Journal of Osteoporosis and Physical

Activity Hurwitz, J Osteopor Phys Act 2016, 4:4

DOI: 10.4172/2329-9509.1000186

Mini review OMICS International

Osteoporosis and Fracture

Shepard Hurwitz*
University of North Carolina, Chapel Hill, North Carolina, USA
*Corresponding author: Shepard Hurwitz, University of North Carolina, Chapel Hill, North Carolina, USA, E-mail: [email protected]
Received date: May 27, 2016; Accepted date: November 02, 2016; Published date: November 09, 2016
Copyright: © 2016 Hurwitz S. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original author and source are credited.

Keywords: Bone; Bone strength; Bone density; Osteoporosis Fracture

fracture; Treatment of osteoporosis
When osteoporosis exists in bones there is a greater chance of a
fracture happening under relative normal conditions, meaning that a
The Problem less serious trauma is needed to create a hip or wrist fracture. An adult
Osteoporosis is a condition that is defined by a loss of bone who trips and fall forward will likely put out their hands to protect the
substance that renders the entire bone weaker mechanically thus more fall and with normal bone strength it is unlikely that a wrist fracture
likely to fracture. The majority of the more than 10 million Americans will occur. That same adult in later years with weakened bone due to
with osteoporosis are at risk of fracturing the hip, spine (vertebra) or osteoporosis will likely fracture one or both wrists from a similar fall.
wrist (distal radius). Nearly 1.5 million fractures are attributed in part Fracture may occur without a single event due to repetitive force to a
to osteoporosis annually in the US, making osteoporosis a public bone that is significantly weakened by osteoporosis- this may be
health issue of a very large scale. The direct costs (in current dollars) referred to as a stress or fatigue fracture. Fractures occur in bones with
attributed to care/treatment of osteoporosis-related fracture is in the normal mechanical strength but there is greater external force
range of $20 billion per year in the US. With a population living longer (trauma) needed when compared with a bone weakened by
and co-existing medical conditions (e.g. cancer survivors) and osteoporosis.
medication (e.g., corticosteroids) that predispose to osteoporosis, the The diagnosis of osteoporosis is made by non-invasive imaging
number of osteoporosis related fractures is expected to increase for the using low intensity radiation either via a conventional computed
next 60 years [National Osteoporosis Foundation website, accessed tomogram or a dual energy photon analysis (DEXA). These imaging
August 2, 2016. studies focus on a particular region of the skeleton that is
representative of the general bone health and has proven predictive
Background value for increased incidence of hip, spine or distal radius fracture. The
gold standard previous to the advent of advanced imaging was a bone
The natural history of bone strength in the general population is the
biopsy from the pelvis. The biopsy could distinguish between
loss of bone content and strength starting around age 25. Women lose
osteoporosis and other metabolic conditions such as osteomalacia (a
bone more quickly than men on average with acceleration of bone loss
lack of Calcium Phosphate in the protein fabric of bone)- which also
after menopause- thus the term ‘post-menopausal osteoporosis’.
leaves adults with weakened bone strength. Osteomalacia may be
Population studies have shown that those individuals who maximize
confused with osteoporosis and does weaken bone, though treatment
their bone strength in their younger years will retain greater bone
of osteomalacia is different that treatment for osteoporosis.
strength later in life. Those same population studies have shown that in
the U.S. women, on average maximize their bone strength at a lower The World Health Organization defines osteoporosis
threshold than men, thus another problem causing greater numbers of mathematically as greater than 2.5 standard deviations [World Health
fractures later in life after decades of bone strength loss. The incidence Organization website, accessed August 4, 2016] below the population
of hip, spine and wrist fracture in women over a lifetime is between 3 mean bone density for a person of the same age and gender. That is not
times and 5 times more common than in same-aged men. Caucasians a very helpful definition for everyday use by non-specialists in bone
men and women have less bone density, thus less bone strength, than health, however, the use of a defined standard does help with
African Americans and Asian-Americans. The lifetime risk of fracture establishing a diagnosis, predicting the risk of future fractures and
is accordingly less for African-American and Asian-American people. monitoring treatment. Having non-invasive screening tests that can
accurately define bone density has aided in the recognition and
Bone mineral density is the term that is used to describe the amount
treatment by replacing an invasive (possibly painful) bone biopsy with
of bone present when tested by an imaging technique such as Dexa or
an easy, painless imaging study.
in vivo when demonstrated in bone biopsy tissue. Bone as a tissue is
composed of a biological polymer protein called collagen plus the One of the leading public health concerns of osteoporosis is the
chemicals Calcium and Phosphate (Phosphorous and Oxygen occurrence of a ‘fragility fracture’. A fracture of the proximal femur
combined). It is the Calcium Phosphate that makes bone stiff and hard, (hip area), distal radius (wrist) or vertebra (spine). When these
the collagen is very soft and flexible. When bone loses Calcium it fractures occur from a fall, modern best practice should include an
becomes weaker mechanically and if bone loses the collagen it will also evaluation of bone quality via one of the imaging studies to establish a
lose Calcium, thus becoming weaker. Bone the organ is organized to diagnosis of osteoporosis. At present the number of patients admitted
have a blood supply and nerves- e.g. your leg bone the tibia. When a to hospital with fragility fractures, mostly hip fractures since distal
bone cracks or breaks apart into pieces- the loss of continuity is called radius and vertebral fractures are orthopaedically treated out-patient,
a fracture. who receive an appropriate evaluation for osteoporosis is unknown.
There are screening criteria for adults at risk for osteoporosis without

J Osteopor Phys Act, an open access journal Volume 4 • Issue 4 • 1000186

ISSN:2329-9509
Citation: Hurwitz S (2016) Osteoporosis and Fracture. J Osteopor Phys Act 4: 185. doi:10.4172/2329-9509.1000186

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having a fragility fracture. These people are for the most part tendency of weakening bones with age. Programs that encourage
asymptomatic for bone problems yet may have a list of factors such as walking and exercise to strengthen muscles in the lower extremities
lactose intolerance, family history, lack of exposure to sunshine, low have the benefit of helping maintain bone strength. Dietary sources of
circulating level of vitamin D3, use of systemic corticosteroids, chronic vitamin D, calcium and protein similarly provide some protection
renal failure, and many other medical conditions and medications. against bone atrophy or weakening due to decreased walking activity.
When osteoporosis is diagnosed and over time there is measurable
The population living longer with chronic conditions that over time
bone loss despite increased physical activity, vitamin D3 and calcium,
weaken bones, the prevalence of osteoporosis in theory should be
there are several medications now available for use to reduce bone loss
increasing. Increasing public awareness and willingness of primary
and even help improve bone density. Prescription drugs include
care physicians to initiate treatment to reduce or reverse bone loss will
bisphosphonates, teriparatide, hormone (estrogen) replacement,
blunt the theoretical rise of age related osteoporosis in the population
denosumab, raloxifene and calcitonin. Of particular value is initiating
most at risk. Simple measure to slow the progression of bone loss
osteoporosis treatment with one of these drugs following major
during middle years may provide protection in later years against
fractures [1].
fracture.
The healing of fractures in osteoporotic bones is nearly the same as Summary
healing in bones unaffected by osteoporosis. A confounding issue is the
number of co-morbidities and medications taken by elderly with As the public awareness and the treatment awareness of physicians
osteoporosis. Someone with a hip fracture and osteoporosis may have improves concerning osteoporosis, the consequences of unrecognized
insufficient vitamin D and calcium intake, mild renal failure and using and untreated osteoporosis are likely to be lessened. There already is
medication that inhibits calcium absorption form the gut. This evidence that the number of hip fractures in the United States is
theoretical patient may have delayed healing of the fracture and considerably lower than projected 20 years ago based on the then
require further surgery to replace the hip, while suffering from prevalence of elderly people with hip fracture [2]. And the incidence of
inactivity a decline in overall health is likely that affects cardio- spontaneous vertebral fracture associated with osteoporosis has
pulmonary function and endurance. The osteoporotic person with leveled-out and not increased in the past 5 years. These are indirect
overall poor health will likely have greater difficulty recovering from measures of success but encouraging signs that individuals and society
the surgical treatment of a hip fracture. Poor standing balance, weak are making gains over the threats of osteoporosis and other forms of
lower extremity muscles, painful lower extremity joints, poor cardiac metabolic conditions that weaken bone.
function all combine to lessen the independence of a person recovering In addition to a public health approach to osteoporosis there are
from hip fracture surgery and likely leads to a shortening of lifespan. numerous advances in medical management, nutritional support,
exercise therapy, fall prevention and post-surgery rehabilitation. The
Surgery for Osteoporotic Fracture attention of the medical community to the consequences of
osteoporosis have helped support the many stakeholders in society
The objective of surgery for fractures is to reduce the pain and loss
who are trying to lessen the harm that comes from not treating or
of function that comes from a bone that no longer is performing its
simply neglecting osteoporosis. Today there are many more resources
structural task, to restore more normal alignment, to ensure bone
to help people with osteoporosis find information and treatment.
healing. Fracture of the hip (proximal femur or acetabulum) makes it
Physicians, physical therapists, nurse practitioners, dieticians as well as
nearly impossible to stand, walk and change position. Surgery restores
surgeons are learning to recognize osteoporosis in the populations at
mechanical integrity and allows movement and weight-bearing while
risk and matching patients to treatment earlier in the course of this
the bone is healing. In earlier times, a hip fracture in an elderly person
disorder. Eventually there may be a treatment/prevention strategy that
led to death from immobility. Progress that began in the mid-20th
will nearly eliminate the threat of osteoporosis to the lives of ageing
century in designing more efficient surgical procedures allows for
citizens and others with this disorder.
earlier mobility and thus earlier rehabilitation with return of overall
function and health has improved the prognosis from fracture of the
hip. A vertebral fracture in the thoracic or lumbar spine is initially References
inhibitory of standing, walking, changing position and possibly 1. Jennings LA, Auerbach AD, Maselli J, Pekow PS, Lindenauer PK, et al.
inhibits chest wall expansion (breathing) - and later may develop (2010) Missed opportunities for osteoporosis treatment in patients
spinal deformity that affects posture and balance. By reducing the pain hospitalized for hip fracture. J Am Geriatr Soc 58: 650-656.
of vertebral fracture which in some cases is by surgical stabilization, 2. Donnelly E, Lane JM, Boskey A (2014) Research perspectives: the 2013
mobility is restored much sooner and overall function is preserved. AAOS/ORS Research symposium on bone quality and fracture
prevention. J Ortho Res 32:855-864.
Recent public health measures to improve awareness of osteoporosis
and enhance bone health in adults may very well counter the natural

J Osteopor Phys Act, an open access journal Volume 4 • Issue 4 • 1000186

ISSN:2329-9509