One Broken Bone? You May Be at Risk for Another

Let’s say you’re a woman in your mid-50s, or perhaps a man in your early 70s, and you break a leg or a hip after falling from a six-foot ladder. That would be distressing, to be sure, but neither you nor your doctor would likely be surprised by the severity of your injury given the nature of the accident.

And, chances are, your doctor would not likely warn you after your fall that weakened bones may have contributed to your break, or that you might be at risk of breaking another bone next time from a minor mishap, like tripping over the dog. And so, after the break is immobilized in a cast or surgically repaired, your doctor would likely do nothing more to head off the possibility of a future fracture.

Physicians are trained to think that only bones that break after minimal or no trauma are a sign of fragile bones. And that such breaks are the only ones that warrant an evaluation of the patient’s bone health, as well as treatment and counseling to prevent another broken bone. Furthermore, professional recommendations reinforce this thinking, and prompt doctors to discharge patients after a high-trauma fracture is repaired.

Yet, there is now mounting evidence that for women past menopause and men in their Medicare years, a broken bone from any kind of trauma — whether it’s severe (car accident) or not (fall on the sidewalk) — fragile bones are likely the culprit.

In a commentary published in JAMA Internal Medicine in June, Dr. Anne L. Schafer and Dr. Dolores M. Shoback of the San Francisco Veterans Affairs Health Care System suggested that fractures following either serious or minimal trauma represent “a distinction without a difference” for middle-aged and older people. No matter how the accident occurred, current evidence indicates, when an older person breaks a bone, further evaluation of that person’s overall bone health and advice on how to maintain it should follow as an integral part of treatment.

In a column I published in November, I cited an important finding that only 9 percent of Medicare patients who sustained a hip or spinal fracture were tested for bone loss and offered treatment to head off a future fracture. Within three years, 20 percent of them were afflicted with another fracture. I probably don’t need to tell you that “an ounce of prevention is worth a pound of cure,” yet doctors are often reluctant, (and patients are often resistant) to go beyond patching up the initial injury.

Why older women who’ve broken a bone need a bone test

The JAMA Internal Medicine commentary was a response to a major new study published in the same issue of the journal. The study cataloged the incidence of subsequent fractures among 7,142 postmenopausal women, many in their 50s and 60s, who had sustained a first fracture, and compared their risk of having a second fracture to 66,874 of their peers who had not had an initial fracture. The researchers followed the women for an average of about eight years.

Among the women who sustained an initial fracture from minimal trauma, which is considered a hallmark of weakened bones, their risk of having another fracture was increased by 52 percent. Among the women whose first fracture followed a traumatic accident, like falling off a ladder, the risk of a second fracture was 25 percent greater than would have been expected based on women who had no initial fracture.

The study’s authors concluded from their statistical analysis that both “nontraumatic and traumatic initial fractures” were “similarly associated with risk of subsequent fracture.”

Contrary to current guidelines, the authors wrote, “our study’s results are clinically important because, in contrast to a nontraumatic fracture, a fracture that is considered traumatic often does not trigger further evaluation for osteoporosis or counseling regarding increased subsequent fracture risk.” However, they added, “high-trauma and low-trauma fractures show similar associations with low bone mineral density.”

Even younger postmenopausal women who have sustained a serious fracture, studies have found, are at higher risk of having osteoporosis, said Dr. Sundeep Khosla, a bone expert at the Mayo Clinic in Rochester, Minn. “The evidence is pretty compelling that postmenopausal women who fracture, regardless of the level of trauma, should have their bone density evaluated,” he told me. “A fracture suffered in a fall from a standing height confers almost as high a risk of a second fracture as if the first fracture resulted from falling down the stairs.”

Older men are also at high risk of second fractures

Men also face an often ignored risk of second fractures, especially because their first fractures are more likely to result from a traumatic event like a car accident and are not recognized as a harbinger of future fractures, Dr. Schafer said in an interview. Dr. Carolyn J. Crandall, an internal medicine physician at U.C.L.A.’s David Geffen School of Medicine who led the JAMA Internal Medicine study, said that recent studies have documented that older men who suffered a high-trauma fracture were often as likely to have low bone densities as men with a low-trauma fracture and were also at risk of a future fracture.

“Older men may be at a particular disadvantage if we brush off their high-trauma fractures,” Dr. Schafer said. “Men do lose bone with age and develop osteoporosis, though generally later in life than women. They’ve been overlooked. Men who have fractured bones in the past should not be brushed off.”

How to test for and treat fragile bones

What, then, is the message for older men and middle-aged and older women and for their physicians?

For starters, the question doctors usually ask, “How did this break occur?” is not relevant. What counts, Dr. Khosla said, is the health of the patient’s bones, and that is determined by a bone density test that measures the mineral content of bones in the spine, hips and sometimes the forearm. The test is painless, noninvasive and brief, and its results are best interpreted by a specialist in osteoporosis.

If the test shows abnormally weakened bones, doctors usually prescribe medication to slow, stop or reverse the process. Treatment should also include lifestyle counseling on diet and exercise, Dr. Khosla said. “Being physically active helps to maintain strength, balance and agility and decreases the chances of falling and breaking a bone.” Weight-bearing and strength-building exercises are important throughout life.

Equally important: Eat a well-balanced diet rich in vegetables, fruits and whole grains, as well as calcium and vitamin D. Avoid smoking and limit your alcohol and caffeine consumption.

Finally, check your home and surroundings for trip hazards and eliminate them. Scatter rugs, shoes and other articles left in mid-floor, lack of handrails, poor lighting especially on stairs — all are bone-shattering falls waiting to happen.

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