Consider All Prior Fractures During Osteoporosis Assessment, Study Suggests

Fractures that occurred at any prior time in adulthood were associated with fracture risk in older adults, a cohort study indicated.

In fact, a first fracture in younger adulthood was linked with the greatest increased risk. Compared with no fracture, any non-high-trauma fracture during ages 20 to 39 years was associated with a more than twofold greater risk of fracture in older patients following their first osteoporosis assessment.

“This finding contrasts with the commonly held notion that only adult fractures occurring at older ages are associated with increased risk of future fractures,” wrote researchers led by Carrie Ye, MD, of the University of Alberta in Edmonton, in JAMA Network Open.

Nonetheless, their study showed that a first fracture at any decade of life was associated with an increased fracture risk following bone mineral density testing:

• 20-29 years: adjusted hazard ratio (aHR) 2.12 (95% CI 1.67-2.71)
• 30-39 years: aHR 2.10 (95% CI 1.86-2.37)
• 40-49 years: aHR 1.71 (95% CI 1.57-1.86)
• 50-59 years: aHR 1.59 (95% CI 1.50-1.69)
• 60-69 years: aHR 1.51 (95% CI 1.42-1.60)
• 70-79 years: aHR 1.70 (95% CI 1.58-1.83)
• ≥80 years: aHR 1.70 (95% CI 1.50-1.92)

“Importantly, although the most commonly considered osteoporotic fractures (hip, vertebral, forearm, humerus, and pelvis) were the most frequent prior fractures to occur after 50 years of age, other fractures made up the largest percentage of fractures in the three youngest age categories,” wrote Ye and co-authors.

Ye told MedPage Today that “the general sentiment is that fractures are only considered fragility fractures when they occur in older adults.”

“There is a misconception that fractures are ‘normal’ in younger people and physicians don’t necessarily think about osteoporosis or increased future fracture risk when young adults break a bone,” she added. But the current findings — which support some prior studies — indicate that doctors should take into consideration all prior low-trauma fractures that occur at any point in adulthood when calculating a patient’s risk for fracture.

“Don’t ignore that fracture that occurred when someone was 25 years old,” Ye advised. “If you ignore fractures occurring in early adulthood, you may be underestimating someone’s fracture risk, which could result in not offering fracture prevention treatment when it is warranted.”

Most fracture risk prediction tools only consider fractures that occur after a certain age, the researchers pointed out. For instance, the American Bone Health Fracture Risk Calculator only considers previous fractures occurring after age 45. However, the FRAX tool is one calculator that takes into consideration all low-trauma adult fractures regardless of age at the time of fracture.

Ye’s group pulled data from the Manitoba Bone Mineral Density Registry, which included Canadian adults with a first dual energy x-ray absorptiometry (DXA) from 1996 to 2018. The date of a patient’s first DXA scan was considered the index date, and this was restricted to people age 40 and older. Using ICD codes, all clinical fractures that occurred after age 20 outside of those involving the head, neck, hands, and feet were included.

Of the 88,696 individuals included in the cohort, 90.3% were women; the average age was 65 years. Average femoral neck T score was -1.4, while 15% had a secondary cause of osteoporosis and 29% were receiving anti-osteoporosis treatment.

Over a mean period of 25 years before their DXA scan, 21,105 of the individuals (23.8%) had experienced at least one prior fracture (including multiple fractures for 5%). Average age of the first fracture prior to the index date was 57.7. The most common site of specific fracture before the index date was forearm fracture (31.5%), followed by ankle fracture (16.1%), and vertebral fracture (12.3%).

The aHRs for osteoporotic fractures ranged from 1.57 for those who had a first fracture during ages 50-59 to 2.11 for those with a first fracture during ages 20-39 years. Likewise, aHRs for major osteoporotic fractures ranged from 1.47 for ages ≥80 for a first fracture to 2.18 for ages 20-29 for first fracture. Any age besides the youngest age (20-29 years) of first prior fracture was tied with a significantly higher risk for hip fracture.

All models were adjusted for age at index date, sex, BMI, parental hip fracture, smoking status, prolonged glucocorticoid use, rheumatoid arthritis, secondary osteoporosis, alcohol use, anti-osteoporosis treatment, and femoral neck T score.

Study limitations included the small proportion of men in the cohort and that childhood fractures were not included.

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