Predictive Risk Of A Major Osteoporotic Fracture

Studies have shown that half of all the patients who have suffered a hip fracture had already sought medical attention because of a previous fracture due to brittle bones. As is commonly experienced, the broken bone is simply fixed and the patient is discharged home without the underlying cause of the first fracture being properly diagnosed and treated.

This issue warranted further research which will be discussed further.

The research

Preliminary results of the Reykjavic Study, which was performed in order to determine what the predictive value of a past major osteoporotic fracture (MOF) was on the development of a future MOF over time, has been presented at a recent orthopaedic world congress.

Data was collected from over 118,000 patients who were born between 1907-1935. Of these patients, it was noted that over 5,000 had experienced one or more osteoporotic fractures and nearly 2,000 had sustained a second fracture.

The findings

The following observations were made on the analyzed data:

• It was therefore found that the risk of developing a second osteoporotic fracture had increased by 4% for each year of age.
• It was also discovered that the risk for females was 41% higher than in males.
• The risk of sustaining the second fracture also seemed to be at its highest immediately after the first fracture.
• Even though the risk had decreased over time, it still remained higher than the risk to the population throughout follow-up of the patients.
• The risk of sustaining a second MOF was still 3 times higher than those who had never sustained a fracture.
• After 10 years, the risk of a second MOF was still 2 times higher than the population who never sustained a fracture.

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The clinical significance

This study is very significant in terms of clinical governance. The fact that the risk of a second osteoporotic fracture is immediately increased after an initial fracture is quite concerning.

It is estimated that around 80% of patients who sustained a first fracture were never diagnosed and treated accordingly. In order for this serious issue to be addressed, coordinated systems of secondary fracture prevention need to be implemented. This has become a major health-policy focus of the International Osteoporosis Foundation (IOF).

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Complications of osteoporotic fractures

Fractures due to osteoporosis are the most common complications of this disorder. The most commonly involved bones are those of the spine, the wrists and the hips. 

Secondary complications due to the fractures themselves can also occur, namely:

• Second fracture - as mentioned above.
• Deep venous thrombosis - Blood clots can develop in the deep venous system of the leg(s).
• Pulmonary embolus - The mentioned blood clots can detach and then travel to the pulmonary veins where they cause an obstruction. This can be fatal as cardiac output is then compromised.
• Stasis pneumonia - due to a fracture possibly immobilizing a patient, airway secretions aren't properly expelled and this can lead to a pneumonia, especially in the elderly.

Osteoporosis: Diagnosis, Management, Bisphosphonates and Hormone-related Therapy

Diagnosis

Osteoporosis is diagnosed based on clinical suspicion and is then confirmed by performing a specific test.

This test is called a bone density scan which uses low levels of radiation (X-rays) to measure the proportion of mineral density in specific bones of the body. The bones which are examined are those of the wrists, the spine and the hips.

Management

Lifestyle changes and home remedies

In low risk patients, the management of this condition will be conservative. This would include the following suggestions:

• Lifestyle changes - such as increasing one's physical activity and increasing the intake of calcium through dietary inclusions or supplementation. Calcium supplements combined with vitamin D are a good choice as they offer more benefits and minimal complications. 
• Modification of risk factors - such as reduced alcohol consumption to less than 2 drinks every day, and stopping tobacco use.
• Prevention of falls - patients with osteoporosis should make sure they wear shoes that have flat heels and are non-slip. They should also remove any small items of furniture which they can bump into, and rugs that they could slip on. Any electrical cords or wires should be removed so that one can't trip over them. Handle bars should also be installed around baths and showers, too.

READ Osteoporosis Is No More a Women-Only Disease

Bisphosphonates

Patients who are at high risk of sustaining fractures are prescribed medications such as the bisphosphonates, of which Alendronate is the most commonly used.

Bisphosphonates can cause a patient to experience issues such as the following:

• Nausea.
• Difficulty swallowing.
• Abdominal pain.
• Oesophageal ulcers.
• Inflamed oesophagus.

These side-effects can be limited by swallowing the medication while in an upright position and then remain standing for 30 minutes. Sometimes these effects are still present despite taking the medication properly. In this case, intravenous forms of the medication, such as zoledronic acid, would be more appropriate for these patients. Another benefit of this form of the medication is that it is given yearly instead of the patient having to drink pills every week.

READ Beyond Osteoporosis: How To Promote Bone Health

Hormone-related therapy

Estrogen supplementation, after menopause, can help the body maintain the density of bone. Estrogen shouldn't be prescribed to only maintain bone health if the patient isn't menopausal, as the increased hormone levels can increase the risk of the patient developing breast and/or uterine cancer as well as cardiovascular complications.

Raloxifene is a medication which has the bone density benefits of estrogen without many of the increased risks. Some side-effects include hot flashes and an increased risk in developing blood clots.

In men, osteoporosis is associated with reduced testosterone levels. Therefore, testosterone supplementation combined with osteoporosis medication can help increase the bone density in men.