ORIGINAL ARTICLE

Low-energy distal radius fractures in middle-aged and elderlymen and women—the burden of osteoporosis and fracture riskA study of 1794 consecutive patients

J. Øyen & C. G. Gjesdal & C. Brudvik & L. M. Hove &

E. M. Apalset & H. C. Gulseth & G. Haugeberg

Received: 16 March 2009 /Accepted: 7 September 2009 /Published online: 8 October 2009# International Osteoporosis Foundation and National Osteoporosis Foundation 2009

AbstractSummary One third of 218 men and half of 1,576 womenwith low-energy distal radius fractures met the bonemineral density (BMD) criteria for osteoporosis treatment.A large proportion of patients with increased fracture riskdid not have osteoporosis. Thus, all distal radius fracturepatients ≥50 years should be referred to bone densitometry.Introduction Main objectives were to determine the prev-alence of patients with a low-energy distal radius fracture inneed of osteoporosis treatment according to existing guide-lines using T-score ≤ −2.0 or ≤−2.5 standard deviation (SD)and calculate their fracture risk.Methods A total of 218 men and 1,576 women ≥50 yearswere included. BMD was assessed by dual energy X-rayabsorptiometry (DXA) at femoral neck, total hip, and lumbarspine (L2–L4). The WHO fracture risk assessment tool(FRAX®) was applied to calculate the 10-year fracture risk.

Results T-scores ≤−2.0 and ≤−2.5 SD at femoral neck wasfound in 37.7% and 19.6% of men and 51.1% and 31.2%of women, respectively. The risk of hip fracture was 6.2%for men and 9.0% for women. The corresponding figuresfor patients with T-score ≤−2.0 SD were 11.6% and14.5% and for T-score ≤−2.5 SD 16.3% and 18.2%,respectively. A large proportion of distal radius fracturepatients with a high 10-year FRAX® risk did not haveosteoporosis.Conclusions Every second to every third fracture patientmet the present BMD criteria for osteoporosis treatment.Because a large proportion of distal radius fracture patientsdid not have osteoporosis, treatment decisions should notbe based on fracture risk assessment without bone den-sitometry. Thus, all distal radius fracture patients ≥50 yearsshould be referred to bone densitometry, and if indicated,offered medical treatment.

J. Øyen (*) : C. Brudvik : L. M. HoveDepartment of Surgical Sciences,Faculty of Medicine and Dentistry, University of Bergen,5021 Bergen, Norwaye-mail: jannike.oyen@kir.uib.no

C. G. Gjesdal : E. M. ApalsetDepartment of Rheumatology, Haukeland University Hospital,Bergen, Norway

C. G. GjesdalSection of Rheumatology, Institute of Medicine,University of Bergen,Bergen, Norway

C. BrudvikBergen Accident and Emergency Department,University of Bergen,Bergen, Norway

L. M. HoveDepartment of Orthopedic Surgery,Haukeland University Hospital,Bergen, Norway

E. M. ApalsetDepartment of Public Health and Primary Health Care,University of Bergen,Bergen, Norway

H. C. GulsethDepartment of Rheumatology, Betanien Hospital,Skien, Norway

G. HaugebergDepartment of Rheumatology, Sørlandet Hospital,Kristiansand, Norway

G. HaugebergDepartment of Neuroscience, Division of Rheumatology,Norwegian University of Science and Technology,Trondheim, Norway

Osteoporos Int (2010) 21:1257–1267DOI 10.1007/s00198-009-1068-x

Keywords Bonedensitometry . Bonemineral density . Distalradius fractures . FRAX® . Norway . Osteoporosis

Introduction

Osteoporosis is more common in Scandinavia than in anyother part of the world, and the incidence of low-energyfractures, e.g., of the distal radius or hip, is among thehighest worldwide [1–3]. A previous fracture, low bonedensity, and high age are the most important risk factors forlow-energy fractures [4–6]. Persons with a low-energydistal radius fracture are also at increased risk of subsequentfractures both at the hip and spine [7]. Thus, a distal radiusfracture may be the first presentation of a potentiallydevastating disease.

