Risk factors for fracture and fracture severity of the distal radius and ankle : What about osteoporosis, celiac disease and obesity?

Background: Fractures are a substantial burden for both individuals and society. For the individual it leads to pain, reduced quality of life, disability and increased mortality. For society, it carries a great cost and requires substantial resources. With the increasing age in the population, this burden is expected to increase. There is potential to prevent more fractures than we do today by increased knowledge about groups at risk and individual risk factors, both through awareness, case finding in defined populations, and targeted treatment in the case of osteoporosis. Aim: The overall aim of this thesis is to contribute to better fracture prevention through increased knowledge of risk factors and patient groups at risk, focusing on celiac disease, osteoporosis and obesity as risk factors for peripheral fractures. Materials and methods: The dissertation is based on a case control study of consecutive patients with acute ankle- or distal radius fracture treated at the Helse Førde Hospital Trust in Norway, March 2014- January 2017, and community-based controls. Results: Our findings are presented in four papers. The first paper is a review on celiac disease and risk of fractures in adults. Previous studies performed on the subject were heterogeneous and difficult to compare, but the overall findings indicate a positive association between celiac disease and risk of fracture. We concluded that adult patients with celiac disease should be considered for bone densitometry in order to estimate fracture risk, thus enabling fracture prevention. In the second paper we report the prevalence of positive IgA transglutaminase 2 (TG2), a marker for both subclinical and clinically active celiac disease, and celiac disease in patients with distal radius or ankle fracture compared to community-based controls. We found that 2.5 % of the fracture patients had positive TG2, compared to 1 % in the control group, but the results did not show significantly increased odds of fracture. This study indicates that universal screening for celiac disease in fracture patients is not warranted, but that diagnostic tests should be performed in case of additional factors present increasing the patients’ risk of having celiac disease. The aim of the study reported in the third paper was to determine whether radiographic complexity of a distal radius fracture can be used to see if different distal radius fracture subtypes differ with regard to the prevalence of osteoporosis. When classifying the fractures according to the AO-classification system, we found no association between the severity of distal radius fractures and osteoporosis, hereby challenging a common perception that such an association exists. The study reported in the fourth paper investigated associations of overweight, obesity and osteoporosis with ankle fracture and the Danis-Weber (D-W) ankle fracture classification. We concluded that overweight increased the odds of ankle fractures and the odds of sustaining an ankle fracture with possible instability (D-W type B and C). Osteoporosis did not significantly increase the odds of ankle fracture, nor the odds of an instable distal fibula fracture. Conclusion: Understanding the impact common medical conditions such as osteoporosis, celiac disease and obesity have on fracture risk is important in order to identify and treat people at risk. This dissertation aims to expand the knowledge in this research landscape, look into and challenge the perception of common clinical beliefs, and contribute to the path towards new clinical practice guidelines for clinicians.Doktorgradsavhandlin

Associations of overweight, obesity and osteoporosis with ankle fractures

Background: Studies exploring risk factors for ankle fractures in adults are scarce, and with diverging conclusions. This study aims to investigate whether overweight, obesity and osteoporosis may be identified as risk factors for ankle fractures and ankle fracture subgroups according to the Danis-Weber (D-W) classification. Methods: 108 patients ≥40 years with fracture of the lateral malleolus were included. Controls were 199 persons without a previous fracture history. Bone mineral density of the hips and spine was measured by dual-energy x-ray absorptiometry, and history of previous fracture, comorbidities, medication, physical activity, smoking habits, body mass index and nutritional factors were registered. Results: Higher body mass index with increments of 5 gave an adjusted odds ratio (OR) of 1.30 (95% confidence interval (CI) 1.03–1.64) for ankle fracture, and an adjusted OR of 1.96 (CI 0.99–4.41) for sustaining a D-W type B or C fracture compared to type A. Compared to patients with normal bone mineral density, the odds of ankle fracture in patients with osteoporosis was 1.53, but the 95% CI was wide (0.79–2.98). Patients with osteoporosis had reduced odds of sustaining a D-W fracture type B or C compared to type A (OR 0.18, CI 0.03–0.83). Conclusions: Overweight increased the odds of ankle fractures and the odds of sustaining an ankle fracture with possible syndesmosis disruption and instability (D-W fracture type B or C) compared to the stable and more distal fibula fracture (D-W type A). Osteoporosis did not significantly increase the odds of ankle fractures, thus suffering an ankle fracture does not automatically warrant further osteoporosis assessment.publishedVersio

Risk factors for fracture and fracture severity of the distal radius and ankle : What about osteoporosis, celiac disease and obesity?

