Distal radius fracture risk reduction with a comprehensive osteoporosis management program

Declining Trend in Anti-osteoporotic Treatment, Despite a Rise in DEXA Screening Following "Sentinel" Distal Radius Fractures

PURPOSE

To understand national trends and costs associated with the utilization of anti-osteoporotic medication and DEXA screening within the year following a sentinel/primary distal radius fracture.

METHODS

The 2008-2015Q1 Humana Administrative Claims database was queried to identify patients aged ≥50 years, with a "sentinel" occurrence of a primary closed distal radius fracture. Linear regression models were used to report and assess for significant trends in utilization of anti-osteoporotic medication and DEXA screenings within the year following the fracture. Multivariate logistic regression analyses were used to assess for factors associated with receiving or not receiving anti-osteoporotic medication.

RESULTS

A total of 14 526 sentinel distal radius fractures were included in the study. Only 7.2% (n = 1046) of patients received anti-osteoporosis medication in the year following the distal radius fracture. Treatment with medication for osteoporosis declined from 8.2% in 2008 to 5.9% in 2015, whereas the rate of DEXA screening increased from 14.8% in 2008 to 23.6% in 2015. The most common prescribed treatment was alendronate sodium (n = 835; 79.8%-$49/patient). Factors associated with increased odds of receiving anti-osteoporotic medication were age 70 to 79 years (odds ratio [OR], 1.45; P = .014), age 80 to 89 years (OR, 1.66; P = .001), Asian (OR, 2.95; P = .002) or Hispanic (OR, 1.77; P = .006) ethnicity, belonging to South (OR, 1.19; P = .029) or West (OR, 1.37; P = .010), and having an Elixhauser Comorbidity Index score of 3 (OR, 2.14; P = .024) or > 3 (OR, 2.05; P = .022).

CONCLUSIONS

Despite a rising utilization of DEXA screening following "sentinel" distal radius fractures, the proportion of individuals who receive anti-osteoporotic treatment is decreasing over time.

Impact of an Outpatient Fracture Liaison Service on Osteoporosis Evaluation Among Patients With Upper Extremity Fragility Fracture

BACKGROUND

The purpose of this study was to assess the impact of implementation of an outpatient fracture liaison service (FLS) on completion rates of dual-energy x-ray absorptiometry (DXA) and screening labs including 25-OH vitamin D and parathyroid hormone (PTH) in patients with upper extremity (UE) fragility fractures.

METHODS

At our institution, 367 patients were treated in 2014-2015 for UE fragility fractures of the distal radius and proximal humerus before implementation of our outpatient FLS and 395 patients in 2017-2018 after implementation. Retrospective chart review was conducted to identify completed DXA scans within 2 years of fracture treatment and completed 25-OH vitamin D and PTH labs within 1 year of fracture treatment.

RESULTS

There were no statistical differences in the demographics of patients treated for distal radial and proximal humeral fragility fractures during the 2014-2015 and 2017-2018 time periods. Implementation of the FLS resulted in a 9.9% increase (P value = .021) in completed DXA scans within 2 years of fracture treatment. Completed 25-OH vitamin D and PTH labs saw a significant increase of 17.1% and 23.8%, respectively (P values < .001).

CONCLUSIONS

Implementation of an outpatient FLS can help to improve osteoporosis evaluation with completed DXA scans and 25-OH vitamin D and PTH labs.

Assessing Bone Mineral Density Using Radiographs of the Hand: A Multicenter Validation

PURPOSE

Osteoporosis and fragility fractures incur substantial costs to quality of life and global health care systems. The current gold standard for quantifying bone density is dual-energy X-ray absorptiometry. Our hypothesis is that bone density can be accurately predicted with a simpler method using plain radiographs of the hand.

