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Association Between Decreased Bone Mineral Density and Severity of Distal Radial Fractures
Robert A.E. Clayton, BSc(Hons), MBChB(Hons), FRCSEd(Tr&Orth)1; Mark S. Gaston, MBBChir, MA, FRCSEd(Tr&Orth)1; Stuart H. Ralston, MD, FRSE2; Charles M. Court-Brown, MD, FRCSEd(Tr&Orth)1; Margaret M. McQueen, MD, FRCSEd(Tr&Orth)1
1 Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SU, United Kingdom. E-mail address for R.A.E. Clayton: raeclayton@onetel.com
2 Department of Rheumatology, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, United Kingdom
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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. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
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Investigation performed at the Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, United Kingdom

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Mar 01;91(3):613-619. doi: 10.2106/JBJS.H.00486
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Abstract

Background: The role of osteoporosis and osteopenia in the etiology of fractures of the distal part of the radius is well established, but any link between osteoporosis and the severity of the distal radial fracture has not been extensively investigated. The aim of this study was to investigate the association between the degree of osteoporosis and the severity of distal radial fractures.

Methods: All patients over fifty-five years of age with a low-energy distal radial fracture were offered dual x-ray absorptiometry scanning of the hip. Data on the 137 consecutive patients were collected prospectively. Plain radiographs of the fractured distal part of the radius were assessed for angulation, metaphyseal and articular comminution, carpal malalignment, ulnar variance, AO/OTA group and subgroup classification, early and late displacement, and malunion. Fracture severity was quantified with use of previously published algorithms for calculating the probability of early and late displacement, late carpal malalignment, and malunion. These severity scores were correlated with the dual x-ray absorptiometry T-scores, which represent the number of standard deviations by which the measured bone density differs from the mean value in healthy controls.

Results: There was a significant linear correlation between increasingly negative T-scores and increasing likelihood of early instability, late carpal malalignment, and malunion. Patients with osteoporosis (a T-score of less than -2.5) had a 43% probability of having early instability, a 39% probability of having late carpal malalignment, and a 66% probability of having malunion. Patients with osteopenia (a T-score of more than -2.5 but less than -1) had a 35% probability of having early instability, a 31% probability of having late carpal malalignment, and a 56% probability of having malunion. This compared with a 28% probability of early instability, a 25% probability of late carpal malalignment, and a 48% probability of malunion in patients with normal bone mineral density (a T-score of more than -1).

Conclusions: There is a definite correlation between bone mineral density and the severity of distal radial fractures.

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

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    References

    Accreditation Statement
    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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    Robert A. E. Clayton, BSc(Hons)
    Posted on April 10, 2009
    Drs. Clayton and McQueen respond to Dr. Hollevoet
    Royal Infirmary of Edinburgh, United Kingdom

    We thank Dr. Hollevoet for her interest and her comments on our paper and for bringing these other interesting articles to our attention. It is unfortunate that we had not identified the first two very good papers to which she refers. The third paper was published after our paper was submitted. All three papers use slightly different methods of analysis and outcomes from our own. However, taking the four studies together provides strong corroborating evidence that loss of bone mineral density leads to an increase in the severity of distal radius fractures. It will be interesting to see whether there is a similar correlation in other osteoporotic fracture types.

    Nadine Hollevoet
    Posted on March 26, 2009
    Association of Bone Mineral Density and Fracture Displacement of Distal Radius Fractures
    Department of Orthopaedic Surgery and Traumatology, University Hospital Gent, Belgium

    To the Editor:

    I read the paper by Clayton et al. (1) with much interest. I would point out that, although the authors were unable to cite previous clinical studies investigating an association between osteoporosis and fracture severity or an association between bone mineral density and radiographic outcomes after injury, a number of relevant publications on these subjects do exist.

    Xie and Bärenholdt found that bone mineral density of the cortex of the distal radius was lower in displaced than in undisplaced distal radius fractures (2).

    We reported that bone mineral density correlated with an increase in ulnar variance of the fractured wrist (3). Increase in ulnar variance gives an indication of fracture severity and is higher with radial shortening and/or change in palmar tilt.

    In a recent Japanese study, an association has been shown between bone mineral density and deformity of the distal radius in low-energy Colles' fractures in women above 50 years of age, before treatment (4).

    However, only the study of Clayton et al. demonstrated an association between fracture severity and bone mineral density measured with dual-energy X-ray absorptiometry at the hip (1). Xie and Bärenholdt measured bone mineral density with peripheral quantitative tomography at the distal radius. They could not find a difference between displaced and undisplaced distal radius fractures when bone mineral density was measured at the lumbar spine or the femoral neck with Dual-energy X-ray absorptiometry (2). We found that bone mineral density correlated with an increase in ulnar variance when it was measured at the contralateral distal forearm, but not at the hip or lumbar spine (3). Sakai et al. measured bone mineral density of the lumbar spine with dual-energy X- ray absorptiometry (4).

    The author did not receive any outside funding or grants in support of her research for or preparation of this work. Neither she nor a member of her immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of her immediate family, is affiliated or associated.

    References

    1. Clayton RA, Gaston MS, Ralston SH, Court-Brown CM, McQueen MM. Association between decreased bone mineral density and severity of distal radius fractures. J Bone and Joint Surg Am. 2009;91:613-9.

    2. Xie X, Bärenholdt O. Bone density and geometric properties of the distal radius in displaced and undisplaced Colles’ fractures: quantitative CT in 70 women. Acta Orthop Scand. 2001;72:62-6.

    3. Hollevoet N, Verdonk R. Outcome of distal radius fractures in relation to bone mineral density. Acta Orthop Belg. 2003;69:510-4.

    4. Sakai A, Oshige T, Zenke Y, Suzuki M, Yamanaka Y, Nakamura T. Association of bone mineral density with deformity of the distal radius in low-energy Colles’ fractures in Japanese women above 50 years of age. J Hand Surg [Am]. 2008;33:820-6.

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