Osteoporosis treatment, e.g., with bisphosponates anddenosumab, reduces the fracture risk significantly inpostmenopausal women with osteoporosis [8–11]. However,treatment has not been found to reduce fracture risk inpatients with osteopenia. Guidelines based on cost-effectiveness have been developed to allocate treatment toindividuals at the highest risk of a new low-energy fracture[12, 13]. Some guidelines recommend considering treatmentafter a low-energy fracture in subjects aged 50 years and olderwith low bone mineral density (BMD) defined as aT-score ≤−2.0 standard deviation (SD) [14–16] or defined asa T-score ≤−2.5 SD (osteoporosis) [17, 18]. On the otherhand, the National Institute of Health and Clinical Excellence(NICE) guideline suggests treatment for all women aged75 years and older presenting with a low-energy fracturewithout the need of including bone measurements [19].

The World Health Organization (WHO) fracture riskassessment tool (FRAX®) allows the 10-year risk of hipfracture and any major osteoporotic fracture (clinical spine,forearm, hip, or shoulder) to be calculated. The algorithmincludes both demographic and clinical risk factors and canbe used with or without taking the femoral neck BMD intoconsideration [20]. FRAX® has also been used to calculatecost effective treatment thresholds for medical intervention.In one study from USA, [21] FRAX® threshold for hipfracture was calculated to be 3%, whereas in one studyfrom UK [22] FRAX® threshold for any major osteoporoticfracture was 7%.

Data on the prevalence of low BMD or osteoporosis inpatients with distal radius fractures are scarce, and thus, thenumber of distal radius fracture patients in need of medicaltreatment according to treatment guidelines is unknown. Instudies of small numbers of patients, BMD has beenreported to be lower in distal radius fracture patients thanin controls both in men [23] and women [13, 24, 25].However, BMD has not been thoroughly investigated inlarge patient samples.

The aim of this study was to include both BMDmeasurements and FRAX® calculations in the study of alarge group of patients with distal radius fractures aged50 years and older. The main objectives were to determinethe prevalence of patients in need of osteoporosis treatmentdefined as either a T-score ≤−2.0 SD according to, e.g., theNorwegian Medicines Agency's (NMA) or a T-score ≤−2.5SD according to the WHO definition of osteoporosis, andto estimate the 10-year risk of hip fracture and any majorosteoporotic fracture. A further aim was to investigatewhether these patients had a lower age- and gender-adjusted BMD (Z-score ≤−1.0 SD) than a healthy referencepopulation.

Methods

Study design and patient recruitment

In 2003, in accordance with the osteoporosis guidelines ofthe NMA [15], we established an automatic referral tobone densitometry in three Norwegian cities (Bergen,Kristiansand, and Skien) for all patients aged 50 years andolder who suffered a low-energy distal radius fracture(Table 1). This routine assessment was based on theFracture Liaison Service model set up in Glasgow [26].Patients were consecutively recruited from the referralcenters for orthopedic trauma: the Bergen Accident andEmergency Department and Haukeland University Hospitalin Bergen, Sørlandet Hospital in Kristiansand, and TelemarkHospital in Skien. These patients were invited for osteopo-rosis assessment at the osteoporosis centers of their localhospital.

Clinical data were collected for fracture risk assessment,and BMD was measured. Patients with fractures due toobvious high-energy trauma were excluded. Low-energyfracture was defined as a result of minimal trauma, e.g.,falling from standing height or less [27]. A distal radiusfracture was defined as located within 3 cm of theradiocarpal joint [28]. Data were collected from March2003 to December 2007. The study was approved by theNational Data Inspectorate and the regional committees formedical research ethics.

Demographic and clinical data

As part of the clinical fracture risk assessment at theosteoporosis centers, a broad spectrum of demographic andclinical data was routinely collected as listed in Table 2.The data were obtained both by self-report and interview bymedical staff. At the osteoporosis centers, patients weregiven counseling and offered treatment in accordance withthe NMA recommendations.

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BMD measurements and reference population

BMD was measured at the total hip, femoral neck, andlumbar spine (L2–L4) by dual energy X-ray absorptiometry(DXA) using Prodigy in Bergen and Kristiansand andEXPERT-XL in Skien (GE Lunar, Madison, WI). We choseto investigate the prevalence of T-score ≤−2.0 SD andT-score ≤−2.5 SD at femoral neck alone and at either totalhip, femoral neck, or L2–L4 as both of these alternativesreflect common clinical practice [29]. The DXA machineswere stable during the whole study period, and the in vitrolong-term coefficient of variation (CV%) was 0.86% inBergen, 0.62% in Kristiansand, and 0.92% in Skien. The invivo short-term precision for total hip, femoral neck, andL2–L4 measurements were 0.77%, 1.47%, and 1.36% inBergen, 0.89%, 1.56%, and 1.19% in Kristiansand, and0.80%, 1.58%, and 1.50% in Skien. The mean time fromthe occurrence of the distal radius fracture until DXAmeasurements was 41 days in men and 49 days in women.The left hip was scanned unless there was a history ofprevious fracture or surgery; scans of the right hip wereused in 103 (5.7%) patients. Due to bilateral fracture orsurgery in 57 (3.6%) patients, only spine scans were used.In 11 (0.7%) patients, spine scans could not be analyzeddue to degenerative changes.