Background: Fractures are a substantial burden for both individuals and society. For the individual it leads to pain, reduced quality of life, disability and increased mortality. For society, it carries a great cost and requires substantial resources. With the increasing age in the population, this burden is expected to increase. There is potential to prevent more fractures than we do today by increased knowledge about groups at risk and individual risk factors, both through awareness, case finding in defined populations, and targeted treatment in the case of osteoporosis. Aim: The overall aim of this thesis is to contribute to better fracture prevention through increased knowledge of risk factors and patient groups at risk, focusing on celiac disease, osteoporosis and obesity as risk factors for peripheral fractures. Materials and methods: The dissertation is based on a case control study of consecutive patients with acute ankle- or distal radius fracture treated at the Helse Førde Hospital Trust in Norway, March 2014- January 2017, and community-based controls. Results: Our findings are presented in four papers. The first paper is a review on celiac disease and risk of fractures in adults. Previous studies performed on the subject were heterogeneous and difficult to compare, but the overall findings indicate a positive association between celiac disease and risk of fracture. We concluded that adult patients with celiac disease should be considered for bone densitometry in order to estimate fracture risk, thus enabling fracture prevention. In the second paper we report the prevalence of positive IgA transglutaminase 2 (TG2), a marker for both subclinical and clinically active celiac disease, and celiac disease in patients with distal radius or ankle fracture compared to community-based controls. We found that 2.5 % of the fracture patients had positive TG2, compared to 1 % in the control group, but the results did not show significantly increased odds of fracture. This study indicates that universal screening for celiac disease in fracture patients is not warranted, but that diagnostic tests should be performed in case of additional factors present increasing the patients’ risk of having celiac disease. The aim of the study reported in the third paper was to determine whether radiographic complexity of a distal radius fracture can be used to see if different distal radius fracture subtypes differ with regard to the prevalence of osteoporosis. When classifying the fractures according to the AO-classification system, we found no association between the severity of distal radius fractures and osteoporosis, hereby challenging a common perception that such an association exists. The study reported in the fourth paper investigated associations of overweight, obesity and osteoporosis with ankle fracture and the Danis-Weber (D-W) ankle fracture classification. We concluded that overweight increased the odds of ankle fractures and the odds of sustaining an ankle fracture with possible instability (D-W type B and C). Osteoporosis did not significantly increase the odds of ankle fracture, nor the odds of an instable distal fibula fracture. Conclusion: Understanding the impact common medical conditions such as osteoporosis, celiac disease and obesity have on fracture risk is important in order to identify and treat people at risk. This dissertation aims to expand the knowledge in this research landscape, look into and challenge the perception of common clinical beliefs, and contribute to the path towards new clinical practice guidelines for clinicians

No association between osteoporosis and AO classification of distal radius fractures: an observational study of 289 patients

Background: It is mechanically plausible that osteoporosis leads to more severe peripheral fractures, but studies investigating associations between BMD and radiographically verified complexity of distal radius fractures are scarce. This study aims to study the association between osteoporosis, as well as other risk factors for fracture, and the AO classification of distal radius fractures. Methods: In this observational study, 289 consecutive patients aged ≥40 years with a distal radius fracture were included. Bone mineral density (BMD) of the hips and spine was measured by dual-energy x-ray absorptiometry (DXA), and comorbidities, medication, physical activity, smoking habits, body mass index (BMI), and history of previous fracture were registered. The distal radius fractures were classified according to the Müller AO system (AO) (type B and C regarded as most complex). Results: Patients with osteoporosis (n = 130) did not have increased odds of a more complex distal radius fracture (type B + C, n = 192)) (n = vs type A (n = 92) (OR 1.1 [95% CI 0.5 to 2.3]) compared to those with osteopenia /normal BMD (n = 159). Patients with AO fracture types A or C had a higher prevalence of osteoporosis than patients with type B fracture. Conclusions: Distal radius fracture patients with osteoporosis did not sustain more complex fractures than those with osteopenia/normal BMD according to the AO classification system. The AO classification of distal radius fracture cannot be used to decide which patients should be referred to DXA scan and considered for secondary fracture prevention

