Blog post written by OrthoVirginia Lynchburg's Daniel Acevedo, PA-C for the Healio Orthopaedics Today blog. Read the full blog post here
Mrs. Smith is a 65-year-old woman who fell outside her apartment complex 2 days ago. She did not report feeling dizzy or lightheaded and lost no consciousness prior to her fall. It was raining 2 days ago, and she lost her footing and fell from a standing height onto an outstretched right hand. Mrs. Smith says her hand and wrist hurt immediately but just thought it was sprained. Two days later when her right hand was so swollen and bruised that she could not use it, she presented to your clinic. Appropriate radiographs were ordered and a distal radius fracture was appreciated. There was enough intra-articular extension and displacement to warrant surgical fixation. Six weeks later, postoperative films showed a healing fracture, and with her pain improved, she was discharged from her surgeon’s care and was told to follow up as needed.
This is a common scenario played out in many orthopaedic clinics. In fact, distal radius fractures account for 20% of all emergency department visits and is the most common upper extremity fracture in elderly patients. However, we are not doing justice to the underlying problem by simply calling this a simple distal radius fracture. This injury is a fragility fracture, likely caused by osteoporosis. Mrs. Smith is likely to fall again and is at risk for future fractures. She also has a statistically significant chance of fracturing her hip and thus, increasing her 1-year mortality risk.
The purpose of this article is to highlight the importance of recognizing the underlying metabolic cause of Mrs. Smith’s fracture — her underlying osteoporosis. More than 10 million Americans are osteoporotic and another 40 million have low bone mass. Of those who suffer an osteoporotic hip fracture, 24% will die within 1 year. These are staggering statistics. What is more alarming is that most patients who suffer a fragility fracture are not treated for their underlying osteoporosis.
In this multipart series, I will present the basics of diagnosis, treatment and prevention of osteoporosis for physician assistants (PAs). This is applicable to those PAs practicing in orthopaedics, primary care, emergency medicine and any specialty caring for those patients older than 65 years.
According to Kloztbuecher and colleagues, osteoporosis is “a systemic disease, characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk.” Objectively, the World Health Organization criteria for the diagnosis of osteoporosis is 2.5 standard deviations below the average peak bone mass for a healthy 20-year-old sex-matched person, as measured on a DEXA scan. Osteoporosis is a common disease. For example, 750,000 osteoporotic vertebral fractures occur every year and up to a quarter of patients older than the age of 50 years will sustain at least one vertebral fracture in their lifetime.
Why is osteoporosis a problem?
Osteoporosis represents significant public health and economic burdens. According to Miller and colleagues, fractures caused by osteoporosis “were responsible for an estimated $19 billion in costs in the United States. By 2025, experts predict that these costs will rise to approximately $25.3 billion.” Osteoporosis accounts for 80% to 90% of all fracture hospitalizations for patients between 60 years and 74 years of age. Osteoporosis-related fractures account for more than 400,000 hospital admissions and 2.5 million medical office visits per year. Hip fractures, which are most commonly caused by osteoporosis, will kill more women than breast cancer. At the very least, two-thirds of patients who sustain a hip fracture will never regain their previous level of function.
A fragility fracture is any type of fracture that results from a low-energy trauma and is likely due to osteoporosis. For example, a fall from a ground level or seated height that results in a hip fracture is considered fragility type injury. Classically, fragility fractures occur around the hip, distal radius, proximal humerus and vertebrae. However, any break can make this classification if it results from low energy and the risk of subsequent fractures appears to increase with the number of prior fractures.
In the next series of articles, we will delve into the risk factors for osteoporosis, diagnostic modalities and treatment strategies.
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Daniel J. Acevedo, PA-C, is a board-certified physician assistant who practices at the Orthopaedic Center of Central Virginia in Lynchburg, Va. His research interests include physician assistant education, osteoarthritis and periprosthetic joint infections.