Patients suffering from hip fractures will note a long and convoluted recovery period, this is rarely a full recovery with ongoing morbidity including loss of independence and mobility.1,2 Identifying risks of future events is important and ideally should be done in a prospective way. This can allow targeting of treatments and reinforce the need for a proactive approach. There is some information about the incidence of risk of the first hip fracture and second hip fractures but they have not been clarified. This study included a large amount of work towards this issue. To look prospectively at 6331 patients shows great industry. The information that at one year about 1 in 40 patients will have a second hip fracture and about 1 in 12 by the completion of their study or 8.5 years, quantifies risk. It is notable that there is a some variability in risk of further fracture at the hip in the referenced papers which were retrospective and with less high quality data but suggests a similar risk at 2.3 -5% in the first year.3,4 As the first year is the greatest period of risk of a further hip fracture and Moran and his colleagues are quite right to suggest early treatments.
It has been accepted that those who were on the younger side and certainly younger than 65 years may have a high incidence of ill health as compared with the general population. They may have neurological problems, respiratory problems, be immunosuppressed with steroids, alcoholic or self harming. Alternatively they may be fit and suffered from significant violence.5 Some of these patients should be receiving primary preventative treatments for osteoporosis.6.7
The description of hip fractures being the presentation of the effects of osteoporosis and the forerunner of fractures effecting contralateral hips wrists and vertebra is quite valid. It is probably gaining acceptance that most areas can be affected by osteoporotic fractures especially in the very elderly including the proximal humerus and ankle and many other regions.8,9
This study from Nottingham helps clarify several issues including the identification of such a high level of further fractures in females aged 55-64 and is of great importance. The use of treatment for the osteoporotic groups will often follow NICE guidelines and this group to a degree may have been missed out.10 The initial guidance suggested leaving the decision on treatments to the clinician and that bone densitometry should be organised before treatment takes place in those patients betweenn 65 and 74 years and younger. For those under 65 years getting a densitometry was at the discretion of the clinician who would make that decision if the fracture was likely to be osteoporotic.11 The British Orthopaedic Association12 have made recommendations and a review article from the American Journal is available to download,13 it quotes the New England Journal of Medicine that once yearly intravenous treatment is important for fracture prevention and it can even reduce mortality with it decreasing in the treated group by 25%.14 The initial treatment with first line oral bisphosphonates is not always tolerated because of gastrointestinal problems such that 30% may not be protected.13 If the fracture is alcohol or behaviour related compliance to treatment may be limited. It may be that this at risk group should receive a treatment of intravenenous zolendronic acid and thus be covered for a year.15 This is on the assumption that this population is osteoporotic. It may not be valid. Are there behavioural factors such that a rehabilitative program be helpful? Fracture prevention services might help, with avoidance of high risk activities. The knowledge of risk levels should be communicated to the patient. It is notable that for the very elderly female over 85 years there was a lower risk of a further hip fracture. I hope I am not mistaken but could this be because one side is treated? Certainly those with a well fixed hemiarthroplasty or a hip which is splinted with a hip fracture screw will have less risk of fractures on the ipsilateral side.
It would appear that the second fracture can occur quite quickly with a range of 3 to 2773 days. Unfortunately falls whilst in hospital causing second fractures are well described.16 Early implementation of treatment seems necessary in a group who will commonly refracture in the first year, the most dangerous period. A similar fracture pattern, that is subcapital or intertrochanteric fracture is described for 71% of patients. Investigation into this area has looked at whether the intertrochanteric fracture may have one mechanism and the intracapsular fracture another. It is not thought that a fall onto the side rather than backwards may predispose more to either type of injury. Body habitus may be more important than the mechanism of injury in causing a particular fracture pattern.17,18 The results for the mortality of the study group in Nottingham seem to follow general trends with a mortality of 10% at 30-days and 32% at one year. This did not seem to change with the second fracture. At the end of their study period 25% of patients were still alive. The knowledge that the risk of further fracture is 45 times more likely in the younger group of patients than the average adult of a similar age would seem to suggest these patients need early treatment and investigation. We should evaluate all of our patients with fractured neck of femur, ideally treatment should commence as an inpatient, if we are not able to deal with this ourselves rapid referral to the appropriate agency should take place.
1. Pande I, Scott DL, O'Neill TW, et al. Quality of life, morbidity, and mortality after low trauma hip fracture in men. Ann Rheum Dis 2006;65:87-92.
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3. Chapurlat RD, Bauer DC, Nevitt M, Stone K, Cummings SR. Incidence and risk factors for a second hip fracture in elderly women: the study of osteoporotic fractures. Osteoporos Int 2003;14:130-6.
4. Chiu KY, Pun WK, Luk KD, Chow SP. Sequential fractures of both hips in elderly patients--a prospective study. J Trauma 1992;32:584-7.
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14. Lyles KW, Colón-Emeric CS, Magaziner JS, et al. HORIZON Recurrent Fracture Trial. Zoledronic acid and clinical fractures and mortality after hip fracture. N Engl J Med 2007;357:1799-809.
15. McClung M, Recker R, Miller P, et al. Intravenous zoledronic acid 5 mg in the treatment of postmenopausal women with low bone density previously treated with alendronate. Bone 2007;41:122-8.
16. Oliver D, Killick S, Even T, Willmott M. Do falls and falls-injuries in hospital indicate negligent care -- and how big is the risk? A retrospective analysis of the NHS Litigation Authority Database of clinical negligence claims, resulting from falls in hospitals in England 1995 to 2006. BMJ 2007;334:82.
17. Meriläinen S, Nevalainen T, Luukinen H, Jalovaara P. Risk factors for cervical and trochanteric hip fracture during a fall on the hip. Scand J Prim Health Care 2002;20:188-92.
18. Greenspan SL, Myers ER, Kiel DP, et al. Fall direction, bone mineral density, and function: risk factors for hip fracture in frail nursing home elderly. Am J Med 1998;104:539-45.
Wytheshawe Hospital, Wytheshawe, Manchester