SYDNEY, Australia—Low-trauma osteoporotic fractures are associated with increased risk of dying during the next 5-10 years for women and men age 60 years or older, and each subsequent fracture adds another 5 years to the high-risk period, according to a new study in the February 4, 2009 issue of the Journal of the American Medical Association.¹

“Overall, this study highlights the premature mortality associated with all types of fractures, particularly that which occurs after subsequent fracture across the whole age spectrum of older men and women," conclude researchers who were led by Dana Bliuc, M.Med., of the Garvan Institute of Medical Research at St. Vincent's Hospital in Sydney, Australia.

The new study included women and men age 60 years and older from Dubbo, Australia who sustained a fracture between April 1989 and May 2007. In 1989, this consisted of 2,245 women and 1,760 men. In women, there were 952 low-trauma fractures followed by 461 deaths, and 343 fractures followed by 197 deaths among men.

Non-hip, non-vertebral fractures count too

The increased mortality risk was seen across all age groups following hip, vertebral, and major fractures for 5 years post-fracture. Study participants aged 75 years and older had an increased mortality following even minor fractures such as those in the forearm, wrist, ankle, foot, clavicle and rib.

After 5 years the mortality risk decreased, except for hip fracture–associated mortality, which remained elevated for up to 10 years. After 10 years, mortality rates were not different from that of an appropriately age-matched population, the study found.

Non-hip, non-vertebral fractures constituted almost half of the fractures studied, but also were associated with 29% of the premature mortality. Mortality risk decreased with time. The occurrence of a subsequent fracture was associated with a 3- to 4-fold increased mortality risk for a further 5 years, the study showed.

Predictors of death after any fragility fracture for both men and women included age, quadriceps weakness and subsequent fracture, but not co-existing illnesses. Low bone mineral density and having smoked were also predictors for women and less physical activity was a mortality predictor for men.

“These data suggest fracture is a signal event that heralds an increased mortality risk: whether it is related to an underlying increased risk for both fracture and mortality, which may be the case for women, or whether it is related to some aspect of the fracture event itself, as appears to be the case for men, needs further exploration,” the researchers conclude.

Osteoporosis and death risk: translating research into practice

“This documents for all types of fractures what we already knew for hip and vertebral fractures, namely that following a significant fracture event there is an increase in mortality,” said Ethel S. Siris, MD, the Madeline C. Stabile professor of clinical medicine and director of the Toni Stabile osteoporosis center at Columbia University Medical Center in New York City. “The fracture event may impact very substantially on the function of someone who is already somewhat frail (and that frailty is one of the risk factors for the fracture event in the first place) pushing people one step closer to decompensating,” she told MSKreport.com. The new study “underscores the need to assess fracture risk in people as they age and getting the higher risk patients treated to lower that risk,” she said.

“The present study highlights the observation that fragility fractures are associated with increased mortality in all age groups following hip, vertebral, shoulder, multiple ribs, pelvic and limb fractures,” said Stephen Honig, MD, director of the osteoporosis center at New York University Hospital for Joint Diseases in New York City.

“Previous reports have suggested that increased mortality among fracture patients reflected poorer underlying health, but this report only pointed to increased age, quadriceps weakness and subsequent fractures as being predictors of mortality and no associated co-morbidities,” Dr. Honig said. “Additionally, low bone density, smoking history and increased postural sway were factors seen in women with increased mortality.”

The new study also confirmed the observation that men sustain fewer fractures than women, but have a higher mortality rate than women do once sustaining a fracture, he said.

All in all, this is “an important study that raises some interesting questions and one that needs further follow up.”

Reference

1. Bliuc D, Nguyen ND, Milch VE, et al. Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women. JAMA. 2009; 301:513-521.