FragilityFractures

KennethJ.Koval,MD
LauraTosi,MD
AOACommitteeforthe
OwntheBonePilotProject
CreatedFebruary2007

Prevalence
Morethan34millionAmericanssuffer
fromosteoporosisorlowbonemass
80%arewomen
1in2womenover50yearsold
1in4menover50yearsold

Annual incidence of common diseases

Osteoporosisfracture
OccurrencesvsOtherDiseases
2,000,000

1,500,000
1,500,000
250,000
hip

1,000,000

250,000
other sites

513,000

500,000

228,000

750,000
vertebral

Osteoporotic
fractures

Heart
Attack

Stroke

184,300

Breast
Cancer
Source: National Osteoporosis Foundation

1.5MillionFracturesAnnually
Vertebral Fractures:
700,000+
Wrist Fractures:
200,000+

Hip Fractures:
300,000+
Source: National Osteoporosis Foundation,
2000

Other Fractures:
300,000+

BurdenofDisease
$14 billion annually
Approximately$38milliondaily
Congestiveheartfailurecosts$8billion
annually
Asthmacosts$9.8billionannually

BurdenofDisease
1outof4osteoporotichipfractures
resultinlongtermnursinghomecare
Onehalfoftheseareunabletowalk
withoutassistance
24%greaterriskofdyingwithinone
year

FragilityFractures&Osteoporosis
Whats the link?
Fragility fractures
Fractures of the distal radius, proximal humerus, vertebrae and proximal
femur that result from minimal trauma, such as a fall from a standing
height.

Up to 95% of hospitalized fracture inpatients over 75 years of age, and 80%90% of fractures in patients between 60 and 74 years of age can be
attributed to osteoporosis.
Only 23% of hip fracture patients received the care
recommended on the basis of good practice standards.!
Source: RAND Report

AlarmingFractureStatistics
40% of postmenopausal women and ~25-33% of
men will eventually experience osteoporotic
fractures.
~20 percent of senior citizens who suffer a hip
fracture die within a year
Risk of mortality is 2.8-4 times greater among
hip fracture patients during the first 3 months
after the fracture
Nearly 1 in 5 hip fracture patients ends up in a
nursing home within a year
Source: Surgeon Generals Report, 2004, Jrnl of Bone and Mineral Research

TheCostsContinuetoGrow
Fractures cost
$18 billion/year
and expected to
increase if action
is not taken.

RiskFactorsforOsteoporosis

Female
Thinorsmallframe
Lowbodyweight
Smoker

RiskFactorsforOsteoporosis
Advancedage
Historyoffragility
fracture
Familyhistoryprimary
relativewith
osteoporosisorfragility
fracture

RiskFactorsforOsteoporosis
PostMenopausal

Hormonalimbalancescanresultin
rapidboneloss
Womencanloseupto20%oftheir
bonemassin57years

RiskFactorsforOsteoporosis

Amenorrhea,Anorexia&Bulimia
Dietlowincalcium
Certainmedications
Lowtestosteroneinmen

RiskFactorsforOsteoporosis

Inactivelifestyle
Excessivealcohol
consumption

Ethnicity&Osteoporosis
Hispanic women at highest risk
13-16% with
osteoporosis now
36-49% of Mexican
American women 50+
have experienced
significant bone loss

Ethnicity&Osteoporosis
Caucasian & Asian-American women
also high risk

Ethnicity&Osteoporosis

10%ofAfricanAmericanwomen50+have
osteoporosis
30%morehavelowbonedensity

Ethnicity&Osteoporosis
300,000AfricanAmericanwomenhave
osteoporosis
8095%ofallfracturessustainedby
AfricanAmericans64+areosteoporotic
AfricanAmericanwomenmorelikelyto
diefromhipfracturesthanWhitewomen

Men&Osteoporosis
Underdiagnosed
Unrecognized
Underreported
Inadequately researched

Men&Osteoporosis
2millionAmericanmenhave
osteoporosis
3millionmoreareatrisk
1/3ofmalehipfracturesrelatedto
osteoporosis
1/3ofthesemenwillnotsurvive1
yearafterfracture

