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Which bones am I more likely to break?

For all women with or without osteoporosis who are 50 years or older, the lifetime risk of fracturing any bone is about 40%, though most fractures occurring after age 50 are related to osteoporosis. For all U.S. adults, the lifetime risk of fracturing a bone is greater than the combined risk of developing breast, uterine, or ovarian cancers. If you are a woman, the risk of fracturing your hip, your spine, or your wrist is between 15% and 18% each. If you are a White older woman who either has hyperthyroidism (overactive thyroid), cannot get out of a chair without using your arms, or has a resting pulse rate of over 80 beats per minute, the risk for fracturing your hip is about 70%. If your only risk factor is that your mother broke her hip, then your risk is about 80%, but it's only about 50% if you fractured any of your bones since the age of 50. Even without any of these specific risk factors, age increases your risk for fracture by about 40% every 5 years. Your risk for hip fracture increases with more risk factors, so making changes to reduce your risk, such as increasing exercise, getting enough vitamin D and calcium, and quitting smoking, is important. The FRAX algorithm makes it possible to determine your individual 10-year risk probability for a hip fracture and for any major osteoporotic fracture (see Question 55).

All together, there are more fractures related to osteoporosis than the combined number of heart attacks, strokes, and new diagnoses of breast cancer among women each year. The combined 250,000 hip fractures, 250,000 wrist fractures, 750,000 spinal fractures, and 250,000 other fractures amounts to 1.5 million fractures related to osteoporosis per year. So, if you are going to break a bone, you are about 3 times more likely to break a bone in your spine than you are in your hip. And you are just as likely to break your wrist as your hip.

Marie's comment:

My grandmother had osteoporosis. Well, actually, I don't think she was ever officially diagnosed with it, but she must have had it because she had so many broken bones. I remember when she visited us at our house when she was about 85 or 86 and she had such terrible back pain, she couldn't even get dressed by herself. She told us she had fallen onto her bottom and back when she was at home and reached up into her closet to get something off the top shelf. She didn't fall that far or hard, but she said her back had been hurting ever since. We took her to the doctor and they did x-rays that showed she had 4 or 5 fractures in her spine bones. She was admitted to the hospital and was progressing slowly, and then she came home to our house and recuperated therefore another 2 or 3 weeks. She eventually went back to her home (after about 2 months all together), but within 2 weeks she fell again, this time in the bathtub, and was admitted to the hospital. This time she had cracked her pelvis and was eventually admitted to a nursing home. After she had been in the nursing home for 6 years or so, she broke her thigh bone while trying to get out of bed. Her leg got caught up in the side rail on the bed, and when she turned, it just broke. She wasn't ever treated for osteoporosis, except for taking calcium. And she wasn't at such high risk. She was a good-sized woman, not fat or anything, but not frail. And she was active her whole life. But after she cracked her pelvis, she never left that nursing home. She died there.

I am 45years old. I recently stumbled on a rug. I fell against the wall. I broke my wrist and my clinician is now concerned that I have osteoporosis. She called my fracture a "fragility fracture." What is that, and what does it have to do with osteoporosis?

Fragility fracture[1] is a term used by clinicians to describe fractures that occur without much force and from a height usually not great enough to cause broken bones. They are also called osteoporotic fractures. The term is used to help clinicians evaluate the state of their patients' bones. A history or presence of one or more fragility fractures also helps clinicians in the decision to send you for BMD testing and treat you for osteoporosis (see Questions 19 and 20). The degree of osteoporosis is also diagnosed by the presence or history of fragility fractures. Severe osteoporosis is diagnosed when BMD indicates a T-score more than 2.5 standard deviations below the mean with a history or presence of one or more fragility fractures. However, you don't have to have osteoporosis to have a fragility fracture. In fact, according to the NORA (National Osteoporosis Risk Assessment) study, 50% of fragility fractures occur in individuals with osteopenia. Interestingly enough, you can even have a fragility fracture while still having normal BMD.

One of the problems with fragility fractures is that sometimes they occur not because you have osteoporosis or low bone mass as measured by BMD testing, but because your bones have poor bone quality. This means that while your bone density tests may indicate that you have normal bone density, the "architecture" of the bones may be weak. Machines used to measure BMD cannot "see" inside the bone to evaluate its structure, and therefore a DXA machine cannot measure your bone quality. Because BMD testing does not measure bone quality, your risk of getting a fragility fracture may still be high despite a normal T-score.

Because most of the research has been conducted on women over the age of 65, there are not enough data yet to provide useful information on younger women and men. So, even though younger women are not expected to be at high risk for fracture, your clinician is right to be concerned simply based on the low level of force of your fall. Some clinicians believe that the angle of breaking a bone determines whether the bone has enough strength to withstand force. This would be likened to a breakable dish that when dropped at one angle may shatter, but from another angle it remains unharmed. Your bone strength could actually be quite weak even though your bones appear to be normal on BMD testing.

Fragility fractures can happen when you fall or bang against something, but most often they occur spontaneously in your back (see Question 83). Sometimes you will experience significant pain with a vertebral fracture and other times it will be "silent," meaning that a fracture occurs but you are not even aware of it.

If you experience a fragility fracture, your clinician will send you for a DXA test. You also will be evaluated for possible causes, such as using medication that weakens bones or having an illness that interferes with bone development or quality (see Questions 15 and 16).

If possible secondary causes for the fragility fracture are ruled out, you should be referred to a specialist to discuss treatment for osteoporosis. This presents an opportunity for beginning medications for osteoporosis to increase bone density and to decrease further fracture risk, even though the quality of your bones may cause you to fracture a bone more easily. You should also receive counseling about your calcium and vitamin D intake, exercise, and any lifestyle changes that may improve the health of your bones. Once you have sustained one fracture, you are at high risk for having another, so it's important to evaluate your surroundings for the things that could put you at risk for falling. Question 79 discusses ways to reduce your risk of falls. You would also want to make sure that you are not bending forward or twisting your spine if you have bone loss in the spine, since both actions could cause vertebral fractures. Figure 10 in Question 44 shows exercises to avoid.

  • [1] Term used to describe fractures that occur with very little trauma or force and from a height that is usually not great enough to cause broken bones, usually indicating that the bone is weak. Also called osteoporotic fractures.
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