.003; Seo JY, Kwon YS, Kim KJ, Shin JY, Kim YH, Ha KY. Clinical importance of posterior vertebral height loss on plain radiography when conservatively treating osteoporotic vertebral fractures. Injury. 2017;48(7):1503-1509. doi:10.1016/j.injury.2017.04.057; Shahinian VB, Kuo YF, Freeman JL, et al. Risk of fracture after androgen deprivation for prostate cancer. N Engl J Med. 2005;352(2):154-164. doi:10.1056/NEJMoa041943; Wong CC, McGirt MJ. Vertebral compression fractures: a review of current management and multimodal therapy. J Multidiscip Healthc. 2013;6:205-214. Published 2013 Jun 17. doi:10.2147/JMDH.S31659; Wu CC, Chen PY, Wang SW, et al. Risk of fracture during androgen deprivation therapy among patients with prostate cancer: a systematic review and meta-analysis of cohort studies. Front Pharmacol. 2021;12:652979. Published 2021 Aug 6. doi:10.3389/fphar.2021.652979.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Gruntmanis was recorded at Osteoporosis Update for Primary Care 2022, held on November 4, 2022, in Colchester, VT and presented by the Larner College of Medicine at The University of Vermont. For information about upcoming CME activities from this presenter, please visit https://www.med.uvm.edu/cmie. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

IM701202

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.