n Feature Article
Medical Management of Fragility Fractures
of the Distal Radius
CPT Emily N. Morgan, MD; MAJ David A. Crawford, MD; MAJ William F. Scully, MD;
LTC Nicholas J. Noce, MD
abstract
Full article available online at Healio.com/Orthopedics
Fragility fractures of the distal radius represent an opportunity to diagnose and treat osteoporosis before further fractures occur. The goal of this study was to determine the prevalence of prescriptions for calcium/vitamin D supplementation and the prevalence of dualenergy x-ray absorptiometry (DEXA) scans in patients who sustained fragility fractures of
the distal radius. A further goal was to determine the prevalence of patients who received
prescriptions for the treatment of osteoporosis after DEXA scans. The authors performed a
retrospective review of all patients 50 years and older who sustained a fragility fracture of
the distal radius and were treated by the orthopedic surgery service at the authors’ institution from 2004 to 2010. After a fragility fracture of the distal radius, fewer than 25% of
previously unidentified at-risk patients received a prescription for vitamin supplementation and underwent a DEXA scan. Women were 7 times more likely than men to receive
calcium/vitamin D supplementation, 14 times more likely to undergo a DEXA scan for the
evaluation of osteoporosis, and 25 times more likely to receive a prescription for bisphosphonates. Patients who underwent a DEXA scan were 9 times more likely to receive
pharmacologic treatment than those who did not undergo this scan. More than half of
patients did not receive a prescription for calcium/vitamin D supplementation and did not
undergo DEXA scanning as recommended by current National Osteoporosis Foundation
guidelines. Most patients who received prescriptions or underwent DEXA scans did so
before rather than after fracture, indicating poor compliance with National Osteoporosis
Foundation guidelines. [Orthopedics. 2014; 37(12):e1068-e1073.]
Figure: A fragility fracture of the distal radius before closed reduction and molded cast application.
The authors are from the Department of Orthopaedics (ENM, NJN), Madigan Army Medical Center,
Tacoma, Washington; the Department of Orthopaedics (DAC), Blanchfield Army Community Hospital,
Fort Campbell, Kentucky; and the Orthopaedics Service, Department of Surgery (WFS), Martin Army
Community Hospital, Fort Benning, Georgia.
The authors have no relevant financial relationships to disclose.
The views expressed in this article are those of the authors and do not reflect the official policy of the
Department of the Army, the Department of Defense, or the US Government.
Correspondence should be addressed to: CPT Emily N. Morgan, MD, Department of Orthopaedics,
Madigan Army Medical Center, 9040A Fitzsimmon Dr, Tacoma, WA 98431 (emily.n.morgan3.mil@mail.
mil).
Received: January 18, 2014; Accepted: March 5, 2014; Posted: December 10, 2014.
doi: 10.3928/01477447-20141124-53
e1068
ORTHOPEDICS | Healio.com/Orthopedics
n Feature Article
O
steoporosis is defined by the National Institutes of Health as a
skeletal disorder characterized
by low bone strength and increased risk
of fracture.1 The lifetime risk of osteoporosis is approximately 50% in women
and 13% to 25% in men.2 According to
recent estimates, 10 million Americans
currently have osteoporosis and by 2020
approximately 14 million Americans
older than 50 years will have this condition.3,4 The incidence of osteoporotic
fractures currently exceeds that of breast
cancer, stroke, and myocardial infarction
combined.5
Osteoporotic, or fragility, fractures
have a significant economic effect, with
an annual cost of $19 billion.6 These injuries also have a significant effect on the
use of health care. Osteoporotic fractures
result in 432,000 hospital admissions, 2.5
million medical office visits, and approximately 180,000 nursing home admissions
annually in the United States.4 Most concerning, however, is the indirect effect of
these fractures on patient morbidity and
mortality. Approximately 1 in 5 patients
with an osteoporotic fracture, especially
involving the proximal femur, will die
within 12 months of injury.7
The treatment of fragility fractures of
the distal radius highlights the high costs
and time-intensive demands associated
with osteoporotic injuries. Distal radius
fractures often require formal reduction
and immobilization (Figures A-B) and
may require surgery (Figures C-D), with
the inherent costs and resource expenditures associated with these procedures and
subsequent care. However, fragility fractures also represent an important early opportunity to diagnose, treat, and potentially prevent future osteoporotic fractures.8
Fragility fractures of the distal radius are
associated with an increased risk of future
hip fracture in both men and women.9-12
Therefore, these injuries can be used to
detect osteoporosis and initiate treatment
before these predisposed patients sustain
more serious fragility fractures.
