Do You Know Your Danger for a Fragility Fracture?

As a result of osteoporosis could also be a “silent” illness, a fragility fracture would be the first apparent signal of the dysfunction. (Picture supply: iStock)

About two weeks, after I fractured my shoulder a couple of years in the past, I bought a cellphone name from Kaiser Permanente, the well being system the place I get my care. The girl on the road recognized herself as being a part of my medical middle’s Bone Well being crew. She stated they had been calling me as a result of I had sustained a fracture that’s suggestive of low bone density. She referred to as it a fragility fracture.

What are fragility fractures?

Fragility fractures are fractures that happen on account of low vitality trauma, for instance, falling from a standing peak – or no trauma in any respect.

Frequent fragility fractures embody the next:

      • vertebral fractures,
      • humeral head (shoulder) fractures,
      • fractures of the neck of the femur (a.ok.a. hip fractures), and
      • Colles fractures of the wrist.

It turned out that Kaiser routinely scans its digital well being data so as to determine sufferers with these kind of fractures to allow them to carry them in to guage their bone well being.

How a inhabitants well being program can assist determine “silent” osteoporosis

My first response to listening to that I had a fragility fracture was “I’m not fragile, I simply tripped and fell.” However the Bone Well being girl identified that individuals with regular bone well being don’t normally fracture their large bones (humerus or femur) once they fall from a standing peak. She stated I wanted to return in for a bone density take a look at and blood checks to measure my vitamin D degree (amongst different checks) to find out my threat of fragility fractures.

I used to be impressed. I’m a very long time fan of inhabitants well being applications and have seen well being plans and supplier teams use them to proactively attain out to individuals with diabetes, coronary heart failure, and bronchial asthma. On the time, I had by no means come throughout a inhabitants well being program that focused osteoporosis regardless that, in accordance with the Nationwide Osteoporosis Basis, 54 million People have both osteoporosis or low bone density (osteopenia). Not solely that, however 1 in 2 girls and 1 in Four males over the age of 50 will break a bone attributable to osteoporosis.

Take into consideration that for a minute! That’s an terrible lot of people that will expertise the ache, struggling, and value of a bone fracture that maybe may have been prevented if their low bone density had been detected earlier.

Routine screening for osteoporosis

Hopefully, you gained’t wait till you maintain a fragility fracture earlier than being evaluated on your threat of sustaining one. In reality, the USPSTF, a revered group that critiques tips for the prevention of well being circumstances has concluded with reasonable certainty that there’s “not less than reasonable profit” of screening for osteoporosis within the following people:

  • girls 65 and older 
  • postmenopausal girls youthful than 65 years who’re at elevated threat of osteoporosis is not less than reasonable

Nonetheless, they discovered that present proof is “inadequate to evaluate the steadiness of profit and harms of screening for osteoporosis in males.” This was based on the dearth of proof for efficient therapies of osteoporosis in males. The USPSTF report states that,

“…it can’t be assumed that [effective treatments for women] will likely be equally efficient in males as a result of the underlying biology of bones might differ in males attributable to variations in testosterone and estrogen ranges.”

Bone mineral density

Till not too long ago, bone density checks—additionally referred to as Bone Mineral Density (BMD), DXA, or DEXA (for dual-energy X-ray absorptiometry) take a look at—had been thought-about the gold normal to make the analysis of osteoporosis. The outcomes of the BMD are nonetheless crucial in making the analysis of low bone density (osteopenia or osteoporosis) and predicting the danger of fractures, significantly when used along with a bone fracture threat prediction software, such because the Fracture threat evaluation (FRAX) software (see under). BMD checks are additionally used to evaluate modifications in bone density over time and to watch the consequences of remedy.

The BMD machine works by firing X-rays from two completely different sources by means of the bones which can be being examined in the direction of a detector. The usage of two completely different X-ray sources reasonably than one permits a extra correct studying of bone density. Mineralized bone blocks a certain quantity of the X-rays. The denser the bone is, the less X-rays get by means of to the detector.

