Do Incident Wrist Fractures Increase the Risk for Subsequent Fractures?
Authors:
Nicole C. Wright, Meryl LeBoff, Carolyn Crandall, on behalf of the Bone SIG
Background:
- Having a fracture increases your risk for a second fracture
- Wrist fractures
o 1. GLOW
2. J Clin Densitom. 2004 Winter;7(4):419-23.Forearm bone mineral density in 1294 middle-aged
women: a strong predictor of fragility fractures.Holmberg A, Johnell O, Akesson K, Nilsson
P, Nilsson JA, Berglund G.
Abstract
The aim of this study was to find out whether a single bone mineral density (BMD)
measurement performed at middle age in early postmenopausal women could predict future
fragility fractures. The Malmo Preventive Project, a population-based cardiovascular prevention
study, included a subgroup of 1294 women, mean age 53, on which forearm BMD
measurements were made using single-photon absorptiometry (SPA). Risk ratios (RRs) were
calculated for an age-adjusted decrease in BMD of one standard deviation. During the 9-yr
follow-up, 65 women sustained 86 fractures. The data were analyzed with Cox's proportional
hazard analysis. The relative risk for sustaining any fragility fracture were 2.02 (95% confidence
interval [CI] = 1.56-2.61) and 1.62 (CI = 1.26-2.08) at the distal and proximal forearm BMD
measurement, respectively. The risk increase was significant for forearm fracture at the distal
BMD level (RR = 1.94; range = 1.40-2.68) and at the proximal BMD level (RR = 1.77; range =
1.29-2.42). Our study is one of the first to show that a BMD measurement in a population at age
50 can predict fracture over almost 10 yr, indicating that early identification of women with
increased fracture risk is possible, and the cost-effectiveness of such an approach needs to be
further evaluated.
3. Osteoporos Int. 1999;9(6):469-75. Forearm fractures as predictors of subsequent
osteoporotic fractures.Cuddihy MT, Gabriel SE, Crowson CS, O'Fallon WM, Melton LJ 3rd.
Abstract
To assess the ability of distal forearm fractures to predict future fractures, we conducted a
population-based retrospective cohort study among the 1288 residents (243 men, 1045 women)
of Rochester, Minnesota age 35 years or older who experienced their first distal forearm fracture
in 1975-94. During 9664 person-years of follow-up, 548 patients experienced 1109
subsequent fractures, excluding 195 that occurred on the same day as the
index forearm fracture. The cumulative incidence of any subsequent fracture was 55% by 10
years and 80% by 20 years following the initial distalforearm fracture. Compared to expected
fracture rates in the community, the risk of a hip fracture following the index forearm fracture
was increased 1.4-fold in women (95% CI, 1.1-1.8) and 2.7-fold in men (95% CI, 0.98-5.8). In
women, the risk of hip fracture differed by age, as we had found in a previous study. Women
over age 70 had a 1.6-fold increase (95% CI, 1.2-2.0) in subsequent hip fracture risk whereas
women who sustained their firstforearm fracture before age 70 years did not have significantly
increase risk. By contrast, vertebral fractures were significantly increased at all ages, with a 5.2fold increase (95% CI, 4.5-5.9) in risk among women and a 10.7-fold increase (95% CI, 6.716.3) among men following a first distal forearmfracture. The increased risk in men suggests
that a sentinel forearm fracture should not be ignored. Among the women, we also found a
missed opportunity for intervention as hormone replacement therapy was underutilized.
4. Calcif Tissue Int. 1993 Apr;52(4):269-72. Fracture of the distal forearm as a forecaster of
subsequent hip fracture: a population-based cohort study with 24 years of follow-up. Mallmin
H, Ljunghall S, Persson I, Naessén T, Krusemo UB, Bergström R.
Abstract
OBJECTIVE:
To determine the long-term risk of hip fracture following fracture of the distal forearm.
DESIGN:
Registry-based cohort study comparing patients with a fracture of the distal forearm with a
population-based cohort. FRACTURE COHORT: All women and men above 40 years of age
with a radiologically verified fracture of the distal forearm during a 5-year period, 1968-1972, in
all 1,126 women and 212 men. CONTROL COHORT: An equal number of population-based,
age- and sex-matched control persons selected from a population register.
MEASUREMENTS:
All cohort members were followed up individually through record linkage until the first hip
fracture, emigration, death, or the end of 1991. The cohort members contributed a total of
40,832 person-years of observation, and altogether 365 cases of hip fractures were observed.
RESULTS:
Both women and men with a fracture of the distal forearm ran an increased risk of sustaining a
subsequent hip fracture. The overall relative hazard for the women was 1.54 and for men 2.27.
The increased risk in the women was independent of age at inclusion, but that in the men was
more pronounced in the younger age groups.
CONCLUSIONS:
Patients with a fracture of the distal forearm run an increased risk of sustaining a subsequent
hip fracture. They therefore appear to constitute a group in which appropriate prophylactic
measures against osteoporosis and fractures should be considered.
