TO THE EDITOR:
I read "Editorial. Osteoporosis Prevention and the Orthopaedic Surgeon: When Fracture Care Is Not Enough" (80-A: 1567—1569, Nov. 1998), by Tosi and Lane, with great interest. These authors are to be commended for their excellent review of the role of the orthopaedic surgeon in the prevention and treatment of osteoporosis. In their review, the authors cited the recently approved "Standardization of Medicare Coverage of Bone Mass Measurement," which defines five diagnostic categories that meet approval for the use of bone-density technologies: (1) estrogen-deficient women who are at clinical risk for osteoporosis, (2) patients who have vertebral abnormalities, (3) patients who are receiving long-term glucocorticoid therapy, (4) patients who have primary hyperparathyroidism, and (5) patients who are being monitored to assess the response to, or the efficacy of, an approved drug for osteoporosis. I am writing to suggest that a sixth category be established: postmenopausal women who have a low-energy fracture of the distal end of the radius.
Fracture of the distal end of the radius often represents the initial event in a patient who is at high risk for a later fracture about the hip, indicating the importance of intervention in this high-risk group12. Patients who have sustained a fracture of the distal end of the radius have nearly twice the relative risk of a future fracture about the hip10,12,15, and elderly women who have a fracture of the distal end of the radius have been shown to have both site-specific and generalized decreases in bone-mineral density compared with young adults and age-matched controls3,9,11,13. Earnshaw et al.4 recently found that ninety-six (91 percent) of 106 postmenopausal women who sustained a fracture of the distal end of the radius met the World Health Organization's diagnostic criteria for osteoporosis or osteopenia as determined with dual-energy x-ray absorptiometry. Therefore, in most patients, a fracture of the distal end of the radius should alert the treating physician that osteoporosis is present and should prompt diagnostic confirmation or medical treatment, or both.
Despite convincing evidence that patients who have a fracture of the distal end of the radius should be diagnosed with and managed for osteoporosis, there are data to suggest that these patients are being managed inadequately. In a preliminary study, only nine (3 percent) of 329 postmenopausal women who had a fracture of the distal end of the radius had bone-density testing to confirm the diagnosis of osteoporosis, and only sixty-five (20 percent) of the 329 women were managed with one of the medications approved for osteoporosis6,7. In addition, a Danish survey of fifty-six orthopaedic surgery departments revealed that only seven departments (13 percent) referred patients who had a low-energy fracture for a bone-density scan and that only six (11 percent) managed these patients for osteoporosis5.
There should be an increased emphasis on the diagnosis and treatment of osteoporosis in postmenopausal women who sustain a fracture of the distal end of the radius. Appropriate intervention could have a profound impact on public health by decreasing the burden of future osteoporotic fractures. It is certainly true that "fracture care is not enough." When orthopaedic surgeons treat a fracture of the distal end of the radius, we must ensure that they treat the osteoporosis as well.
Kevin B. Freedman, M.D.: Department of Orthopaedic Surgery, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, 2 Silverstein Pavilion, 3400 Spruce Street, Philadelphia, Pennsylvania 19104-4283
Dr. Tosi and Dr. Lane reply:
We thank Dr. Freedman for his thoughtful response to our Editorial. Dr. Freedman correctly argues that the Medicare criteria are an inadequate guide to who might benefit from bone-density technologies. We applaud his recommendation that another category (postmenopausal women who have a low-energy fracture of the distal end of the radius) be added to these criteria. Indeed, we argue that a history of any fracture in a postmenopausal woman is prima facie evidence of fragility and raises the question of whether to initiate an investigation, if not treatment.
