Many of us who have followed the osteoporosis field over the last twenty years have noticed an increased awareness of fragility fractures by orthopaedic surgeons. This beneficial trend has resulted in the satisfactory treatment of osteoporosis-related fractures in a larger numbers of patients. The importance of this cannot be understated, as it has been shown many times that sustaining one fracture increases the risk of sustaining additional osteoporotic fractures1.
Hip and vertebral fractures have typically been associated with osteoporosis, and patients with these fractures are increasingly being treated or referred for treatment. This has not been the case with distal radial fractures. This fact is unfortunate, as the majority of fragility fractures involve the forearm. Patients who present with distal radial fractures are usually younger than patients who present with hip and vertebral fractures. The identification of osteoporosis in these younger patients therefore would present a tremendous opportunity to start treatment early in order to prevent future fractures2.
The first thing that can be said of the paper by Gong et al. in this issue of The Journal is with regard to the large study size. Utilizing a nationwide database in South Korea that contained information for 97% of the South Korean population, the authors looked at more than 150,000 fractures that occurred during 2007. This size alone makes the study worthy of note. The results show a significant difference (p < 0.001) between the number of patients with hip or vertebral fractures who received a referral for bone density testing or who received treatment for osteoporosis as compared with the number of patients with distal radial fractures who received referrals and treatment. Only 7.5% of female patients with wrist fractures received treatment for osteoporosis as compared with 21.9% of female patients with hip fractures and 30.1% of female patients with vertebral fractures.
Many health-care providers and many patients themselves do not have the perception that a wrist fracture may be associated with osteoporosis and in need of osteoporosis follow-up and possible treatment. This study confirms that, in comparison with hip and vertebral fractures, a disproportionate number of distal radial fractures are not being identified properly as fragility fractures. This may be related to the many ongoing media promotional activities that stress the need to prevent hip and spinal fractures. Wrist fractures have been largely disregarded even though the relationship to osteoporosis has been documented in the orthopaedic literature3.
The Korean health system is somewhat different than the American system in that most fractures are treated and also followed up by a "musculoskeletal specialist," often an orthopaedic surgeon. A primary-care doctor may not be involved. Although the American system works differently, the orthopaedic surgeon is still responsible for most patients who have sustained a fracture and, in fact, may be the only health-care provider the patient ever sees. In all likelihood, the results of this study would be similar to the results seen in an American population.
The paper does not include men or women with multiple fractures, as these types of patients would be more prone to have been involved in high-energy trauma. Although recent data have shown that patients with low bone density are more prone to fracture even in high-energy trauma events4, this exclusion makes good sense. The study population is so large that even excluding these patients does not make the conclusions any less significant; in fact, the exclusion probably increases the accuracy of the results.
Many barriers have been identified that interfere with the recognition of fragility fractures as those needing osteoporosis management5,6. These include misconceptions and a lack of knowledge on the part of both the physician and the patient. The relevance to the orthopaedic surgeon is clear. Hip and vertebral fractures are not the only fractures associated with osteoporosis. Plainly, an opportunity to recognize other fractures that typically also are fragility fractures must not be missed. These include not only distal radial fractures but also proximal humeral fractures, pelvic fractures, and, in fact, most other fractures that may occur as the result of a fall from a standing height.
*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
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2. Rozental TD, Makhni EC, Day CS, Bouxsein ML. Improving evaluation and treatment for osteoporosis following distal radial fractures. A prospective randomized intervention. J Bone Joint Surg Am. 2008;90:953-61.
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