Copyright © 2009 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Thomas A. Einhorn, MD*,
Boston University Medical Center, Boston, Massachusetts
Posted March 2009
Technological advances in science and medicine carry the promise of improving
health and preventing disease. Indeed, the advent of bone densitometry and the
use of specific sensitive serum markers of bone turnover have enhanced our ability
to prevent and treat osteoporosis. However, these technologies come with considerable
costs, and the associated requirements to monitor precision, accuracy, and reproducibility
are not insignificant. In their paper, Clinton et al. report the notable finding
that the occurrence of a proximal humeral fracture is independently associated
with a six-times higher risk of sustaining a subsequent hip fracture in the first
year after the incident fracture. Since hip fracture is arguably the most dreaded
consequence of osteoporosis, this kind of information, when provided in such
a scientifically sound and statistically robust way, provides very important
clinical information by means of an astute clinical observation.
In a cohort of 8,049 older white women with no prior history of hip or humeral
fracture who were enrolled in the Study of Osteoporotic Fractures, the risk of
hip fracture after an incident humeral fracture was estimated with the use of
age-adjusted Cox proportional hazards regression analysis with time-dependent
variables. Women without a humeral fracture served as the controls. This analysis
was also used to evaluate the timing between proximal humeral and subsequent
hip fracture. The Study of Osteoporotic Fractures is a prospective multicenter
cohort study of 9,704 women, sixty-five years of age and older, from four separate
geographic areas and possibly represents the most powerful source of clinical
data on osteoporotic fractures ever collected. It has yielded numerous reports
of high scientific quality and strong clinical impact, and the article by Clinton
et al. appears to be another.
Proximal humeral fractures commonly occur in patients with osteoporosis, with
up to 73% occurring in women1-3. It is the second most common upper-extremity
fracture1-3, and at least two prior studies have suggested that proximal
humeral fractures appear to be a risk factor for other incident fractures, including
those of the hip4,5. Johnell et al. found that the time of highest
risk of hip fracture was immediately following the incident fracture and that
the risk decreased with time6. Moreover, these authors suggested that
a fracture of the proximal part of the humerus may be predictive of an increased
risk of a subsequent hip fracture and invoked the intriguing hypothesis that
the mechanism of proximal humeral fracture is similar to that of hip fracture
in that when an individual is unable to break a forward or oblique fall, that
person would tend to land directly on the shoulder or the hip.
The results of this study have important implications for the evaluation,
treatment, and prevention of fractures in patients who have sustained a proximal
humeral fracture. Not only do the authors suggest that it is essential to initiate
treatment as quickly as possible, they also lead us to consider if other risk
factors need to be identified. Indeed, a recent meta-analysis demonstrated that
a multifaceted approach is required to prevent falls in hospitals and nursing
homes and that no single intervention has proved to be successful7.
While studies have shown that oral bisphosphonate treatment reduces the risk
of fractures within three to six months after treatment has begun, nearly 80%
of proximal humeral fractures and 90% of hip fractures are associated with a
fall from a standing height. Thus, the propensity to fall is another important
risk factor that must be addressed8,9.
The findings and relevance of this study are consistent with emerging trends
in the management of patients with osteoporosis. This study focuses our attention
on the role of humeral fracture in predicting future hip fracture, but within
the past few years, an even more sophisticated approach to this question has
led to the development of the World Health Organization's FRAX tool, an instrument
that allows computation of the ten-year probability of fractures in men and women
from clinical risk factors with or without measurement of femoral bone mineral
density. Indeed, the FRAX tool captures humeral fracture as one of the risk factors
in its calculation10,11.
Orthopaedic surgeons are more aware than ever of the essential role they play
in identifying patients who have osteoporosis and associated bone diseases. Within
the past several years, The Journal has published several reports identifying
the effectiveness of clinical initiatives that have led to improved outcomes
for patients12-14. These types of programs, as well as the recent "Own
the Bone" initiative championed by the American Orthopaedic Association, have
positioned orthopaedic surgeons to make a much needed impact on improving the
skeletal health of their patients and preventing future fractures.
*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
References
1. Karagas MR, Baron JA, Barrett JA, Jacobsen SJ. Patterns of fracture among the United States elderly: geographic and fluoride effects. Ann Epidemiol, 1996;6:209-16.
2. Seeley DG, Browner WS, Nevitt MC, Genant HK, Scott JC, Cummings SR. Which fractures are associated with low appendicular bone mass in elderly women? The Study of Osteoporotic Fractures Research Group. Ann Intern Med. 1991;115:837-42.
3. Palvanen M, Kannus P, Niemi S, Parkkari J. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res. 2006;442:87-92.
4. Lauritzen JB, Schwarz P, McNair P, Lund B, Transbøl I. Radial and humeral fractures as predictors of subsequent hip, radial or humeral fractures in women, and their seasonal variation. Osteoporosis Int. 1993.3:133-7.
5. Robinson CM, Royds M, Abraham A, McQueen MM, Court-Brown CM, Christie J. Refractures in patients at least forty-five years old. A prospective analysis of twenty-two thousand and sixty patients. J Bone Joint Surg Am. 2002;84:1528-33.
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7. Oliver D, Connelly JB, Victor CR, Shaw FE, Whitehead A, Genc Y, Vanoli A, Martin FC, Gosney MA. Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses.
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10. Kanis JA, Oden A, Johnell O, Johansson H, De Laet C, Brown J, Burckhardt P, Cooper C, Christiansen C, Cummings S, Eisman JA, Fujiwara S, Glüer C, Goltzman D, Hans D, Krieg MA, La Croix A, McCloskey E, Mellstrom D, Melton LJ 3rd, Pols H, Reeve J, Sanders K, Schott AM, Silman A, Torgerson D, van Staa T, Watts NB, Yoshimura N. The use of clinical risk factors enhances performance of BMD in the prediction of hip and osteoporotic fractures in men and women. Osteoporos Int. 2007;18:1033-46.
11. Kanis JA, Johnell O, Oden A, Johansson H. McCloskey E. FRAX and the assessment of fracture probability in men and women from the UK. Osteoporosis Int. 2008;19:385-97.
12. Haentjens P, Autier P, Collins J, Velkeniers B, Vanderschueren D, Boonen S. Colles fracture, spine fracture, and subsequent risk of hip fracture in men and women. A meta-analysis. J Bone Joint Surg Am. 2003;85:1936-43.
13. Bogoch ER, Elliot-Gibson V, Beaton DE, Jamal SA, Josse RG, Murray TM. Effective initiation of osteoporosis diagnosis and treatment for patients with a fragility fracture in an orthopaedic environment. J Bone Joint Surg Am. 2006;88:25-34.
14. Sander B, Elliot-Gibson V, Beaton DE, Bogoch ER, Maetzel A. A coordinator program in post-fracture osteoporosis management improves outcomes and saves costs. J Bone Joint Surg Am. 2008;90:1197-205.
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