Osteoporosis and Fragility Fractures in Women
April 26, 2023
By: Justin Kauk, MD
Categories: Orthopaedics, Women's
Take care of your bones, so your bones can take care of you. Whether you’re a middle-aged adult or a teenage star athlete, neglecting your bone health can lead to osteoporosis — a common yet serious disease affecting both men and women.
To help combat this condition, Women’s Health Month is a great time to get educated about osteoporosis and fragility fractures.
Let’s launch right in with some little-known facts regarding the impact on women.
- In the United States, one in two women will experience a fracture due to osteoporosis in their remaining lifetime.
- During the course of one hour, approximately 1,200 people in the world will sustain a fragility fracture.
- 30 percent of women who have a fragility fracture are over the age of 65, and the lifetime risk of a fragility fracture for women is 40 percent.
- The lifetime risk of a hip fracture for women is 70 percent, and 20 percent of hip fracture patients require long-term nursing home care. Sadly, 20 to 30 percent of those who sustain a hip fracture die within one year. (Downey, et al., 2019)
Often there are no symptoms of osteoporosis until the first fracture occurs. People who experience a fragility fracture are five times more likely to suffer another fracture within the next one to two years — if they survive.
A fragility fracture incidence is greater than a new stroke, heart attack and invasive breast cancer combined.
The Dangers of Fragility Fractures
You may be wondering why a bone fracture is so serious for women. A fracture, especially in older adults, who are typically less healthy than younger adults, speaks to their underlying medical status. Then, for people with balance issues, both mortality rates and complications are higher. When these individuals break a bone, such as the pelvis, this exacerbates mobility and already underlying ill health. Without the ability to maneuver the body, urinary tract infections, bed sores, pneumonia and blood clots often occur. It is these resulting secondary infections that lead to complications and even death.
In fact, the mortality rate from osteoporosis is greater than breast and cervical cancer combined.
Bones Prone to Fragility Fractures
The occurrence of a fragility fracture automatically gives an individual a diagnosis of osteoporosis. Here are the most common broken bones:
- Vertebrae — 27 percent
- Proximal humerus
- Forearm/wrist — 19 percent
- Ribs
- Pelvis — 7 percent
- Hip/femur (including fractures around hip and knee replacements) — 14 percent
- 33 percent of fragility fractures occur in other bones (including ribs, shoulder) (Kanis, et al., 2001, 2008)
Causes of Osteoporosis
Certain medications, heredity and lifestyle choices can contribute to acquired osteoporosis.
Medications that Can Lead to Bone Loss
Many medications intended to treat other conditions impact bone porosity, thus making a person more susceptible to bone loss. Examples include:
- Aluminum (in antacids)
- Anticoagulants (heparin)
- Anticonvulsants (seizure medications)
- Aromatase inhibitors
- Barbiturates
- Cancer (chemotherapeutic) drugs
- Cyclosporine A
- Depo-medroxyprogesterone (premenopausal contraception)
- Glucocorticoids (>= 5 mg/day of prednisone or equivalent for >= 3 months)
- GnRH (Gonadotropin releasing hormone) agonists
- Lithium
- Methotrexate
- Proton pump inhibitors – reflux medications
- Selective serotonin reuptake inhibitors (SSRIs) – anxiety/depression medications
- Tacrolimus
- Tamoxifen (premenopausal use)
- Thiazolidinediones (e.g., Actos, Avandia) – Diabetes medications
- TPN (total parenteral nutrition)
- Thyroid hormone (in excess)
Medical Conditions that Increase the Risk of Osteoporosis
Many disease states can increase the risk of osteoporosis. One reason is that certain diseases prevent calcium from reaching the bones. A sustained lack of calcium plays a role in the development of osteoporosis. Low calcium contributes to diminished bone density, early bone loss and an increased risk of fractures. Second, for reasons that are unclear to medical providers, some diseases shut down bone formation. Poorly formed bones are more likely to fracture. Third, certain conditions cause the body to attack healthy cells and tissue, leading to inflammation and bone loss.
