Analysis

Shifting the focus in fracture prevention from osteoporosis to falls

BMJ 2008; 336 doi: http://dx.doi.org/10.1136/bmj.39428.470752.AD (Published 17 January 2008) Cite this as: BMJ 2008;336:124
  1. Teppo L N Järvinen, orthopaedic resident1,
  2. Harri Sievänen, head2,
  3. Karim M Khan, associate professor3,
  4. Ari Heinonen, professor4,
  5. Pekka Kannus, professor12
  1. 1Division of Orthopaedics and Traumatology, Department of Trauma, Musculoskeletal Surgery and Rehabilitation, Tampere University Hospital, 33 520 Tampere, Finland
  2. 2Bone Research Group, UKK-Institute, Tampere, Finland
  3. 3Department of Family Practice and Centre for Hip Health, University of British Columbia, Vancouver, British Columbia, Canada
  4. 4Department of Health Sciences, University of Jyväskylä, Jyväskylä, Finland
  1. Correspondence to: T L N Järvinen teppo.jarvinen{at}uta.fi
  • Accepted 11 November 2007

Preventing fractures in older people is important. But Teppo Järvinen and colleagues believe that we should be putting our efforts into stopping falls not treating low bone mineral density

Fractures are a rapidly growing problem among older people. Hip fractures alone cost over $20bn (£10bn; €13bn) in the United States in 1997.1 Any intervention that may reduce the risk of fracture at either the individual or population level therefore warrants critical appraisal. The mainstay of current strategies to prevent fractures is to screen for osteoporosis by bone densitometry and then treat people with low bone density with antiresorptive or other bone-specific drugs.234 However, the strongest single risk factor for fracture is falling and not osteoporosis.5 6 Despite this fact, few general practitioners will have assessed the risk of falling among their elderly patients or even know how to do it.7 Risk of falling is also completely overlooked in many important publications on preventing fractures.4 We argue that a change of approach is needed.

Predictive value of bone density measurements

Bone densitometry does not give reliable estimates of a person’s true bone mineral density. The planar scanning principle of dual energy x ray absorptiometry, and assumptions in processing the scan data, can underestimate or overestimate bone mineral density by 20-50%.8 This means that a patient with a bone mineral density T score of −1.5 may have a true value between −3.0 and 0−that is, a range from clear osteoporosis to normal. Thus, not surprisingly, bone mineral density is a poor predictor of fracture in individuals (fig 1). In addition, when different scanners are used on the same patients, the proportion of patients diagnosed with osteoporosis varies from 6% up to 15%.9

Fig 1 Femoral neck bone mineral density versus age at time of fall in people who …

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