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Proximal Humeral Fracture as a Risk Factor for Subsequent Hip Fractures
Jeremiah Clinton, MD1; Amy Franta, MD2; Nayak L. Polissar, PhD3; Blazej Neradilek, MS3; Doug Mounce, MS1; Howard A. Fink, MD, MPH4; John T. Schousboe, MD, MS5; Frederick A. MatsenIII, MD1
1 Department of Orthopaedics, Box 356500, University of Washington Medical Center, 1959 N.E. Pacific Street, Seattle, WA 98195-6500. E-mail address for F.A. Matsen III: matsen@u.washington.edu
2 875 South Waterville Lake Road, Oconomowoc, WI 53066
3 The Mountain-Whisper-Light Statistical Consulting, 1827 23rd Avenue East, Seattle, WA 98112
4 Geriatric Research Education and Clinical Center, VA Medical Center, 11-G, One Veterans Drive, Minneapolis, MN 55417
5 Division of Health Policy and Management, School of Public Health, University of Minnesota, 3800 Park Nicollet Boulevard, Minneapolis, MN 55416
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. A commercial entity (Roche, Inc.) paid or directed in any one year, or agreed to pay or direct, benefits of less than $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.
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Investigation performed at the Department of Orthopaedics, University of Washington, Seattle, Washington

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Mar 01;91(3):503-511. doi: 10.2106/JBJS.G.01529
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Background: With the aging of the world's population, the social and economic implications of osteoporotic fractures are at epidemic proportions. This study was performed to test the hypothesis that a proximal humeral fracture is an independent risk factor for a subsequent hip fracture and that the risk of the subsequent hip fracture is highest within the first five years after the humeral fracture.

Methods: A cohort of 8049 older white women with no history of a hip or humeral fracture who were enrolled in the Study of Osteoporotic Fractures was followed for a mean of 9.8 years. The risk of hip fracture after an incident humeral fracture was estimated with use of age-adjusted Cox proportional hazards regression analysis with time-varying variables; women without a humeral fracture were the reference group. Cox regression analysis was used to evaluate the timing between the proximal humeral and subsequent hip fracture. Risk factors were determined on the basis of a review of the current literature, and we chose the variables that were most predictive and easily ascertained in a clinical setting.

Results: Three hundred and twenty-one women sustained a proximal humeral fracture, and forty-four of them sustained a subsequent hip fracture. After adjustment for age and bone mineral density, the hazard ratio for hip fracture for subjects with a proximal humeral fracture relative to those without a proximal humeral fracture was 1.83 (95% confidence interval = 1.32 to 2.53). After multivariate adjustment, this risk appeared attenuated but was still significant (hazard ratio = 1.57; 95% confidence interval = 1.12 to 2.19). The risk of a subsequent hip fracture after a proximal humeral fracture was highest within one year after the proximal humeral fracture, with a hazard ratio of 5.68 (95% confidence interval = 3.70 to 8.73). This association between humeral and hip fracture was not significant after the first year, with hazard ratios of 0.87 (95% confidence interval = 0.48 to 1.59) between one and five years after the humeral fracture and 0.58 (95% confidence interval = 0.22 to 1.56) after five years.

Conclusions: In this cohort of older white women, a proximal humeral fracture independently increased the risk of a subsequent hip fracture more than five times in the first year after the humeral fracture but was not associated with a significant increase in the hip fracture risk in subsequent years.

Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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