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minimal trauma (pathologic, osteoporotic, fragility, insufficiency) fracture

Etiology: - osteoporosis - hyperparathyroidism (in the absence of osteoporosis) [6] - malasborption syndrome(s) with vitamin D deficiency - celiac disease - multiple myeloma - renal insufficiency (stage 3 or 4, ESRD) - hypogonadism in men [7] - rheumatoid arthritis & other chronic inflammatory rheumatic diseases [10] - fracture risk increase by higher dosed of proton pump inhibitor & duration of use > 1 year [6] Includes: 1) fracture from a fall from standing height or less 2) vertebral fractures without known trauma 3) foot fractures in patients with rheumatoid arthritis without known trauma Pathology: - 44% of patients with pathological foot fractures have multiple fractures [10] Laboratory: - serum 25-OH vitamin D Radiology: - X-ray detects 25% of foot fractures - magnetic resonance imaging [10] - subchondral hypointensity with adjacent bone marrow edema of the medial femoral condyle seen with an osteoporotic fracture of the knee - dual energy X-ray absorptiometry (DEXA) scan [11] even if result will not affect management [12] Complications: 1) associated with increased mortality [5] 2) a minimal-trauma fracture predicts risk for another fracture within a year, with concomitant adverse effects on quality of life [4] 3) predictive value of minimal trauma fracture: relative risk of hip fracture after 1st fracture 1st fracture RR women RR men wrist 1.5 3.0 vertebral 2.0 - hip 2.0 3.0 any 1.5 - RR: relative risk Differential diagnosis: - stress fracture Management: - bisphosphonate may be of some benefit - bisphosphonates do not interfere with long bone fracture healing [9] - Ca+2 & vitamin D may (or may not) be of benefit [2,3] - parathyroidectomy for hyperparathyroidism [6]

Related

hip fracture osteoporosis stress fracture (fatigue fracture)

Specific

sacral insufficiency fracture; osteoporotic sacral fracture

General

bone fracture

References

  1. Greendale, GA: UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  2. Bischoff-Ferrari HA, Willett WC, Wong JB, Giovannucci E, Dietrich T, Dawson-Hughes B. Fracture prevention with vitamin D supplementation: a meta-analysis of randomized controlled trials. JAMA. 2005 May 11;293(18):2257-64. Review. PMID: 15886381
  3. Journal Watch 25(13):106, 2005 Grant AM, Avenell A, Campbell MK, McDonald AM, MacLennan GS, McPherson GC, Anderson FH, Cooper C, Francis RM, Donaldson C, Gillespie WJ, Robinson CM, Torgerson DJ, Wallace WA; RECORD Trial Group. Oral vitamin D3 and calcium for secondary prevention of low-trauma fractures in elderly people (Randomised Evaluation of Calcium Or vitamin D, RECORD): a randomised placebo- controlled trial. Lancet. 2005 May 7;365(9471):1621-8. PMID: 15885294 - Sambrook P. Vitamin D and fractures: quo vadis? Lancet. 2005 May 7;365(9471):1599-600. No abstract available. PMID: 15885279
  4. Cooper C et al, Fracture incidence and changes in quality of life in women with an inadequate clinical outcome from osteoporosis therapy: The Observational Study of Severe Osteoporosis (OSSO). Osteoporos Int 2008 Apr; 19:493. PMID: 17968611
  5. Bliuc D et al Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women. AMA 2009 Feb 4; 301:513. PMID: 19190316
  6. Medical Knowledge Self Assessment Program (MKSAP) 16, 19 American College of Physicians, Philadelphia 2012, 2022
  7. Bours SP, van Geel TA, Geusens PP et al Contributors to secondary osteoporosis and metabolic bone diseases in patients presenting with a clinical fracture. J Clin Endocrinol Metab. 2011 May;96(5):1360-7 PMID: 21411547
  8. Friedman SM, Mendelson DA. Epidemiology of fragility fractures. Clin Geriatr Med. 2014 May;30(2):175-81. Review. PMID: 24721358
  9. Thorne TJ et al. No increased risk of nonunion with bisphosphonate use in a Medicare claims cohort following operatively treated long-bone fractures. J Bone Joint Surg Am 2023 Apr 5; 105:549. PMID: 36753557 https://journals.lww.com/jbjsjournal/Abstract/2023/04050/No_Increased_Risk_of_Nonunion_with_Bisphosphonate.6.aspx
  10. Buehring B et al. High prevalence of foot insufficiency fractures in patients with inflammatory rheumatic musculoskeletal diseases. J Rheumatol 2023 Aug; 50:1071. PMID: 36521920 https://www.jrheum.org/content/50/8/1071
  11. Camacho PM, Petak SM, Binkley N et al AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS/AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS-2020 UPDATE. Endocr Pract. 2020 May;26(Suppl 1):1-46. PMID: 32427503
  12. Kline GA, Morin SN, Feldman S et al. Diminishing value from multiple serial bone densitometry in women receiving antiresorptive medication for osteoporosis. J Clin Endocrinol Metab 2021 Sep; 106:2718. PMID: 33784384 https://academic.oup.com/jcem/article-abstract/106/9/2718/6204740