Clinton, Thatcher fractures were lost opportunities to educate the public

Upper-extremity fractures made news last summer: two of the world’s most powerful women demonstrated that serving in high office does not protect a woman from commonplace fractures. Margaret Thatcher, 83, former prime minister of Great Britain, fell in her home and fractured her wrist. Hillary Clinton, 61, U.S. Secretary of State, fell in a State Department parking lot and fractured her elbow.

The mechanisms and locations of the two fractures may differ, but they share the following critical similarities:

    • Both injuries occurred in women who fell from a standing height.
    • Both women are older than 50 years of age.

From these two facts alone, orthopaedic surgeons should know that these women face an elevated risk of future hip fracture. Although the press quickly reported the need for surgery, it failed to educate the public about the broader bone health implications—that fractures beget fractures.

The predictive value of wrist fractures
Wrist fractures are often overlooked as an early sign of reduced bone strength. Recent studies, however, warn that a history of wrist fracture is highly predictive of hip fracture. Based on the National Osteoporosis Risk Assessment study, a recent report indicates that prior wrist fracture strongly predicts 3-year risk of any future osteoporotic fracture for both older and younger postmenopausal women, independent of baseline bone density measurement and common osteoporosis risk factors.
As a result, the report includes a recommendation that clinicians evaluate and manage osteoporosis in both younger and older women with a history of wrist fracture, independent of their bone mineral density. More authors are now cautioning that virtually all fractures (except of the phalanges) predict an increased risk of future fractures.

Unfortunately, even though patients may be aware of osteoporosis or osteopenia, few believe they could be affected. Recent studies emphasize that every patient with a fragility fracture of the wrist needs to understand the following points:

    • The fracture may be related to osteoporosis.
    • By having a fragility fracture, the patient faces a higher risk for hip fracture.
    • Preventive treatment is effective and safe.

Patients who believe that weak bones didn’t cause their fractures require additional attention to motivate them to undergo treatment. These patients need to understand the significance of preventing hip fractures and the complications that can accompany them. Preventing fractures needs to be as much a public health focus as preventing heart attacks.

Lady Thatcher’s fracture underscores another critical issue. Even if her other risk factors for future fracture are the same as Secretary Clinton’s, her risk of another injury is much higher. Why? Because age is an independent risk factor for fracture. It is incorrect to assume that because a patient is older, preventive treatment can be ignored. In fact, the older fracture patient has a greater need for preventive care.

What can YOU do?
Orthopaedic specialists are acutely aware of the complications of fracture, particularly hip fracture. Two recent articles from the Journal of Bone and Joint Surgery demonstrate the powerful impact orthopaedic surgeons can have on patient care.

The first study prospectively randomized 50 patients with wrist fractures into two groups. In one group, the orthopaedic surgeon ordered a bone mineral density test and forwarded the results to the patient’s primary care provider. In the second group, the orthopaedic surgeon sent only a letter to the primary care provider outlining guidelines for osteoporosis screening.

When an orthopaedist ordered the test, patients received it more than three times as often as when patients were sent to primary care providers with a letter recommending the test. Similarly dramatic differences between orthopaedic specialists and primary care physicians were noted with respect to discussions about osteoporosis—patients were more likely to receive treatment after discussion with an orthopaedist.

The second prospective randomized trial assessed the difference in the rate of osteoporosis treatment initiated by either orthopaedic specialists or primary care physicians. The study compared an in-house assessment of osteoporosis, initiated by an orthopaedic surgeon with follow-up conducted in a specialized orthopaedic osteoporosis clinic, to osteoporosis education by a primary care physician among hip fracture patients.

The percentage of patients on pharmacologic treatment for osteoporosis 6 months post-fracture was significantly greater when the evaluation was initiated by the orthopaedic surgeon and managed in a specialized orthopaedic osteoporosis clinic (58 percent) than when the patient was managed by a primary care physician (29 percent) (p = 0.04). The conclusions are clear: active intervention by orthopaedic surgeons in the management of osteoporosis improves the rate of appropriate preventive treatment following a hip fracture, compared to primary care physicians.

It is vital for orthopaedists to understand the risk factors for osteoporosis and fragility fractures to protect the bone health of patients. Monitoring patients with wrist fractures, or any fracture sustained from falling from a standing height, providing education on maintaining and improving bone density, and ensuring that patients are properly referred for treatment can significantly help prevent painful and costly hip fractures.

By Daneca DiPaolo, MD, and Laura L. Tosi, MD

Daneca DiPaolo, MD, is the Ruth Jackson Orthopaedic Society representative to the AAOS Women’s Health Issues Advisory Board. Laura L. Tosi, MD, is director of the Bone Health Program at Children’s National Medical Center in Washington, D.C.

References:
1. Barrett-Connor E, Sajjan SG, Siris ES, Miller PD, Chen YT, Markson LE: Wrist fracture as a predictor of future fractures in younger versus older postmenopausal women: Results from the National Osteoporosis Risk Assessment (NORA). Osteoporos Int 2008;19:607-613.
2. Bogoch ER, Elliot-Gibson V, Escott BG, Beaton DE: The osteoporosis needs of patients with wrist fracture. J Orthop Trauma 2008(8 Suppl):S73-78.
3. Rozental TD, Makhni EC, Day CS, Bouxsein ML: Improving evaluation and treatment for osteoporosis following distal radial fractures: A prospective randomized intervention. J Bone Joint Surg Am 2008;90:953-961.
4. Miki RA, Oetgen ME, Kirk J, Insogna KL, Lindskog DM: Orthopaedic management improves the rate of early osteoporosis treatment after hip fracture: A randomized clinical trial. J Bone Joint Surg Am 2008;90:2346-2353.