METHODS

This retrospective cohort study was undertaken in two centers in the United Kingdom, where the second metacarpal cortical percentage (2MCP) scores were calculated from radiographs. This study included patients who had sustained a distal radius fracture between 2020 and 2022 and had received both a posteroanterior radiograph of the hand and a dual-energy X-ray absorptiometry scan within 12 months of their radiograph and fracture. The Pearson correlation coefficient was calculated to determine the correlation between 2MCP scores and t-scores of the femoral neck on dual-energy X-ray absorptiometry scans.

RESULTS

Of the 188 patients, the 2MCP score significantly correlated with bone density t-scores of the femoral neck. A 2MCP score <50% demonstrated 100% sensitivity and 100% specificity for differentiating osteoporotic from normal subjects, whereas a 2MCP score <60% demonstrated 94.4% sensitivity and 83.0% specificity in differentiating osteopenic from normal subjects.

CONCLUSIONS

These data confirm that the likelihood of osteoporosis being present can be determined via the 2MCP score.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic I.

Future Fracture Risk in Upper Extremity Fracture and Non-Fracture Patients

BACKGROUND

Upper extremity (UE) fragility fractures are common and strong predictors of subsequent fractures. To investigate the relative importance of an UE fragility fracture in determining future fracture risk, we conducted a cross-sectional study to compare future fracture risk between patients presenting for osteoporosis evaluation after an UE fragility fracture and a similarly aged cohort of patients without an UE fracture.

METHODS

In all, 129 UE fracture patients seen in our bone health clinic (BHC) and 114 non-fracture UE fracture patients seen in an UE clinic completed clinic intake surveys assessing for fracture risk factors. Prefracture fracture risk (PFFR) and fracture risk assessment tool (FRAX) scores estimated the future fracture risks at the timepoint before and after the UE fragility fracture event, respectively. The primary study outcome was the 10-year risk of future fracture.

RESULTS

The 10-year probability of major osteoporotic and hip fractures were significantly higher among the BHC group when estimated with FRAX. When estimated with PFFR score, there was no difference in the 10-year probability of hip fracture between the groups. Prevalence of secondary osteoporosis and glucocorticoid use was higher in the BHC group, and prevalence of rheumatoid arthritis was higher in the UE clinic group.

CONCLUSIONS

This study underscores the importance of an UE fragility fracture in determining the risk of future fracture. A fragility fracture of the UE should be considered a sentinel event and physicians who evaluate these patients should recognize them as a high-risk group for future hip fracture.

Patients undergoing surgical treatment for low-energy distal radius fractures are more likely to receive a referral and participate in a fracture liaison service program

INTRODUCTION

Patients often do not receive osteoporosis screening after a low-energy distal radius fracture (DRF). The effect of osteoporosis on the healing of DRFs remains a debate, and it is unclear if surgical treatment of this injury affects the referral and participation rates in a fracture liaison service (FLS) program. The purpose of this study is to report on a large cohort of low-energy DRFs and identify demographic, clinical, and treatment factors that affect referral and participation rates in an FLS program.

METHODS

A retrospective review identified patients over 50 years old who sustained a low-energy DRF between 2013 and 2018. Patients with high-energy or unknown injury mechanisms were excluded. The primary outcome was the effect of DRF surgical treatment on referral and participation rates in an FLS program. Secondary outcomes included patient demographic and clinical characteristic effects on referral and participation rates in an FLS program.

RESULTS

In total, 950 patients met inclusion criteria. Two hundred thirty patients (24.2%) were referred and 149 (15.7%) participated in the FLS program. Patients who underwent surgery were more likely to be referred to the FLS (OR 1.893, CI 1.403-2.555, p < 0.001) and participate in the FLS program (OR 2.47, CI 1.723-3.542, p < 0.001) compared to patients who received non-operative treatment of their DRF.

CONCLUSIONS

Patients who undergo surgical treatment of a low-energy DRF are more likely to be referred and participate in a FLS program. Further study is needed to identify why surgical treatment may affect referral and participation rates.

Models of care for osteoporosis: A systematic scoping review of efficacy and implementation characteristics

BACKGROUND

Osteoporosis affects over half of adults over 50 years worldwide. With an ageing population, osteoporosis, fractures and their associated costs are increasing. Unfortunately, despite effective therapies, many with osteoporosis remain undiagnosed and untreated. Models of care (MoC) to improve outcomes include fracture liaison services, screening, education, and exercise programs, however efficacy for these is mixed. The aim of this study is to summarise MoC in osteoporosis and describe implementation characteristics and evidence for improving outcomes.

METHODS

This systematic scoping review identified articles via Ovid Medline and Embase, published in English between 01/01/2009 and 15/06/2021, describing MoC for adults aged ≥18 years with, or at risk of, osteoporosis and / or health professionals caring for this group. All included at least one of clinical, consumer or clinician outcomes, with fractures and bone mineral density (BMD) change the primary clinical outcomes. Exclusion criteria were studies assessing pharmaceuticals or procedures without other interventions, or insufficient operational details. All study designs were included, with no comparator necessary. Title and abstract were reviewed by two reviewers. Full text review and data extraction was performed by these reviewers for 20% of article and, thereafter by a single author. As the review was predominantly descriptive, no comparator statistics were used.

FINDINGS

314 articles were identified describing 289 MoC with fracture liaison services (n=89) and education programs (n=86) predominating. The population had prior fragility fracture in 77 studies, the median (IQR) patient number was 210 (87, 667) and the median (IQR) follow-up duration for outcome assessment was 12 (6, 12·5) months. Fracture reduction was reported by 65 studies, with 16 (37%) graded as high quality, and 19 / 47 studies with a comparator group found a reduction in fractures. BMD change was reported by 73 studies, with 41 finding improved BMD. Implementation characteristics including reach, fidelity and loss to follow-up were under-reported, and consumer and clinician perspectives rare.

INTERPRETATION

This comprehensive review of MoC for osteoporosis demonstrated inconsistent evidence for improving outcomes despite similar types of models. Future studies should include implementation outcomes, consumer and clinician perspectives, and fracture or BMD outcomes with sufficient duration of follow-up. Authors should consider pragmatic trial designs and co-design with clinicians and consumers.

Rate of Bone Mineral Density Testing and Subsequent Fracture-Free Interval After Distal Forearm Fracture in the Medicare Population

PURPOSE

Distal forearm fractures are prevalent among the Medicare population. Many patients who sustain these fractures have poor bone health and are at increased risk for subsequent fractures. We sought to determine the rate of bone mineral density (BMD) testing and subsequent fragility fracture-free interval after distal forearm fractures in the Medicare population.

METHODS

We examined the 5% Medicare Standard Analytic File dataset using the PearlDiver Application from 2005 to 2014 to identify patients with distal forearm fractures based on International Classification of Diseases-Ninth Revision and Current Procedural Terminology codes. We queried these records to determine the incidence and timing of BMD testing after fracture and the number of patients who went on to hip or vertebral fractures. Survival curves were generated using Kaplan-Meier analysis with hip or vertebral fracture as the end point.

RESULTS

A total of 37,473 patients with distal forearm fractures were identified who did not have BMD testing within the 2 years before fracture. Only 9,605 of this unscreened cohort underwent testing after the fracture (26%) and only 2,684 underwent testing within 6 months (7%). The patients least likely to be tested were males (9%), those aged over 85 years (12%), and those less than 65 years (22%). Twenty percent of these patients sustained a subsequent hip or vertebral fracture (n = 7,326). Patients who underwent testing after fracture had a longer fracture-free interval compared with patients without BMD testing (819 vs 579 days). When separated by sex and controlling for comorbidities, males with BMD testing had a worsened fracture-free interval whereas females had an improved fracture-free interval.

CONCLUSIONS

Bone mineral density testing is underused nationwide in patients sustaining distal forearm fractures despite current guidelines. Orthopedic surgeons should ensure proper testing of patients because this may be an important time point for intervention.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognosis II.

Ability of a Risk Prediction Tool to Stratify Quality and Cost for Older Patients With Operative Distal Radius Fractures

Introduction:

Distal radius fractures are the second most common fracture in the elderly population. The incidence of these fractures has increased over time, and is projected to continue to do so. The aim of this study is to utilize a validated trauma risk prediction tool to stratify middle-aged and geriatric patients with operative distal radius fractures as well as compare hospital quality metrics and inpatient hospitalization costs among the risk groups.

Materials and Methods:

Patients were prospectively enrolled in an orthopedic trauma registry. The Score for Trauma Triage in Geriatric and Middle Aged (STTGMA) was calculated using patient demographics, injury severity, and functional status. Patients were then stratified into minimal-risk, moderate-risk, and high-risk cohorts based on their scores. Length of stay, need for escalation of care, complications, mortality, discharge location, 1-year patient reported outcomes, and index admission costs were evaluated.

Results:

Ninety-two patients met inclusion criteria. Sixty-three (68.5%) patients were managed with outpatient surgery. The mean inpatient length of stay for the high-risk cohort was 2.9x and 2.2x higher than the minimal and moderate-risk cohorts, respectively (2.0 + 2.9 days vs. 0.7 + 0.9 and 0.9 + 1.1 days, P = .019). There were no complications or mortality in any of the risk groups. No patients required intensive care and all patients were discharged home. There was no difference in readmission rates, inpatient cost, or 1-year patient reported outcomes among the risk cohorts.

Discussion/Conclusions:

The Score for Trauma Triage in Geriatric and Middle-Aged is able to risk-stratify patients that undergo operative intervention of distal radius fractures. Middle aged and elderly patients with isolated closed distal radius fractures can be safely managed on an outpatient basis regardless of risk. Standardized pathways can be created in the management of these injuries, thereby optimizing value-based care.

Level of evidence:

Prognostic Level III

Diabetes mellitus effect on rates of perioperative complications after operative treatment of distal radius fractures

PURPOSE

This study focuses on distal radius fractures that require surgical treatment. Patients with diabetes mellitus (DM) are at increased risk of bone fracture despite normal areal bone mineral density. The aim of this study is to identify the impact of DM on perioperative complications for patients undergoing operative treatment of distal radius fracture.

METHODS

A retrospective cohort study was conducted using data collected through the National Surgical Quality Improvement Program database. All patients who underwent operative treatments for distal radius fractures from 2007 through 2018 were identified. Data collected include demographic information, comorbidities, and complications occurring within 30 days of initial surgical intervention. The incidence of adverse events following surgery was evaluated with univariate and multivariate analyses where appropriate.

RESULTS

Patients with DM were found to have a low rate of complications postsurgical repair of distal radius fractures. Preoperative comorbidity analysis showed that the diabetic group had significantly higher rates of chronic obstructive pulmonary disease, hypertension, congestive heart failure, renal failure, steroid use, bleeding disorders, dyspnea, and poorer functional status. Diabetes was found to be an independent predictor for unplanned intubation, sepsis, and septic shock. Diabetes was not found to be an independent predictor of other postoperative complications.

CONCLUSION

Complications after surgical repair of distal radius fracture are low except when it comes to reintubation, sepsis, and septic shock. While the risks of independent complications remain relatively low, diabetes remains an important factor to consider when selecting surgical candidates and to ensure appropriate pre-operative risk assessment.

What Factors Contribute to Falls-Related Distal Radius Fracture?

