Cagri KARACIKLAR

19 May 2020

Fragility Fractures
Fragility fractures are fractures that result from mechanical forces that would not ordinarily result in fracture,
known as low-level (or 'low-energy') trauma, quantified by The World Health Organization (WHO) as forces
equivalent to a fall from a standing height or less. Vertebral fractures may occur without a fall.
Osteoporotic fractures are often thought to be synonymous with fragility (low energy) fractures. Hence there
is the temptation to treat all fragility fractures with agents that improve bone mineral density. However, the
root cause may not lie here.
An osteoporotic fracture is a fragility fracture which has occurred as a consequence of osteoporosis.
Osteoporosis is a major risk factor for fragility fractures; however, other causes include:
Advancing age.
Other conditions affecting bone strength, such as acromegaly or osteogenesis imperfecta.
Predisposition to falls due to loss of balance or poor muscle strength.

Osteoporosis is defined by
reduced bone mineral
density as measured by dual
energy X-ray absorptiometry
(DXA), but due to its low
sensitivity, most osteopo-
rotic fractures will occur in
people who do not have
osteoporosis as defined by T
score.

There has been some debate as to which fractures

are osteoporotic fragility fractures. Traditionally four
fractures have been regarded as osteoporotic or
fragility fractures, these being fractures of the
proximal femur, distal radius, proximal humerus, and
the thoracolumbar spine. However it is self-evident
that other fractures commonly occurring in
osteopenic or osteoporotic bone should also be
regarded as fragility fractures.

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Aetiology
Fragility fractures may result from minor falls or minor trauma. Vertebral fractures often occur without a
causative fall and may follow normal activity such as bending or lifting or sneezing.

Risk Factors
Age
From 50 years, fracture risk increases, with doubling of risk for every decade thereafter
because bone mineral density decreases and other risk factors such as
falling or comorbidities increase.
Female gender
Women are more at risk of developing osteoporosis due to menopausal
decrease in oestrogen. Women have a lower peak bone mass than men.
Family history of osteoporosis
Having a parent with a hip fracture at any time in their lives is associated
with an increased risk of fracture (independent of bone mineral density).
Previous fracture
Doubles the risk of a second fracture in both men and women.
Ethnicity
Caucasian and Asian people have a higher incidence of osteoporosis and
fractures of the hip and spine.
Menopause
Osteoclasts are more active, and bone loss increases due to decrease in
oestrogen levels following menopause or oophorectomy.
Long-term glucocorticoid therapy
Increases bone loss and impairs bone formation and calcium absorption and
muscle weakness can increase the risk of falling.
Rheumatoid arthritis
Inflammatory cytokines and impaired mobility increase bone loss.
Primary/secondary hypogonadism in men
Rapidly increases bone loss due to normal ageing or following orchidectomy
or androgen deprivation therapy.
Secondary risk factors
Disorders and medications that make the bone more fragile and/or effect
balance (increasing risk of falling). Also including immobility, inflammatory
bowel diseases, eating disorders and endocrine disorders.

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There are also modifiable risk factors for fragility fractures;

Alcohol
Excessive alcohol consumption (>2 U daily) increases the risk of a fracture by 40% due to direct adverse
effects on osteoblasts and parathyroid hormone levels; associated with poor nutritional status (calcium,
protein and vitamin D deficiency).
Smoking
The exact mechanism is unknown, but increased fracture risk is reported when there is a history of cigarette
smoking.
Low body mass index (BMI)
Regardless of age, sex and weight loss, BMI <20 kg/m is associated with a twofold increased risk of fracture
compared to people with a BMI of 25 kg/m .
Poor nutrition
Inadequate intake of calcium, vitamin D or both will
influence calcium-regulating hormones; deficiency of
either calcium or vitamin D will result in impaired
calcium absorption and lower concentration of
circulating calcium; parathyroid hormone (PTH)
secretion is stimulated, increasing PTH levels and
leading to an increase in bone remodelling,
significant loss of bone and increased risk of fracture.

Vitamin D deficiency
Vitamin D plays an essential role in calcium absorption
Eating disorders
Due to poor nutrition and vitamin D deficiency and obtaining a lower peak
bone mass in early adulthood.
Oestrogen deficiency
Accelerates bone loss and reduces the build-up of bone mass; related to
both hormone imbalance (e.g. menopause) and nutritional factors.
Insufficient exercise
Due to sedentary lifestyle; bone remodelling is regulated by mechanical
load; load-bearing physical activity and muscle activity; placing tension and
torsion on bone is detected by osteocytes.
Frequent falls

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 All humeral and all femoral fractures, with the
exception of the very rare femoral head fracture,
should now be regarded as fragility fractures as
should many long bone metaphysical fractures. It
seems likely that the problem will increase and with
increasing ageing of the population other fractures
will be regarded as fragility fractures and will be
added to the list shown in Table.