The reference database used for T-score and Z-scorecalculations were provided by the DXA manufacturer asincorporated in the accompanying software. This European/US reference population consists of 9,643 hip measure-ments, 11,460 femoral neck measurements, and 12,549spine measurements of women aged 20 to 89 years [30] anda total of 3,163 hip measurements, 3,584 femoral neckmeasurements, and 2,880 spine measurements of men in thesame age span. The database is compiled from severalsubstudies of ambulatory subjects, and most excludepersons with previous fractures, chronic diseases, ormedications known to influence bone metabolism. Scoreswere gender-specific, and reference population for calculation

of T-score was young adults between 20 and 40 years old.Equations for the Z-score calculations have previously beenpublished [31, 32]. Previous studies have shown that theEuropean/US reference population database supplied by themanufacturer Lunar corresponds well with the Norwegiannormal population across all adult age groups [33, 34].

BMDwas categorized according to theWHO definition ofosteoporosis (T-score ≤−2.5 SD) and the NMA treatmentguidelines (T-score ≤−2.0 SD). Normal BMD was defined asT-score ≥–1.0 SD. If T-score was ≤−2.0 SD at femoral neck,the patient was categorized as having low BMD and in needof treatment according to NMA. A patient was categorized tohave osteoporosis if T-score was ≤−2.5 SD at femoral neck.We also investigated the proportion of patients with these T-score levels at either total hip, femoral neck, or L2–L4. Wedivided the patients into 10-years age spans. Patients werealso categorized according to a Z-score cut off <–1.0 SD.

The NICE guideline suggests treatment for all womenaged 75 years and older presenting with a low-energyfracture without the need of BMD measurement [19].According to this, we investigated the proportion ofT-score ≤−2.5 SD at femoral neck in our women aged 75 yearsand older. We did the same in men aged 75 years and older.

Fracture risk assessed by FRAX®

The FRAX® model for predicting fracture risk is based ondifferent patient cohorts from around the world includingNorth America and Europe. It has been validated inindependent cohorts with a similar geographic distribution[35]. We used the Swedish FRAX® model version 3.0 toestimate the 10-year risk of hip fracture and any majorosteoporotic fracture (clinical spine, forearm, hip, orshoulder). The FRAX® model covers ages 40 to 90 years.For this reason, men (n=3) and women (n=25) older than90 years were excluded from the FRAX® analyses. Sixfemale patients from Asia were also excluded due toethnicity other than Caucasian. The clinical risk factors

Table 1 Attending and nonattending patients with low-energy distal radius fractures from three cities in Norway

Bergen Kristiansand Skien Total

Men Women Men Women Men Women Men Women

All Totalnumber

185 1,252 58 470 114 627 357 2,349

Age(range)

66.7(50.2–93.4)

70.6(50.1–97.4)

67.4(50.3–89.3)

72.5(50.1–100.3)

66.4(50.3–91.8)

74.8(48.9–97.9)

66.6(50.1–93.4)

72.5(48.9–100.3)

Nonattendees N (%) 99 (53.5) 571 (45.6) 13 (22.4) 100 (21.3) 27 (23.7) 102 (16.3) 139 (38.9) 773 (32.9)

Age(range)

68.3(50.2–93.4)

74.6(50.1–97.2)

66.5(50.7–89.3)

76.3(51.2–100.3)

68.5(50.3–91.8)

80.8(48.9–97.9)

67.8(50.2–93.4)

77.2(48.9–100.3)

Attendees N (%) 86 (46.5) 681 (54.4) 45 (77.6) 370 (78.7) 87 (76.3) 525 (83.7) 218 (61.1) 1,576 (67.1)

Age(range)

65.0(50.4–86.1)

66.6(50.2–97.4)

68.2(50.3–68.2)

68.7(50.1–99.8)

64.3(50.3–91.5)

68.8(50.3–97.0)

65.3(50.3–91.5)

67.8(50.1–99.8)

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included in the FRAX® model comprise information onrace, age, sex, weight, height, femoral neck BMD (g/cm2), aprevious fracture, parental history of hip fracture, currentsmoking, use of oral glucocorticoids for more than threemonths, rheumatoid arthritis, other secondary causes of

osteoporosis, and alcohol intake of three or more units perday [20]. Our questionnaire did not include the alcohol unitvariable recommended in FRAX® as the participants onlyreported whether or not they considered themselves asalcohol abusers.

