Distal radius fractures (DRFs) are common in patients’ aged 50 and older, typically resulting from a low energy mechanism such as a fall from standing height.
DRFs in this population offer an opportunity to identify patients with a high likelihood of osteoporosis or osteopenia and represent a potential to intervene and prevent future fragility fractures.
Recognition of at risk adults using tools such as Fracture Risk Assessment Tool provides an opportunity to treat low bone density and implement fall prevention strategies, which may significantly decrease the incidence of subsequent fragility fractures in this population.
Interventions for fall prevention are effective at decreasing falls on a population and individual level.
A 61-year-old male fell while walking his dog, sustaining a left, displaced DRF ( Fig. 1 A ). This was successfully treated with closed reduction ( Fig. 1 B), cast immobilization, and physiotherapy ( Fig. 1 C). Two years later, he slips on ice, fracturing his right distal radius ( Fig. 2 ). What interventions could have been employed following his first fracture to decrease the risk of his second, contralateral fracture?
Importance of the Problem
Distal radius fractures (DRFs) are the second most common overall fracture type in elderly patients, typically occurring from low energy injuries such as a fall from standing height. A low energy DRF in patients 50 years and older is an indication of potential low bone density and suggests a significant risk for a future osteoporotic fracture. DRFs tend to occur earlier than other fragility fractures and typically in patients that are otherwise fairly healthy and mobile. This makes a DRF an important sentinel event, offering an opportunity to optimize bone health and prevent future fractures. That is why patients over the age of 50 years, presenting with a DRF should be screened for osteoporosis and fall risk to prevent secondary fragility fractures such as hip fractures, which carry a higher morbidity and mortality rate as well as societal cost. Unfortunately, despite significant evidence suggesting the importance of this, screening for osteoporosis remains suboptimal and the rate of secondary fractures is significant. Recent literature has suggested that secondary fracture prevention strategies are most often implemented when a bone mineral density (BMD) scan is ordered by the treating orthopedic surgeon or when a patient is directly referred to a fracture liaison service (FLS).
Although secondary prevention of future fractures is important, primary prevention of the initial DRF must not be overlooked. Fragility fractures result in significant patient morbidity and societal costs. Programs targeted at identifying at risk individuals and initiating screening for osteoporosis as well as falls education before a fracture occurs can be successful in significantly reducing DRF rates. One useful method for identifying at-risk individuals is the Fracture Risk Assessment Tool (FRAX). The FRAX score predicts an individual’s 10-year fragility fracture risk based on the following factors: age, sex, body mass index (weight to height ratio calculation), previous fracture, parental hip fracture, history of rheumatoid arthritis, glucocorticoid use, secondary conditions that contribute to bone loss, current smoking, osteoporosis, intake of more than three alcoholic drinks per day, and femoral neck bone mineral density. As our population continues to age, low energy DRFs will continue to increase, placing strain on our healthcare resources. Preventative programs may help ease this burden, and more importantly reduce associated patient morbidity.
What strategies can be employed to prevent or decrease the risk of low energy DRFs from both a bone health and fall prevention perspective?
The majority of treating orthopedic surgeons view DRFs as an indication of low bone density and a risk factor for future fragility fractures. The responsibility of bone density investigation, ongoing treatment of osteoporosis, and referral to falls prevention programs is currently debated, with some suggesting this should be initiated by the treating orthopedic surgeon while others advocate for an alerting system or fracture liaison service. Furthermore, effective prevention of the initial DRF requires identification of at risk adults (from both a bone health and fall prevention perspective) and initiation of prevention strategies at the primary care level.
Finding the Evidence
A Cochrane database search was carried out using the search terms “fall prevention” and “injury prevention.”
Provided below is our Pubmed (Medline) search strategy employed to identify relevant literature used to construct this chapter:
For Osteoporosis :
(“distal radius fracture” OR radial fracture [MeSH]) AND (“prevention”) AND (“osteoporosis” OR “low bone density”)
For Falls Prevention :
(“fall prevention”) AND (“radial fracture” [MeSH] OR “distal radius fracture” or colles fracture [MeSH] or “fragility fracture”)
Bibliographies of eligible articles identified in our search were reviewed for additional relevant studies. Articles that were not in English were excluded.
Quality of the Evidence
No randomized controlled trials or metaanalyses were found that specifically addressed our main question, however there were high quality systematic reviews and one randomized controlled trial that related to aspects of our main question. Four Cochrane reviews were identified that contained information addressing a component of our main question. We identified 22 studies with relevant information relating to DRF prevention through osteoporosis management and fall prevention education. The strength of this evidence is as follows:
Cochrane Reviews: 4
Systematic Reviews of RCTs: 4
Randomized Controlled Trial: 1
Cohort Studies: 4
Retrospective comparative studies: 9
Evidence for Screening and Osteoporosis Management
There is substantial literature surrounding various aspects of DRFs and osteoporosis, with most of this focusing on screening and secondary prevention of fragility fractures (including distal radius fractures) following an initial fragility fracture. The majority of studies are level III evidence. There is a paucity of evidence which specifically examines routine screening of at-risk patients for osteoporosis as a means of preventing DRFs, with most primary prevention studies looking at overall fragility fracture reduction or reduction of hip fractures, which carry a higher mortality risk.