It is very important observe {that a} BMD take a look at isn’t the identical factor as a bone scan which may be used to search for different varieties of abnormalities in your bones, resembling metastases from most cancers, an infection, or irritation.

There isn’t any particular preparation required for the take a look at, though you must let your doctor know forward of time if there’s a risk you’re pregnant or for those who not too long ago had a barium examination or obtained an injection of distinction materials for a CT or radioisotope scan.

The FRAX software

While you arrive for testing, you’ll seemingly be given a type to fill out that appears one thing like this. Info from this type is used to calculate your general fracture threat as will likely be defined under.

FRAX Questionnaire screenshot 600 x 361
Screenshot of FRAX Questionnaire

You’ll be requested to take away any jewellery and alter right into a hospital robe. Then, you’ll be positioned in your again on a particular examination desk. For a part of my examination, I had a rectangular-shaped foam pillow positioned underneath my knees and I used to be requested to stay very nonetheless whereas the machine was actively scanning the bones of my again (the vertebrae) and hip.

Some individuals will even have scans of their wrists as nicely. The entire time for the take a look at—scan time plus repositioning time—is about 10 to 20 minutes, relying on which components of your physique are being examined. I used to be strolling again to my automotive 20 minutes after I checked in for the take a look at—and that included stopping on the lab for some blood checks.

Understanding the outcomes

The info from the detector is shipped to a pc which calculates a rating of the typical density of the bone in grams/cm². The pc program compares your rating to teams of individuals of the identical ethnicity and gender to calculate two completely different scores, a T-score and a Z rating. While you get the outcomes (and you must ask for a replica of the total report) it can look one thing like this:

“A bone mineral density (BMD) measurement was carried out of the L1-L4 vertebrae and the proximal femur (complete femur, neck, trochanteric, and intertrochanteric area) utilizing a Hologic Twin Vitality X-ray Absorptiometry Mannequin Discovery C machine.”

It would be best to know the identify and mannequin of the machine as it will be important in figuring out your fracture threat. It is usually vital on your clinician to know this info as a result of the outcomes might range by kind of machine used. Evaluating the outcomes to a previous take a look at performed on a distinct make and mannequin of machine could be problematic. The take a look at consequence will even describe the measurement values and the comparability group:

The take a look at consequence describes the measurement values and the comparability group:

“BMD values had been decided in gms/cm² and in comparison with a younger regular
reference inhabitants (T-score = normal deviations (SDs) under or above the younger regular imply), and to an age-matched regular reference inhabitants
(Z-score = SDs under or above the age-matched regular imply).”

The T and Z scores are each vital when decoding the outcomes and deciding for those who want remedy. The T-score compares your bone density to that of younger regular people. Bone density peaks someplace between 18-35 years outdated. After that, there’s a regular lack of bone that accelerates after menopause and doesn’t decelerate once more till the age of 70 or so. 

The T-score tells you ways a lot bone you’ve gotten misplaced in comparison with a mean peak worth of younger wholesome people of the identical intercourse and ethnicity. The Z-score compares your bone density to that of individuals of the identical gender and ethnicity and roughly your similar age.

If this rating is decrease than the reference inhabitants, it suggests you’re dropping bone quicker than the typical on your friends. This alerts you and your physician that one thing apart from “regular” bone loss attributable to getting older could also be happening. For instance, that bone loss associated to taking sure varieties of medicine, resembling glucocorticoids, aromatase inhibitors, or sure varieties of anti-epilepsy medication. This sort of osteoporosis is known as secondary osteoporosis (secondary to an element apart from getting older).

“Reference BMD values for the hip had been derived from the NHANES information and for the backbone from the Hologic reference information. In accordance with the WHO, standards osteoporosis is outlined by T-scores however you must observe that these are solely outlined for a Caucasian feminine 65 years or older.”

In accordance with a wonderful overview of greatest practices for Bone Mineral Density testing revealed in Quantity 19 of the 2016 Journal of Medical Densitometry (sure, there may be such a journal),

“Producers are suggested to make use of Nationwide Well being and Dietary Examination Survey III younger grownup Caucasian feminine BM information because the reference normal for femoral neck and complete proximal femur T-score calculation.”

