Traumatic fractures increase subsequent fracture risk for postmenopausal women
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Postmenopausal women have an increased risk for a subsequent fracture after both traumatic and nontraumatic initial fractures, according to a study published in JAMA Internal Medicine.
“Clinicians traditionally do not consider trauma-associated fracture to indicate a higher risk of future fracture,” Carolyn J. Crandall, MD, MS, FACP, professor of medicine at David Geffen School of Medicine at University of California, Los Angeles, told Healio. “Rather, it is only the postmenopausal women with nontraumatic initial fractures who are traditionally considered to be at higher risk of future fracture. However, this long-held traditional viewpoint was not supported by actual evidence.”
Crandall and colleagues conducted a prospective observational study of 66,874 postmenopausal women aged 50 to 79 years who enrolled in the Women’s Health Initiative clinical trials or the WHI Bone Density Substudy between September 1994 and December 1998. Women self-reported fractures and their circumstances in annual or semiannual questionnaires. All fractures were confirmed in medical records. Fractures resulting from a motor vehicle crash, falling downstairs, falling from a height or a sports activity were considered traumatic. Other fractures were defined as nontraumatic.
Subsequent fracture risk
Of the study cohort, 7,142 women had an incident fracture during a median follow-up time of 8.2 years. Of the women who sustained an incident fracture, 721 experienced a subsequent fracture.
After adjusting for covariates, women had a higher risk for a subsequent fracture if they sustained any initial fracture (adjusted HR = 1.49; 95% CI, 1.38-1.61; P < .001), an initial traumatic fracture (aHR = 1.25; 95% CI, 1.06-1.48), an initial nontraumatic fracture (aHR = 1.52; 95% CI, 1.37-1.68) or an initial fracture of unknown cause (aHR = 1.67; 95% CI, 1.44-1.93).
“If you consider the traditional viewpoint to be your frame of reference, then the findings are quite surprising and will change clinical practice,” Crandall said. “On the other hand, if you think about the biology underlying bone fragility, it seems intuitive that if you start out with more fragile bones, where you already have preexisting tendency to fracture, then exposure to trauma would certainly be likely to cause a fracture. In that sense, traumatic fractures could be expected to be indicative of increased risk of higher future fracture risk.”
Deeper look at bone health
In a related commentary, Anne L. Schafer, MD, chief of endocrinology and metabolism at the San Francisco VA Health Care System, and Dolores M. Shoback, MD, professor of medicine and associate program director of the fellowship program in diabetes, endocrinology and metabolism at the University of California, San Francisco-School of Medicine, wrote that people who have a traumatic fracture may not be receiving proper attention to bone health.
“When clinicians communicate that a fracture was nontraumatic, we signal to each other that additional attention to the patient’s bone health is indicated,” Schafer and Shoback wrote. “As we do this, though, we implicitly signal that fracture sustained after higher trauma is the predictable result of the trauma and not a reflection of impaired bone strength.”
Schafer and Shoback said providers should evaluate all people sustaining a fracture for factors that may increase their risk for subsequent fractures.
“Appropriate interventions may include counseling about adequate nutrition, weight-bearing exercise, smoking cessation, alcohol moderation and avoidance of medications with detrimental skeletal effects,” Schafer and Shoback wrote. “Pharmacologic therapy will be indicated in some, and it should be noted that the most commonly used antiresorptive agents have been shown to have similar effects on low-trauma and high-trauma nonvertebral fracture risk, prompting the proposal that all nonvertebral fractures — regardless of trauma — should be included as endpoints in osteoporosis trials.”
Reference:
Schafer AL, et al. JAMA Intern Med. 2021;doi:10.1001/jamainternmed.2021.2599.
For more information:
Carolyn J. Crandall, MD, MS, FACP, can be reached at ccrandall@mednet.ucla.edu.
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