You should ask your medical provider if any of your medical issues put you at increased risk. According to Who gets Osteoporosis? (2014), a few conditions categorically increase an individual’s chances for osteoporosis:
- AIDS/HIV
- Congestive heart failure
- COPD
- Depression
- End Stage Renal disease
- Endocrine disorders
- Gastrointestinal disorders
- Genetic diseases
- Hematologic disorders
- Hypogonadal states
- Neurologic and musculoskeletal disorders
- Post-transplant bone disease
- Rheumatologic and autoimmune disorders
- Weight loss
Lifestyle Choices that Contribute to Osteoporosis
These facts about osteoporosis, while scary, account for what is often a preventable disease. Many lifestyle factors contribute to osteoporosis, so you should take measures to protect your bones.
Here are a few activities and choices you should avoid to keep your bones healthy:
- Alcohol abuse
- Excessive thinness
- Excess vitamin A
- Frequent falling
- High salt intake
- Inadequate physical activity
- Low calcium intake
- Smoking (active or passive exposure)
- Vitamin D insufficiency/deficiency
- Optimization of medical problems that increase the risk of osteoporosis
Correction of any of these lifestyle choices can help decrease your risk for developing osteoporosis.
Supplements to Help Prevent Osteoporosis
It is recommended to take 400-800 international units (IU) of vitamin D, plus 1000-1200 mg of calcium daily. These vitamins can help keep osteoporosis at bay. For those who take these supplements, there is a noted 16 percent reduction in hip fracture risk and six percent reduction in any fracture risk.
Dietary Sources of Calcium
Beyond taking calcium supplements, it is important to eat a diet rich in calcium, including the following:
- Almonds
- Beans
- Cheese (harder cheese, higher calcium)
- Cottage cheese
- Frozen yogurt/ice cream
- Green leafy vegetables — kale, broccoli
- Milk
- Orange juice
- Oranges
- Ready to eat cereal
- Soy milk
- Tofu with calcium
- Yogurt
Dietary Sources of Vitamin D
Additionally, natural sources of vitamin D are essential for bone health. Here are several options:
- Canned tuna fish and sardines
- Cod liver oil
- Cooled salmon
- Eggs
- Fish from ocean
- Mackerel
- Milk and orange juice fortified with vitamin D
- Ready to eat cereals
- Yogurt
Exercises that Build Bone Strength
Along with diet and lifestyle, exercise makes a significant difference in bone health. You should be active at least 30 minutes most days of the week. Here are some of the best fitness options:
- Resistance training (bands, pushups, weights)
- Aerobics (walking, jogging, running, jumping, biking)
- Core/posture exercises (yoga, Pilates, Tai-Chi)
How to Prevent Fragility Fractures
Aging often brings with it lower vision, more medical issues and poorer balance. So, you should do what you can to prevent fractures if you do fall.
Here are several helpful ideas:
- Obtain a home risk assessment: This evaluation, often available through an occupational specialist, can help you spot danger zones that make falls more likely and more dangerous. A few hazards include uncarpeted stairs, clutter, tubs without grip support and area rugs.
- Avoid high impact activities: Exercise is a critical way to maintain your health, but the types of exercise you engage in can mean the difference between strengthening your bones and breaking your bones. Avoid contact sports as well as high-risk activities, such as bungee jumping and skydiving.
- Eat quality and consistent nutrition: I’ve stated previously what you should eat, but it is also important to know what not to eat. As you age, it is best to eliminate or cut back considerably on caffeine, foods high in sodium, soft drinks, excessive alcohol, processed meat and fried foods.
Bone Density Testing
Aside from prevention through lifestyle choices, it is also important to visit your medical provider for regular bone density testing. If you have apparently healthy bones, you should begin by age 65, and if you are at risk for osteoporosis, you should begin earlier.
Testing should take place every two years. If you suffer a fragility fracture, bone density testing should take place annually.
When you receive your bone density score, it’s important to understand it since it provides a diagnostic value to a bone density (DEXA) test.
| Percentile | T-score | Your Risk Explained |
| Low Risk | -1.0 or above | This is within the normal bone density range and considered low risk. |
| Medium Risk | -1.0 to -2.5 | This score is considered low bone density or osteopenia. People in this range are at medium risk for fractures or osteoporosis. |
| High Risk | -2.5 or below | Anything below -2.5 indicates osteoporosis and is high risk for fractures. |
| Severe Risk | -3.5 or below | People with these scores have severe or established osteoporosis that ranges in severity. |
Osteoporosis Medications that Prevent Bone Loss
If you are diagnosed with osteoporosis, there are medications that can help in addition to taking vitamin D and calcium supplements.
