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