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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 18  |  Issue : 2  |  Page : 73-75

Forgoing the opportunity and ordaining the preventable catastrophe: Overlooking the remedial portal for osteoporosis by orthopedic surgeons while managing patients with distal radius fragility fracture


1 Department of Orthopaedics, District Hospital; Department of Orthopaedics, SSPM Medical College and Lifetime Hospital, Sindhudurg, Maharashtra, India
2 Department of Orthopaedics, District Hospital, Sindhudurg, Maharashtra; Department of Anatomy, Jawaharlal Nehru Medical College, Belgavi, Karnataka, India
3 Department of Orthopaedics, SSPM Medical College and Lifetime Hospital, Sindhudurg, Maharashtra, India

Date of Submission10-Aug-2021
Date of Acceptance19-Sep-2021
Date of Web Publication27-Jan-2022

Correspondence Address:
Raghavendra S Kulkarni
Bungalow No. 6, SSPM Medical College and Lifetime Hospital, Padve, Sindhudurg - 416 534, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joasis.joasis_18_21

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  Abstract 


Introduction: The previous history of fracture in the elderly confers an increased risk of subsequent future fracture. The aim of this study is to identify what proportion of fragility distal radius fracture with subsequent skeletal fracture had their osteoporosis investigation and treatment was addressed in the interval between two events. Materials and Methods: It is a retrospective study of 272 isolated, low-energy distal radius fractures above the age of 50 years, between 2011 and 2015. In addition, during the same period in the same hospital, all patients above 50 years with other skeletal injuries with the previous history of distal radius fracture were also identified. Both groups were cross referenced to produce a single cohort of patients with both injuries. It was also examined whether the patients had received any treatment relating to osteoporosis before they sustained a subsequent fracture. Results: A study cohort of 28 distal radius fracture patients with subsequent other skeletal injuries were identified. Out of these, 2 (7.1%) patients were treated for osteoporosis and 26 (92.9%) were not. The differences in event rates between patients with and without osteoporosis treatment were statistically highly significant (P > 0.001). Conclusions: A substantial proportion of hospitalized elderly, fragility distal radius fracture patients were not sufficiently evaluated and treated for their potential risk of osteoporosis. This issue warrants osteoporosis to be addressed by multidisciplinary approach to prevent further fracture.

Keywords: Distal radius fracture, fragility fracture, hip fracture, osteoporosis, subsequent fracture, treatment of osteoporosis


How to cite this article:
Kulkarni RS, Kulkarni RA, Kulkarni SR. Forgoing the opportunity and ordaining the preventable catastrophe: Overlooking the remedial portal for osteoporosis by orthopedic surgeons while managing patients with distal radius fragility fracture. J Orthop Assoc South Indian States 2021;18:73-5

How to cite this URL:
Kulkarni RS, Kulkarni RA, Kulkarni SR. Forgoing the opportunity and ordaining the preventable catastrophe: Overlooking the remedial portal for osteoporosis by orthopedic surgeons while managing patients with distal radius fragility fracture. J Orthop Assoc South Indian States [serial online] 2021 [cited 2022 May 26];18:73-5. Available from: https://www.joasis.org/text.asp?2021/18/2/73/336651




  Introduction Top


Osteoporosis represents a major public health problem, particularly in elderly men and women incurring a serious cost to health care providers.[1] The main consequence of osteoporosis is an increased incidence of skeletal fractures resulting from very low energy trauma. One cannot afford to miss any opportunities for the prevention of these fractures. Treating osteoporosis in elderly patients certainly and significantly reduce the incidence of subsequent fragility fractures.[2]

Distal radius fracture has been shown to be associated with increased risk for further skeletal fractures in the elderly.[3] Interestingly, the incidence of distal radius fracture starts to rise 15 years earlier than that of hip fracture.[4] Thus, a distal radius fracture is a potential marker of imminent hip fracture.[5] This low-energy distal radius fracture in the elderly should alert the orthopedic surgeon to make a diagnosis of osteoporosis. These elderly distal radius fragility fractures constitute a high-risk group and are ideal candidates for secondary prevention for further assessment and treatment of osteoporosis.[6] The aim of this retrospective study is to identify what proportion of elderly distal radius fractures with subsequent skeletal fracture had their osteoporosis medication addressed in the interval between two occasions.


  Materials and Methods Top


Total enrollment of patients with distal radius fracture above the age of 50 years in this study is 272 between 2011 and 2015. This present retrospective analysis focuses on elderly patients with isolated low-energy distal radius fractures. The minimum age recruited in this report was set at 50 years, as it is much more likely to have osteoporosis in men, and this is the average age of menopause in women.

