Elsevier

Joint Bone Spine

Volume 72, Issue 5, October 2005, Pages 372-375
Joint Bone Spine

Review
Osteoporotic fractures of the proximal humerus, pelvis, and ankle: epidemiology and diagnosis

https://doi.org/10.1016/j.jbspin.2004.04.002Get rights and content

Abstract

Although fractures involving the wrist, spine, and proximal femur are known to be strongly associated with osteoporosis, the underlying bone insufficiency often receives insufficient diagnostic and therapeutic attention. Osteoporosis also increases the risk of fractures at other sites. Low-energy fractures in patients older than 50 years should lead to investigations for osteoporosis, the only exceptions being fractures of the skull, cervical spine, fingers, and toes. The incidence rates of fractures of the proximal humerus, pelvis, and ankle are climbing relentlessly. Whereas fractures of the proximal humerus and pelvis are undoubtedly related to osteoporosis, the link is less well established for fractures of the ankle. Mortality and morbidity rates associated with pelvic fractures are similar to those seen with fractures of the proximal femur, in keeping with the fact that both fractures occur in elderly individuals.

Introduction

Osteoporotic fractures occur in response to low-energy trauma in patients with low bone mass and abnormal bone microarchitecture [1]. In practice, in patients older than 50 years of age, fractures caused by low-energy trauma should suggest osteoporosis, except those involving the skull, cervical spine, and digits [2]. However, a high-energy trauma such as a motor vehicle injury does not rule out bone disease, and risk factors for osteoporosis should be sought in this situation also [3], [4]. Considerable effort has been expended to educate physicians about the causative role for osteoporosis, the usefulness of reliable diagnostic investigations such as bone mineral density (BMD) measurement, and the efficacy of antiosteoporotic treatments in preventing fractures. However, many older patients with fractures fail to receive adequate diagnostic evaluation and treatment for osteoporosis. The most common sites of osteoporotic fractures are the wrist, spine, and proximal femur, in that order with advancing age. Fractures at these three sites are associated with high morbidity and mortality rates. Fractures at other sites are even less likely to be taken by physicians as possible manifestations of osteoporosis. Nevertheless, in the European Prospective Osteoporosis Study (EPOS) of 6936 women and 6451 men aged 50–79 years and followed up for a mean of 3 years, the fracture incidence was 0.8‰ person-years for the proximal femur as compared to 1.7‰ for the humerus; more importantly, fractures at other limb sites occurred with an incidence of 4‰ person-years [5]. A study from the US reported in 1995 found the following fracture site distribution among patients older than 45 years admitted for fractures: proximal femur, 57%; spine, 6.8%; wrist, 3.1%; and other sites, 33%. Fractures whose relationship with osteoporosis were overlooked account for 30% of total fracture-related costs and 50% of costs related to fractures of the proximal femur [6]. Clearly, these fractures constitute a major epidemiological and economic burden.

Here, we discuss fractures of the proximal humerus, pelvis, and ankle, all of which are common. We reviewed the literature for information on their incidence and possible links with osteoporosis.

Section snippets

Fractures of the proximal humerus

The risk factors for fractures of the proximal humerus are those classically associated with osteoporotic fractures. The incidence increases with advancing age in both men and women [7], [8], [9]. Most cases occur after a low-energy trauma. A study from Finland of 109 patients with fractures of the proximal humerus ascribed to osteoporosis, the trauma was a simple fall in 97% of cases. Among the falls, 54% occurred outdoors, 61% while walking normally, and 72% after slipping or tripping. The

Pelvic fractures

Although posttraumatic fractures of the pelvis have been extensively studied, their incidence has decreased over recent years in parallel with the decrease in motor vehicle accidents. They will not be reviewed here, and neither will we deal with fatigue fractures of the pelvis in female athletes. Rather, we will focus on osteoporotic fractures.

Here also, registries from Finland provide valuable data, showing a sharp rise in incidence with increasing age and a marked predominance in women. The

Ankle fractures

Ankle fractures raise nosological problems. Rather than directly related to osteoporosis, ankle fractures predict osteoporotic fractures at other sites. In a study by Gunnes et al. [13] of 29,802 individuals in Sweden, a history of ankle fracture was associated with an increased risk of fracture of the proximal femur (odds ratio (OR), 1.38–1.59) and of the spine (OR = 1.5). The incidence of ankle fractures did not increase with age. In a study of 5% of the Americans who used healthcare services

Conclusion

Osteoporotic fractures can occur at many sites in addition to the classic wrist–spine–femur triad. Fractures of the proximal humerus clearly meet criteria for osteoporotic fractures. Pelvic fractures deserve special attention as they are associated with high morbidity and mortality rates similar to those of proximal femoral fractures, the main reason being the advanced age of the patients. Ankle fractures are more difficult to categorize; in women, they are associated with overweight but not

References (37)

  • RayN.F. et al.

    Medical expenditures for the treatment of osteoporotic fractures in the United States in 1995: report from the National Osteoporosis Foundation

    J Bone Miner Res

    (1997)
  • RoseS.H. et al.

    Epidemiologic features of humeral fractures

    Clin Orthop

    (1982)
  • NguyenT.V. et al.

    Risk factors for proximal humerus, forearm, and wrist fractures in elderly

    Am J Epidemiol

    (2001)
  • PalvavenM. et al.

    The injury mechanisms of osteoporotic upper extremity fractures among older adults: a controlled study of 287 consecutive patients and their 108 controls

    Osteoporos Int

    (2000)
  • SeeleyD.G. et al.

    Which fractures are associated with low appendicular bone mass in elderly women?

    Ann Intern Med

    (1991)
  • LeeS.H. et al.

    Risk factor for fractures of the proximal humerus: results from the EPIDOS prospective study

    J Bone Miner Res

    (2002)
  • GunnesM. et al.

    How well can a previous fracture indicate a new fracture?

    Acta Orthop Scand

    (1998)
  • KannusP. et al.

    Osteoporotic fractures of the proximal humerus in elderly Finnish persons

    Acta Orthop Scand

    (2000)
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