Objective: This mixed methods study analyzed the factors that led to a fall in a cohort of patients with distal radius fracture (DRF). Methods: A sample of 1,453 patients (430 men; 1,023 women; age range: 18-89 years) supplemented by new interview data from 29 patients (19 women) were examined. Chi-square and descriptive analysis of quantitative data and descriptive thematic analysis of qualitative data were compared to determine data convergence and divergence. Results: A higher number of DRF were observed in the 45- to 64-year-old group (44%), employed people (48%), in winter months (41%), and in low-energy fractures (75%). Themes emerged from qualitative data on the cause of the fracture, including environmental factors, behavioral factors, physical factors, and sports activities. Conclusion: Reasons for DRF are multifactorial. Preventive strategies with an emphasis on environmental and behavioral factor modifications are likely to decrease the number of DRF.

Distal Radius Fractures: Does Obesity Affect Fracture Pattern, Treatment, and Functional Outcomes?

BACKGROUND

Distal radius fractures (DRFs) are 16% of fractures treated by orthopedic surgeons. Obesity's influence on DRF complexity has not been studied. This study was undertaken to determine if body mass index (BMI) affects DRF pattern, treatment, and functional outcomes.

METHODS

Part 1 was a retrospective review of patients who sustained a DRF after a fall from standing height with no prior reduction or treatment. Radiographs were classified as "simple" or "complex." Part 2 consisted of contacting patients from Part 1 and obtaining a Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score. Retrospective review also identified patients who failed initial nonoperative treatment. Fracture pattern, failure of nonoperative treatment, and QuickDASH scores were compared with BMI at the time of injury.

RESULTS

For Part 1, 130 patients (132 wrists) were identified. Average age was 57 years, 77% were female, and average BMI was 28.2 kg/m². Each point increase in BMI increased the chance of having a complex DRF (odds ratio = 1.07). Part 2 identified 50 patients who completed a QuickDASH at an average of 4.6 years after injury. Those with a BMI <25 kg/m² (n = 15) had an average QuickDASH score of 37; patients with a BMI ≥25 kg/m² (n = 35) had an average QuickDASH score of 18. Increasing BMI was suggestive of a lower QuickDASH score ( P = .08). No significant difference was found with respect to BMI and failure of nonoperative treatment.

CONCLUSIONS

A higher BMI increases the odds of a complex DRF. Despite more complex fractures, overweight patients may experience less disability after sustaining a DRF.

Discordant pattern of peripheral fractures in diabetes: a meta-analysis on the risk of wrist and ankle fractures

To clarify if the peripheral microarchitectural abnormalities described in diabetics have clinical consequences, we evaluated the risk of wrist and ankle fractures. The meta-analysis resulted in an increase in the risk of ankle fractures and a decrease in wrist fractures risk, suggesting that microarchitecture may not be the major fracture determinant.

INTRODUCTION

There is evidence for an increase in the risk of hip fractures in diabetes (both in type 1 and 2), but the risk is not established for other skeletal sites. Microarchitecture evaluations have reported a decrease in volumetric bone mineral density and an increase in cortical porosity at the radius and tibia. To investigate if there is a clinical consequence for these microarchitectural abnormalities, we performed a systematic review and meta-analysis on the risk of ankle and wrist fractures in diabetes.

METHODS

Medline and Embase were searched using the terms 'diabetes mellitus', 'fracture', 'ankle', 'radius' and 'wrist'. Relative risks and 95% confidence intervals were calculated using random effects model.

RESULTS

For ankle fractures, six studies were selected including 2,137,223 participants and 15,395 fractures. For wrist fractures, 10 studies were eligible with 2,773,222 subjects and 39,738 fractures. The studies included men and women, ages 20 to 109 years for the wrist and 27 to 109 years for the ankle. The vast majority of subjects had type 2 diabetes. Diabetes was associated with an increase in the risk of ankle fractures (RR 1.30 95%CI 1.15-1.48) and a decrease in wrist fractures (RR 0.85 95%CI 0.77-0.95). In the studies that reported body mass index (BMI), the mean values were 10% higher in the diabetic groups than controls.

