Copyright © 2009 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
John Kaufman, MD*,
Santa Clarita, California
Posted October 2009
Many of us who have followed the osteoporosis field over the last twenty years
have noticed an increased awareness of fragility fractures by orthopaedic surgeons.
This beneficial trend has resulted in the satisfactory treatment of osteoporosis-related
fractures in a larger numbers of patients. The importance of this cannot be understated,
as it has been shown many times that sustaining one fracture increases the risk
of sustaining additional osteoporotic fractures1.
Hip and vertebral fractures have typically been associated with osteoporosis,
and patients with these fractures are increasingly being treated or referred
for treatment. This has not been the case with distal radial fractures. This
fact is unfortunate, as the majority of fragility fractures involve the forearm.
Patients who present with distal radial fractures are usually younger than patients
who present with hip and vertebral fractures. The identification of osteoporosis
in these younger patients therefore would present a tremendous opportunity to
start treatment early in order to prevent future fractures2.
The first thing that can be said of the paper by Gong et al. in this issue of The Journal is
with regard to the large study size. Utilizing a nationwide database in South
Korea that contained information for 97% of the South Korean population, the
authors looked at more than 150,000 fractures that occurred during 2007. This
size alone makes the study worthy of note. The results show a significant difference
(p < 0.001) between the number of patients with hip or vertebral fractures
who received a referral for bone density testing or who received treatment for
osteoporosis as compared with the number of patients with distal radial fractures
who received referrals and treatment. Only 7.5% of female patients with wrist
fractures received treatment for osteoporosis as compared with 21.9% of female
patients with hip fractures and 30.1% of female patients with vertebral fractures.
Many health-care providers and many patients themselves do not have the perception
that a wrist fracture may be associated with osteoporosis and in need of osteoporosis
follow-up and possible treatment. This study confirms that, in comparison with
hip and vertebral fractures, a disproportionate number of distal radial fractures
are not being identified properly as fragility fractures. This may be related
to the many ongoing media promotional activities that stress the need to prevent
hip and spinal fractures. Wrist fractures have been largely disregarded even
though the relationship to osteoporosis has been documented in the orthopaedic
literature3.
The Korean health system is somewhat different than the American system in
that most fractures are treated and also followed up by a
"musculoskeletal specialist," often an orthopaedic surgeon. A primary-care doctor
may not be involved. Although the American system works differently, the orthopaedic
surgeon is still responsible for most patients who have sustained a fracture
and, in fact, may be the only health-care provider the patient ever sees. In
all likelihood, the results of this study would be similar to the results seen
in an American population.
The paper does not include men or women with multiple fractures, as these
types of patients would be more prone to have been involved in high-energy trauma.
Although recent data have shown that patients with low bone density are more
prone to fracture even in high-energy trauma events4, this exclusion
makes good sense. The study population is so large that even excluding these
patients does not make the conclusions any less significant; in fact, the exclusion
probably increases the accuracy of the results.
Many barriers have been identified that interfere with the recognition of
fragility fractures as those needing osteoporosis management5,6. These
include misconceptions and a lack of knowledge on the part of both the physician
and the patient. The relevance to the orthopaedic surgeon is clear. Hip and vertebral
fractures are not the only fractures associated with osteoporosis. Plainly, an
opportunity to recognize other fractures that typically also are fragility fractures
must not be missed. These include not only distal radial fractures but also proximal
humeral fractures, pelvic fractures, and, in fact, most other fractures that
may occur as the result of a fall from a standing height.
*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. Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA 3rd, Berger M. Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res. 2000;15:721-39.
2. Rozental TD, Makhni EC, Day CS, Bouxsein ML. Improving evaluation and treatment for osteoporosis following distal radial fractures. A prospective randomized intervention. J Bone Joint Surg Am. 2008;90:953-61.
3. Freedman KB, Kaplan FS, Bilker WB, Strom BL, Lowe RA. Treatment of osteoporosis: are physicians missing an opportunity? J Bone Joint Surg Am. 2000;82:1063-70.
4. Mackey DC, Lui LY, Cawthon PM, Bauer DC, Nevitt MC, Cauley JA, Hillier TA, Lewis CE, Barrett-Connor E, Cummings SR; Study of Osteoporotic Fractures (SOF) and Osteoporotic Fractures in Men Study (MrOS) Research Groups. High-trauma fractures and low bone mineral density in older women and men. JAMA. 2007;298:2381-8.
5. Switzer JA, Jaglal S, Bogoch ER. Overcoming barriers to osteoporosis care in vulnerable elderly patients with hip fractures. J Orthop Trauma. 2009;23:454-9.
6. Kaufman JD, Bolander ME, Bunta AD, Edwards BJ, Fitzpatrick LA, Simonelli C. Barriers and solutions to osteoporosis care in patients with a hip fracture. J Bone Joint Surg Am. 2003;85:1837-43.
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