Presumably, the identification of osteoporosis should derive from the currently accepted definition: a condition of skeletal fragility due to low bone mass or microarchitectural deterioration of bone tissue, or both2. However, because fragility cannot be measured clinically, we use bone density, which can be measured. The World Health Organization's definition of osteoporosis is a bone-mineral density of less than 2.5 standard deviations below the mean for young adults17. Many other factors independently predict fragility fracture, including age, a history of any fracture after forty years of age, a maternal history of fracture about the hip, low body weight, and smoking. In many cases, these factors predict fracture more accurately than does low bone mass. Thus, we concur with the Physician's Guide to Prevention and Treatment of Osteoporosis14, which was recently published by the National Osteoporosis Foundation in collaboration with the American Academy of Orthopaedic Surgeons. That document recommends that bone-density testing be performed for "postmenopausal women who present with fractures (to confirm diagnosis and determine disease severity)."
In addition to the literature cited by Dr. Freedman, two recent articles support the argument that any fracture should trigger consideration of osteoporosis. Sanders et al.16 noted that fractures associated with severe trauma are generally excluded from estimates of the prevalence of osteoporotic fractures. Those authors studied the bone density of 1084 women who were more than thirty-five years old and had sustained a fracture as a result of either low-energy or high-energy trauma and compared it with that of a random sample of women who had not had a fracture. The bone-mineral density Z-scores were lower in both groups of patients compared with the control group. Moreover, at most sites, the deficits in the patients who had sustained a high-energy fracture were no smaller than those in the patients who had sustained a low-energy fracture. (The age-adjusted odds ratio for osteoporosis at one scanning site or more was 3.1 [95 percent confidence interval, 1.9 to 5.0] in the group that had sustained a high-energy fracture and 2.7 [95 percent confidence interval, 1.9 to 3.8] in the group that had sustained a low-energy fracture.) The authors suggested that measurement of bone-mineral density may be warranted for women who sustain a fracture after the age of fifty years, irrespective of the type of trauma.
Goulding et al.8 compared the bone-mineral density of 100 white girls who were three to fifteen years old and had sustained a fracture of the forearm with that of 100 age and gender-matched controls. Those authors found that the patients who had a fracture had reduced bone density not only in the radius but also in the lumbar spine, the greater trochanter, and the total body. Moreover, osteopenia (defined as a Z score of less than -1) of the forearms, spine, and hips was more common in patients than in controls (p < 0.05). One-third of the patients who had a fracture had low bone-mineral density in the spine. These data strongly suggest that even children who sustain a fracture should be counseled with regard to risk factors for osteoporosis and that every effort should be made to ensure that they have adequate calcium in their diet and that they exercise regularly.
Sir William Osler once pointed out that we see what we look for and we find what we know. The knowledge base among both physicians and patients regarding osteoporosis is currently very low. Dr. Freedman points to his preliminary study in which only 3 percent of women who had a fracture of the distal end of the radius were evaluated for osteoporosis and only 20 percent had medical treatment. The findings of the Danish study that he cited are not much better. This weak knowledge base is underscored by the recent report from the Centers for Disease Control on osteoporosis among estrogen-deficient women in the United States from 1988 to 1994, which presented the findings of the Third National Health and Nutrition Examination Survey (NHANES III)1. The Centers for Disease Control found that only 7 percent of women in whom osteoporosis was diagnosed with bone-density testing were aware of their condition. The rate was much lower among women who had limited financial and health resources.
Thus far, routine bone-density screening is not recommended because it is expensive and because it is not clear that it will influence behavior or treatment decisions or decrease the prevalence of fractures. There is also still debate as to when treatment should be initiated. However, these uncertainties recede once a fracture has occurred, which is when many people—men and women, boys and girls—first meet an orthopaedist. At this point, a discussion about the importance of bone health and the possible need for evaluation for osteoporosis should be initiated with all patients.
Laura L. Tosi, M.D.: Department of Orthopaedics, Children's National Medical Center, 111 Michigan Avenue N.W., Washington, D.C. 20010
Joseph M. Lane, M.D.: The Hospital for Special Surgery, 535 East 70th Street, New York, N.Y. 10021