5. Osteoporos Int. 2002 Aug;13(8):624-9. Does a fracture at one site predict later fractures at
other sites? A British cohort study. van Staa TP, Leufkens HG, Cooper C.
Abstract
The extent to which a fracture at one skeletal site predicts further fractures at other sites
remains uncertain. We addressed this issue using information from the UK General Practice
Research Database, which contains the medical records of general practitioners; our study
population consisted of all patients aged 20 years or older with an incident fracture during 1988
to 1998. We identified 222 369 subjects (119 317 women, 103 052 men) who had sustained at
least one fracture during follow-up. There was a 2- to 3-fold increase in the risk of subsequent
fractures at different skeletal sites. A patient with a radius/ulna fracture had a standardized
incidence ratio (SIR) of 3.0 (95% confidence interval 2.9-3.1) for fractures at a different skeletal
site; for initial vertebral fracture, this ratio was 2.9 (2.8-3.1) and for initial femur/hip fracture it
was 2.6 (2.5-2.7). The SIRs were generally higher among men than women. Men aged 65-74
years with a radius/ulna fracture or vertebral fracture had substantially higher rates of
subsequent femur/hip fractures than expected; SIRs were 6.0 (3.4-9.9) and 13.4 (7.3-22.5).
Corresponding SIRs among women of similar age were 3.3 (2.8-3.9) and 5.8 (4.1-8.1),
respectively. Men and women aged 65 years or older with a vertebral fracture had a 5-year risk
of femur/hip fracture of 6.7% and 13.3%, respectively. Our results indicate that fractures at any
site are strong risk factors for subsequent fractures, among both elderly men and women.
6. JAMA. 2007 Jan 24;297(4):387-94. Risk of subsequent fracture after low-trauma fracture
in men and women. Center JR, Bliuc D, Nguyen TV, Eisman JA.
7 . Osteoporos Int. 1993 May;3(3):133-7. Radial and humeral fractures as predictors of
subsequent hip, radial or humeral fractures in women, and their seasonal variation. Lauritzen
JB, Schwarz P, McNair P, Lund B, Transbøl I.
Abstract
Hip fractures are common in elderly women, and early risk assessment of future hip fractures is
relevant in relation to prevention. We studied the predictive value of radial and humeral fractures
in women. The influence of weather conditions on the risk was also studied. Women aged 20-99
years with a fracture of the distal radius (n = 1162) or proximal humerus (n = 406) were followed
for 0 to 9 years. The relative risk (RR) and 95% confidence limits (CL) of subsequent fracture
among women suffering radial or humeral fractures compared with the background population
were calculated. Women 60-79 years of age who had suffered a fracture of the distal radius or
proximal humerus had relative risks of sustaining a hip fracture of 1.9 (1.3-2.6, 95% CL) and 2.5
(1.3-3.6, 95% CL) respectively. The relative risk of hip fracture was highest within the first years
following a fracture of the radius or the humerus. Women suffering an upper extremity fracture
(radius or humerus) in snowy or icy weather had a marginally increased risk (RR = 1.3, 0.4-2.3,
95% CL and RR = 1.8, 0.3-3.4, 95% CL) for a later hip fracture. A woman 50 years old with a
radial or a humeral fracture had an estimated residual lifetime risk of sustaining a subsequent
hip fracture of 17% and 16% respectively compared with 11% for the background
population.(ABSTRACT TRUNCATED AT 250 WORDS)
Objective:
To investigate the risk of subsequent fractures following a wrist fracture among participants of
the Women’s Health Initiative
Study Population:
WHI participants with Medicare with 13+ months of traditional fee-for-service coverage (A+B-C)
Methods:
Exposure- wrist fracture (distal radius/ulna, distal forearm)
An incident wrist fracture will defined as women meeting the case qualifying definition of a wrist
fracture that do not have any evidence of a fragility fracture in the first 12 months of A+B-C
coverage (baseline period) AND did not report having a prior fracture on baseline WHI
questionnaire.
Outcome- fragility fracture
Any fragility fracture (hip, spine, wrist, humerus, pelvis, femur) will be considered an incident
outcome if it is at least 90 days post wrist fracture
CovariatesOsteoporosis diagnoses
Follow-up TimeStart date – day of fracture
End date – day of first incident fracture, day of loss of A+B-C coverage, day of death, last day of
Medicare data
Statistical AnalysisWe will calculate the crude and age-adjusted total fracture and fracture-specific incidence rates
for the entire population as well as by age of wrist fracture (65-69, 70-74, 75-79, 80+) (Table 1).
Total
Population
N
IR/py
65-69
70-74
75-79
80+
N
IR/py
N
IR/py
N
IR/py
N
IR/py
All Fragility Fractures
Wrist
Humerus
Spine
Hip
Pelvis
Femur
We will used Cox-proportional hazards models to investigate the fragility fracture risk associated
with wrist fracture after adjustments for covariates (Table or time to event figure). Sensitivity
analyses will include:
References: