Fractures Linked to Greater Risk of Subsequent Fractures in Postmenopausal Women

Carolyn J. Crandall, MD, MS

While the burden of fractures for postmenopausal women can be high, current guidelines do not address traumatic fractures as strong risk factors for future fractures.

A team, led by Carolyn J. Crandall, MD, MS, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California Los Angeles, determined how fracture risk varies based on whether an initial fracture in traumatic or non-traumatic.

The Study

In the prospective observational study, the investigators used data from the Women’s Health Initiative Study (WHI). The WHI study enrolled postmenopausal women between 50-79 years old at baseline at 40 US clinical centers between September 1994 and December 1998.

In the WHI Clinical Trials and WHI Bone Density Substudy, the researchers asked participants at 3 of the clinical centers to report the mechanism of incident fractures. The final analysis included 66,874 (88.8%) of the 75,335 patients included in the parent cohort. The mean follow-up period was 8.1 years and the mean age was 63.1 and 65. 3 years old among women without and with clinical fracture, respectively.

The investigators sought main outcomes of the incidence clinical fractures, which were self-reported at least annually and confirmed using medical records. Each participant reported the mechanism of incident-fracture as either traumatic or nontraumatic.

A total of 7142 (10.7%) individuals suffered an incident fracture during the follow-up period, with an adjusted hazard ratio (aHR) of subsequent fracture following the initial fracture of 1.49 (95% CI, 1.38-1.61).

The Link

The association between initial fracture and subsequent fracture was also increased (aHR, 1.52; 95% CI, 1.37-1.68) among women whose initial fracture was nontraumatic.

The confidence intervals for links between initial fractures and subsequent fractures were overlapping for traumatic and nontraumatic initial fracture strata.

“In this cohort study, among postmenopausal women older than 50 years, fracture was associated with a greater risk of subsequent fracture regardless of whether the fracture was traumatic or nontraumatic,” the authors wrote. “These findings suggest that clinical osteoporosis assessment should include high-trauma as well as low-trauma fractures.”

Corticosteroids and Osteoporosis

Earlier this year, findings from a new study indicated that potent or high cumulative amounts of topical corticosteroids was associated with increased risk of osteoporosis and major osteoporotic fractures.

Given the widespread use of topical corticosteroids in patients with psoriasis, atopic dermatitis, and other inflammatory diseases, assessing the risk of prolonged use of such medications may prove valuable from a public health perspective.

Therefore, a team led by Alexander Egeberg, MD, PhD, Herlev and Gentofte Hospital, University of Copenhagen, Denmark, conducted a nationwide retrospective cohort study to evaluate associations between topical corticosteroids and risks related to osteoporosis.

As such, in terms of risk of osteoporosis, the hazard ratio was 1.06 (95% CI, 1.02-1.09) for exposure to 500-999 g, 1.09 (95% CI, 1.05-1.13) for 1000-1999 g, 1.10 (95% CI, 1.06-1.14) for 2000-9999 g, and 1.24 (95% CI, 1.13-1.36) for exposure to ≥10, 000 g.

In terms of major osteoporotic fractures, the hazard ratio for 500-999 g was 1.01 (95% CI, 0.99-1.03), followed by 1.05 (95% CI, 1.02-1.08) for 1000-1999 g, 1.10 (95% CI, 1.07-1.13) for 2000-9999 g, and 1.27 (95% CI, 1.19-1.35) for exposure to ≥10,000 g.

The study, “Risk of Subsequent Fractures in Postmenopausal Women After Nontraumatic vs Traumatic Fractures,” was published online in JAMA Internal Medicine.