Men (n=218) Women (n=1,576)

Demographics

Age (years) 65.3 (10.6) 67.8 (10.5)

Height (cm) 177.1 (7.9) 163.4 (6.4)

Weight (kg) 81.0 (14.8) 67.7 (12.6)

BMI (kg/m2) 25.7 (3.9) 25.3 (4.3)

Clinical characteristics

History of hip fracture in parenta 20 (9.2) 158 (10.1)

Rheumatoid arthritisa 1 (0.5) 47 (3.0)

Secondary osteoporosisa 3 (1.4) 221 (14.1)

Alcohol abusea 2 (0.9) 4 (0.3)

Smoking

Never 83 (38.1) 832 (53.2)

Previous 79 (36.2) 437 (28.0)

Currenta 56 (25.7) 293 (18.7)

Glucocorticosteroids

Never 184 (93.9) 1328 (91.0)

Previous 3 (1.5) 75 (5.1)

Current 9 (4.6) 56 (3.8)

≥3 monthsa 9 (4.6) 111 (7.1)

Inflammatory diseases 15 (6.9) 156 (9.9)

Endocrine diseases 13(6.0) 89 (5.6)

Cardiovascular diseases 20 (9.2) 98 (6.2)

Diabetes

Type I 3 (1.4) 11 (0.7)

Type II 10 (4.6) 50 (3.2)

Loss of height (≥3 cm) 51 (25.2) 489 (34.0)

Menopause <45 years – 210 (13.3)

Previous fracture 49 (22.5) 501 (31.8)

BMD

BMD total hip (g/cm2) 0.90 (0.15) 0.81 (1.09)

BMD femoral neck (g/cm2) 0.84 (0.12) 0.78 (0.13)

BMD L2–L4 (g/cm2) 1.09 (0.21) 1.00 (0.18)

T-score total hip (SD) −1.27 (1.25) −1.58 (1.14)

T-score femoral neck (SD) −1.71 (0.98) −1.93 (1.07)

T-score L2–L4 (SD) −1.22 (1.72) −1.66 (1.50)

Z-score total hip (SD) −0.69 (1.01) −0.43 (0.89)

Z-score femoral neck (SD) −0.67 (0.90) −0.38 (0.88)

Z-score L2–L4 (SD) −0.80 (1.67) −0.24 (1.39)

T-score ≤−2.0 SD total hip 54 (25.5) 592 (38.8)

T-score ≤−2.0 SD femoral neck 80 (37.7) 779 (51.1)

T-score ≤−2.0 SD L2-L4 71 (32.9) 690 (44.0)

T-score ≤−2.5 SD total hip 30 (14.2) 345 (22.6)

T-score ≤−2.5 SD femoral neck 42 (19.6) 476 (31.2)

T-score ≤−2.5 SD L2-L4 48 (22.2) 485 (31.0)

Table 2 Demographicvariables, clinical characteris-tics, and BMD measures in thedistal radius fracture patients

Mean (SD) for continuousvariables and numbers (%) forcategorical variables. Totals mayvary between different variablesaccording to differences in theamount of missing data.Secondary osteoporosiscomprised type I diabetes, oste-ogenesis imperfecta, untreatedhyperthyroidism, hypogonadismor premature menopause(<45 years), chronic malnutri-tion or malabsorption, andchronic liver disease. Inflamma-tory disease comprisedinflammatory bowel disease andinflammatory rheumaticdiseases (rheumatoid arthritis,ankylosing spondylitis, psoriat-ric, and reactive arthritis, andcollagenosis). Endocrinediseases comprised hyperpara-thyroidism, hypothyroidism, andhyperthyroidism. Cardiovasculardisease comprised anginapectoris and cardiac infarction.Loss of height is defined as thedifference between presentheight and the given maximumadult height. Previous fracture isdefined as previous fracturebefore the current distal radiusfracture and comprised fractureof the distal radius, upper arm,rib, spine, hip, femur, or lowerleg from low-energy traumaafter the age of 50 yearsa Variables included in FRAX®

BMI body mass index, BMDbone mineral density, SDstandard deviation

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The 10-year risk of hip fracture and any major osteoporoticfracture was calculated by FRAX® in two different ways:first, based on clinical risk factors only and thereafter, byincluding femoral neck BMD in the FRAX® algorithm. Wecombined the FRAX® results with respectively any-T-score,different T-scores, and across different age and fracturegroups. Patients were divided into three groups according tofracture history after the age of 50 years; current distal radiusfracture only, current and one previous fracture, and currentand two or more previous fractures.

