In Brief
Trauma and Fractures
By Daniel H, Solomon, MD, MPH
Abstract
Context: It is widely believed that fractures resulting from high trauma are not osteoporotic; however, this assumption has not been studied prospectively.
Objective: To examine the association between BMD and high-trauma fracture and between high-trauma fracture and subsequent fracture in older women and men.
Design, setting, and participants: Two prospective U.S. cohort studies in community-dwelling adults 65 or older from geographically diverse sites. The Study of Osteoporotic Fractures followed up 8,022 women for 9.1 years (1988–2006). The Osteoporotic Fractures in Men Study followed up 5,995 men for 5.1 years (2000–2007).
Main outcome measures: Hip and spine BMD were assessed by dual-energy X-ray absorptiometry. Incident nonspine fractures were confirmed by radiographic report. Fractures were classified, without knowledge of BMD, as high trauma (due to motor vehicle crashes and falls from greater than standing height) or as low trauma (due to falls from standing height and less severe trauma).
Results: Overall, 264 women and 94 men sustained an initial high-trauma fracture and 3,211 women and 346 men sustained an initial low-trauma fracture. For women, each 1-SD reduction in total hip BMD was similarly associated with an increased risk of high-trauma fracture (multivariate relative hazard [RH], 1.45; 95% confidence interval [CI], 1.23–1.72) and low-trauma fracture (RH, 1.49; 95% CI, 1.42–1.57). Results were consistent in men (high-trauma fracture RH, 1.54; 95% CI, 1.20–1.96; low-trauma fracture RH, 1.69; 95% CI, 1.49–1.91). Risk of subsequent fracture was 34% (95% CI, 7%–67%) greater among women with an initial high-trauma fracture and 31% (95% CI, 20%–43%) greater among women with an initial low-trauma fracture, compared with women having no high- or low-trauma fracture, respectively. Risk of subsequent fracture was not modeled for men.
Conclusions: Similar to low-trauma nonspine fractures, high-trauma nonspine fractures are associated with low BMD and increased risk of subsequent fracture in older adults. High-trauma nonspine fractures should be included as outcomes in osteoporosis trials and observational studies.
Commentary
Many clinicians have long suspected that even fractures occurring after high trauma (such as in a motor vehicle accident) might be related to osteoporosis in a given individual. Mackey and colleagues used data from several large prospective cohorts to prove that this is the case. They found that high-trauma fractures had a similar relationship with bone mineral density as did low-trauma fractures and that high-trauma fractures predicted future fractures equally as well as their low-trauma counterparts. These findings should spur physicians to consider any prior fracture (low- or high-trauma) as a marker of patients that need vigorous screening and possible treatment for osteoporosis.
CORRECTION
In the article “Difficult Gout” (July 2007 issue, p. 1), regarding statements that oxypurinol does not effectively inhibit the oxidized form of xanthine oxidase, the statements should read as follows:
