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Should women attending fracture clinics be counselled about osteoporosis?
Injury (1993)
24,
(7), 441-442
Prided
in Great Britain
441
Should women attending fracture clinics be counselled about osteoporosis? R. Gundle and A. H. R. W. Simpson The Accident
Service, John Radcliffe Hospital, Oxford, UK
Osteoporoticfracfures cause muchmorbidity and mortality and are a great burden on health care resources. If is well established thaf hormone replacement therapy (HRTlJreduces the risk of osfeoporofic fracture; if is also known to be wot+h initiating fherapy even when one osfeoporofic fracture has occurred in order to reduce the incidence of further fractures. In this study, defailed questionnaires assessing risk ftiors for osteoporosis were gnxm to all women aged Z-60 years affending a daily fracfure clinic over a IO-week period, and their radiographs were studied for signs of early frabecular bone loss, in order to determine whether at-risk patients could be identified easily. The findings were that 50 per cent of the premenopausal women had lifestyle-related risk factors about which they could be counselled. Using current guidelines, 90 per cent of the per+ and post-menopausal group should be considered for HRT. Overall, only 7 per cent of patients who should be on HRT were receiving if. It was concluded that mosf of those at risk can be identified very simply in thefiacture clinic. This aspect offracture management is currently being neglected.
Introduction Osteoporotic fractures are a major and increasing burden on hospital and community health services in the United Kingdom, and a cause of considerable morbidity and mortality (Wallace, 1987). There is much evidence that treatment with hormone replacement therapy (HRT) reduces osteoporotic fracture rate (Weiss et al., 1980; Paganini-Hill et al., 1981; Ettinger et al., 1985) and also evidence that treatment with HRT and calcium after one osteoporotic fracture reduces the incidence of further such fractures later in life (Riggs et al., 1982). Furthermore, oestrogens appear to halve mortality due to cardiovascular disease (Stampfer et al., 1991). Osteoporosis is a condition that is more effectively prevevted than treated. Identifying women at risk can be achieved with bone densitometry but facilities for this in the United Kingdom fall far short of the need (Belchetz, 1989). Another approach is to assess risk factors at times of patient contact with the medical profession. In this study a questionnaire was used to assess the distribution of risk factors for osteoporosis in women attending fracture clinics. In addition, the injury pattern and radiographic appearances were studied to see whether these could be used in a busy fracture clinic to determine the need for osteoporosis management, 0 19% Butterworth-Heinemann 00.X-1383/93/070441-02
Ltd
Patients and methods A detailed questionnaire assessing risk factors for osteoporosis was given to all women aged 25 to 60 years attending the daily fracture clinics at the John Radcliffe Hospital, Oxford, over a lo-week period. The study had the approval of the Central Oxford Research Ethics Committee. Out of 135 women, 110 completed the forms, and this was a predominantly Caucasian population. The patients’ initial injuries and their mechanism were recorded and their radiographs carefully analysed for signs of early trabecular bone loss, namely accentuated primary trabeculae with thinning of secondary trabeculae in the metaphyses. These features taken together were used to determine whether the fracture could be deemed at least in part due to reduced bone strength.
Results The results are shown in Table I. In the premenopausal group of 50 women, only 17 had no risk factors; 14 had one or more of the following ‘unavoidable’ risk factors: family history, lean build, corticosteroid therapy or a predisposing endocrine disorder, e.g. thyrotoxicosis. Twenty-five had one or more of the ‘avoidable’ lifestyle risk factors: high alcohol intake, sedentary lifestyle or smoking. On radiographic analysis only one premenopausal patient, aged 42 years, had an osteoporotic fracture. She was a smoker but had no other risk factors. No other patient in this group had trabecular thinning. Of the 60 peri- and postmenopausal women, 41 had osteoporotic fractures and a further five patients who had sustained soft tissue injuries also had easily identifiable evidence of trabecular bone loss on radiographs; these five had all had an early menopause. Only four of these 46 patients were on HRT despite current recommendations which indicate that all 46 would benefit from it. Of the remaining 14 patients whose bone texture was within normal limits, eight had one or more of the following risk factors for osteoporosis: early menopause, lean build, corticosteroid therapy or high alcohol intake, and these patients should also be considered for HRT.