To evaluate treatment discordance for our population ofdistal radius fracture patients treated based on osteoporosiscut off alone versus those treated on the basis of a FRAX®threshold, we tested four different FRAX® interventionthresholds (>3%, >7%, >10%, and >15%), and comparedwith T-score ≤−2.5 SD at femoral neck.

Statistical analyses

Categorical variables were expressed as numbers andpercentages, and continuous variables as means withvariance expressed as SD or range. To compare BMDlevels in our group of fracture patients with the referencepopulation defined in the Lunar database, we evaluated theproportion of individuals with a Z-score ≤−1.0 SD [33].Assuming a normal distribution, the risk is 0.68 of beingwithin ±1 SD of the mean; thus, the expected proportion ofZ-scores ≤−1.0 SD is 16% by default. The 95% confidenceinterval (CI) range for proportions of patients having aZ-score of ≤−1.0 SD was calculated using the equation forbinomial distribution [36]. A two-tailed p value< 0.05 wasconsidered statistically significant. All analyses wereperformed using SPSS software for Windows, version15.0 (SPSS Inc., Chicago, IL).

Results

A total of 357 men and 2,349 women aged 50 years and olderwere identified as having suffered a distal radius fracture inthe catchment areas during the recruitment period. Of these,61.1% of the men (n=218) and 67.1% of the women (n=1,576) were examined at their local osteoporosis clinics(Table 1). The mean (range) age was 65.3 years (50.3–91.5)for men and 67.8 years (50.1–99.8) for women. A previouslow-energy fracture before the current distal radius fracturewas found in 22.5% of the men and 31.8% of the women.Demographic data, clinical characteristics, and the BMDdata of the participants are shown in Table 2. No majordifferences in these data were found between the threeosteoporosis centers (data not shown).

Prevalence of low BMD and indication for treatment

A total of 80 (37.7%) men and 779 (51.1%) women had a T-score ≤−2.0 SD at femoral neck while 106 (48.6%) men and1,000 (63.5%) women had a T-score ≤−2.0 SD at total hip,femoral neck, and/or L2–L4. T-scores ≤−2.5 SD at femoralneck were found in 42 (19.6%) men and 476 (31.2%) women.The corresponding figures at total hip, femoral neck, and/orL2–L4 were 71 (32.6%) in men and 715 (45.4%) in women. Anormal femoral neck BMD (T-score ≥–1.0 SD) was found in 45(22.1%)men and 289 (19.0%)women. Patients of both gendersclassified by age group and T-score level (−1.0 SD, −2.0 SD,−2.5 SD) for femoral neck are shown in Fig. 1. In the youngestage groups the percentage of men with a T-score ≤−2.0 SDwas the same as in women.

The proportion of men with a Z-score ≤−1.0 SD belowthe mean of controls for total hip, femoral neck, and L2–L4was 38.2% (95% CI 31.7; 44.6), 40.2% (95% CI 33.5;

Fig. 1 Prevalence of T-scores ≤−2.5 SD, >−2.5 SD, but ≤−2.0 SD, but >−1.0 SD and ≥−1.0 SD at femoral neck in male and female patients withlow-energy distal radius fractures

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46.9), and 49.1% (95% CI 42.4; 55.8), respectively. Inwomen, the corresponding figures were 27.7% (95% CI25.5; 29.9), 25.7% (95% CI 23.5; 27.9), and 31.5% (95%CI 29.2; 33.8), respectively. The highest proportions ofpatients with a Z-score ≤−1.0 SD were in the youngest agegroups of both genders as shown in Fig. 2.

Only 14 (32.6%) of the men and 225 (53.8%) of thewomen aged 75 years and older had indication forosteoporosis treatment (femoral neck T-score ≤−2.5 SD).

