Fracture risk assessment
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Fracture risk assessment. Norwich, John A Kanis. SCOOP Launch, November 07. 03ca011. Definition a systemic skeletal disease characterised by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture

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Fracture risk assessment

Fracture risk assessment

Norwich,John A Kanis

SCOOP Launch, November 07


03ca011

03ca011

Definition

a systemic skeletal disease

characterised by low bone massand microarchitecturaldeterioration of bone tissue,with a consequent increasein bone fragility andsusceptibility tofracture

Consensus Development Conference, 1993

Common sites of fracture

Spine

03Osteoporosis

Hip

Wrist


99ca160 ex94ca117 from 91ca129

99ca160 ex94ca117 from 91ca129

Percent of population

0.6

15

50

85

>99

Osteoporosis

Low bone

Normal

mass

Diagnostic thresholds for women

-4

-3

-2

-1

0

1

2

3

4

Bone mineral density (SD units or T-score)


99ca021

- Presence of strong risk factors

oestrogen deficiency

corticosteroid therapy (>7.5 mg >1 year)

maternal history of hip fracture

low BMI (<19 kg/m )

- Radiographic osteopenia

- Previous fragility fracture

- Height loss/ thoracic kyphosis (after radiography)

99ca021

Indications for the diagnostic use of BMD


04ca226

04ca226

IOF NOF

Case finding strategies


05ca085

05ca085

Fractures/1,000 person-years

Number of fractures

50

Fracture rate

Women with fractures

400

40

300

Osteoporotic fracture and BMD

30

200

20

100

10

0

0

1.0

0.5

0.0

-0.5

-1.0

-1.5

-2.0

-2.5

-3.0

-3.5

Siris. Surgeon General’s Workshop on Osteoporosis and Bone Health, December 2002


00ca104

Fracture probability (%)

Age (years)

Women

20

80

70

10

60

50

0

1

-3

-2

-1

0

00ca104

Ten year probability of hip fracture in Sweden

T-score (SD)


04ca148rev

04ca148rev

Objectives - to optimise sensitivity for fracture risk prediction - case finding or screening strategy

- men and women

- cost-effective setting

- international validity

- suitable for primary care

Assessment of osteoporosis at primary health care level


Risk factors

03ca175

Risk factors

  • Validated in multiple populations

  • Data for age, sex and type of fracture

  • Readily assessable by primary care practitioners

  • Be intuitive rather than counterintuitive to medical care.

  • Contribute to a risk that is amenable to the therapeutic manipulation intended


04ca130

04ca130

Hiroshima

CaMoS

EVOS / EPOS

Rochester

Sheffield

Rotterdam

Gothenburg I

Kuopio

Gothenberg II

Dubbo

OFELY

EPIDOS

Cohorts studied

n = 59,232 person-years = 249,898 % female = 74

Any fracture = 5,444 osteoporotic fractures = 3,495 hip fractures = 957


04ca138

04ca138

RR/SD

5

Men and women

4

3

Femoral neck BMD and hip fracture prediction

2

1

0

50

55

60

65

70

75

80

85

Age (years)


05ca186

RR

6

4

2

0

50

55

60

65

70

75

80

85

Age (years)

05ca186

Prior fracture and hip fracture risk


07ca080

07ca080

RR (20 v 25 kg/m2)

3.0

Without BMD

With BMD

2.0

BMI and fracture risk

1.0

0.0

Osteoporotic fracture

Hip fracture


04ca248

Alcohol

>2u

FH

(hip)

Steroids

ever

Smoking

current

RA

Prior

fracture

04ca248

RR

3.0

2.0

Risk factors for hip fracture in men and women

1.0

0.0

Without BMD With BMD


99ca094

99ca094

Probability (%)

20

women

15

10-year probability of hip fracture in Malmo

10

5

men

0

50

60

70

80

90

Age (years)


01ca048

01ca048

10 year risk (%)

70

60

Ten year probability of hip fracture - Swedish women

50

40

30

6.0

5.0

20

4.0

RR

3.0

10

2.0

0

1.0

50

55

60

65

70

75

80

85

Age (years)


06ca106

06ca106

Patient

65

-2.5

FRAX

65

165

24

23.9

8.0


04ca014

04ca014

10 year hip fracture probability (%)

Mrs X

Age = 65 y

Height =161cm

Weight = 61kg

BMI = 23.5 kg/m2

6

4

Clinical risk factors and fracture probability

2

0

FH

None

Prior Fx

Alcohol

Steroids

Smoking

2o osteoporosis


05ca106

None

Prior fracture

+Glucocorticoids

+Family history

05ca106

Men Women

10-year probability (%)

70

60

50

Probability of osteoporotic fracture* at age 65

40

30

20

10

0

0

-1

-2

-3

0

-1

-2

-3

T-score

US Caucasian, no CRF, BMI=24

*Hip, spine, humerus, forearm


05ca092

05ca092

Case finding strategies


05ca200

05ca200

Woman aged 65, BMI=24

No

Yes

Rheumatoid arthritis

Stratification of hip fracture risk

Yes

No

No

Yes

Glucocorticoids

No

Yes

No

Yes

No

No

Yes

Yes

Prior fracture

10-year hip fracture

probability (%)

1.5

3.7

3.1

7.5

2.6

6.4

5.4

12.9


07ca027

07ca027

RR/SD

6

CRFs BMD CRFs+BMD

5

4

Gradient of risk for hip fracture prediction

3

2

1

50

60

70

80

90

50

60

70

80

90

50

60

70

80

90

Age (years)


07ca030

Risk ratio (vs. general population)

10

GR=2.6

GR

1.6

2.6

Z-score

2.57

1.63

8

% Population

0.5

5.0

6

GR=1.6

Mean RR

3.5

4.9

4

2

0

-4

-3

-2

-1

0

1

2

3

4

Z-score

%

100.0

99.9

97.7

84.1

50.0

15.9

2.3

0.1

0.0

07ca030

Gradient of risk and fracture prediction


01ca025

01ca025

Relative probability

Very high

High

Moderate

Low risk

1.2

Sweden

1.0

Denmark

China (TW)

0.8

Switzerland

Australia

Netherlands

Ten year probability of hip fracture compared with Sweden

Finland

Greece

0.6

Argentina

Hungary

Japan

France

0.4

China

0.2

Korea

0

Spain

Italy

Chile

USA

UK

Canada

Norway

Kuwait

Iceland

Turkey

Germany

Portugal

Singapore

Venezuela

China (HK)


00ca008

00ca008

End


04ca191

04ca191

  • Risk amenable to interventionLow BMDPrevious fractureUse of glucocorticoids

  • Presence of risk factor does adversely affect therapeutic responseAgeBody mass indexFamily history of fractureSmoking and alcoholMarkers of bone turnover

  • Uncertain effectsNeuromuscular incompetenceLiability to falling

Identification of reversible risk


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