They will use their very own reference information for lumbar backbone T-score calculation. This overview makes it clear that, as is true of most issues in medication, the satan is within the particulars. BMD checks should be carried out correctly with well-trained technicians and correctly calibrated and maintained machines. The interpretations have to be performed by individuals who know what they’re doing and perceive the crucial significance of making use of the proper comparisons. Embarking on remedy for osteoporosis requires that greatest practices be adopted.

“A traditional T-score is between Zero and -1.0. Osteopenia is outlined as a T-score of -1.1 to -2.4. Osteoporosis is outlined as a T-score of lower than -2.5.”

Evaluation of threat of fragility fractures

The T-score is just one piece of data that’s used to estimate the danger of getting an osteoporotic fracture over the subsequent 10 years. Though there are a number of fracture threat predictors out there, the one mostly used is the FRAX software. You’ll find a web based model of the software right here:

The software calculates threat primarily based on age, gender, BMI, and the medical threat elements reported obtained from a questionnaire stuffed out on the time of the bone density take a look at (see above). You may get an estimate of your threat even when you have not but had your BMD take a look at. However it’s extra correct if you’ll be able to embody the measured density of your femoral neck—observe that you’ll be requested to incorporate the make of the machine used on your take a look at.

The medical threat elements thought-about by FRAX are:

  • a earlier fracture
  • a mum or dad who fractured a hip
  • present smoking
  • use of glucocorticoids
  • rheumatoid arthritis
  • a analysis of secondary osteoporosis
  • alcohol consumption larger than Three models per day

That is how this info appeared in my report:

“10-year fracture dangers had been calculated utilizing the World Well being Group FRAX software primarily based on the age, gender, BMI, medical threat elements reported by the affected person, and the BMD of the femoral neck measured. Medical threat elements thought-about by FRAX are: earlier fracture, mum or dad fractured hip, present smoking, glucocorticoids, RA, 2nd osteoporosis, and three or extra alcohol models per day.”

The FRAX rating (estimated threat of getting an osteoporotic fracture over the subsequent 10 years) is reported as two completely different dangers: The % threat for any main osteoporotic fracture and the % threat for a hip fracture.

Who needs to be thought-about for remedy?

My report additionally contained the next language about remedy:

“Nationwide Osteoporosis Basis recommends to think about initiating remedy:

1) postmenopausal men and women age 50 and older with hip or
vertebral fractures, or fragility fractures
2) DEXA BMD T-scores ? -2.5 (after excluding secondary causes for
3) For osteopenic sufferers: 10-year hip fracture likelihood ? 3% or a 10-year main osteoporosis-related fracture likelihood ? 20% primarily based on the US-adapted WHO absolute fracture threat mannequin FRAX…

…all remedy selections require medical judgments and consideration of medical threat elements which will or might not have been captured within the FRAX mannequin and doable under-or-over estimation of fracture threat by FRAX.”

Lacking from the report, however crucial is the affected person’s desire. Failure to take this into consideration could also be one cause why so many individuals refuse to provoke remedy, fail to take medicines as prescribed or discontinue remedy that may very well be useful. We are going to, in fact, dive into all the points associated to the remedy of osteoporosis in a future submit.

Listed here are some articles that you could be discover useful:

  • Analysis and Remedy of Osteoporosis. Medical Clinic of North America, 2016; Vol 100 (2016) 807-826. It may be bought right here:
  • Bone mineral density: testing for osteoporosis. Australian Prescriber April 2016; 39 (2) 35-39
  • Finest Practices for Twin-Vitality X-ray Absorptiometry Measurement and Reporting: Worldwide Society for Medical Densitometry Steering. Journal of Medical Densitometry: Evaluation and Administration of Musculoskeletal Well being, 2016; 19 (2):127-140

Please go away a remark or contact me at [email protected] if you want to share your private journey with osteoporosis. Please don’t go away feedback asking for medical recommendation as that’s greatest mentioned along with your physician.

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