Discussion Two-thirds subsequent
of our premenopausal group had risk factors for development of osteoporosis, many of them
Injury: International Journal of Care of the Injured (1993) Vol. 24/No.
442 Table I. Results of 110 osteoporosis questionnaires
PreNumber of patients Age range (years) Fracture Soft tissue injury Trabecular bone loss on radiograph Menopause or bilateral oophorectomy at 45 years or before Lean build > 14 units alcohol per week Family history Sedentary lifestyle Smoker Steroids or predisposing illness On HRT
Peri-
Post-
392-253 14 8
38 43-60 33 5
1
12
34
0 4
9 1
7 2
4 11 7 18
1 6 4 6
1 12 6 11
z
1 5
3 1
50 25-51 34 16
Notes Perimenopausal defined as having hot flushes and irregular periods but 3 months or less since last menstrual period. Postmenopausal when more than 3 months since last menstrual period. Lean build defined as Quetelet Index (weight in kg/height in m’) of 19 or less. Sedentary lifestyle defined as those who cycle or walk less than 1.61 km per week.
avoidable, and this group could benefit from information regarding lifestyle, which could be provided in leaflet form in the fracture clinic. UK guidelines (Drug and Therapeutics Bulletin, 1989) state that all women with two or more of the following risk factors: Caucasian or Asian race, osteoporotic fracture, early menopause, lean build, high alcohol intake, current or recent corticosteroid therapy, or predisposing illness should be recommended for HRT. Using these criteria for the group of 60 peri- and postmenopausal women, 54 should have been considered for HRT, yet only four were receiving it. In this busy fracture clinic, 85 per cent of the patients who would benefit from HRT could have been identified simply by noting the osteoporotic nature of the fracture or the obvious trabecular thinning. This aspect of the general care of the injured patient is currently neglected. Unless general practitioners are made
7
aware of the osteoporotic nature of the fracture this beneficial treatment may not be considered. Although only a relatively small proportion of the population come to fracture clinics, those that do would be expected to have a higher incidence of osteoporosis than the general population. A closer liaison between orthopaedic and accident and emergency personnel on the one hand and general practitioners and gynaecologists interested in osteoporosis management on the other is recommended to help identify and counsel those who may benefit from treatment.
Acknowledgements We would like to thank Drs Roger Smith and Jill Meara for their help with the construction of the questionnaire.
References Belchetz P. (1989) Hormone
treatment.
Br. Med. J
C. E. (1985)
Long-term
replacement
298,1467. Ettinger
B., Genant
H. K. and Cann
estrogen replacement therapy prevents bone loss and fractures.
Ann. ht. Med. 102, 319. Osteoporosis: Prevention and Treatment. (1989) Drug and %aperrficsBulletin27, 1. Paganini-Hill A., Ross R. K., Gerkins V. R. et al. (1981) Menopausal estrogen therapy and hip fractures. Ann. Int. Med. 95,~ Riggs B. L., Seeman E., Hodgson S. F. et al. (1982) Effect of the fluoride/calcium regimen on vertebral fracture occurrence in postmenopausal osteoporosis: comparison with conventional therapy. N. Engl. ]. Med. 306, 446. Stampfer M. J., Colditz G. A., Willet W. C. et al. (1991) Postmenopausal oestrogen therapy and cardiovascular disease. N. Engl.]. Med. 325, 756. Wallace W. A. (1987) The scale and financial implications of osteoporosis. Ink Med. Suppl. 12,3. Weiss N. S., Ure C. L., Ballard J. H. et al. (1980) Decreased risk of fractures of the hip and lower foreann with postmenopausal use of estrogen. N. Engl. 1. Med. 303, 1195.
Paper accepted 22 January
1993.
Requests for reprints should be addressed to: Mr R. Gundle, The Nuffield Orthopaedic Centre NHS Trust, Headington, Oxford OX3 7LD, UK.