DECEMBER 2014 | Volume 37 • Number 12
B
A
D
C
Current recommendations by the National Osteoporosis Foundation (NOF) for
patients older than 50 years who sustain a
fragility fracture of the distal radius include:
(1) initiation of calcium/vitamin D supplementation and (2) completion of a dual-energy x-ray absorptiometry (DEXA) scan.1
Based on the results of the DEXA scan, additional treatment may be warranted.
Studies of the efficacy of calcium/
vitamin D supplementation in preventing
Figure: Examples of fragility fractures of the distal
radius. A fragility fracture before (A) and after (B)
closed reduction and molded cast application. A fragility fracture before (C) and after (D) open reduction and internal fixation.
fragility fractures have had problems with
patient compliance, leading to mixed results.13 However, based on the available
data, calcium/vitamin D supplementation can decrease bone loss and prevent
at least 12% to 29% of subsequent fractures in compliant patients.14,15 In addition
to calcium/vitamin D supplementation,
the NOF recommends treatment with
bisphosphonates, calcitonin, teriparatide,
e1069
n Feature Article
Table 1
Interventions Related to Prevention, Diagnosis, or Treatment of
Osteoporosisa
Timing
Calcium/
Vitamin D
DEXA Scan
Treatment
Nonestrogen
Treatment
Before, No.
68 (32%)
95 (45%)
113 (54%)
61 (29%)
After, No.
34 (24%)
26 (23%)
12 (12%)
25 (17%)
Total, No.
102 (48%)
121 (58%)
125 (60%)
86 (41%)
Abbreviation: DEXA, dual-energy x-ray absorptiometry.
a
No patients within the study cohort received a prescription for teriparatide or raloxifene.
Percentage of patients who received calcium/vitamin D supplementation, underwent a
DEXA scan, and/or received a prescription for pharmacologic treatment of osteoporosis to
include bisphosphonates, calcitonin, teriparatide, estrogen, and/or raloxifene before or after
sustaining a fragility fracture of the distal radius.
Table 2
Patients Who Received Pharmacologic Treatment for
Osteoporosis Before Fragility Fracture, After Fracture, and
Combined (Total)a
Timing
Bisphosphonates
Teriparatide
Calcitonin
Estrogen
Raloxifene
Before, No.
60 (29%)
0 (0%)
10 (5%)
88 (54%)
0 (0%)
After, No.
25 (17%)
0 (0%)
3 (2%)
1 (1%)
0 (0%)
Total, No.
85 (40%)
0 (0%)
13 (6%)
89 (54%)
0 (0%)
a
Percentage for each group after fracture computed by dividing the number of patients
who received a prescription for that particular medication by the total number of patients
remaining who had not already received each particular prescription. Estrogen/hormonal
therapy expressed as the percentage of female patients within the study.
estrogen or hormonal therapy, raloxifene,
and/or denosumab for patients diagnosed
with osteoporosis.4 Bisphosphonates not
only have been found to be cost-effective
for the treatment of osteoporosis in reducing future hip fractures but also are associated with a 50% reduction in vertebral
fractures and a 20% to 30% reduction in
nonvertebral fractures.6,16
Although the magnitude of this problem is beginning to be more fully recognized, much remains to be studied. The
goal of this study was to evaluate a cohort
of patients older than 50 years who sustained fragility fractures of the distal radius. By analyzing the diagnostic studies
and pharmacologic treatment that these
patients received, the authors sought to
e1070
identify general trends and potential opportunities to improve patient treatment
after fragility fracture of the distal radius.
Materials and Methods
The cohort of patients was drawn from
a military facility that serves a beneficiary
population that covers a 6-state region.
The authors performed a retrospective review of all men and women 50 years and
older who were treated for a fragility fracture of the distal radius between January
2002 and July 2010 at the authors’ institution. Menopausal status of female patients
was not included in the medical record.
Therefore, the authors included all female
patients 50 years and older to capture all
postmenopausal women within the study
because the average age at menopause has
previously been reported to be 51 years.17
Patients were identified through the electronic medical record by a combination of
International Classification of Diseases,
9th edition (ICD-9), and Current Procedural Terminology (CPT) codes. Patients
with high-energy mechanisms of injury,
pathologic fracture, or iatrogenic fracture
were excluded.
Patient records were reviewed to determine whether and when a DEXA scan had
been performed and the resulting T-score.
Records were also examined to determine
whether and when each patient received a
prescription for calcium/vitamin D supplementation, bisphosphonates, calcitonin,
teriparatide, estrogen, and/or raloxifene.