There are two Cochrane reviews and two level one studies examining the role of osteoporosis treatment in reducing fragility fracture risk. These studies examined both primary and secondary prevention of fractures, and while the studies included DRFs, they were not specific to DRFs and instead grouped “nonvertebral fractures” together. A 2010 Cochrane review by Wells et al. found that the use of Etidronate for 1 year did not reduce primary or secondary DRFs when compared to placebo treatment (which included patients on calcium and/or vitamin D) in patients with osteoporosis. A subsequent 2016 Cochrane review examined the role of vitamin D and calcium supplementation in the prevention of future fractures, and found that when used in combination there was a significant reduction in nonvertebral fractures (10,380 participants, RR 0.86, 95% CI 0.78–0.96). Furthermore, a systematic review by MacLean et al. compared fracture risk reduction among various pharmacologic treatments, finding significant evidence for alendronate, risedronate, and estrogen in the prevented nonvertebral fractures, suggesting that there may be differences between pharmacologic therapies. Lastly, a 2014 systematic review by Crandal et al. found significant reductions in fragility fractures with the use of bisphosphonates, denosumab, and teriparatide compared to placebo (RRR 0.60–0.80 for nonvertebral fractures), but commented that comparative evidence between different treatment options is lacking.
Osteoporosis as a Risk Factor for Distal Radius Fracture
Two studies highlighted osteoporosis as a clear risk factor for DRF (one level I and one level II). In a recent study by Uusi-Rasi et al., 197 women were followed prospectively for 20 years. These women were divided into two groups based on whether they experienced a fall-related fracture over the study period. The authors found that those who had sustained a fracture had 4%–11% lower BMD than those who had not, suggesting that the presence of low BMD is a significant risk factor for fracture if a person falls. Similarly, a case-control study by Kelsey et al. aimed to evaluate risk factors for DRFs. These authors used a previous fragility fracture as a rough marker for osteoporosis, and found this to be a significant risk factor for a future DRF (OR = 1.48 [1.20–1.84] 95% CI).
Much of the literature surrounding osteoporosis and DRFs focuses on secondary prevention. A DRF is considered by many to represent a sentinel event indicating a person is at significant risk for further fragility fracture, distal radius, or otherwise. DRFs occur at a younger age, on average, compared to other fragility fractures making them an ideal catalyst for osteoporosis screening and treatment. There were three studies that highlight DRFs as a risk factor for secondary fracture (one level I and two level II). In a retrospective cohort study of 1288 participants, Cuddihy et al. showed that patients who experience a DRF had a 55% incidence of another fracture at 10 years and 80% at 20 years. This was significantly higher than expected fracture rates for all comers but was not specific to DRFs. Two retrospective reviews showed a high rate of subsequent fracture following and initial DRF. Benzvi et al. found that at an average of 25.2 months, 28% of patients had sustained a secondary fragility fracture, with only 21% of patients treated for osteoporosis at any time. Similarly, Smith et al. found that in patients with a DRF and a subsequent femoral neck fracture, only 8% received investigation and treatment for osteoporosis following their DRF.
Given the known risk of secondary fragility fracture following a DRF many studies have investigated the ideal protocol to ensure adequate screening and treatment of patients with these injuries. Five studies ( Table 1 ) highlight poor screening and treatment of osteoporosis following DRFs (level II to IV evidence). These studies show that the rate of BMD scanning following a DRF ranges from 9% to 25% and the rate of medical treatment for osteoporosis ranges from 13% to 31%. These numbers have been shown to be even lower in men. In a systematic review of randomized controlled trials, Little et al. found that baseline rates of osteoporosis screening and treatment following fragility fractures was low (typically less than 20%) and that while an intervention of any kind targeted at improving these rates did result in increased screening and treatment, overall rates remained suboptimal. Baba et al. found that while overall screening rates were low, in cases where a BMD scan was ordered a significantly higher proportion of patients received treatment for osteoporosis (73.8% vs 8.2%). This suggests that when adequate screening occurs, appropriate treatment ensues; therefore, targeting the best strategy for improved osteoporosis screening is paramount. Several studies have investigated the best means of ensuring appropriate screening. In a randomized controlled trial by Rozental et al. patients in whom the treating orthopedic surgeon ordered the BMD scan received significantly higher rates of screening (93% vs 30%), osteoporosis counseling (89% vs 35%), and osteoporosis treatment (74% vs 26%) compared to patients whose orthopedic surgeon sent a letter with screening guidelines to the primary care physician. Aside from the treating orthopedic surgeon, a FLS has also been shown to be a reliable way to improve osteoporosis screening and treatment following DRFs, with an improvement in osteoporosis screening and treatment to 77.8% compared to 22.9% with usual care.