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SummaryThe present study, drawn from a sample of the Icelandic population, quantified high immediate risk and utility loss of subsequent fracture after a sentinel fracture (at the hip, spine, distal forearm and humerus) that attenuated with time.IntroductionThe risk of a subsequent osteoporotic fracture is particularly acute immediately after an index fracture and wanes progressively with time. The aim of this study was to quantify the risk and utility consequences of subsequent fracture after a sentinel fracture (at the hip, spine, distal forearm and humerus) with an emphasis on the time course of recurrent fracture.MethodsThe Reykjavik Study fracture registration, drawn from a sample of the Icelandic population (n = 18,872), recorded all fractures of the participants from their entry into the study until December 31, 2012. Medical records for the participants were manually examined and verified. First sentinel fractures were identified. Subsequent fractures, deaths, 10-year probability of fracture and cumulative disutility using multipliers derived from the International Costs and Utilities Related to Osteoporotic fractures Study (ICUROS) were examined as a function of time after fracture, age and sex.ResultsOver 10 years, subsequent fractures were sustained in 28% of 1498 individuals with a sentinel hip fracture. For other sentinel fractures, the proportion ranged from 35 to 38%. After each sentinel fracture, the risk of subsequent fracture was highest in the immediate post fracture interval and decreased markedly with time. Thus, amongst individuals who sustained a recurrent fracture, 31–45% did so within 1 year of the sentinel fracture. Hazard ratios for fracture recurrence (population relative risks) were accordingly highest immediately after the sentinel fracture (2.6–5.3, depending on the site of fracture) and fell progressively over 10 years (1.5–2.2). Population relative risks also decreased progressively with age. The utility loss during the first 10 years after a sentinel fracture varied by age (less with age) and sex (greater in women). In women at the age of 70 years, the mean utility loss due to fractures in the whole cohort was 0.081 whereas this was 12-fold greater in women with a sentinel hip fracture, and was increased 15-fold for spine fracture, 4-fold for forearm fracture and 8-fold for humeral fracture.ConclusionHigh fracture risks and utility loss immediately after fracture suggest that treatment given as soon as possible after fracture would avoid a higher number of new fractures compared with treatment given later. This provides the rationale for very early intervention immediately after a sentinel fracture.

ObjectiveDiabetes mellitus (DM) is associated with an increased fracture risk; however, the impact of DM and subsequent fracture at different sites and the associations according to patient characteristics remain unknown.DesignMeta-analysisData sourcesThe PubMed, EMBASE and Cochrane Library databases were searched from inception to March 2018.Eligibility criteriaWe included prospective and retrospective cohort studies on the associations of DM and subsequent fracture risk at different sites.Data extraction and synthesisTwo authors independently extracted data and assessed the study quality. Relative risks (RRs) with 95% CIs were calculated using a random-effects model, and the heterogeneity across the included studies was evaluated using I2 and Q statistics.ResultsOverall, DM was associated with an increased risk of total (RR: 1.32; 95% CI 1.17 to 1.48; p<0.001), hip (RR: 1.77; 95% CI 1.56 to 2.02; p<0.001), upper arm (RR: 1.47; 95% CI 1.02 to 2.10; p=0.037) and ankle fractures (RR: 1.24; 95% CI 1.10 to 1.40; p<0.001), whereas DM had no significant impact on the incidence of distal forearm (RR: 1.02; 95% CI 0.88 to 1.19; p=0.809) and vertebral fractures (RR: 1.56; 95% CI 0.78 to 3.12; p=0.209). RR ratios suggested that compared with patients with type 2 DM (T2DM), patients with type 1 DM (T1DM) had greater risk of total (RR: 1.24; 95% CI 1.08 to 1.41; p=0.002), hip (RR: 3.43; 95% CI 2.27 to 5.17; p<0.001) and ankle fractures (RR: 1.71; 95% CI 1.06 to 2.78; p=0.029). Although no other significant differences were observed between subgroups, the association of DM with upper arm or ankle, vertebrae and total fracture differed according to sex, study design and country, respectively.ConclusionsPatients with DM had greater risks of total, hip, upper arm and ankle fractures, with T1DM having a more harmful effect than T2DM.

Background Humeral fractures are common, but the association between the patho-anatomical fracture pattern and patient characteristics has been inadequately studied and epidemiological knowledge is scarce. Following the introduction of the Swedish Fracture Register (SFR), risk factors for various fractures can be studied, as well as the outcome of different treatments. The objective of this study was to analyse adult humeral fractures in Gothenburg from a descriptive epidemiological perspective. Methods All humeral fractures registered in the SFR at Sahlgrenska University Hospital in 2011–2013 in patients aged ≥ 16 years were included. The fractures were divided into humeral segments (proximal, shaft and distal humerus) and analysed according to patient characteristics and patho-anatomical pattern. Furthermore, overall and age-specific incidence rates were calculated. Results A total of 2,011 humeral fractures were registered in the SFR, of which 79 % were proximal, 13 % shaft and 8 % distal humeral fractures. The mean age was 66.8 years and women ran a higher risk of humeral fractures than men (female/male ratio 2.4:1). On average, women were older than men at the time of fracture (mean age 70.1 years for women vs. 58.9 years for men). The overall incidence of humeral fractures was 104.7 per 100,000 inhabitants per year, with a segment-specific incidence of 83.0 for proximal fractures, 13.4 for shaft fractures and 8.3 per 100,000 person-years for distal fractures. There was a distinct increase in the age-specific incidence from the fifth decade and onwards, regardless of fracture site. Most fractures occurred in older patients (83 % > 50 years) as a result of a simple or an unspecified fall (79 % > 50 years). Only 1.2 % of all fractures were open injuries and 1.3 % were pathological. Conclusion This population-based study provides updated epidemiological data on humeral fractures in a Western-European setting. Most humeral fractures occur as the result of low-energy falls in the elderly population, indicating the influence of age-related risk factors in these fractures. The SFR will be a useful tool for providing continuous information on fracture epidemiology, risk factors and treatment outcome and these population-based data are essential in the planning of future fracture prevention and management.

The aim of this study was to quantify the global burden of osteoporotic fracture worldwide. The incidence of hip fractures was identified by systematic review and the incidence of osteoporotic fractures was imputed from the incidence of hip fractures in different regions of the world. Excess mortality and disability weights used age- and sex-specific data from Sweden to calculate the Disability Adjusted Life Years (DALYs) lost due to osteoporotic fracture. In the year 2000 there were an estimated 9.0 million osteoporotic fractures of which 1.6 million were at the hip, 1.7 million at the forearm and 1.4 million were clinical vertebral fractures. The greatest number of osteoporotic fractures occurred in Europe (34.8%). The total DALYs lost was 5.8 million of which 51% were accounted for by fractures that occurred in Europe and the Americas. World-wide, osteoporotic fractures accounted for 0.83% of the global burden of non-communicable disease and was 1.75% of the global burden in Europe. In Europe, osteoporotic fractures accounted for more DALYs lost than common cancers with the exception of lung cancer. For chronic musculo-skeletal disorders the DALYs lost in Europe due to osteoporosis (2.0 million) were less than for osteoarthrosis (3.1 million) but greater than for rheumatoid arthritis (1.0 million). We conclude that osteoporotic fractures are a significant cause of morbidity and mortality, particularly in the developed countries.

Summary This population study investigated the association between birth characteristics and fracture risk in 11,099 young adults (aged 19–54 years). Our findings indicate that birth weight, gestational age, and birth weight for gestational age were not associated with fractures in the wrist, humerus, hip, and spine in this population. Purpose Skeletal development starts during fetal life, and it is estimated that most bone formation occurs in the 3rd trimester. This study examined the association between birth characteristics and fractures of the wrist, humerus, hip, and spine, in young adults (19–54 years). Methods 11.099 participants in the 3 rd survey of the HUNT Study (2006–2008) were linked with the Medical Birth Registry of Norway and hospital records. Fractures of the wrist, humerus, hip, and spine were identified using ICD9/10 codes between 1988 and 2021. Follow-up was from date of participation in HUNT until a first fracture, emigration, death, or end of study. Cox regression was used to estimate hazard ratios (HR) of fracture associated with birth characteristics (95% CI), adjusted for birth year, sex, maternal age, and maternal morbidity. In a secondary analysis, follow-up started in 1988. Results During a median follow-up of 14.0 years (153,657 person-years), 290 fractures occurred. Mean age at first fracture was 41.4 years (SD 7.4). Overall, there were no clear associations between birth characteristics and fractures in these data. HR for fracture was 0.43 (0.15–1.24) for those with a birth weight < 2.5 kg (reference birth weight 3.5 − 3.9 kg); 1.04 (0.74 − 1.46) for those born small for gestational age (< 10th percentile, reference 10 − 90 th percentile); and 0.63 (0.33 − 1.23) for those born preterm (reference term births). The secondary analysis from 1988, including 539 fractures, gave similar results as the main analysis. Conclusion Birth weight, gestational age, or birth weight for gestational age was not associated with an increased risk of fractures of the wrist, humerus, hip, and spine in young adults.