24,
(7), 441-442
Prided
in Great Britain
441
Should women attending fracture clinics be counselled about osteoporosis? R. Gundle and A. H. R. W. Simpson The Accident
Service, John Radcliffe Hospital, Oxford, UK
Osteoporoticfracfures cause muchmorbidity and mortality and are a great burden on health care resources. If is well established thaf hormone replacement therapy (HRTlJreduces the risk of osfeoporofic fracture; if is also known to be wot+h initiating fherapy even when one osfeoporofic fracture has occurred in order to reduce the incidence of further fractures. In this study, defailed questionnaires assessing risk ftiors for osteoporosis were gnxm to all women aged Z-60 years affending a daily fracfure clinic over a IO-week period, and their radiographs were studied for signs of early frabecular bone loss, in order to determine whether at-risk patients could be identified easily. The findings were that 50 per cent of the premenopausal women had lifestyle-related risk factors about which they could be counselled. Using current guidelines, 90 per cent of the per+ and post-menopausal group should be considered for HRT. Overall, only 7 per cent of patients who should be on HRT were receiving if. It was concluded that mosf of those at risk can be identified very simply in thefiacture clinic. This aspect offracture management is currently being neglected.
Introduction Osteoporotic fractures are a major and increasing burden on hospital and community health services in the United Kingdom, and a cause of considerable morbidity and mortality (Wallace, 1987). There is much evidence that treatment with hormone replacement therapy (HRT) reduces osteoporotic fracture rate (Weiss et al., 1980; Paganini-Hill et al., 1981; Ettinger et al., 1985) and also evidence that treatment with HRT and calcium after one osteoporotic fracture reduces the incidence of further such fractures later in life (Riggs et al., 1982). Furthermore, oestrogens appear to halve mortality due to cardiovascular disease (Stampfer et al., 1991). Osteoporosis is a condition that is more effectively prevevted than treated. Identifying women at risk can be achieved with bone densitometry but facilities for this in the United Kingdom fall far short of the need (Belchetz, 1989). Another approach is to assess risk factors at times of patient contact with the medical profession. In this study a questionnaire was used to assess the distribution of risk factors for osteoporosis in women attending fracture clinics. In addition, the injury pattern and radiographic appearances were studied to see whether these could be used in a busy fracture clinic to determine the need for osteoporosis management, 0 19% Butterworth-Heinemann 00.X-1383/93/070441-02
Ltd
Patients and methods A detailed questionnaire assessing risk factors for osteoporosis was given to all women aged 25 to 60 years attending the daily fracture clinics at the John Radcliffe Hospital, Oxford, over a lo-week period. The study had the approval of the Central Oxford Research Ethics Committee. Out of 135 women, 110 completed the forms, and this was a predominantly Caucasian population. The patients’ initial injuries and their mechanism were recorded and their radiographs carefully analysed for signs of early trabecular bone loss, namely accentuated primary trabeculae with thinning of secondary trabeculae in the metaphyses. These features taken together were used to determine whether the fracture could be deemed at least in part due to reduced bone strength.
Results The results are shown in Table I. In the premenopausal group of 50 women, only 17 had no risk factors; 14 had one or more of the following ‘unavoidable’ risk factors: family history, lean build, corticosteroid therapy or a predisposing endocrine disorder, e.g. thyrotoxicosis. Twenty-five had one or more of the ‘avoidable’ lifestyle risk factors: high alcohol intake, sedentary lifestyle or smoking. On radiographic analysis only one premenopausal patient, aged 42 years, had an osteoporotic fracture. She was a smoker but had no other risk factors. No other patient in this group had trabecular thinning. Of the 60 peri- and postmenopausal women, 41 had osteoporotic fractures and a further five patients who had sustained soft tissue injuries also had easily identifiable evidence of trabecular bone loss on radiographs; these five had all had an early menopause. Only four of these 46 patients were on HRT despite current recommendations which indicate that all 46 would benefit from it. Of the remaining 14 patients whose bone texture was within normal limits, eight had one or more of the following risk factors for osteoporosis: early menopause, lean build, corticosteroid therapy or high alcohol intake, and these patients should also be considered for HRT.