Estrogen is an option for women, though it is not recommended for treatment of postmenopausal osteoporosis. While it may slightly increase risk of stroke, blood clot or breast cancer, it is relatively safe for premenopausal women whose ovaries do not make estrogen.
Bisphosphonates are another option. Some individuals are remiss to take these since there is a very slight chance of developing osteonecrosis of the jaw. Because this is frequently a concern among patients, many choose not to treat their osteopenia/osteoporosis (Khan, et al., 2015).
Patients who may need to avoid bisphosphonates include those receiving intravenous medication during cancer treatment. Otherwise, the chances of developing osteonecrosis of the jaw is one in 10,000 (.01%) to one in 100,000 (.001%). For comparison, lifetime risk of being struck by lightning ~1 in 15,300 (.007%). Meanwhile, the risk of death within a year after a hip fracture is 20 to 30 percent.
If you think neither of these medication interventions mentioned above will work for your body, additional medication options are available for treating osteoporosis:
- Selective Estrogen Receptor Modulators (SERMs)
- Denosumab (Prolia)
- Romosozumab-aggq (Evenity)
- Parathyroid hormone (PTH) analogs — e.g. teriparatide (Forteo) and abaloparatide (Tymlos)
It’s important to speak with your primary care provider before taking any of these medications or aforementioned supplements.
Repair for Fragility Fractures
If you suffer a fragility fracture, there are treatments we as orthopaedic surgeons can administer to help mend the bone, so you can regain your mobility as quickly as possible. These treatments depend upon the type of fracture and degree of displacement.
Many fractures of the shoulder, wrist, ribs, spine and pelvis can be managed without surgery. Those requiring surgery are often fixed with plates and/or screws. Most fractures of the hip/femur require surgery with plates/screws or intramedullary nails (rods). Spine fractures requiring surgery can be treated with bone cement or spinal fusion.
Tips to Prevent Another Fragility Fracture after an Initial One
As mentioned previously, once you suffer a fragility fracture, you are highly likely to suffer another one, so it is essential that you do what you can to prevent this from happening.
- Get a bone density DEXA scan to assess your degree of osteoporosis. This helps with monitoring after start of therapy. While a bone density DEXA scan doesn’t prevent a fracture, it does track the effectiveness of treatments.
- Start osteoporosis medication or reevaluate current therapy and possibly switch to a new medication.
- Have your home assessed for fall prevention.
- Make lifestyle changes, including limiting alcohol and stopping smoking.
- Modify your diet to intake more vitamin D- and calcium-rich foods.
- Exercise daily, including aerobic and resistance training.
- Examine your current medications for their risk for harming bone health.
- Treat medical conditions that increase your risk for bone loss.
If you expect your bones to protect you for a lifetime, your dedication to your bone health is essential. With the proper bone health guidance, better outcomes are in your future. Don’t let bone fragility and osteoporosis stand in the way of you leading a healthy and long life.
About Justin Kauk, MD
Dr. Justin Kauk is a board-certified orthopaedic trauma surgeon at Wake Orthopaedics. He is dedicated to restoring patients of all ages, backgrounds and identities to pre-injury level of function through collaborative, high quality and efficient care.
Dr. Kauk’s clinical interests include orthopaedic trauma and program development, streamlining processes to provide more cost-conscious and efficient patient care. He earned his medical degree from the University of Missouri – Columbia School of Medicine and completed his orthopaedic surgery residency at the University of North Carolina at Chapel Hill. Dr. Kauk is fellowship trained in orthopaedic trauma surgery from the Reno Orthopedic Clinic and Renown Regional Medical Center Trauma Fellowship in Nevada. During this time, he gained advanced training in the care of simple and complex extremity trauma in children, adults and geriatric patients as well as fracture related complications such as nonunion and infection. Dr. Kauk brings over 15 years of experience to WakeMed with a wealth of patient care experience.
An active member of the American Academy of Orthopaedic Surgeons and the Orthopaedic Trauma Association, he has been published in peer-reviewed journals and presented at local and national meetings.
Dr. Kauk believes strongly in partnering with patients throughout their entire treatment and recovery process, working together to obtain an optimal outcome. In a collaborative approach, he and his patients identify the best treatment option for their injury.
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