No association between osteoporosis and AO classification of distal radius fractures: an observational study of 289 patients

Background It is mechanically plausible that osteoporosis leads to more severe peripheral fractures, but studies investigating associations between BMD and radiographically verified complexity of distal radius fractures are scarce. This study aims to study the association between osteoporosis, as well as other risk factors for fracture, and the AO classification of distal radius fractures. Methods In this observational study, 289 consecutive patients aged ≥40 years with a distal radius fracture were included. Bone mineral density (BMD) of the hips and spine was measured by dual-energy x-ray absorptiometry (DXA), and comorbidities, medication, physical activity, smoking habits, body mass index (BMI), and history of previous fracture were registered. The distal radius fractures were classified according to the Müller AO system (AO) (type B and C regarded as most complex). Results Patients with osteoporosis (n = 130) did not have increased odds of a more complex distal radius fracture (type B + C, n = 192)) (n = vs type A (n = 92) (OR 1.1 [95% CI 0.5 to 2.3]) compared to those with osteopenia /normal BMD (n = 159). Patients with AO fracture types A or C had a higher prevalence of osteoporosis than patients with type B fracture. Conclusions Distal radius fracture patients with osteoporosis did not sustain more complex fractures than those with osteopenia/normal BMD according to the AO classification system. The AO classification of distal radius fracture cannot be used to decide which patients should be referred to DXA scan and considered for secondary fracture prevention

No association between osteoporosis and AO classification of distal radius fractures: an observational study of 289 patients

Background It is mechanically plausible that osteoporosis leads to more severe peripheral fractures, but studies investigating associations between BMD and radiographically verified complexity of distal radius fractures are scarce. This study aims to study the association between osteoporosis, as well as other risk factors for fracture, and the AO classification of distal radius fractures. Methods In this observational study, 289 consecutive patients aged ≥40 years with a distal radius fracture were included. Bone mineral density (BMD) of the hips and spine was measured by dual-energy x-ray absorptiometry (DXA), and comorbidities, medication, physical activity, smoking habits, body mass index (BMI), and history of previous fracture were registered. The distal radius fractures were classified according to the Müller AO system (AO) (type B and C regarded as most complex). Results Patients with osteoporosis (n = 130) did not have increased odds of a more complex distal radius fracture (type B + C, n = 192)) (n = vs type A (n = 92) (OR 1.1 [95% CI 0.5 to 2.3]) compared to those with osteopenia /normal BMD (n = 159). Patients with AO fracture types A or C had a higher prevalence of osteoporosis than patients with type B fracture. Conclusions Distal radius fracture patients with osteoporosis did not sustain more complex fractures than those with osteopenia/normal BMD according to the AO classification system. The AO classification of distal radius fracture cannot be used to decide which patients should be referred to DXA scan and considered for secondary fracture prevention

Associations of overweight, obesity and osteoporosis with ankle fractures

Background: Studies exploring risk factors for ankle fractures in adults are scarce, and with diverging conclusions. This study aims to investigate whether overweight, obesity and osteoporosis may be identified as risk factors for ankle fractures and ankle fracture subgroups according to the Danis-Weber (D-W) classification. Methods: 108 patients ≥40 years with fracture of the lateral malleolus were included. Controls were 199 persons without a previous fracture history. Bone mineral density of the hips and spine was measured by dual-energy x-ray absorptiometry, and history of previous fracture, comorbidities, medication, physical activity, smoking habits, body mass index and nutritional factors were registered. Results: Higher body mass index with increments of 5 gave an adjusted odds ratio (OR) of 1.30 (95% confidence interval (CI) 1.03–1.64) for ankle fracture, and an adjusted OR of 1.96 (CI 0.99–4.41) for sustaining a D-W type B or C fracture compared to type A. Compared to patients with normal bone mineral density, the odds of ankle fracture in patients with osteoporosis was 1.53, but the 95% CI was wide (0.79–2.98). Patients with osteoporosis had reduced odds of sustaining a D-W fracture type B or C compared to type A (OR 0.18, CI 0.03–0.83). Conclusions: Overweight increased the odds of ankle fractures and the odds of sustaining an ankle fracture with possible syndesmosis disruption and instability (D-W fracture type B or C) compared to the stable and more distal fibula fracture (D-W type A). Osteoporosis did not significantly increase the odds of ankle fractures, thus suffering an ankle fracture does not automatically warrant further osteoporosis assessment

Associations of overweight, obesity and osteoporosis with ankle fractures

Background Studies exploring risk factors for ankle fractures in adults are scarce, and with diverging conclusions. This study aims to investigate whether overweight, obesity and osteoporosis may be identified as risk factors for ankle fractures and ankle fracture subgroups according to the Danis-Weber (D-W) classification. Methods 108 patients ≥40 years with fracture of the lateral malleolus were included. Controls were 199 persons without a previous fracture history. Bone mineral density of the hips and spine was measured by dual-energy x-ray absorptiometry, and history of previous fracture, comorbidities, medication, physical activity, smoking habits, body mass index and nutritional factors were registered. Results Higher body mass index with increments of 5 gave an adjusted odds ratio (OR) of 1.30 (95% confidence interval (CI) 1.03–1.64) for ankle fracture, and an adjusted OR of 1.96 (CI 0.99–4.41) for sustaining a D-W type B or C fracture compared to type A. Compared to patients with normal bone mineral density, the odds of ankle fracture in patients with osteoporosis was 1.53, but the 95% CI was wide (0.79–2.98). Patients with osteoporosis had reduced odds of sustaining a D-W fracture type B or C compared to type A (OR 0.18, CI 0.03–0.83). Conclusions Overweight increased the odds of ankle fractures and the odds of sustaining an ankle fracture with possible syndesmosis disruption and instability (D-W fracture type B or C) compared to the stable and more distal fibula fracture (D-W type A). Osteoporosis did not significantly increase the odds of ankle fractures, thus suffering an ankle fracture does not automatically warrant further osteoporosis assessment

Positive IgA against transglutaminase 2 in patients with distal radius and ankle fractures compared to community-based controls

Background: Patients with celiac disease (CD), including adults with subclinical disease, have low bone mineral density (BMD), deteriorated bone microarchitecture and meta-analysis show an increased risk of fracture. Immunoglobulin A (IgA) against transglutaminase 2 (IgA TG2) is a highly reliable marker to detect CD. Main objective: To explore the prevalence of positive IgA TG2 and CD in patients with distal radius and ankle fracture compared to community-based controls. Methods: Four hundred patients aged 40 years or above with distal fractures were included in a case–control study. About 197 controls were identified from the National Population Registry, those included had never suffered a fracture. BMD was measured, and comorbidities, medications, physical activity, smoking habits, body mass index (BMI) and nutritional factors were registered. Blood analysis to detect common causes of secondary osteoporosis was performed. Results: About 2.5% of the fracture patients had positive IgA TG2, compared to 1% in the control group. The odds ratio, adjusted for sex and age, of having positive IgA TG2 was 2.50 (95% CI 0.54–11.56). Conclusions: There were no significantly increased odds of CD in adult patients with fractures compared to controls; however, results imply that positive IgA TG2 is more prevalent in fracture patients than in controls. This study indicates that universal screening for CD in fracture patients is not warranted, but supports current clinical practice in Norway to suspect and investigate for CD in patients with fracture, osteoporosis and other risk factors for CD