Clinical features
The most common sites for fragility fracture are the vertebrae, hip (proximal femur) and wrist (distal radius).
Other sites affected include the pelvis, ribs, arm and shoulder. Presentation is commonly to an emergency
department with acute pain after an injury; however, vertebral compression fractures may go unrecognised as
a cause of worsening back pain. Up to two thirds of these vertebral fractures are said to be unrecognised at
the time of occurrence. Following a fracture, mobility and independence may be affected, in some cases
resulting in drastic life changes, and there is potential for loss of confidence, anxiety, depression and reduced
quality of life.
Compression fractures can cause :
Pain and morbidity associated with high doses of
analgesia.
Loss of height.
Difficulty breathing.
Loss of mobility.
Gastrointestinal symptoms.
Difficulty sleeping.

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Case Finding
Case finding involves opportunistically identifying patients with osteoporosis when they present with a first
fracture, using the fracture (a risk factor itself) as the starting point. This is the first step towards identifying
those patients most urgently in need of fracture prevention through one of two approaches:
Primary prevention
Preventing the first fracture by identifying patient risk factors and starting treatment; often in primary
healthcare settings where there may be a lack of structured or organised programmes.
Secondary prevention
Preventing a second fracture after the first; assessment and treatment is performed in hospitals using
structured programmes such as fracture liaison services (FLS) and often initiated in the emergency
department.

Risk Evaluation
Bone mineral density (BMD) is a measure of bone strength
estimated by dual-energy X-ray absorptiometry (DXA). Low
BMD is the strongest risk factor for fracture. Clinical diag-
nosis of osteoporosis is based on BMD measurements and
the presence of fractures; BMD is transformed into a T-
score, which reflects the number of standard deviations
(SD) above or below the mean in healthy young adults.

Another way to estimate the risk of fracture is by using

the FRAX calculation tool, a validated web-based risk
assessment tool in the form of a questionnaire (12
questions) that calculates the 10-year risk of fracture
based on individual risk factors with or without a
known BMD. FRAX is integrated into many national
guidelines, is available in multiple languages, is easy
and quick to use and is available to any healthcare
professional through a website and mobile app-
lications. It can assist in targeting patients needing
intervention and can be used by all.

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Management
Management of fragility fractures requires
collaboration and multidisciplinary care.
Management of the acute injury may require
orthopaedic intervention, but elderly fragile
people may require medical care as inpatients
during and after surgery, physiotherapy and
occupational therapy as part of rehabilitation
during admission and following discharge.
General practitioners have a crucial role in
identifying fractures as fragility fractures and
managing secondary prevention, and before fractures occur, identifying those at risk and considering primary
preventative measures. Rheumatologists and endocrinologists are often also involved in primary and secon-
dary prevention.

Management of the acute injury

Pain relief, management of associated chronic disease,
fluid management, fracture stabilisation and surgery may
be involved. Decisions regarding surgical management
should take into account comorbidity and pre-fracture
condition. Where surgery is required, pre-operative
investigations to prevent complications or exacerbation
of existing conditions would usually include:
Chest X-ray.
ECG.
FBC, blood group and clotting studies.
Renal function.
Glucose.
Assessment of cognitive function.

For the elderly person admitted with a fragility fracture, an assessment by a geriatrician is advisable to reduce
morbidity and mortality associated with the injury and any subsequent surgery.

Treatment of low bone density

Ensure adequate calcium intake and vitamin D status, prescribing supplements if required. Dietary calcium
may be assessed by one of a number of online tools . Elderly people who are housebound or living in a
nursing home may be assumed to require vitamin D supplementation. If there is adequate dietary calcium
intake of more than 1000 mg/day but a lack of vitamin D, consider prescribing 10 micrograms (400 units) of
vitamin D without a full replacement dose of calcium. For people who have a dietary calcium intake of less
than 1000 mg/day, prescribe 10 micrograms (400 units) of vitamin D with at least 1000 mg of calcium daily.

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References
1. Falls: assessment and prevention of falls in older people; NICE Clinical Guideline
2. The Care of Patients with Fragility Fractures; British Orthopaedic Association
3. 1. Osteoporosis: assessing the risk of fragility fracture; NICE Clinical Guideline
4. Bukata SV et al (2011) A guide to improving the care of patients with fragility fractures.
5. Osteoporosis - Prevention of fragility fractures; NICE CKS
6. 17. Jarvinen TL, Michaelsson K, Jokihaara J, et al; Overdiagnosis of bone fragility in the quest to
prevent hip fracture.

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