Which older women are at high risk of hip fracture?
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
|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|
|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)||No|
|4 (five-year risk)|
|Ahmed, et al., 200611||Women 65 to 74 years of age||1,410||14||Yes|
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
|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|
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 27 ), 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.