RiskFactorsfor
FragilityFractures
Impairedvisiondespitecorrection
Estrogendeficiencyatanearlyage
(<45yrs)
Dementia
Poorhealth/frailty
Recentfalls
Lifelonglowcalciumintake
Lowphysicalactivity

FracturesbegetFractures
Risk of future fractures increases 1.59.5 fold following initial fracture
History of fragility fracture is more
predictive of future fracture than bone
density

Diagnosis:BoneDensitometry
Recommendationsforbonedensity

Anyonewithafragilityfracture
Allwomenage65andolder
Postmenopausalyoungerthan65with
riskfactors
Menover50withriskfactors

Treatment
Goals
Prevent future fractures
Treat osteoporosis
Decrease the risk of mortality
after fractures

Treatment
1. Calcium and Vitamin D
All patients with bone loss or the potential for bone loss should
be educated on the appropriate intake of calcium and vitamin D

Stronger Bones!
Stronger
Bones!

Treatment
There is a high prevalence of
vitamin D insufficiency in:
Nursing home residents
Hospitalized patients
Adults with hip fractures

Treatment
2. Exercise
Physical activity makes bones and
muscles stronger and helps
prevent bone loss.
All types of physical activity can
contribute to bone health

Treatment
3. Fall Prevention
Each year, more than 1.6 million older U.S. adults go to
emergency departments for fall-related injuries. Among older
adults, falls are the number one cause of:
Fall

Fractures
Hospital admissions for trauma
Loss of independence
Injury deaths

3
factors
that contribute
to fractures

Force
Source: National Institute of Health/National Institute on Aging

Fragility

Treatment
4. BMD/DXA Testing
Single most important diagnostic test to predict whether
a person will have a fracture in the future. It helps
diagnose osteoporosis and predict the risk for having a
fracture by comparing bone density to the bones of an
average healthy young adult

Treatment
5. Cessation of smoking
Smoking can reduce bone mass, increase fracture risk and should
be avoided for a variety of health reasons

Treatment
6. Pharmacotherapy
Treatment & prevention
Bisphosphonates are approved by the FDA and can help stop or
slow bone loss, or help form new bone, and reduce the risk of
fractures
Type

Brand Name

Alendronate

Fosamax

Ibandronate

Boniva

Risedronate

Actonel

Raloxifene

Evista

Bisphosphonates
Bisphosphonates are bone-building drugs that
prevent bone resorption and remain important
treatment options for patients at risk of
debilitating fractures.
But, where does the impact on dental health
figure into the equation? What is the true
incidence of osteonecrosis of the jaw (ONJ)?

TheFacts
Approximately 125 cases of osteonecrosis have been
linked to bisphosphonate usage. The majority of these
cases have been administered through an IV to cancer
patients

Source: Bamias A. Osteonecrosis of the jaw in cancer after treatment with

bisphosphonates: incidence and risk factors. J Clin Oncol 2005;23(34):8580-7.

Bisphosphonates
A man with a hip fracture has a 1:3 chance of
dying within a year
A woman with a hip fracture has a 1:4 chance
of dying within a year
The risk for ONJ among patients taking oral
bisphosphonates is likely to be 1:100,000

Treatment
7. Patient Note
Provide the patient with written information
regarding fragility fractures and preventive
measures that can be taken. Encourage them to
speak with their primary care physicians for
additional follow-up after the fracture has healed

Treatment
8. Physician Referral
A letter sent to the primary care
physician can provide information
regarding the patients fracture and
recommend appropriate measures
be taken

FallPreventionintheHome

Use handrails on stairs, bathroom

Keep rooms free of clutter
Keep floors clean but not slippery
Wear supportive, low-heeled shoes.
Dont walk in socks; floppy slippers
Use 100 watt bulbs in all rooms
Install ceiling lighting in bedrooms
Use rubber matt in shower/tub
Keep a flashlight at bedside
Check posture in mirror often

MoreHomeFallPrevention
Keepfloorsfreefromclutter
Useportablephone;keepphoneandelectricalwiresout
ofwalkways
Skidproofbackingoncarpets/scatterrugs
Keepweekssupplyofprescriptionmedicationsonhand
Dailycontactwithfamilymember/neighbor
Contractwithmonitoringcompanyfor24hour
responsetimeinemergency
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