Fracture risk assessment

The 10-year risk of hip fracture calculated with BMDwas 6.2%for men and 9.0% for women and of any major osteoporoticfracture 14.4% and 23.1%, respectively (Table 3). Men with aT-score ≤−2.5 SD had a 16.3% risk of hip fracture and a25.1% risk of any major osteoporotic fracture. Equivalentfigures for women were 18.2% and 34.7%. The fracture risk

increased by age and by number of previous fractures(Table 3). Compared with the rest of the male group, theoldest men with osteoporosis (T-score ≤−2.5 SD) had thehighest risk of hip fracture (20.6%) and any majorosteoporotic fracture (28.2%). The corresponding figuresfor women in the oldest age group were 21.9% and 39.7%.However, women with osteoporosis and a current and twoor more previous fractures had the highest risk of hipfracture (24.2%) and any major osteoporotic fracture(40.2%). Equivalent figures in men were 20.6% and28.2%. The 10-year hip fracture risk calculated without BMDwas 5.8% for men and 13.2% for women and of any majorosteoporotic fracture 13.8% and 27.7%, respectively (Table 3).

The prevalence of osteoporosis in patients with distalradius fracture as shown in Table 4 increased withincreasing FRAX® score. However, a large proportion ofpatients even in those with a high FRAX® score did nothave osteoporosis.

Fig. 2 Prevalence with 95%confidence intervals ofZ-scores ≤ −1.0 SD at total hip,femoral neck, and spine in maleand female patients with low-energy distal radius fractures,compared with the Lunar refer-ence population (expected to be16% by definition)

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Table 3 The 10-year risk of hip fracture and any major osteoporotic fracture in the distal radius fracture patients calculated with and withoutfemoral neck BMD

aWithoutBMD

Any T-score T-score ≤−2.5 SD

T-score ≤−2.0 SD

T-score >−2.0 SD

T-score ≥−1.0 SD

Men (n=215) Hip fx Maj fx Hip fx Maj fx Hip fx Maj fx Hip fx Maj fx Hip fx Maj fx Hip fx Maj fx

All men 5.8 13.8 6.2 14.4 16.3 25.1 11.6 20.3 3.1 11.0 1.3 8.6

Fractures

Current fracture 5.1 13.0 5.5 13.6 16.2 24.7 11.1 19.7 2.6 10.4 1.2 8.3

Current and one previous fracture 7.1 15.4 8.6 17.4 16.5 26.2 12.9 22.4 5.0 13.3 2.2 10.6

Current and two or more previous fractures 11.3 19.1 8.5 16.5 17.6 25.4 12.6 20.7 4.4 12.6 0.4 9.7

Age groups

50–59 1.9 9.1 3.8 11.4 13.5 22.0 8.9 17.6 1.7 8.9 0.7 7.6

60–69 4.4 13.6 5.9 15.4 13.5 24.0 9.7 19.5 2.6 11.9 1.3 9.7b70–90 12.3 20.1 9.8 17.3 20.6 28.2 16.4 24.0 5.6 13.1 3.1 10.0cWomen (n=1,545)

All women 13.2 27.7 9.0 23.1 18.2 34.7 14.5 30.5 3.5 15.5 1.7 12.5

Fractures

Current fracture 11.4 25.4 7.7 21.2 16.7 32.8 13.0 28.5 3.1 15.0 1.3 11.7

Current and one previous fracture 16.1 31.6 11.3 26.4 18.8 36.0 16.0 32.9 4.1 16.6 2.8 15.1

Current and two or more previous fractures 20.4 35.8 14.4 29.4 24.2 40.2 20.0 36.2 5.6 18.9 2.7 15.2

Age groups

50–59 3.8 14.7 3.4 14.0 9.5 22.0 7.1. 19.7 1.8 11.5 0.9 10.1

60–69 7.8 22.9 5.7 20.2 13.3 30.5 9.6 25.9 2.7 15.9 1.3 13.3

70–79 22.0 38.2 14.6 30.3 21.4 38.0 18.1 34.5 7.3 21.6 3.6 16.5

80–90 27.9 45.1 18.4 35.8 21.9 39.7 20.8 38.5 9.2 25.0 6.2 20.6

Data are given as percentages. As FRAX® only accepts ages between 40 and 90 years, men (n=3) and women (n=25) over 90 years of age wereexcludeda FRAX® calculated without BMDbBecause of the small number of patients in the oldest age groups, the groups were mergedc Six female patients from Asia were excluded from the FRAX® analysis due to ethnicity other than Caucasian

Hip Fx hip fracture, Maj Fx any major osteoporotic fracture, SD standard deviation

Table 4 Prevalence of osteoporosis at femoral neck in patients with distal radius fractures with various FRAX® thresholds for 10-year fracturerisk for hip and any major osteoporotic fracture

FRAX® with BMD FRAX® without BMD

Men (n=212) Women (n=1,525) Men (n=212) Women (n=1,525)

Hip fracture

>3 31.1 44.9 25.0 34.8

>7 66.7 65.9 31.5 44.2

>10 88.5 75.6 37.5 49.3

>15 84.6 81.8 55.6 54.0

Any major osteoporotic fracture

>3 18.8 30.6 18.8 30.5

>7 20.3 30.7 19.9 30.6

>10 25.7 33.7 23.1 31.5

>15 53.7 43.3 29.7 36.5

Data are given as percentages

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Discussion

This study highlights the significance of osteoporosis and itsinvolvement in low-energy distal radius fractures in middle-aged and elderly patients of both genders, and the FRAX®calculated increased risk of future fractures in these patients.As many as 38% of the men and 51% of the women aged50 years and older with a distal radius fracture had anindication for treatment according to guidelines using aT-score threshold of ≤−2.0 SD at femoral neck, and about20% of men and 31% of women using T-score ≤−2.5 SD. Theprevalence of osteoporosis increased with increasing FRAX®score; but even in patients with a high FRAX® score, a largeproportion of patients did not have osteoporosis.

To our knowledge, this is the largest study to explore theproportion of distal radius fracture patients in need of treatmentaccording to BMD treatment guidelines and the first to estimatethe 10-year risk of fractures using FRAX® in a population ofpatients with distal radius fractures. Despite the large numberof patients, selection bias may have influenced our results asonly 61% of male and 67% of female patients underwentdensitometry. The oldest age groups, in particular, had a lowparticipation rate. The participation rate was lower in Bergenthan in the two other cities. Bergen is a larger city offeringconsultation for osteoporosis at several clinics, whereas the twosmaller cites only have one orthopedic referral center each.

In the present study, DXA measurements and assessmentof clinical risk factors were in average conducted within2 months after the fracture. As retrospective data collectioncan be biased by recall problems, this may have influencedthe results for some of the clinical variables, e.g., loss ofheight, menopause, and previous fractures.

Although no specific FRAX®model has been developed forthe Norwegian population, the incidences of low-energyfractures have been shown to be comparable in the Scandina-vian countries and are among the highest in the world [1–3].Thus, the Swedish FRAX® model is probably also reliable forthe Norwegian population. The optimal estimate of alcoholconsumption as a risk factor according to FRAX® is three ormore units per day. In our study, participants simply reportedwhether or not they considered themselves to be alcoholabusers. This may have lead to misclassifications, and wemay have underestimated the 10-year risk of fractures in somepatients especially among the younger men with low BMD.

In previous studies, lower BMD in patients with a distalradius fracture compared with controls has been reported inboth men [23] and women [14, 24, 25, 37]. However, intwo studies where heel BMD was used, no differences werefound between patients with a distal radius fracture andcontrols [38, 39]. The impact of low BMD in younger andolder age groups is inconsistent in previous studies. In onesmall study, odds ratio for having low BMD weresignificantly greater in women younger than 65 years than

in those aged 65 years and older presenting with a distalradius fracture [24] while, in another study, reduced BMDwas more frequently seen in elderly distal radius fracturepatients aged 65 years and older than in those younger than65 years [40]. Contradictive results like this may beattributed to qualitative and quantitative differences betweenthe examined cohorts as well as methodological discrepanciesrelated to, e.g., patient recruitment and study design. Thenumber of participants in all these studies are relatively smallcompared with our cohort of distal radius fracture patients.

The total prevalence of low BMD (T-score ≤−2.0 SD) andosteoporosis (T-score ≤−2.5 SD) in our study is similar tofindings in two previous studies on women [25, 26]. Löfmanet al. [25] found T-scores <−2.0 SD in 53% and <−2.5 SD(osteoporosis) in 37% at total hip or spine in 171 Swedishwomen (mean age, 67 years) with distal radius fractureswhile McLellan et al. [26] diagnosed osteoporosis at thesame measurement sites in 41% of the 420 Glasgowwomen aged 50 years and older with similar fractures.

There are limited BMD data on distal radius fractures inmen [23, 41]. The prevalence of osteoporosis in men washigher in our study (33%) compared with the FractureLiaison Service study in Glasgow. A total of 221 men witha distal radius fracture (mean age, 65 years) were reportedto have 23% prevalence of osteoporosis at total hip, femoralneck, or spine [41]. In a small British study of 67 men(mean age, 61 years), as many as 42% were diagnosed withosteoporosis at the same measurements sites [23].