Denosumab was not available at the authors’ institution within the study period,
so it was not included. Patients were divided into cohorts by sex. Power analysis
determined that a group of 30 patients per
cohort was required to determine the statistical significance of the results. These
endpoints were examined for statistical
significance with the chi-square test, Fisher
exact test, and Student’s t test as indicated.
Results
During the study period, 210 patients
were identified. Of this group, 46 were
male (22%) and 164 were female (78%).
The average patient age was 67 years,
with a standard deviation of 10.6 years.
Sixty-six patients required operative treatment for a fracture, representing 31% of
the patient population. Among the entire
patient population, 48% received calcium/
vitamin D supplementation and 58% underwent a DEXA scan in accordance with
NOF guidelines.
Approximately one-third of the patients studied were receiving calcium/
vitamin D supplementation (32%) before
injury. Forty-five percent of the patients
had obtained a DEXA scan before their
distal radius fracture. Fifty-four percent
of the patients were receiving a drug included in the NOF guidelines for the treat-
ORTHOPEDICS | Healio.com/Orthopedics
n Feature Article
Table 3
Interventions Related to Prevention, Diagnosis, or Treatment of Osteoporosis by Sex
Sex
Calcium/Vitamin D
DEXA Scan
Bisphosphonates
Calcitonin
Female, %
0.60
0.72
0.51
0.05
Male, %
0.09
0.05
0.02
0.02
Abbreviation: DEXA, dual-energy x-ray absorptiometry.
a
No patients within the study cohort received a prescription for teriparatide. The sex disparity was statistically significant, P=.028. Patients
within each cohort by sex who received calcium/vitamin D supplementation, underwent a DEXA scan, or received a prescription for
bisphosphonates or calcitonin before or after sustaining a fragility fracture of the distal radius.
ment of osteoporosis before the fracture
occurred. However, 51 of the 113 patients
included in the patient group receiving
treatment before injury, or 45% of this
patient cohort, were women being treated
with estrogen for unknown conditions and
may not have been receiving this medication specifically for osteoporosis. With estrogen removed from the pool of pharmacologic treatments for osteoporosis, 29%
of the patients received a prescription
for a drug designated by the NOF for the
treatment of osteoporosis before the distal
radius fracture occurred (Tables 1-2).
To assess provider compliance with
NOF guidelines, postinjury data percentages were calculated after elimination
of patients who had already received the
recommended treatment or diagnostic
procedure. Twenty-four percent of the
patients who were prescribed calcium/
vitamin D after the fracture occurred had
not received supplementation before their
fracture. This finding was not statistically
significant, with P=.1. Additionally, 23%
of patients who had not previously had a
DEXA scan were sent for the study after
injury. This difference in the number of
patients who underwent a DEXA scan before vs after sustaining a fragility fracture
was statistically significant, with P<.0001.
Twelve percent of patients who had
not received a prescription for pharmacologic treatment of osteoporosis received
a prescription after fracture. The difference between patient groups receiving a prescription for the treatment of
DECEMBER 2014 | Volume 37 • Number 12
osteoporosis before and after a fragility
fracture of the distal radius was statistically significant, with P<.0001. This significance was maintained when estrogen
was excluded, with P=.0083, suggesting a
statistically significant difference for the
prescription of pharmacologic treatment
in patient groups before and after fragility
fracture (Table 1). When each pharmacologic agent was considered, a statistically
significant difference was also found between patients who received bisphosphonates before (29%) and after fracture
(17%), with P=.01. In women, a statistically significant difference was seen between the prescription of estrogen before
and after fracture, with P<.001 (Table 2).
Most patients received treatment before
injury rather than after, suggesting that
the distal radius fracture was not the event
that led to recognition of the increased
risk of subsequent fracture.
Further data analysis showed a sex disparity within the patient cohort. Women
were 7 times more likely than men to
receive calcium/vitamin D supplementation and 14 times more likely than men
to undergo a DEXA scan for the evaluation of osteoporosis. Even with estrogen
excluded, women were more likely to receive pharmacologic agents for the treatment of osteoporosis. They were 25 times
more likely to receive bisphosphonates
and twice as likely to receive calcitonin
(Table 3).
A DEXA scan was shown to be a helpful tool in the diagnosis of osteopenia and
osteoporosis in this population. It was also
associated with a higher prevalence of
supplementation and pharmacologic treatment. Among patients who underwent a
DEXA scan, 87% had either osteoporosis
or osteopenia. Twenty-nine percent of patients were diagnosed with osteoporosis
and 58% were diagnosed with osteopenia,
according to DEXA scan results. Among
patients who underwent a DEXA scan,
97% received a prescription for calcium/
vitamin D supplementation, bisphosphonates, estrogen, or calcitonin, compared
with 26% among patients who did not
undergo a DEXA scan. This finding was
statistically significant, with P<.001.
