Frax

Current Orthopaedics (2008) 22, 322e327 available at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/cuor

MINI-SYMPOSIUM: OSTEOPOROSIS

(ii) Fracture risk assessment
R.M. Francis
University of Newcastle upon Tyne, Bone Clinic, Freeman Hospital, Newcastle upon Tyne NE7 7DN, United Kingdom

KEYWORDS
Osteoporosis; Fragility fractures; Bone mineral density; Fracture riskassessment; FRAXä

Summary Osteoporotic fractures cause excess mortality, substantial morbidity and health and social service expenditure in older people. The risk of these fractures is determined by skeletal factors, including bone mineral density (BMD), bone turnover, architecture, bone size, and skeletal geometry, together with non-skeletal factors associated with falling. With the advent oftreatments which decrease the incidence of fractures and the development of strategies for preventing falls, there is growing interest in identifying people at high risk of fragility fractures, in whom to target therapeutic intervention. The World Health Organization (WHO) has recently developed a Fracture Risk Assessment Tool (FRAXä). This uses clinical risk factors, including prior fractureafter age of 50 years, parental hip fracture, current smoking, oral steroid therapy, alcohol intake >2 units/day and chronic conditions such as rheumatoid arthritis, with or without femoral neck BMDt, to estimate the ten year probability of hip and other major osteoporotic fractures. ª 2008 Elsevier Ltd. All rights reserved.

Introduction
Osteoporosis has been defined as a skeletal disordercharacterised by compromised bone strength, predisposing a person to an increased risk of fracture.1 The incidence of these fragility fractures increases with advancing age, where they are a major cause of excess mortality, substantial morbidity and vast health and social service expenditure in older people. Effective treatments are now available for osteoporosis, which reduce the incidence of fragilityfractures. As a result of this, and the development of strategies for preventing falls, there is growing interest in identifying people at high risk of fragility fractures in whom to target therapeutic intervention. This paper

reviews the major risk factors for fragility fracture and the approach towards fracture risk assessment, before highlighting the development of the World HealthOrganization (WHO) Fracture Risk Assessment Tool (FRAXä). It also addresses the use of FRAXä in clinical practice, including the selection of the most appropriate thresholds for therapeutic intervention.

Epidemiology of fragility fractures
The three major fragility fractures are those of the distal forearm, vertebra and hip, but fractures of the humerus, clavicle, pelvis and ribs are also common inosteoporosis.2 The incidence of these fracture rises steeply with advancing age, such that that the majority of these fractures occur in people above the age of 65 years. The lifetime risk of fracture for a 50 year old woman in the UK is

E-mail address: Roger.Francis@nuth.nhs.uk

0268-0890/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.cuor.2008.10.007

Fracturerisk assessment 53.2%, compared with 20.7% for a 50 year old man. The risk of individual symptomatic fractures in a 50 year old woman is 16.6% for the forearm, 3.1% for the vertebra and 11.4% for the hip, whereas the corresponding figures for a 50 year old man are 2.9%, 1.2% and 3.1%.3 The overall risk of fractures is 2.3 fold higher in older people living in residential or nursing homes than inthose living in the community, whereas hip fractures are 3.6 fold more common in institutionalised older people,4 probably due to their lower bone mineral density (BMD) and higher incidence of falls. The risk of fracture is determined by skeletal and nonskeletal risk factors. The skeletal risk factors include BMD, bone turnover, cortical and trabecular bone architecture, bone size, and skeletal...