Commentary & Perspective

Commentary & Perspective on
"Colles Fracture, Spine Fracture, and Subsequent Risk of Hip Fracture in Men and Women: A Meta-Analysis"
by Patrick Haentjens, MD, et al.

Commentary & Perspective by
Thomas A. Einhorn, MD*,
Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, Massachusetts

"Wrist" Factors for Hip Fractures in Men

Osteoporosis is a life-threatening disease. It has been shown that up to 4% of previously ambulatory, cognitively intact elderly patients who sustain a hip fracture die during hospitalization, and 12.7% die within one year after fracture¹. Although several factors are predictive of mortality in these patients, the best way to prevent this outcome is by early identification of fracture risk and implementation of preventive measures.

In the October issue of The Journal, Haentjens et al.² reported on a meta-analysis that suggests that the impact of a previous spine fracture on the risk of subsequent hip fracture is equal in men and women, while the prospective association between a Colles fracture and a subsequent hip fracture is significantly stronger in men. They concluded that men with Colles fracture are at high risk for a future hip fracture and should be evaluated as candidates for preventive measures. The investigators used well-accepted meta-analysis methodology to analyze nine cohort studies conducted in the United States and the European Union. Studies were selected from those associated with minimal trauma of the wrist or spine as a risk factor for subsequent hip fracture among (White) women and men who were fifty years old or older. The results showed that the relative risks for a future hip fracture were 1.53 after a wrist fracture and 2.20 after a spine fracture among postmenopausal women, and 3.26 and 3.54, respectively, in men, all with 95% confidence intervals. Fractures of the distal part of the radius (Colles fracture) increased the relative risk of hip fracture significantly more in men than in women (p = 0.002). The impact of a spine fracture, conversely, did not differ between genders.

Because osteoporosis and fragility fractures are typically considered diseases of postmenopausal women, our attention as physicians is typically drawn to data that analyze the predictive value of certain risk factors in predicting the occurrence of fractures in women. Indeed, a history of the occurrence of any fracture has been shown to be an important risk factor for future hip fracture in women,³ and the data collected by Haentjens et al. support that conclusion. However, at least one study has shown that mortality after hip fracture is twice as high in men as in women⁴. Because this difference is only partly explained by differences in comorbidity, it is possible that male gender itself is a risk factor for mortality after hip fracture. Indeed, almost 50% of men who survive a hip fracture become institutionalized as a result of the injury, and up to 80% fail to regain their pre-fracture level of functional independence⁵.

So now we know that if you are a man and sustain a Colles fracture, you are at substantial risk for sustaining a future hip fracture. We also know that if you are a man and sustain a hip fracture, your risk of death and loss of functional independence is great. Now let's look at how well the orthopaedic profession is doing at identifying patients, both men and women, with osteoporotic-associated fractures in terms of preventing the risk of hip fracture in the future. In August 2000, Freedman et al. published an article in The Journal entitled "Treatment of Osteoporosis: Are Physicians Missing an Opportunity?"⁶ This investigation consisted of a search of a claims database that included more than 3,000,000 patients, of whom 1162 were women who were sixty-five years old or older who had sustained a fracture of the distal part of the radius. Of these, thirty-three (2.8%) had undergone a bone density scan and 266 (22.9%) were treated with a least one medication approved for the treatment of established osteoporosis. Only 20 women had both the bone density scan and drug treatment, leading the authors to conclude that "current physician practice may be inadequate for the diagnosis and treatment of osteoporosis in postmenopausal women who have sustained a distal radial fracture."⁶ To my knowledge, a similar investigation in men has not been conducted. However, a subsequent report published in The Journal two years later by Gardner et al.⁷ provided some mildly encouraging news that demonstrated an improvement in this trend. A substantial increase in the rate of treatment was identified by evaluating the data collected from 100 patients who were randomly selected from a retrospective cohort. This cohort was developed with the use of ICD-9 codes for femoral neck fractures from the patient databases of two universities and one university-affiliated medical center. Between 1997 and 2000, the percentage of patients discharged with a prescription for either supplemental calcium or an anti-osteoporotic medication had increased from 11% to 29%. However, while this trend may be encouraging, it is still clear that the ability of the orthopaedist to identify patients at risk for future fractures and to implement preventive treatment is woefully inadequate.

These data by Haentjens et al. are telling us that if we begin paying attention to our male patients who have sustained a Colles fracture and if we consider a workup for osteoporosis and subsequent treatment, not only may we be making an important difference in the future skeletal health of these men, but we may in effect be implementing life-saving preventive therapy for the subset of patients who would die or experience functional disability after a subsequent hip fracture. Although similar data are not available for men, data from the Fracture Intervention Trial aimed at investigating the effect of the anti-osteoporotic drug alendronate on the risk of future fractures in postmenopausal women who already had vertebral fractures showed a nearly 50% reduction in the risk of hip fracture over two years⁸. Thus, while there are no data to suggest that men and women respond differently to bisphosphonates, it is reasonable to use these data and those of Haentjens et al. to support the recommendation that men with a Colles fracture should be seriously considered for treatment with an anti-osteoporotic drug as it may very likely prevent the development of hip fracture in the future.

Each year, orthopaedic surgeons seem more and more cognizant of the role of osteoporosis in the genesis of fractures and in the outcomes of treatments rendered. Through the efforts of peer-reviewed journals that publish key articles on this subject and through the efforts of organizations such as the American Academy of Orthopaedic Surgeons, the World Health Organization, and the Bone and Joint Decade project, slow but steady progress is being made in enhancing the role of the orthopaedic surgeon in preventing bone disease and improving skeletal health in the aging population. As orthopaedists become more interested and knowledgeable about the latest diagnostic and treatment modalities that are available for the management of patients with osteoporosis, their ability to directly intervene in the care of these patients is greatly enhanced. For most orthopaedists, however, the ability to refer a patient for this care is easier and ultimately just as effective. With data such as these provided by Haentjens et al., every orthopaedic surgeon should consider referring every man who has sustained a Colles fracture for evaluation and potential preventive treatment. It is a simple message and we should pay careful attention to it.

*The author did not receive grants or outside funding in support of research or preparation of this manuscript. The author did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

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