CONCLUSION

The risk of fractures is increased in diabetes at the ankle and decreased at the wrist. The same pattern is observed in obesity. Although bone microarchitectural features are different in obesity and diabetes, the epidemiology of peripheral fractures is similar in both diseases suggesting that microarchitecture may not be the major determinant of peripheral fractures in these populations.

Simple Assessment of Global Bone Density and Osteoporosis Screening Using Standard Radiographs of the Hand

PURPOSE

Osteoporosis and fragility fractures have consequences both at the individual level and to the overall health care system. Although dual-energy x-ray absorptiometry (DXA) is the reference standard for assessing bone mineral density (BMD), other, simpler tools may be able to screen bone quality provisionally and signal the need for intervention. We hypothesized that the second metacarpal cortical percentage (2MCP) calculated from standard radiographs of the hand or wrist would correlate with hip BMD derived from DXA and could provide a simple screening tool for osteoporosis.

METHODS

Two hundred patients who had hand or wrist radiographs and hip DXA scans within 1 year of each other were included in this series. Mid-diaphyseal 2MCP was calculated as the ratio of the cortical diameter to the total diameter. We assessed the correlation between 2MCP and total hip BMD. Subjects were stratified into normal, osteopenic, and osteoporotic cohorts based on hip t scores, and thresholds were identified to optimize screening sensitivity and specificity.

RESULTS

Second metacarpal cortical percentage correlated significantly with BMD and t scores from the hip. A 2MCP threshold of less than 60% optimized sensitivity (88%) and specificity (60%) for discerning osteopenic subjects from normal subjects, whereas a threshold of less than 50% optimized sensitivity (100%) and specificity (91%) for differentiating osteoporotic from normal subjects.

CONCLUSIONS

By demonstrating that global BMD may be assessed from 2MCP, these data suggest that radiographs of the hand and wrist may have a role in accurately screening for osteopenia and osteoporosis. This simple investigation, which is already used ubiquitously for patients with hand or wrist problems, may identify patients at risk for fragility fractures and allow for appropriate referral or treatment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Hip fractures, preceding distal radius fractures and screening for osteoporosis: should we be screening earlier? A minimum 10-year retrospective cohort study at a single centre

Both men and women who sustain a fracture of the distal forearm run an increased risk of sustaining a subsequent hip fracture. Our study implies that these patients may not necessarily constitute a group in which osteoporosis screening is warranted.

INTRODUCTION

People who sustain a distal radius fracture run an increased risk of sustaining a subsequent hip fracture. However, many institutions only screen for osteoporosis at the time of a hip fracture. We aimed to determine the true incidence of preceding distal radius fractures in an Asian population of patients with a hip fracture aged 60 years or older and whether screening for osteoporosis earlier would be beneficial.

METHODS

We reviewed 22 parameters of 572 patients aged 60 years or older admitted after sustaining a hip fracture over a 3-year period. This included the occurrence or absence of a distal radius fracture in the 10 years preceding their hip fracture.

RESULTS

Twenty-nine patients (5 %) had a fracture of the distal radius in the preceding decade. Univariate analyses suggested that hip fracture patients who had preceding distal radius fractures were older, female, have lower mean haemoglobin levels, and right-sided hip fractures. Of these factors, only age was found to have significant predictive value in a multivariate analysis.

CONCLUSIONS

A number of institutions have started to screen for osteoporosis when a patient presents with a fracture of the distal radius because these patients may have an increased risk of a subsequent hip fracture. Our study implies that this may not be warranted. Implementing such a screening service from both cost and resource utilization point of view must be studied prospectively and in greater detail considering earlier screening may only be beneficial to a very small percentage of patients.

