Point-of-Care Guides

Predicting Hip Fracture Risk in Older Women

MARK H. EBELL, MD, MS, Athens, Georgia

Clinical Question

Which older women are at high risk of hip fracture?

Evidence Summary

Approximately one in six women will have a hip fracture during her lifetime, and approximately one in 35 of all women will die of complications from hip fracture.1 Bone mineral density screening for women is recommended beginning at 65 years of age, or at 60 years of age in the presence of risk factors such as lower body mass index, smoking, or long-term corticosteroid use.2 However, low bone mineral density is only one of many risk factors for hip fracture. Identifying women who are at high risk allows a family physician to recommend additional measures that might reduce the risk of fracture such as exercise and balance regimens,3 cessation of tobacco or alcohol use,4 and modifications of the home environment.5

A number of clinical risk scores have been developed and validated (Table 1).6-11 Two of these scores have not been prospectively validated and thus are inappropriate for use in the clinical setting.9,10 Others are too long for outpatient care8,11 or require data collection that is impractical in the primary care setting.8,9 Two scores have been prospectively validated in a broad spectrum of older women and are simple enough to use in the primary care setting.6,7

Table 1. Studies Used to Develop Clinical Risk Scores for Predicting Hip Fracture in Older Women
Study	Population studied	No. of patients (prospective validation cohort)	No. of items in risk score	BMD included in risk score?
Recommended scores for primary care
Black, et al., 20016	Women older than 65 years	7,575	6 or 7	Optional
Albertsson, et al., 20077	Women older than 70 years	1,498	4	No
Other scores
Colon-Emeric, et al., 20028	Men and women older than 65 years	3,505	9	No
Dargent-Molina, et al., 2002*9	Women older than 75 years witha T-score of -3.5 to -2.5	-	5	No
McGrother, et al., 2002*10	Women older than 70 years	-	6 (three-year risk) 4 (five-year risk)	No
Ahmed, et al., 200611	Women 65 to 74 years of age	1,410	14	Yes
BMD = bone mineral density. *-Not prospectively validated. Information from references 6 through 11.

The FRAMO (Fracture and Mortality) Index (Table 2), validated in 1,498 Swedish women, consists of four items used in a simple scoring system.7 It identifies low- and high-risk groups and is a good predictor of overall mortality and hip fracture risk.7 The Fracture Index (Table 3) is a six-item risk score with an optional seventh item (bone mineral density at the hip).6 It was developed in 7,782 women using data from the Study of Osteoporotic Fractures and was validated in a separate group of 7,575 French women.6

Table 2. FRAMO (Fracture and Mortality) Index for Predicting Hip Fracture and Mortality Risk in Older Women
Patient characteristics			Points
Age >= 80 years			1
Weight < 132 lb (59.9 kg)			1
Unable to rise five times from a chair without using the arms			1
Any fracture of the wrist, lower arm, upper arm, hip, or vertebra after 40 years of age (or vertebral compression seen on a radiograph*)			1
Total:			_____
Risk group (score)	Two-year risk
	Hip fracture	Overall mortality
Low (0 or 1)	6/789 (0.8%)	25/789 (3.2%)
High (2 or more)	25/459 (5.4%)	109/459 (23.7%)
*-A radiograph is not needed if fracture history is known. Adapted with permission from Albertsson DM, Mellström D, Petersson C, Eggertsen R. Validation of a 4-item score predicting hip fracture and mortality risk among elderly women. Ann Fam Med 2007;5:49, 52.

Table 3. Fracture Index for Predicting Hip Fracture Risk in Older Women
Patient characteristics		Points
Age (years)
< 65		0
65 to 69		1
70 to 74		2
75 to 79		3
80 to 84		4
>= 85		5
Any broken bone after 50 years of age		1
Mother had a hip fracture after 50 years of age		1
Weight <= 125 lb (56.7 kg)		1
Current smoker		1
Usually needs arms to assist in rising from a chair		2
Optional: BMD (total hip T-score)
>= -1.0		0
-1.1 to -1.9		2
-2.0 to -2.5		3
< -2.5		4
Total:		______
Score	Four-year hip fracture risk (%)
Without BMD data
2 or 3	1.8
4	2.5
5	3.5
6	5.1
7 to 10	10.4
With BMD data
2 to 5	0.6
6 or 7	2.6
8 or 9	4.5
10	7.8
11 to 14	14.1
BMD = bone mineral density. Adapted with permission from Black DM, Steinbuch M, Palermo L, Dargent-Molina P, Lindsay R, Hoseyni MS, et al. An assessment tool for predicting fracture risk in postmenopausal women. Osteoporos Int 2001;12:523, 525.

