Point-of-Care Guides

Predicting Hip Fracture Risk in Older Women

MARK H. EBELL, MD, MS, Athens, Georgia

This guide is one in a Clinical Question allows a family physician to recommend

series that offers evidence-
based tools to assist family
physicians in improving
their decision making at
the point of care.
A collection of Point-of-
Care Guides published in
AFP is available at http://
www.aafp.org/afp/poc.
Which older women are at high risk of hip
fracture?
Evidence Summary
Approximately one in six women will have
a hip fracture during her lifetime, and
approximately one in 35 of all women will
die of complications from hip fracture.1
Bone mineral density screening for women
is recommended beginning at 65 years of
age, or at 60 years of age in the presence of
risk factors such as lower body mass index,
smoking, or long-term corticosteroid use.2
However, low bone mineral density is only
one of many risk factors for hip fracture.
Identifying women who are at high risk
additional measures that might reduce the
risk of fracture such as exercise and bal-
ance regimens,3 cessation of tobacco or
alcohol use,4 and modifications of the home
environment.5
A number of clinical risk scores have been
developed and validated (Table 1).6-11 Two
of these scores have not been prospectively
validated and thus are inappropriate for use
in the clinical setting.9,10 Others are too long
for outpatient care8,11 or require data collec-
tion that is impractical in the primary care
setting.8,9 Two scores have been prospec-
tively validated in a broad spectrum of older
women and are simple enough to use in the
primary care setting.6,7

Table 1. Studies Used to Develop Clinical Risk Scores for Predicting Hip Fracture in Older Women

No. of patients
(prospective No. of items BMD included
Study Population studied validation cohort) in risk score in risk score?

Recommended scores for primary care

Black, et al., 20016 Women older than 65 years 7,575 6 or 7 Optional

Albertsson, et al., 20077 Women older than 70 years 1,498 4 No

Other scores
Colon-Emeric, et al., 20028 Men and women older than 3,505 9 No
65 years

Dargent-Molina, et al., 2002*9 Women older than 75 years — 5 No

witha T-score of –3.5 to –2.5

McGrother, et al., 2002*10 Women older than 70 years — 6 (three-year risk) No

4 (five-year risk)

Ahmed, et al., 200611 Women 65 to 74 years of age 1,410 14 Yes

BMD = bone mineral density.

*—Not prospectively validated.
Information from references 6 through 11.

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The FRAMO (Fracture and Mortality)
Index (Table 2), validated in 1,498 Swed-
ish women, consists of four items used in a
simple scoring system.7 It identifies low- and
high-risk groups and is a good predictor
of overall mortality and hip fracture risk.7
The Fracture Index (Table 3) is a six-item
risk score with an optional seventh item
(bone mineral density at the hip).6 It was
developed in 7,782 women using data from
the Study of Osteoporotic Fractures and was
validated in a separate group of 7,575 French
women.6
Applying the Evidence
is the patient’s risk of hip fracture and overall
mortality in the next few years?
Answer: Using the FRAMO Index
(Table 2 7), she receives one point for her
weight, one for being unable to rise from
Table 3. Fracture Index for Predicting
Hip Fracture Risk in Older Women
The rights holder did not grant the
American Academy of Family Physicians
the right to sublicense this material to a
third party. For the missing item, see the
original print version of this publication.

A 76-year-old woman weighs 110 lb (49.9 kg),

is a nonsmoker, and had a vertebral fracture
four years ago; her mother never had a hip
fracture. The patient is unable to consistently
lift herself out of a chair without using her
arms, and her T-score at the hip is –2.1. What

Table 2. FRAMO (Fracture and

Mortality) Index for Predicting
Hip Fracture and Mortality Risk in
Older Women

Patient characteristics Points

Age ≥ 80 years 1
Weight < 132 lb (59.9 kg) 1
Unable to rise five times from a chair 1
without using the arms
Any fracture of the wrist, lower 1
arm, upper arm, hip, or vertebra
after 40 years of age (or vertebral
compression seen on a radiograph*)
Total:

Two-year risk

Hip Overall
Risk group (score) fracture mortality

Low (0 or 1) 6/789 25/789

(0.8%) (3.2%)
High (2 or more) 25/459 109/459
(5.4%) (23.7%)

*—A radiograph is not needed if fracture history is

known.
Adapted with permission from Albertsson DM, Mell-
ström D, Petersson C, Eggertsen R. Validation of a
4-item score predicting hip fracture and mortality risk
among elderly women. Ann Fam Med 2007;5:49, 52.
Adapted with permission from Black DM, Steinbuch
M, Palermo L, Dargent-Molina P, Lindsay R, Hoseyni
MS, et al. An assessment tool for predicting frac-
ture risk in postmenopausal women. Osteoporos Int
2001;12:523, 525.

274  American Family Physician www.aafp.org/afp Volume 76, Number 2 ◆ July 15, 2007

a chair five times without using her arms,
and one for having a fracture after 40 years
of age. You determine that her two-year hip
fracture risk is 5.4 percent, and her two-year
overall mortality risk is 23.7 percent. Using
the Fracture Index (Table 36), she receives
three points for her age, one for having a
fracture after 50 years of age, one for her
weight, and two for needing to use her arms
to rise from a chair. If bone mineral density
is considered, she receives three points for
her T-score. You determine that her four-
year risk of hip fracture, according to the
Fracture Index, is 10.4 percent based on risk
factors alone and 7.8 percent based on risk
factors plus bone mineral density at the hip.
Address correspondence to Mark H. Ebell, MD, MS, at
mebell@mcg.edu. Reprints are not available from the
author.
REFERENCES
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2. U.S. Preventive Services Task Force. Recommendations
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ahrq.gov/clinic/3rduspstf/osteoporosis/osteorr.htm.
3. Suzuki T, Kim H, Yoshida H, Ishizaki T. Randomized
July 15, 2007 ◆ Volume 76, Number 2 www.aafp.org/afp
Point-of-Care Guides
controlled trial of exercise intervention for the preven-
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predicting fracture risk in postmenopausal women.
Osteoporos Int 2001;12:519-28.
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R. Validation of a 4-item score predicting hip fracture
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American Family Physician  275