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Any "fragility fracture" is a nearly sure sign that you have osteoporosis. But not every history of broken bones means you have or will develop the disease. And a psychological factor, not a physical factor, is most predictive of a fracture-free future.

When it comes to fractures, there is no doubt that once is enough. If you have ever broken a bone, you totally understand how debilitating and painful that can be. Having one broken bone does not necessarily mean that you are destined to have another. But anyone who suffers a bone fracture needs to consult with a doctor to test for osteoporosis, a condition that could mean more fractures in the future.

The relationship between broken bones and osteoporosis

The brittle bone disease osteoporosis (which literally means "porous bone") is a chronic condition of deficient mineral content in bone. The bones of the wrist, forearm, hip, and spine are most likely to be affected. Osteoporosis makes bones fragile. Minor trauma, sometimes something a minor as a sneeze, causes fractures in fragile bones. People usually don't even know they have osteoporosis until a twist, turn, or fall results in a fracture.

Any "fragility fracture" is a cue to get tested for diagnosis. Bones that break without noteworthy trauma are always symptomatic of osteoporosis. There may be an underlying condition or a prescription medication that is powering the process that leads to bone mineral loss, but that's a matter for medical evaluation.

Don't let the emergency room physicians or the orthopedic surgeon "fix you up" without referring you to another specialist usually an endocrinologist, who specializes in osteoporosis. And any osteoporosis specialist has access to a statistical tool that computes your risk of future fractures to determine whether you need further treatment.

The basic facts about FRAX

FRAX is a standardized, internationally accepted statistical tool for computing a patient's risk of experiencing a fracture over the next 10 years. The mathematical model uses some basic data about each patient: bone mineral density scores from DXA testing, age, country, and gender. It also requires input regarding clinical risk factors such as:

  • Body mass index (BMI)
  • Previous fragility fractures
  • Family history of fragility fractures
  • Smoking
  • Drinking
  • Treatment with glucocorticoids
  • Rheumatoid arthritis
  • Other possible causes of secondary osteoporosis

The FRAX tool gives an immediate calculation of the 10-year risk of a major fracture of the spine, wrist, humerus, or hip. It can also be used to calculate the just the risk of a fracture of the hip. The advantage of the FRAX tool is that it doesn't average out fracture risk across everybody who has a certain level of bone mineral density (the T or Z score of DXA testing). It is age- and gender-specific, and takes into account general differences in genetics, at least as can be identified by country of origin.

FRAX gives absolute risk, not relative risk. It doesn't tell you whether you have "more risk" or "less risk," it gives you a number. What the FRAX model does not take into account, however, is your history of falls.

Falls are meaningful even without FRAX

Your history of falls predicts your risk of fractures. Having had one or more falls predicts risk of bone fractures even without the detailed information required by the FRAX model. Why is reporting falls important?

Most falls are from standing height or less. Only five to 10 percent of falls in adults result in a broken bone. The changes you make to your home and workplace to prevent falls usually appear to be very successful in preventing fractures, because such a small percentage of falls result in broken bones. 

However, the important consideration is not just that falls cause broken bones. It is also necessary to take into account that weak bones cause falls. When a joint has deteriorated because of osteoporosis, muscles don't flow over it naturally. They may pull to one direction or another. The stress of compensating for changes in the "stretch" needed to use a joint causes muscle fatigue. Muscle spasms or weakness lead to loss of balance and loss of balance causes falls that result in fractures.

Falls predict fractures even without taking into account DXA bone mineralization scores or FRAX scores. Even if the printout from FRAX says that it is not necessary to consider treatment, a history of falls is enough to signal that osteoporosis is a real possibility and treatment is needed. At the very least, nutritional interventions such as supplemental calcium, vitamin D, magnesium, and vitamin K2 should be started right away, and pharmaceutical treatment should be considered. However, there is one predictor of fractures that doesn't show up in a 15-minute examination in the doctor's office.

Self-efficacy and the risk of fractures

Researchers have looked at a number of predictors of whether men and women who have had strokes and who have osteoporosis will fall and break a bone. They studied the relationships between falls and age, gender, physical activity level, leg muscle strength, stair climbing time, six-minute walking distance, the Timed Up and Go (TUG) Test, and the Berg Balance Test. None of these indicators was reliable indicator of whether a patient would suffer a future fall. One measurement, however, predicted whether falls and fractures would occur in the future with considerable accuracy.

This measurement was self-efficacy. Psychological testing that revealed that a reasonable belief that patients could accomplish their daily life goals was strongly related to freedom from falls. Patients who had low self-efficacy had more falls. Patients who had high self-efficacy had fewer falls. It is important to avoid over-confidence, but approaching daily life with a combination of confidence and caution predicts a safer future.

  • Guowei Li, Lehana Thabane, Alexandra Papaioannou, Jonathan D. Adachi. Comparison between frailty index of deficit accumulation and fracture risk assessment tool (FRAX) in prediction of risk of fractures. Bone. Author manuscript
  • available in PMC 2016 Nov 10. Published in final edited form as: Bone. 2015 Aug. 77: 107–114. Published online 2015 Apr 25. doi: 10.1016/j.bone.2015.04.028 PMCID: PMC5104554.
  • Nicholas C Harvey, Anders Odén, Eric Orwoll, Jodi Lapidus, Timothy Kwok, Magnus K Karlsson, Björn E Rosengren, Östen Ljunggren, Cyrus Cooper, Eugene McCloskey, John A Kanis, Claes Ohlsson, Dan Mellström, Helena Johansson J Bone Miner Res. 2018 Mar
  • 33(3): 510–516. Published online 2017 Dec 8. doi: 10.1002/jbmr.3331 PMCID: PMC5842893. John A Kanis, Nicholas C Harvey, Cyrus Cooper, Helena Johansson, Anders Odén, Eugene V McCloskey, Advisory Board of the National Osteoporosis Guideline Group. A systematic review of intervention thresholds based on FRAX : A report prepared for the National Osteoporosis Guideline Group and the International Osteoporosis Foundation. Arch Osteoporos. Author manuscript
  • available in PMC 2017 Jun 1. Falls Predict Fractures Independently of FRAX Probability: A Meta‐Analysis of the Osteoporotic Fractures in Men (MrOS) Study. Published in final edited form as: Arch Osteoporos. 2016 Dec. 11(1): 25. Published online 2016 Jul 27. doi: 10.1007/s11657-016-0278-z. PMCID: PMC4978487.
  • Photo courtesy of SteadyHealth

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