Applying the Evidence

A 76-year-old woman weighs 110 lb (49.9 kg), is a nonsmoker, and had a vertebral fracture four years ago; her mother never had a hip fracture. The patient is unable to consistently lift herself out of a chair without using her arms, and her T-score at the hip is -2.1. What is the patient's risk of hip fracture and overall mortality in the next few years?

Answer: Using the FRAMO Index (Table 2 7), she receives one point for her weight, one for being unable to rise from a chair five times without using her arms, and one for having a fracture after 40 years of age. You determine that her two-year hip fracture risk is 5.4 percent, and her two-year overall mortality risk is 23.7 percent. Using the Fracture Index (Table 36), she receives three points for her age, one for having a fracture after 50 years of age, one for her weight, and two for needing to use her arms to rise from a chair. If bone mineral density is considered, she receives three points for her T-score. You determine that her four-year risk of hip fracture, according to the Fracture Index, is 10.4 percent based on risk factors alone and 7.8 percent based on risk factors plus bone mineral density at the hip.

Address correspondence to Mark H. Ebell, MD, MS, at mebell@mcg.edu. Reprints are not available from the author.

REFERENCES

1. Cummings SR, Black DM, Rubin SM. Lifetime risks of hip, Colles', or vertebral fracture and coronary heart disease among white postmenopausal women. Arch Intern Med 1989;149:2445-8.

2. U.S. Preventive Services Task Force. Recommendations and rationale. Screening for osteoporosis in postmenopausal women. Accessed May 1, 2007, at: http://www.ahrq.gov/clinic/3rduspstf/osteoporosis/osteorr.htm.

3. Suzuki T, Kim H, Yoshida H, Ishizaki T. Randomized controlled trial of exercise intervention for the prevention of falls in community-dwelling elderly Japanese women. J Bone Miner Metab 2004;22:602-11.

4. Kanis JA, Johansson H, Johnell O, Oden A, De Laet C, Eisman JA, et al. Alcohol intake as a risk factor for fracture. Osteoporos Int 2005;16:737-42.

5. Clemson L, Cumming RG, Kendig H, Swann M, Heard R, Taylor K. The effectiveness of a community-based program for reducing the incidence of falls in the elderly: a randomized trial. J Am Geriatr Soc 2004;52:1487-94.

6. Black DM, Steinbuch M, Palermo L, Dargent-Molina P, Lindsay R, Hoseyni MS, et al. An assessment tool for predicting fracture risk in postmenopausal women. Osteoporos Int 2001;12:519-28.

7. Albertsson DM, Mellström D, Petersson C, Eggertsen R. Validation of a 4-item score predicting hip fracture and mortality risk among elderly women. Ann Fam Med 2007;5:48-56.

8. Colon-Emeric CS, Pieper CF, Artz MB. Can historical and functional risk factors be used to predict fractures in community-dwelling older adults? Development and validation of a clinical tool. Osteoporos Int 2002;13:955-61.

9. Dargent-Molina P, Douchin MN, Cormier C, Meunier PJ, Breart G; for the EPIDOS Study Group. Use of clinical risk factors in elderly women with low bone mineral density to identify women at higher risk of hip fracture: the EPIDOS prospective study. Osteoporos Int 2002;13:593-9.

10. McGrother CW, Donaldson MM, Clayton D, Abrams KR, Clarke M. Evaluation of a hip fracture risk score for assessing elderly women: the Melton Osteoporotic Fracture (MOF) study. Osteoporos Int 2002;13:89-96.

11. Ahmed LA, Schirmer H, Fonnebo V, Joakimsen RM, Berntsen GK. Validation of the Cummings' risk score; how well does it identify women with high risk of hip fracture: the Tromso Study. Eur J Epidemiol 2006;21:815-22.

This guide is one in a series that offers evidence-based tools to assist family physicians in improving their decision making at the point of care.

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