Supplemental Digital Content is available in the text. Background:Discontinuation of bisphosphonates (BP) or a \"drug holiday\" after several years of treatment is increasingly common. However, the association of drug holiday duration with future fracture risk is unclear.Objectives:We evaluated the rate of fracture in relation to various lengths of drug holidays among women receiving long-term BP therapy.Research Design:Observational cohort study using US Medicare data 2006-2016. Incidence rates (IRs) and Cox proportional hazards models were used to evaluate the rate and adjusted hazard ratios (aHRs) controlling for potential confounders.Subjects:Women aged 65 years and above enrolled in fee-for-service Medicare who had been adherent (≥80%) to alendronate, risedronate, or zoledronate for ≥3 years.Measures:Hip, humerus, distal forearm, and clinical vertebral fracture.Results:Among 81,427 eligible women observed for a median (interquartile range) of 4.0 (2.5, 5.3) years, 28% of women underwent a drug holiday. In the alendronate cohort (73% overall), the IR of hip fracture among women who discontinued BP for >2 years was 13.2 per 1000 person-years. Risk was increased (aHR=1.3, 1.1-1.4) versus continuing therapy (IR=8.8, referent). Rates were elevated for humerus fracture with discontinuation >2 years (aHR=1.3, 1.1-1.66) and for clinical vertebral fracture with discontinuation >2 years (aHR=1.2, 1.1-1.4). Results were similar for risedronate, zoledronate, and ibandronate for hip and clinical vertebral fracture.Conclusion:Discontinuing alendronate beyond 2 years was associated with increased risk of hip, humerus, and clinical vertebral fractures.

SummaryThere are only a few previous population-based studies that include both inpatient and outpatient treatment data. The aim of this study was to investigate the epidemiology of proximal humerus fractures. The incidence of proximal humerus fractures increases with age, and we observe a seasonal variation strongly favoring winter months.PurposeProximal humerus fractures are the third most common osteoporotic fracture type observed in elderly patients, after wrist and hip fractures. However, few previous population-based studies include both inpatient and outpatient treatment data. The aim of this study was to investigate the incidence, fracture morphology, and treatment method provided in cases of proximal humerus fractures.MethodsWe retrospectively studied patient records from a mid-sized town in Finland between the years 2006 and 2010. The following data were collected from the medical records: age, sex, date of the fracture, laterality of the fracture, mechanism of injury, treatment method, and other associated fractures at the time of the original injury. Sex and age distributions of the patient population at risk (>18 years old) were calculated for the study period.ResultsA total of 678 patients (females n = 503, 73 %) with 692 proximal humerus fractures were identified. The unadjusted incidence was 82 (95 % CI 76 to 88) per 100,000 person-years, 114 (95 % CI 104 to 124), and 47 (95 % CI 41 to 54) per 100,000 person-years in females and males, respectively. Incidence increased toward the older age groups. Clear seasonal variation was observed, two-part fractures were most common (428, 62 %), the majority of the fractures (n = 539, 78 %) were treated nonoperatively with a sling.ConclusionThe incidence of proximal humerus fractures increases with age, and we observe a seasonal variation strongly favoring winter months. It is evident that proximal humerus fractures cause considerable morbidity among elderly people and consume health care resources.

