Which fractures are most attributable to osteoporosis?

Abstract

Background: Determining anatomic sites and circumstances under which a fracture may be a consequence of osteoporosis is a topic of ongoing debate and controversy that is important to both clinicians and researchers.

Methods: We conducted a systematic literature review and generated an evidence report on fracture risk based on specific anatomic bone sites and fracture diagnosis codes. Using the Research and Development/University of California at Los Angeles appropriateness process, we convened a multidisciplinary panel of 11 experts who rated fractures according to their likelihood of being because of osteoporosis based on the evidence report. Fracture sites (as determined by International Classification of Diseases Clinical Modification codes) were stratified by four clinical risk factor categories based on age, sex, race/ethnicity (African American and Caucasian), and presence or absence of trauma.

Results: Consistent with current clinical experience, the fractures rated most likely because of osteoporosis were the femoral neck, pathologic fractures of the vertebrae, and lumbar and thoracic vertebral fractures. The fractures rated least likely because of osteoporosis were open proximal humerus fractures, skull, and facial bones. The expert panel rated open fractures of the arm (except proximal humerus) and fractures of the tibia/fibula, patella, ribs, and sacrum as being highly likely because of osteoporosis in older Caucasian women but a lower likelihood in younger African American men.

Conclusion: Osteoporosis attribution scores for all fracture sites were determined by a multidisciplinary expert panel to provide an evidence-based continuum of the likelihood of a fracture being associated with osteoporosis.

FIGURE 1

OSTEOPOROSIS FRACTURE EXPERT PANEL PROCESS

FIGURE 2

Skeletal depiction of Expert Panel (EP) osteoporosis fracture attribution scores. The two halves of the skeleton depict persons with differing clinical risk factors. Colors indicate three levels of fracture attribution by the EP across the 9- point Likert scale. Red: most likely due to osteoporosis (median Likert scores 7–9), Green: least likely due to osteoporosis (scores 1–3), Yellow: indeterminate likelihood of being due to osteoporosis (scores 4–6). Unless specified, scores were of the same level for closed, open and pathological fractures at that site. A single hatch pattern indicates that an open fracture score was one level less likely to be osteoporotic than a closed fracture at the same site and a double hatch pattern indicates a decline of two levels.