Using the comprehensive hospital outpatient, indoor and X-ray records of all distal radius fracture patients treated above the age of 50 years between 2011 and 015 were identified. In addition, all patients over the same period with other skeletal injuries treated in the same hospital with the previous history of distal radius fracture of 50 years and above were also identified. The two groups were cross referenced to produce a single cohort of patients with both injuries. Those patients who sustained other skeletal injuries before or concomitant with their distal radius fracture were excluded from the study. It was also examined from the medical records whether the patients had received any investigation, treatment relating to osteoporosis after sustaining distal radius fracture with subsequent other skeletal injuries.


  Results Top


There were a total of 272 distal radius fracture patients with age 50 years and above in this report. The hip fractures accounted for 296, osteoporotic vertebral fracture 132, refracture of distal radius 6, surgical neck humerus 56, distal humerus fracture 34, opposite distal radius fracture 28, and other fractures 194. Cross referencing of distal radius fracture with subsequent other skeletal fracture identified 28 patients in both groups. This resulted in a study cohort of 28 patients with a median age of 68 years (range 50–102 years). There were 20 (71.4%) men and 8 (28.6%) women [Table 1]. This amounted to 10.3% distal radius and 3.8% other subsequent skeletal injuries. The mean time interval between the initial distal radius fracture and later other skeletal injuries was 3.8 years (range 0–5 years). The proportion of patients who were advised investigation and were put on treatment for osteoporosis at initial distal radius fracture and subsequent other skeletal injury was 2 (7.1%). The total proportion of patients who were not investigated and treated for osteoporosis at the time of and before subsequent other fracture was 26 (92.9%). A significant age difference was found only in distal radius fractures (ƥ=0.016), which were more likely to occur in above 70-year age group. Of those who were prescribed medication for osteoporosis at the time of hospital discharge (n = 2), none suffered subsequent fracture. The subsequent fracture in 26 (92.9%) occurred in particular with a history of not receiving osteoporosis medication at the time of discharge from the hospital. The differences in event rates between patients with and without osteoporosis treatment were statistically highly significant (ƥ >0.001).
Table 1: Age at entry in the study and subsequent fracture cohort

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  Discussion Top


As a consequence of aging, increasing incidence of osteoporotic fractures is becoming major issue.[7] A low-energy distal radius fracture in the elderly is often the first sign of osteoporosis.[8] More than three-fourth of this kind of fracture have been shown to have evidence of osteoporosis at distal radius, spine, or hip.[9] A distal radius fracture is also shown to the associated with an increased risk of subsequent fragility fractures.[10] Therefore, this study focused on hospitalized elderly patients with isolated distal radius fracture from minimal trauma and studied about osteoporosis treatment received during their stay in hospital and afterward. The percentage of patients in this report with subsequent fracture was lower among those receiving osteoporosis treatments than among nontreated individual. These group differences were not large enough to be statistically significant (ƥ = 0.82).

The marked under-treatment of at-risk patients with osteoporosis medication is consistent with reports from other studies.[11] In a larger retrospective cohort study of subsequent fracture, only 2.8% underwent investigations and 23% were treated for osteoporosis.[12] In contrast, in this study data, 7.1% of patients were receiving osteoporosis medication.

This study highlights significant missed opportunities for both patient and orthopedic surgeon. These are the opportunities that can ill afford to be wasted. In a publication from the west, the patients who were prescribed osteoporosis medication at the time of discharge from the hospital range from 15% to 26%.[13] There is a pressing continuous need to educate both orthopedic surgeons and patients in elderly men and women that fragility fracture implies osteoporosis until proven otherwise. It is also very much required to address the knowledge gap among orthopedic surgeons about the importance of low energy distal radius fracture as a risk factor for osteoporosis and subsequent fracture.[14]

Treatment of targeted group of patients such as fragile distal radius fracture will reduce the numbers of subsequent hip fractures by 50%–60%.[15] Naturally, reductions in the number of hip fractures in the order of this magnitude would represent a massive saving to health care providers.[16] The orthopedic surgeons are in an ideal position to identify patients with distal radius fracture following a fall from less than body height, by definition has got osteoporosis. Consequently, all such patients are to be referred to physicians for appropriate investigation and treatment of their bone mineral loss.[17]

This study confirms and quantifies the increased relative risk for further fracture after distal radius fracture. Identification of these high-risk fragility fractures allows resources to be targeted to those who need most. Prevention with a distal radius fracture provides an opportunity to implement interventions and medication of osteoporosis.[18]


  Conclusion Top


The vast majority of elderly distal radius fractures following minimal trauma did not receive adequate assessment and treatment for osteoporosis. The potential to alter this pattern of practice represents a major public health opportunity.

