For Your Patients: Osteoporosis and Fractures

If you've been diagnosed with the bone-thinning disease of osteoporosis, you already know that preventing fractures is a key part of treatment. An osteoporosis-related broken bone is called a fragility fracture and can result from low-energy force encountered in such otherwise innocuous activities as closing a window, lifting a laundry basket, or tripping and falling from a standing height -- compared with traumatic fractures, which are caused by a high-energy direct blow, accident, or fall from a height.

Whether you're at increased risk for a fragility fracture or have already had one, you need to avoid further broken bones and the resulting pain, disability, and costs. The chance of sustaining a further fragility fracture is highest in the year or two after the first one; after that your risk declines but is still higher than before your first fracture.

Sites of Fracture

Spine

The most common site of osteoporosis-related fractures is the vertebrae of the spine, usually in the discs at or just above or below the waist. Many people won't even realize they have one or more broken vertebrae, called compression fractures. People may, however, have a notable loss of height and even a bent-over curving of the back. In extreme cases, this stooped curvature may develop into a posture known colloquially as a "dowager's hump."

Beyond pain and reduced mobility, compressed vertebrae can lead to other problems such as difficulty breathing, reduced appetite, gastrointestinal issues such as pain and constipation, and numbness due to nerve damage.

Most often the pain from spinal fractures improves with rest, restricted activities, appropriate pain medications, and bracing the lower back. Occasionally the pain is so severe and persistent that a procedure may be needed -- typically either kyphoplasty or vertebroplasty.

• Kyphoplasty: In this procedure, the surgeon uses x-ray guidance to insert a needle into the fractured vertebra. A small balloon called a tamp is inserted through the needle into the vertebra. Once inflated, the tamp restores the original height and shape of the disc, and when it's removed, it leaves a cavity. The cavity is filled with a special bone cement to strengthen the vertebra. Kyphoplasty can be performed using general or local anesthesia, and patients can usually return to their normal activities fairly soon with no restrictions.

• Vertebroplasty: In this method, surgical cement is directly inserted into the damaged vertebra to repair it, and patients can usually return to day-to-day activities fairly quickly. The benefits of the procedure, however, may last only in the short term.

Hip

The most debilitating and dangerous fractures are those occurring at the hip. More than 95% of these are caused by falling, usually sideways, and almost 75% occur in women. It is especially important to avoid these fractures as there is a long recovery period and there is also an increased risk of death in the first year after the fracture owing to prolonged immobility, blood clots, and other complications.

Hip fractures are treated with orthopedic surgery, including cementing the joint and repairing it with stabilizing screws, pins, and rods. But in some cases these serious fractures require total hip replacement.

Other sites

Fragility fractures from everyday activities can also occur in the wrist, forearm, elbow, and upper arm.

FRAX: Estimating High Risk

It's important to identify patients at high risk of imminent fracture -- whether an initial or a subsequent broken bone -- and a screening tool called FRAX (fracture risk assessment) is often used to do this. FRAX looks at established risk factors to estimate a patient's likelihood of having a broken bone over the next 10 years.

FRAX calculates 10-year risk based on the following patient criteria:

• Age, sex, weight, height

• Previous fracture, and a hip fracture in either of the patient's parents

• Glucocorticoid use, rheumatoid arthritis, and presence of other diseases strongly associated with osteoporosis such as type 1 (insulin-dependent) diabetes, premature menopause (i.e., before age 45), chronic malnutrition, and chronic liver disease

• Lifestyle habits such as current smoking and excessive alcohol consumption

• Bone mineral density

Managing High Risk

Patients with a high risk of fracture are appropriately managed with more potent medications, often newer bone-building medications. In addition to bone-strengthening medications, diet, and supplements, such individuals are advised to reduce their risk of falling by adjusting activities and modifying their living space. This might entail giving up certain sports; switching to non-slip footwear; avoiding stairs and icy sidewalks; replacing slippery flooring and loose rugs; upgrading lighting; and clearing rooms of obstacles.

The good news, however, is that if you can avoid further fracture in the 2 years after an initial breakage, the risk of having another one does decline.

Read previous installments in this series:

Part 1: For Your Patients: Osteoporosis -- the 'Silent Thief'

Part 2: For Your Patients: What to Know About Osteoporosis Diagnosis and Treatment

"Medical Journeys" is a set of clinical resources reviewed by physicians, meant for the medical team as well as the patients they serve. Each episode of this 12-part journey through a disease state contains both a physician guide and a downloadable/printable patient resource. "Medical Journeys" chart a path each step of the way for physicians and patients and provide continual resources and support, as the caregiver team navigates the course of a disease.