Screening of Osteoporosis After Wrist Fractures

MATERIA SOCIO MEDICA

Vol. 20 • No.3 • 2008

Screening of Osteoporosis After Wrist Fractures Zoran Hadžiahmetović1, Narcisa Vavra - Hadžiahmetović2, Izet Mašic3 Clinic for emergency medicine, Clinical University center Sarajevo1 Institute for physical therapy and rehabilitation, Clinical University center Sarajevo2 Medical Faculty University of Sarajevo3

Original paper Summary Consequences of osteoporosis are fractures, especially of the wrists, vertebrae, and hips. Strategies to prevent such fractures are important both to the individual and from a public health care perspective. Material and methods; This study was conducted at a Clinic for emergency medicine and Institute for physical therapy and rehabilitation Clinical University center Sarajevo. A structured interview format was used to contact 69 (86.25 %) of 80 patients older than 45 years who were diagnosed as having a fracture of the distal radius/ulna from January to June 2007. Information on osteoporosis follow-up and drug therapy was obtained from the patient. Results;  The time between fracture and telephone interview ranged from 6 months to 1 years, with the majority of the sample being interviewed at least 1 year after fracture. Of the 56 patients in this study, 22 had sustained previous fractures on osteoporotic sites, 9 of which had occurred at the wrist, vertebrae, or hip. Thirty-two patients had received treatment for osteoporosis before fracture. A further 12 patients (21%) had undergone osteoporosis follow-up after fracture. After fracture, 21 (38%) of all patients were receiving either hormone replacement therapy or using a bisphosphonate and small increase in the rate of calcium or vitamin D.. Conclusions;  Interventions to improve osteoporosis follow – up of patients with wrist fracture can include identifyng these individuals in the emergency department or family doctors. Refferal of these patients to a dedicated clinic for prevention of osteoporosis is another option. Only 50% of the study population had received osteoporosis follow-up after fracture. Few patients did not have any change in their medication use after the fracture. The findings in this study population suggest that recognition of the potential for osteoporosis in such patients is inadequate. Given the magnitude of this public health care problem, it is clear that attention to case finding and treatment of osteoporosis should be increased. Key words; osteoporosis, wrist fracture

1. INTRODUCTION

Osteoporosis is described as involuntary bone loss that may result in an increase in sensitivity for fractures, especially in wrist, lumbar vertebrae and hip (1). This new constitutive disease is a serious health problem in industrialized countries. Prevalence is projected trough triplication during the next six years, by extending the life and introduction of risk factors as well as practicing unhealthy life styles (for example, by reducing calcium

146

intake, reduction in physical activity, increased consumption of alcohol and cigarettes ..), by overloading the small bone structures, using medications such as the corticosteroids, tiroxine and anticonvulsants (2). The largest consequence of osteoporosis is fractures. Prevention strategies for fractures are extremely important both for individuals and for public health care in the future (3,4,5,6,7). Adults with wrist fracture as a result of low-trauma are the ideal target group for the early findings in identifying osteoporosis. This group has a high probability to have osteoporosis and increased risk for the hip fractures (8,9,10,11,12,13,14). Also wrist fractures generally precede hip fractures within next 15 years (3,19,15). In this way, the identification of patients with wrist fractures, which has a low bone mass, is the signal for the prevention of potential, more serious fractures. There are no published studies which determine the relationship between the osteoporosis degrees of patients in treatment with wrist fractures. Primary in studies there is objective percentage of patients who have had formal osteoporosis after a low-trauma of the wrist, and secondly there is the lack of comparison with patients who use protective hormonal therapy before and after fractures. Test of bone mineral density (BMD) is safe and painless test which provides important information’s about the state of the bone. It is used for: •• Detection of low bone density before person have fracture •• Anticipates, announces changes in the bone (fractures) in the future •• Confirms diagnosis of osteoporosis after bone fracture •• Determines bone density status (lowered or increased) •• Monitors therapeutic response •• BMD test methods are: •• pDXA (Peripheral Dual Energy X-Ray Absorptiometry) •• QUS (Quantitative Ultrasound) Original papers

Vol. 20 • No.3 • 2008

MATERIA SOCIO MEDICA

•• QCT (Quantitative Computerized Tomography) •• pQCT (Peripheral Quantitative Computerized Tomography) Interpretation of the BMD test results The results of BMD test are expressed trough special number called T-score. This is the name for the “standard deviation” or “SD” which indicates bone density above or below normal. It is used in diagnosis of osteoporosis. Tscore presents the comparison between the bone density of an individual and the average bone density of the large group of young people (both males and females) at the top of the bone density with healthy bones. This enables standardizing the results, or value of the bone density is used as the referral value. So for example if the T-score value is -1.0, than the value of the bone density is lower by one standard deviation from the young person value. Within densitometry tests of density World Health Organization (WHO) ranked the T-score results which enable diagnosis of osteoporosis and osteopenia (Table 1). Table 1: WHO criteria’s for osteoporosis based on mineral bone density BMD category

Definition

Normal BMD Osteopenia (low bone mass) Osteoporosis

Normal population–average ± 1 SD T score ranging from 1 -2.5 T score of  -2.5 T score of -2.5 represent one or multiple fragile fractures

Severe osteoporosis

BMD test also involves the Z-score which compares the bone density of an individual with the average value of healthy bones density of the large number of people with same weight, race and age. It is not sufficient to set the diagnosis of osteoporosis. Main role of the Z-score (values below -1.5) is that it can determine the relation with some secondary cause of osteoporosis, not related to aging process or postmenstrual changes. So the healthy person in eighties for sure have the lower bone density in comparison to the young persons, and by that the lower T-score values are not good, but when the bone density is compared with its peers there is no reduction in bone density and the Z-score values are normal. Scoring systems are developed in forms of guides in estimation of osteoporosis risk. Table 2: Interpretation of the SCORE index   1-5 6-10

Interpretation of the SCORE index low risk moderate risk

11-22

high risk

For practical calculations and osteoporosis risk estimation also used is the Simple Calculated Osteoporosis Risk Estimation (SCORE) developed for identifyng low BMD among women in postmenopausal (≤−2.0 SD of young adults, normal), which are selected for DXA testing (16) . SCORE index is very valid method in estimating osteoporosis risk among women (for T–score values < -2 sensitivity is 98% and specificity 28%, while for the value