Acknowledgment

We are grateful to Mrs. Suvarna Avsare, Sharayu Walavalkar for data collection, manuscript preparation, and for their unrestricted support of this work.

Ethical clearance

Ethical clearance is obtained by district hospital ethics committee.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int 2006;17:1726-33.  Back to cited text no. 1
    
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Majumdar SR, Johnson JA, McAlister FA, Bellerose D, Russell AS, Hanley DA, et al. Multifaceted intervention to improve diagnosis and treatment of osteoporosis in patients with recent wrist fracture: A randomized controlled trial. CMAJ 2008;178:569-75.  Back to cited text no. 2
    
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Crandall CJ, Hovey KM, Cauley JA, Andrews CA, Curtis JR, Wactawski-Wende J, et al. Wrist fracture and risk of subsequent fracture: Findings from the women's health initiative study. J Bone Miner Res 2015;30:2086-95.  Back to cited text no. 3
    
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Haentjens P, Johnell O, Kanis JA, Bouillon R, Cooper C, Lamraski G, et al. Evidence from data searches and life-table analyses for gender-related differences in absolute risk of hip fracture after Colles' or spine fracture: Colles' fracture as an early and sensitive marker of skeletal fragility in white men. J Bone Miner Res 2004;19:1933-44.  Back to cited text no. 4
    
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Huang TL, Chen CW. Colles' fracture as a risk factor for subsequent hip fractures: An Asian population based study. Osteoporos Int 2013;24:S528-28.  Back to cited text no. 5
    
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Bliuc D, Ong CR, Eisman JA, Center JR. Barriers to effective management of osteoporosis in moderate and minimal trauma fractures: A prospective study. Osteoporos Int 2005;16:977-82.  Back to cited text no. 6
    
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Kanis JA, Oden A, Johnell O, Jonsson B, de Laet C, Dawson A. The burden of osteoporotic fractures: A method for setting intervention thresholds. Osteoporos Int 2001;12:417-27.  Back to cited text no. 7
    
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Earnshaw SA, Cawte SA, Worley A, Hosking DJ. Colles' fracture of the wrist as an indicator of underlying osteoporosis in postmenopausal women: A prospective study of bone mineral density and bone turnover rate. Osteoporos Int 1998;8:53-60.  Back to cited text no. 8
    
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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.  Back to cited text no. 9
    
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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.  Back to cited text no. 10
    
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Cuddihy MT, Gabriel SE, Crowson CS, Atkinson EJ, Tabini C, O'Fallon WM, et al. Osteoporosis intervention following distal forearm fractures: A missed opportunity? Arch Intern Med 2002;162:421-6.  Back to cited text no. 11
    
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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.  Back to cited text no. 12
    
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Simonelli C, Chen YT, Morancey J, Lewis AF, Abbott TA. Evaluation and management of osteoporosis following hospitalization for low-impact fracture. J Gen Intern Med 2003;18:17-22.  Back to cited text no. 13
    
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Dholakia S, Thilagarajah M, Singh R. Are wrist fractures still a useful predictor of future hip fracture in 2011? Osteoporos Int 2011;22:S654-5.  Back to cited text no. 14
    
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Johnson NA, Stirling ER, Divall P, Thompson JR, Ullah AS, Dias JJ. Risk of hip fracture following a wrist fracture – A meta-analysis. Injury 2017;48:399-405.  Back to cited text no. 15
    
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Cooper C, Mitchell P, Kanis JA. Breaking the fragility fracture cycle. Osteoporos Int 2011;22:2049-50.  Back to cited text no. 16
    
17.
Smith MG, Dunkow P, Lang DM. Treatment of osteoporosis: Missed opportunities in the hospital fracture clinic. Ann R Coll Surg Engl 2004;86:344-6.  Back to cited text no. 17
    
18.
Sanders, Kerrie and Nicholson, G. and Watts, Jennifer and Abimanyi-Ochom, Julie and Shore-Lorenti, Catherine and Stuart, Amanda and Zhang, et al. Are wrist fracture patients less likely to commence anti-fracture therapy? Osteoporosis international 2013:24;S605-6.  Back to cited text no. 18
    



 
 
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