Discussion
Distal radius fractures have long been
associated with poor bone quality in older
patients.9,18 Despite this well-established
association, provider response to distal radius fragility fractures in the elderly continues to be inadequate. The results of this
study, with only 24% of patients receiving
calcium/vitamin D and 23% being referred
for a DEXA scan postinjury among those
who had not already received these measures, reflects these persistent inadequacies
in recognition and treatment. Similar poor
results, related to both initiation of supplementation and completion of a DEXA scan
after fracture, have been reported elsewhere.4,8,18 This leads to the question of
how best to address the lack of intervention
directed toward the prevention, detection,
and treatment of osteoporosis.
e1071
n Feature Article
Although the results of this study cannot answer this question, the data may provide some clues and indicate trends. First,
the patient population with distal radius
fractures comprised 167 women and 46
men, which closely mirrors the commonly
quoted female-to-male ratio of 4:1.19 This
suggests that the patient cohort was representative of the general population. Of
those who were ordered a DEXA scan either before or after injury, 87% were diagnosed with either osteopenia or osteoporosis, reinforcing the idea that these patients
could benefit from intervention.
At the time of injury, approximately
one-third of patients had already been
given calcium/vitamin D supplementation
and had completed a bone mass density
study by DEXA scan. Fifty-four percent
of the patients had also received a prescription for a drug to treat osteoporosis
before the fracture occurred. The reasons
why this subset of patients had already
been identified are likely variable and
include a history of fragility fractures,
other medical diagnoses that prompted
evaluation and treatment for osteoporosis, and a health care provider who was
particularly diligent or conscious of bone
health. Many of the women in the study
were receiving estrogen before fracture,
likely for the treatment of other medical
conditions. Of the remaining patients who
had not received supplementation or undergone a DEXA scan before injury, very
few received the suggested treatment protocol as suggested by the NOF. The authors propose two reasons to explain these
results: (1) complications associated with
defining the role of orthopedic providers
in the medical management of osteoporosis and (2) sex bias.
Multiple studies have shown concern
by orthopedic surgeons about ordering
diagnostic studies and pharmacologic
treatment for osteoporosis.20 The cause
for concern is likely multifactorial and
includes apprehension about managing
the side effect profile of many medications, most notably bisphosphonates, and
e1072
the time-intensive nature of ordering and
reviewing serial DEXA scans. To provide
appropriate care for patients who require
bone health monitoring and medical treatment, many studies advocate either hiring
a dedicated provider within the orthopedic
practice to manage these patients or establishing an easily accessible and trusted
referral network with local primary care
providers to manage this aspect of patient
care.20,21 As a result of this study and in
recognition of this weakness within their
system, the authors established a dedicated orthopedic osteoporosis clinic within
their department. A policy has also been
instituted whereby all patients presenting
with a fragility fracture, whether through
a clinic or the emergency department, are
referred to this designated provider, who
ensures that the appropriate medications
and studies are ordered and subsequently
reviewed.
A sex disparity was evident in both the
evaluation and treatment of osteopenia/
osteoporosis, similar to previously published findings.18 Recognition and correction of this treatment gap is vital. Men
have an even greater risk than women
of subsequent hip fracture after a distal
radius fracture.10-12 Along with this increased risk of future hip fractures, men
have increased mortality and morbidity
rates after a hip fracture. Men are twice as
likely as women to die after a hip fracture
and are less likely than women to return
to autonomous living.22,23 Given that men
traditionally have been more likely than
women to have a fracture as their initial
presentation of osteoporosis,13 injuries
such as distal radius fragility fractures
provide an excellent opportunity to capture this patient population and initiate
treatment.
The results of this study also suggest
that patients who are ordered a DEXA
scan are more likely to be treated for osteoporosis subsequently with both calcium/vitamin D supplementation and pharmacologic agents. Simply recognizing the
underlying bone health considerations of
an injury such as a distal radius fragility
fracture and beginning the evaluation process can improve the likelihood that these
patients will receive the appropriate treatment.
One limitation of the current study was
the relatively smaller number of male vs
female patients. However, as previously
mentioned, this is representative of the
typical sex ratio of those sustaining this
injury and the decreased prevalence of osteoporosis in men. Another limitation of
the study was the inability to capture prescriptions that were placed through pharmacies outside of the authors’ network as
well as the use of over-the-counter calcium/vitamin D supplementation, which
may have affected the results.
Conclusion
Fragility fractures of the distal radius
represent an often missed opportunity to
diagnose and treat osteoporosis before a
more morbid fragility fracture occurs.
