Progress in Osteoporosis and Fracture Prevention: Focus on Postmenopausal Women

Kenneth G Saag; Piet Geusens


Arthritis Res Ther. 2009;11(5):251 

In This Article

Subsequent Fractures and Postfracture Mortality Cluster in Time: The Need for Immediate Clinical Attention in Patients Presenting with a Fracture

A history of nonvertebral fracture is associated with a doubling of the risk of a subsequent fracture, and the subsequent fracture risk is even quadrupled after a vertebral fracture. However, this re-fracture risk is not constant over time and is driven by the high, threefold to fivefold increase in the years immediately after a first fracture, followed by a gradual waning later on (Figure 3).[9] This has been shown for repeat morphometric vertebral fractures, subsequent clinical spine, forearm, and hip fractures after hospitalization because of a vertebral fracture, repeat low trauma fractures in subjects older than 60 years, repeat clinical vertebral and nonvertebral fractures from menopause onwards, and repeat hip fractures.[9–12] As a result, it has been shown in long-term follow-up studies that 40% to 50% of all subsequent fractures occur within 3 to 5 years after a first fracture. The clinical implication is that patients older than 50 years presenting with a fracture need immediate attention to reduce the risk of a subsequent fracture. This is a situation in which it is important to take immediate action in fracture patients, such as a fracture liaison service and other initiatives in the field of postfracture care.[13,14] It also indicates that, in such patients, treatment that has been shown to reduce fracture risk within the short term should be started.[15]

Figure 3.

Risk of first and subsequent fracture over time. (a) Percentage of all first fractures from menopause onwards (grey line) and fractures subsequent to initial fractures (black line). (b) Relative risk of all subsequent fractures calculated as a mean from the time of first fracture (grey line) and per separate year of follow-up after a first fracture (black line).

An increased risk of mortality has been found after hip, vertebral, and several nonhip, nonvertebral fractures.[16] As for subsequent fracture risk, this increase in mortality is higher immediately after fracture than later on. In women and men older than 60 years, nearly 90% of excess deaths related to fracture over the 18 years of observation occurred in the first 5 years. Of the 5-year excess mortality, hip, vertebral, and nonhip, nonvertebral fractures were each associated with approximately one third of deaths. The major causes of death were related to cardiovascular and respiratory comorbidity.[16]


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