Discussion Two-thirds subsequent
of our premenopausal group had risk factors for development of osteoporosis, many of them
Injury: International Journal of Care of the Injured (1993) Vol. 24/No.
442 Table I. Results of 110 osteoporosis questionnaires
PreNumber of patients Age range (years) Fracture Soft tissue injury Trabecular bone loss on radiograph Menopause or bilateral oophorectomy at 45 years or before Lean build > 14 units alcohol per week Family history Sedentary lifestyle Smoker Steroids or predisposing illness On HRT
Peri-
Post-
392-253 14 8
38 43-60 33 5
1
12
34
0 4
9 1
7 2
4 11 7 18
1 6 4 6
1 12 6 11
z
1 5
3 1
50 25-51 34 16
Notes Perimenopausal defined as having hot flushes and irregular periods but 3 months or less since last menstrual period. Postmenopausal when more than 3 months since last menstrual period. Lean build defined as Quetelet Index (weight in kg/height in m’) of 19 or less. Sedentary lifestyle defined as those who cycle or walk less than 1.61 km per week.
avoidable, and this group could benefit from information regarding lifestyle, which could be provided in leaflet form in the fracture clinic. UK guidelines (Drug and Therapeutics Bulletin, 1989) state that all women with two or more of the following risk factors: Caucasian or Asian race, osteoporotic fracture, early menopause, lean build, high alcohol intake, current or recent corticosteroid therapy, or predisposing illness should be recommended for HRT. Using these criteria for the group of 60 peri- and postmenopausal women, 54 should have been considered for HRT, yet only four were receiving it. In this busy fracture clinic, 85 per cent of the patients who would benefit from HRT could have been identified simply by noting the osteoporotic nature of the fracture or the obvious trabecular thinning. This aspect of the general care of the injured patient is currently neglected. Unless general practitioners are made
7
aware of the osteoporotic nature of the fracture this beneficial treatment may not be considered. Although only a relatively small proportion of the population come to fracture clinics, those that do would be expected to have a higher incidence of osteoporosis than the general population. A closer liaison between orthopaedic and accident and emergency personnel on the one hand and general practitioners and gynaecologists interested in osteoporosis management on the other is recommended to help identify and counsel those who may benefit from treatment.
Acknowledgements We would like to thank Drs Roger Smith and Jill Meara for their help with the construction of the questionnaire.
References Belchetz P. (1989) Hormone
treatment.
Br. Med. J
C. E. (1985)
Long-term
replacement
298,1467. Ettinger
B., Genant
H. K. and Cann
estrogen replacement therapy prevents bone loss and fractures.
Ann. ht. Med. 102, 319. Osteoporosis: Prevention and Treatment. (1989) Drug and %aperrficsBulletin27, 1. Paganini-Hill A., Ross R. K., Gerkins V. R. et al. (1981) Menopausal estrogen therapy and hip fractures. Ann. Int. Med. 95,~ Riggs B. L., Seeman E., Hodgson S. F. et al. (1982) Effect of the fluoride/calcium regimen on vertebral fracture occurrence in postmenopausal osteoporosis: comparison with conventional therapy. N. Engl. ]. Med. 306, 446. Stampfer M. J., Colditz G. A., Willet W. C. et al. (1991) Postmenopausal oestrogen therapy and cardiovascular disease. N. Engl.]. Med. 325, 756. Wallace W. A. (1987) The scale and financial implications of osteoporosis. Ink Med. Suppl. 12,3. Weiss N. S., Ure C. L., Ballard J. H. et al. (1980) Decreased risk of fractures of the hip and lower foreann with postmenopausal use of estrogen. N. Engl. 1. Med. 303, 1195.
Paper accepted 22 January
1993.
Requests for reprints should be addressed to: Mr R. Gundle, The Nuffield Orthopaedic Centre NHS Trust, Headington, Oxford OX3 7LD, UK.