Establishing specific osteoporosis providers for each orthopedic institution and
improving recognition of this harbinger
of underlying bone disease, particularly
in men, will improve the overall medical
care provided for these patients.
References
1. Unnanuntana A, Gladnick BP, Donnelly E,
et al. The assessment of fracture risk. J Bone
Joint Surg Am. 2010; 92(3):743-753.
2. Wright VJ. Osteoporosis in men. J Am Acad
Orthop Surg. 2006; 14(6):347-353.
3. US Department of Health and Human Services. Bone Health and Osteoporosis: A Report
of the Surgeon General. Rockville, MD: US
Department of Health and Human Services;
2004.
4.National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment
of Osteoporosis. Washington, DC: National
Osteoporosis Foundation; 2013.
5. Beil FT, Barvencik F, Gebauer M, et al. The
distal radius, the most frequent fracture localization in humans: a histomorphometric
analysis of the microarchitecture of 60 human distal radii and its changes in aging. J
Trauma. 2011; 70(1):154-158.
6. Dell R, Greene D. Is osteoporosis disease
management cost effective? Curr Osteoporos
ORTHOPEDICS | Healio.com/Orthopedics
n Feature Article
Rep. 2010; 8:49-55.
7.Park-Wyllie LY, Mamdani MM, Juurlink
DN, et al. Bisphosphonate use and the risk of
subtrochanteric or femoral shaft fractures in
older women. JAMA. 2011; 305(8):783-789.
8. Freedman KB, Kaplan FS, Bilker WB, et al.
Treatment of osteoporosis: are physicians
missing an opportunity? J Bone Joint Surg
Am. 2000; 82(8):1063-1070.
9. Øyen J, Brudvik C, Gjesdal CG, et al. Osteoporosis as a risk factor for distal radius fractures. J Bone Joint Surg Am. 2011;
93(4):348-356.
10. Cuddihy MT, Gabriel SE, Crowson CS, et al.
Forearm fractures as predictors of subsequent
osteoporotic fractures. Osteoporos Int. 1999;
9(6):469-475.
11. Mallmin H, Ljunghall S, Persson I, et al.
Fracture of the distal forearm as a forecaster
of subsequent hip fracture: a populationbased cohort study with 24 years of followup. Calcif Tissue Int. 1993; 52(4):269-272.
12. Haentijens P, Autier P, Collins J, et al. Col-
DECEMBER 2014 | Volume 37 • Number 12
les fracture, spine fracture, and subsequent
risk of hip fracture in men and women: a
meta-analysis. J Bone Joint Surg Am. 2003;
85(10):1936-1943.
13. Maclean C, Newberry S, Maglione M, et al.
Systematic review: comparative effectiveness
of treatments to prevent fractures in men and
women with low bone density or osteoporosis. Ann Intern Med. 2008; 148(3):197-213.
14. Tang BM, Eslick GD, Nowson C, et al. Use
of calcium or calcium in combination with
vitamin D supplementation to prevent fractures and bone loss in people aged 50 years
and older: a meta-analysis. Lancet. 2007;
370(9588):657-666.
15. Delmas PD. Treatment of postmenopausal
osteoporosis. Lancet. 2002; 359:2018-2026.
16. Reid I. Bisphosphonates in the treatment of
osteoporosis: a review of their contribution
and controversies. Skeletal Radiol. 2011;
40:1164-1169.
17. Kok HS, van Asselt KM, van der Schouw YT,
et al. Genetic studies to identify genes underlying menopausal age. Hum Reprod Update.
2005; 11(5):483-493.
18. Rozental TD, Makhni EC, Day CS, et al. Improving education and treatment for osteoporosis following distal radius fractures. J Bone
Joint Surg Am. 2008; 90:953-961.
19. Cummings SR, Melton J. Epidemiology and
outcomes of osteoporotic fractures. Lancet.
2002; 359(9319):1761-1767.
20. Simonelli C, Killeen K, Mehle S, et al. Barriers to osteoporosis identification and treatment among primary care providers and orthopedic surgeons. Mayo Clinic Proc. 2002;
77:334-338.
21. Bogoch ER, Elliot-Gibson V, Beaton DE, et
al. Effective initiation of osteoporosis diagnosis and treatment for patients with a fragility fracture in an orthopaedic environment. J
Bone Joint Surg Am. 2006; 88(1):25-34.
22. Khosla S, Amin S, Orwoll E. Osteoporosis in
men. Endocr Rev. 2008; 29(4):441-464.
23. Amin S, Felson DT. Osteoporosis in men.
Rheum Dis Clin North Am. 2001; 27(1):1947.
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