Over 300,000 proximal humeral fractures occur each year in the United States, second in frequency only to hip and wrist fractures. Of these, hip fractures are associated with the greatest morbidity and mortality, The authors of Proximal Humeral Fracture as a Risk Factor for Subsequent Hip Fractures asked whether a proximal humeral fracture was associated subsequent hip fracture. They assessed a cohort of 8049 community dwelling white women 65 years or older with no history of a hip or humeral fracture who were enrolled in the Study of Osteoporotic Fractures and were followed for a mean of 9.8 years. The subjects came from four separate geographic areas of the United States (Baltimore, Maryland; Minneapolis, Minnesota; Portland, Oregon; and Monongahela Valley, Pennsylvania), followed prospectively at regular intervals for up to ten years with a followup rate of 99%. Black women were excluded from the study because of the low risk of osteoporotic fractures in these women and the considerably shorter follow-up time available.
The risk of hip fracture after an incident humeral fracture was estimated with use of age-adjusted Cox proportional hazards regression analysis with time-varying variables; women without a humeral fracture were the reference group. Cox regression analysis was used to evaluate the timing between the proximal humeral and subsequent hip fracture.
321 women sustained a proximal humeral fracture, and 44 of them sustained a subsequent hip fracture.
The table below shows other risk factors for hip fracture in this population.
After adjustment for age and bone mineral density, the hazard ratio for hip fracture for subjects with a proximal humeral fracture relative to those without a proximal humeral fracture was 1.83 (95% confidence interval = 1.32 to 2.53). After multivariate adjustment, the risk was still significant (hazard ratio = 1.57; 95% confidence interval = 1.12 to 2.19).
The risk of a subsequent hip fracture after a proximal humeral fracture was highest within one year after the proximal humeral fracture, with a hazard ratio of 5.68 (95% confidence interval = 3.70 to 8.73). This association between humeral and hip fracture was not significant after the first year, with hazard ratios of 0.87 (95% confidence interval = 0.48 to 1.59) between one and five years after the humeral fracture and 0.58 (95% confidence interval = 0.22 to 1.56) after five years.
The bottom line is that in this cohort of older white women, a proximal humeral fracture independently increased the risk of a subsequent hip fracture more than five times in the first year after the humeral fracture.
Comment: This study indicates that there is a small window of time after a proximal humeral fracture during which we can implement medical and environmental interventions that may decrease the risk of subsequent hip fractures. Preventative measures should be implemented without delay.
(1) Informing the patient and family of the increased risk.
(2) Addressing fall risk: the mechanism of proximal humeral fractures tends to be more similar to that of hip fractures than to that of any other osteoporotic fracture; i.e., they occur when the individual is unable to break his or her forward or oblique fall and therefore lands directly onto the shoulder or hip. The humeral fracture itself may compromise the woman's balance and ability to protect herself from falling. Fall risk may be mitigated by addressing balance, vision, home safety, the influence of medications, and the use of assistive devices.
(3) Addressing bone density: oral bisphosphonates begin to reduce the risk of fractures within three to six months after they are started.
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