Mortality after distal radial fractures in the Medicare population

The occurrence of a low energy fracture of the distal radius increases the risk for another, more serious fracture, such as a proximal femoral fracture. Early mortality after a proximal femoral fracture has been widely studied, but the association between a distal radial fracture and mortality is unknown. The date of death for all Medicare beneficiaries who sustained an isolated distal radial fracture in 2007 was determined using Medicare Vital Statistics files. The adjusted mortality rate for each age-sex group was calculated and compared with published US mortality tables. Distal radial fractures were not associated with an increased mortality rate. In fact, beneficiaries had a significantly lower mortality rate after distal radial fractures than the general population. This may be related to the injured beneficiaries' involvement in the healthcare system. Mortality rate did not vary significantly based on time from injury. Our results indicate that any mortality is unlikely to be attributable to the distal radial fracture or its treatment. Level of evidence: III.

Routine use of locking shaft screws is not necessary in volar plate fixation of distal radius fractures

HYPOTHESIS

Volar locking plate fixation is a common treatment method for distal radius fractures. Recently, implants have been designed with an option to use locking screws in the shaft portion of the plate. While there is a high incidence of low bone mineral density in patients who sustain fragility fractures of the distal radius, the need for locking shaft screws is not well defined. Our hypothesis is that the routine use of locking screws in the shaft portion of volar plates is not required to maintain reduction or to prevent hardware failure.

METHODS

A retrospective review was performed in all patients over age 50 years who underwent volar plate fixation using an implant with non-locking shaft screws for a distal radius fracture during a 2-year period. Patients were permitted to perform early range of motion exercises. Radiographs were examined and measurements were obtained to assess maintenance of reduction and incidence of hardware failure. Patients were followed at least until fracture healing. Patients were excluded from analysis if locking shaft screws were utilized or if follow-up was inadequate.

RESULTS

Forty-one patients met the inclusion criteria. The average age was 62 years (range 50-79). There were 12 men and 29 women. The implant used incorporated 3.5-mm shaft screws in 26 patients and 2.4-mm shaft screws in 15 patients. All patients healed within acceptable radiographic parameters (mean volar tilt = 4.9°, mean radial inclination = 21.7°, mean radial height = 11.6 mm). There were not any instances of hardware failure.

DISCUSSION

Distal radius fractures frequently occur in patients with low bone mineral density. Non-locking, bicortically placed shaft screws provide adequate stability to allow for early range of motion without loss of reduction or hardware failure. The routine use of locking screws in the shaft portion of volar plates does not appear justified.

Opportunistic Osteoporosis Screening - Gleaning Additional Information from Diagnostic Wrist CT Scans

BACKGROUND

Although screening for and treating osteoporosis can prevent subsequent fractures, the rates of such interventions are low following a distal radial fracture. One potential method for identifying metabolic bone disease is via Hounsfield unit (HU) measurements from diagnostic computed tomography (CT) scans. We hypothesized that HU values of the distal aspect of the radius could be used to assess local bone quality and would be predictive of distal radial fracture risk, thereby allowing the identification of patients in need of further management.

METHODS

Measurements of bone mineral density (BMD) were made for 100 patients on the basis of HU values of cancellous portions of the distal aspect of the radius, the ulnar head, and the capitate. The HU values in twenty-five male and twenty-five female patients with an acute distal radial fracture documented on CT were compared with those of age and sex-matched control patients who had a CT scan obtained for other indications.

RESULTS

Among the control patients, HU values decreased as age increased. When assessed on the basis of sex, both male and female patients with a distal radial fracture had significantly lower regional BMD compared with nonfracture control patients. A distal radial HU value of 218 for females and 246 for males optimized sensitivity and specificity; values below this threshold were associated with an increased risk of distal radial fracture.

CONCLUSIONS

HU measurements can be obtained from any diagnostic CT scan using modern software programs and can be obtained by physicians in the office setting with minimal effort and at no additional cost or radiation exposure to the patient. Regardless of imaging indications, we suggest that patients with HU values below the identified thresholds be considered for further metabolic bone disease work-up, such as additional imaging, laboratory assessments, the initiation of osteoporosis treatment, or appropriate referral.