A previous low-energy fracture in middle-aged andelderly patients is a predictor for osteoporosis and subse-quent fractures [4–7], and several guidelines recommendbone densitometry for these patients [14–18, 42, 43]. TheNICE guideline recommends treatment for all femalepatients aged 75 years and older with a low-energy fracturewithout the need of BMD measurement [19]. If we hadfollowed the NICE guidelines, 67% of the men and 46% ofthe women would receive treatment without havingosteoporosis. The evidence that fracture patients withoutosteoporosis will benefit from treatment is weak. Thus,bone densitometry should be performed before startingosteoporosis treatment to avoid over treatment.

Compared with hip fractures, costs associated with distalradius fractures are relatively low and the long-term impact onfuture quality of life is limited [44]. Distal radius fractureshave been shown to occur at an average of 15 years earlier inlife than hip fractures [45] and can predict future hip andvertebral fractures [7]. In the current study, the highestproportion of patients with low age- and gender-adjustedBMD (Z-score ≤−1.0 SD) was found among the youngestgroups of middle-aged men and women (Fig. 2 and Table 3).A good fracture preventive strategy would be to designatedistal radius fracture patients as a target group to detect andtreat osteoporosis at an early stage. This could reduce the

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future risk of the devastating consequences of osteoporosis[7, 46]. Pharmacological antiresorptive therapy has beenshown to reduce the total fracture risk in postmenopausalwomen [8–10] and vertebral fractures in middle-aged andelderly men with primary osteoporosis [47]. The clinicalimplication of identifying these patients is further emphasizedas antiresorptive treatment has been shown to be cost-effectivein women with previous fracture and low BMD [22].

Analysis from the USA have shown cost-effectiveness intreating patients aged 50 years and older if the 10-year risk of ahip fracture (calculated without BMD) reached approximately3% [21], and analyses from the UK have shown thattreatment is cost-effective at a major osteoporotic fractureprobability of 7% (calculated with BMD) [22]. In ourpopulation of distal radius fracture patients, only 25% ofthe men and 35% of the women did have osteoporosis due tothe US FRAX® intervention threshold and only 20% of themen and 31% of the women due to the UK FRAX®intervention threshold. The prevalence of osteoporosisincreased with increasing FRAX® score, but even when theFRAX® score was above 15%, a large proportion of patientsdid not have osteoporosis as shown in Table 4. Thepercentage of cost-effectiveness will differ from country tocountry depending on, e.g., the willingness of society orpatient to pay, gross domestic product, and fracture rates[48]. However, our results show that all distal radius fracturepatients ≥50 years should be referred to bone densitometrybefore starting osteoporosis treatment. Today, the mostdisappointing fact is the low follow-up rate of these patientsat risk of subsequent fractures. Generally, less than 10% arereferred to further consultation or treatment for osteoporosis[49, 50].

In conclusion, our data emphasize the same need of anincreased awareness of osteoporosis in both middle-agedmen and women as well as in elderly patients with low-energy distal radius fractures. Every second to every thirdfracture patient met the present BMD criteria for osteoporo-sis treatment. A high prevalence of patients with a highFRAX® score did not have osteoporosis. Our data furtherhighlights that treatment decisions should not be based onfracture risk assessment for future fracture risk alone but alsoinclude assessment of osteoporosis. Thus, all men and womenaged 50 years and older with a distal radius fracture should bereferred to osteoporosis assessment and, if indicated, treated.

Acknowledgements The authors are grateful to the medical staff atBergen Accident and Emergency Department, the centers for orthopedictrauma at Haukeland University Hospital in Bergen, Sørlandet Hospital inKristiansand, and Telemark Hospital in Skien and the technicians at theOsteoporosis centers in Bergen, Kristiansand, and Skien. We would alsolike to thank Stein Atle Lie for statistical advice, and Professor John A.Kanis and Helena Johansson at the WHO Collaborating Centre forMetabolic Bone Diseases for helping us estimate the FRAX® data. Thiswork has been supported by research grants from The Research Council

of Norway and the University of Bergen to associate professor ChristinaBrudvik, research grants from The Western Norway Regional HealthAuthority to professor Leiv Hove, and research grants from TheCompetence Development Fund of Southern Norway and SørlandetHospital HF to professor Glenn Haugeberg.

Conflicts of interest None.

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