Falling is the true direct cause of rib fracture
Professor Barrett-Connor and her colleagues published recently an
original study on epidemiology of rib fracture in older men (1). Since
circumstances resulting in an incident rib fracture (in most cases
falling) were not included in their fracture prediction models and the
conclusions and policy implications were therefore flawed favouring
osteoporosis pharmacotherapy, we wrote a BMJ Rapid Response on March 19,
We thank Barrett-Connor et al. for their recent reply to us (3). The
authors clarified further that baseline history of falls in the past 12
months was not an independent risk factor for incident rib fracture. The
point is that it does not have to be; it is the incident falling preceding
the fracture that matters!
In the study of Barrett-Connor et al. (1), 122 of the 126 incident
rib fractures (97%) were trauma-induced, most of which followed a fall.
It is regrettable that the authors could not formally analyse this
important variable, because in great majority of older patients falling is
the true immediate cause of the fracture (4, 5). In other words, authors’
decision to examine baseline osteoporosis risk factors as predictors of
future fracture only limits the study conclusions and policy implications
Many clinical risk factors for fractures, such as high age,
medications, functional impairments, difficulties in activities of daily
living and history of fracture, operate mostly through falling, not
osteoporosis (4-6). Therefore we have suggested that fractures of older
adults should be called “fall-induced high-impact injuries” instead of the
commonly used, partly misleading terms of osteoporotic fractures or
minimal-trauma fractures (6).
Pekka Kannus, MD, PhD
Injury and Osteoporosis Research Center, UKK-Institute, Tampere, Finland
Teppo LN Järvinen, MD, PhD
Department of Surgery, University and University Hospital of Tampere,
1 Barrett-Connor E, Nielson CM, Orwoll E, Bauer DC, Cauley JA.
Epidemiology of rib fractures in older men: Osteoporotic Fractures in Men
(MrOS) prospective cohort study. BMJ 2010;340:c1069.
2 Kannus P, Järvinen TLN. Falling, not osteoporosis, is the
strongest risk factor for rib fracture. BMJ Rapid Responses. 19 March,
3 Barrett-Connor E, Nielson CM, Orwoll E, Bauer DC, Cauley JA. Re:
Falling, not osteoporosis, is the strongest risk factor for fracture. BMJ
Rapid Responses. 7 April, 2010.
4. Kannus P, Sievanen H, Palvanen M, Järvinen T, Parkkari J.
Prevention of falls and consequent injuries in elderly people. Lancet
5 Järvinen TL, Sievänen H, Khan KM, Heinonen A, Kannus P. Shifting
the focus in fracture prevention from osteoporosis to falls. BMJ.
6 Kannus P, Uusi-Rasi K, Palvanen M, Parkkari J. Non-
pharmacological means to prevent fractures among older adults. Ann Med
Competing interests: No competing interests