Elsevier

Bone

Volume 18, Issue 1, Supplement 1, January 1996, Pages S77-S86
Bone

Etiology and prevention of age-related hip fractures

https://doi.org/10.1016/8756-3282(95)00383-5Get rights and content

Abstract

Falls and fall-related injuries are among the most serious and common medical problems experienced by the elderly. Hip fracture, one of the most severe consequence of falling in the elderly, occurs in only about 1% of falls. Despite this, hip fracture accounts for a large share of the disability, death, and medical costs associated with falls. As measured by their frequency, influence on quality of life, and economic cost, hip fractures are a public health problem of crisis proportions. Without successful international initiatives aimed at reducing the incidence of falls and hip fractures, the implications for allocations of the health resources in this and the next century are staggering. Identifying those at risk for harmful falls requires an understanding of what kinds of falls result in injury and fracture. In elderly persons who fall, in most of whom hip bone mineral density is already several standard deviations below peak values, fall severity (as reflected in falling to the side and impacting the hip) and body habitus are important risk factors for hip fracture and touch on a domain of risk entirely missed by knowledge of bone mineral density. These findings clearly suggest that factors related to both loading and bone fragility play important roles in the etiology of hip fracture. We provide a strategy, based on engineering approaches to fracture risk prediction, for determining the relative etiologic importance of loading and bone fragility and to summarize some of what is known about both sets of factors. We define a factor of risk, Φ, as the ratio of the loads applied to the hip divided by the loads necessary to cause fracture and summarize available data on the numerator and the denominator of Φ. We then provide an overview of the complex interplay between the risks associated with the initiation, descent, and impact phases of a fall, thereby suggesting an organized approach for evaluating intervention efforts being used to prevent hip fractures. The findings emphasize the continuing need for combined intervention strategies that focus on fall prevention, reductions in fall severity, and maintaining or increasing femoral bone mass and strength, either through targeted exercise programs, optimal nutrition (Ca, Vitamin D), and/or in the use of osteodynamic agents. By developing and refining the factor of risk, a property that captures both the contributions of bone density and the confounding influences of body habitus and fall severity, we believe these intervention strategies can be targeted more appropriately.

References (110)

  • D. Apple et al.
    (1994)
  • A. Blake et al.

    Falls by elderly people at home: prevalence and associated factors

    Age Ageing

    (1988)
  • A.J. Campbell et al.

    Risk factors for falls in a community-based prospective study of people 70 years and older

    J Gerontol

    (1989)
  • D. Colvin et al.

    A fall intervention/mobility aid system for elderly and rehabilitative populations

    Technol Aging

    (1990)
  • A.C. Courtney et al.

    Effects of loading rate on strength of the proximal femur

    Calcif Tissue Int

    (1994)
  • A.C. Courtney et al.

    Age-related reductions in the strength of the femur tested in a fall-loading configuration

    J Bone Joint Surg [Am]

    (1995)
  • R. Cumming et al.

    Case-control study of risk factors for hip fracture in the elderly

    Am J. Epidemiol

    (1994)
  • R. Cumming et al.

    Fall frequency and characteristics and the risk of hip fractures

    J Am Geriatr Soc.

    (1994)
  • S.R. Cummings

    Epidemiology of hip fractures

  • S.R. Cummings et al.

    Appendicular bone density and age predict hip fracture in women.

    JAMA

    (1990)
  • S.R. Cummings et al.

    A hypothesis: The causes of hip fracture

    J Gerontol

    (1989)
  • S.R. Cummings et al.

    Falls [editorial]

    N Engl J Med

    (1994)
  • S.R. Cummings et al.

    Risk factors for hip fracture in white women

    N Engl J Med

    (1995)
  • J. Dias

    An analysis of the nature of injury in fractures of the neck of the femur

    Age Ageing

    (1987)
  • J. Dunn et al.

    Mortality, disability, and falls in older persons: the role of underlying disease and disability

    Am J Public Health

    (1992)
  • M.E. Farmer et al.

    Anthropometric indicators and hip fracture: the NHANES I epidemiologic follow-up study

    J Am Geriat Soc

    (1989)
  • D. Felson et al.

    Effects of weight and body mass index on bone mineral density in men and women: The Framingham study

    J Bone Miner Res

    (1993)
  • D. Felson et al.

    The effect of postmenopausal estrogen therapy on bone density in elderly women

    N Engl J Med

    (1993)
  • V.H. Frankel et al.
    (1970)
  • P. Gardsell et al.

    Predicting various fragility fractures in women by forearm bone densitometry; a follow-up study

    Calcif Tissue Int

    (1993)
  • S.L. Greenspan et al.

    Femoral bone loss progresses with age: A longitudinal study in women over age 65

    J Bone Miner Res

    (1994)
  • S.L. Greenspan et al.

    Fall severity and bone mineral density as risk factors for hip fracture in ambulatory elderly

    JAMA

    (1994)
  • J.A. Grisso et al.

    Risk factors for falls as a cause of hip fracture in women

    N Engl J Med

    (1991)
  • J.A. Grisso et al.

    Risk factors for hip fractures in men: A preliminary study

    J Bone Miner Res

    (1991)
  • J.A. Grisso et al.

    Risk factors for hip fracture in black women

    N Engl J Med

    (1994)
  • C.I. Gryfe et al.

    A longitudinal study of falls in an elderly population: I. Incidence and morbidity

    Age Ageing

    (1977)
  • W.C. Hayes et al.

    Impact near the hip dominates fracture risk in elderly nursing home residents who fall

    Calcif Tissue Int

    (1993)
  • W.C. Hayes et al.
    (1992)
  • R. Hedlund et al.

    Trauma type, age and gender as determinants of hip fracture

    J Orthop Res

    (1987)
  • D. Hemenway et al.

    Risk factors for hip fracture in U.S. men aged 40–75 years

    Am J Public Health

    (1994)
  • Hemenway, D., Feskanich, D., and Colditz, G. A. Body height and hip fracture: Ten years of follow-up on over 90,000...
  • J. Hindmarsh et al.

    Falls in older persons

    Arch Intern Med

    (1989)
  • R. Hinton et al.

    Relative rates of fracture of the hip in the United States

    J Bone Joint Surg [Am]

    (1995)
  • T.L. Holbrook et al.
    (1984)
  • M. Hornbrook et al.

    Preventing falls among community-dwelling older persons: results from a randomized trial

    Gerontologist

    (1994)
  • J.S. Jensen

    Determining factors for the mortality following hip fractures

    Injury

    (1984)
  • P. Jokl

    Muscle and low back pain

  • J.L. Kelsey et al.

    Risk factors for hip fracture

    N Engl J Med

    (1987)
  • J.E. Kenzora et al.

    Hip fracture mortality

    Clin Orthop

    (1984)
  • D. Kiel et al.

    Hip fracture and the use of estrogens in postmenopausal women

    N Engl J Med

    (1987)
  • Cited by (234)

    View all citing articles on Scopus
    1

    Biomechanics Laboratory, Division of Orthopedic Surgery, San Francisco General Hospital, San Francisco, CA 94110.

    2

    Department of Biomedical Engineering, The Cleveland Clinic Foundation, Cleveland, OH 44195.

    View full text