This meta-analysis was conducted to investigate whether heart failure is associated with an increased risk of fractures by summarizing all the available evidence. The PubMed, EMBASE, and Cochrane Library databases were searched for all relevant studies published from the date of database inception to April 2018. Studies that investigated the association between heart failure and fracture risk and conducted a comparison with controls were included. Seven cohort studies were finally identified as eligible for inclusion in the meta-analysis. All included studies were of high quality as evaluated by the Newcastle-Ottawa Scale. There was a significantly higher risk of any fracture in patients diagnosed with heart failure (N = 53,038) than in controls (N = 126,727) (RR 1.66, 95% CI 1.14–2.43, I2 = 94%, P = 0.008). The results were the same for hip (RR 3.45, 95% CI: 1.86–6.40, I2 = 95%, P < 0.0001) and humerus fractures (RR 1.91, 95% CI 1.07–3.40, I2 = 39%, P = 0.03) but not for vertebral and forearm fractures. To conclude, this meta-analysis demonstrated that patients with heart failure had an increased risk of fractures, especially hip and humerus fractures. Patients with heart failure may need to pay greater attention to their bone health. This meta-analysis found a significantly higher risk of fractures in patients with heart failure than in those without heart failure. Greater attention should be paid to bone health in patients with heart failure.

Background Most fractures in children are fractures of the upper extremity. Proximal and diaphyseal humeral fractures account for a minority of these fractures. To our knowledge, few previous reports address these fractures. This study aimed to describe the epidemiology and current treatment of proximal and diaphyseal humeral fractures by using the Swedish Fracture Register (SFR). Methods In this nationwide observational study from the SFR we analysed data on patient characteristics, injury mechanism, fracture classification and treatment. We included patients aged < 16 years at time of injury with proximal or diaphyseal humeral fracture registered in 2015–2019. Results 1996 (1696 proximal and 300 diaphyseal) fractures were registered. Proximal fractures were more frequent in girls whereas diaphyseal fractures were more frequent in boys. The median age at fracture was 10 years in both fracture types but patient’s age was more widespread in diaphyseal fracture (IQR 5–13 compared to IQR 7–12 in proximal). In both sexes, the most registered injury mechanism was fall. Horse-riding was a common mechanism of injury in girls, whereas ice-skating and skiing were common mechanisms in boys. Most proximal fractures were metaphyseal fractures. Most diaphyseal fractures were simple transverse or oblique/spiral fractures. The majority of fractures were treated non-surgically (92% of proximal and 80% of diaphyseal fractures). The treatment method was not associated with the patient’s sex. Surgery was more often performed in adolescents. The most common surgical methods were K-wire and cerclage fixation in proximal fracture and intramedullary nailing in diaphyseal fracture. Conclusion Following falls, we found sex-specific sport activities to cause most proximal and diaphyseal paediatric fractures. Further studies on prophylactic efforts in these activities are needed to investigate whether these fractures are preventable. The majority of the fractures were treated non-surgically, although surgical treatment increased with increasing age in both sexes. Trial registration Not applicable. The present study is a register-based cohort study. No health care intervention had been undertaken .

Background Occult and missed surgical neck fractures can be found in patients diagnosed with isolated greater tuberosity (GT) fracture during the follow up period. The purpose of this study was to retrospectively assess the incidence rate of occult and missed surgical neck fractures in those initially diagnosed with isolated GT fracture. Methods Records of patients diagnosed as having an isolated GT fracture were retrieved from a database in a medical center. Two senior orthopedic surgeons blindly reviewed all images of these patients three times to classify GT fracture types (split, avulsion and depression types), and recorded any surgical neck fractures found. Then a meeting was help to confirm the fracture types and presence of surgical neck fracture. Results Occult surgical neck fractures were found in 5 out of 68 (7.4%) patients, whereas missed surgical neck fractures were found in 3 out of 68 (4.4%) patients. In total, 32 patients had split type GT fracture, 32 had avulsion type and 4 had depression type. For those with occult surgical neck fractures, 7 had the split type GT fracture, while the remaining one had the avulsion type. Although the proportion of occult surgical neck fracture was higher in the split-type GT fracture (21.9%) than in the avulsion-type GT fracture (3.1%), the difference was not statistically significant ( p  = 0.056). Conclusion Occult humeral surgical neck fractures occurred in 7.4% of isolated greater tuberosity fractures after re-evaluation, while missed humeral surgical neck fractures occurred in 4.4%.