Even high-trauma fractures are a risk factor for osteoporosis

Lessons from a fall and my broken ribs

My partner and I recently took a long-planned exercise vacation. As the date neared, rates of COVID-19 had just begun to spike and so we made some additional modifications to our itinerary for safety. The first day we did an 8 mile hike and the second a 27 1/2 mile bike ride with about 2,500 feet of climbing. I was really nervous about that climb and was so excited that I did the entire route. Go 55 year-old me! Day three we planned a 60 mile ride, all flat or slightly downhill. I was unsure when we started if I would do the entire ride, but at mile 40 when we stopped for lunch, I felt great. Sure I would go for it! I’d been training for months and my legs felt strong.

And then, maybe 100 yards from our lunch stop, my wheel got stuck in a tram track and over I went, hard on my left side. I knew immediately I had broken at least one rib. The pain in my chest made the amount of skin I’d left on the pavement seem inconsequential.

Multiple good Samaritans came running, and I am happy to report that all were wearing masks, which even though I was in agony I noticed. They stopped traffic and two nurses helped me up.

The nurses wanted to call an ambulance, but like all Americans my first thought was weighing my imminent risk of dying versus potential hassles with my insurer over paying for the ambulance ratio given I was out of network. While I was wearing a helmet, I hadn’t hit my head and could talk, so a friend took me and my partner to the closest emergency room.

The good news, no pneumothorax (no collapsed lung). The bad news, two broken ribs, the 4th and 6th one on my left side. And lots of bruising, swelling and road rash. Like a lot. So much so that two days later I became dehydrated likely in part from all of the fluid shifting.

After the initial shock of it wore off and I was well-hydrated, I started thinking about the rib fractures and what might that mean for me health wise? Many people have heard that a fracture from low impact trauma, for example, a fall from slipping on a rug, is evidence of osteoporosis, but what about a fracture after a high impact trauma, such as my bike accident? For a long time the common thinking was bones that break easily (low-trauma) are a sign of weak bones (osteoporosis), but with enough force bones eventually break, so a high-trauma fracture wasn’t a concern bone-health wise. But I’d remembered reading a recent study on trauma, fractures, and osteoporosis that challenged that thinking, so I decided to dig a little deeper.

I had indeed remembered correctly. The article I was thinking about was published in 2020 by researchers in Manitoba (my home province in Canada!). They looked at the bone density for women and men ages 40 and older and whether they had a history of a low-impact fracture or a high-impact fracture, like my bike-to-pavement encounter. The researchers also looked to see if having either a low or high-impact fracture was predictive of subsequently having a future fracture related to osteoporosis.

Just so we are all on the same page, let’s review some basics. Osteoporosis is a disease of brittle bones. Knowing if you have osteoporosis is important as there are interventions to help preserve bone mass and to reduce the risk of fractures. Osteoporosis is diagnosed in the following situations:

• A very low bone mass on a scan called a DEXA (a T score less than -2.5 signifies osteoporosis).

• A history of a vertebral or hip fracture

• A low bone mass (a T score of -1 to -2.5, so not low enough for osteoporosis, but lower than expected) and also a history of multiple other fractures, or other specific risk factors for osteoporosis.

What the researchers found was very interesting. People who had previously had a low-trauma fracture were more likely to have low bone mineral density, which isn’t surprising, but so were people with a history of a high trauma fracture. In addition, both a low-trauma fracture and a high-trauma fracture were equally predictive of whether or not an osteoporosis-related fracture would occur later in life.

And this isn’t the only study to show the association between high trauma fractures and osteoporosis, I had just remembered this one because it was recent.

In fact, the 2021 position statement of The North American Menopause Society on the management of osteoporosis in postmenopausal women states that “all fractures, except those of the face, skull, hands, and feet, are associated with low bone mineral density and future fracture risk, irrespective of association with trauma.”

Basically, if you break a bone and it isn’t in your head, hands, or feet, it’s a sign that you are at risk for breaking another bone regardless of the trauma involved.

And this makes sense. After all, not everyone who has a high impact injury breaks a bone. My partner who is one year older than I am, and one of his biking club members had a pretty bad fall on their bikes last year. Similar amounts of road rash, but he didn’t break any bones and neither did his 72 year old riding partner!

So what does that mean for me?

I had my bone density tested when I was 50 because I am at higher risk for osteoporosis as mother had a hip fracture. (She developed osteoporosis in her fifties, so quite early, and had multiple osteoporosis-related fractures, eventually dying from complications related to osteoporosis). I had a low bone mass when I was tested, T score was -1.2. Until I broke my ribs, I wouldn’t have needed my bone density retested until age 65, unless I was going to stop estrogen (I’m on menopausal hormone therapy or MHT), but now I have an additional risk factor for osteoporosis, a post menopausal fracture. Looking at all the calculations, my risk of having a major fracture from osteoporosis in the next 10 years jumped from 12% to 21%. This now puts me in the category of being a candidate for drug therapy for osteoporosis.

It’s been five years since my last bone density exam, so another bone density evaluation is probably indicated (it takes several years to see changes, so repeat testing isn’t always indicated). But I shouldn’t be my own doctor here, so given this new piece of painful information, I’m going to ask for an endocrinology referral to learn the best course of action. For example, I may need some lab tests to look for other reasons for my fracture. I think I am getting enough calcium in my diet, but I am going to count my intake for the next few days to be sure and I am going to try to do better with my vitamin D supplementation (I forget a lot). Vitamin D helps with absorption of calcium and our ability to produce it decreases with age. I’m already doing weight bearing exercises, so once my ribs don’t feel like a hot poker, I will get back to that as it is excellent for healthy bones. Alcohol intake of 3 units or more a day, which is two small glasses of wine, is a risk factor for osteoporosis, but I have 2 drinks a week, so I don’t think cutting back there will help. If I drank daily, I’d stop.

What might this mean for you?

If you break a bone (not in your head, hands or feet) and are in menopause (meaning a year from your last menstrual period), that is a risk factor for osteoporosis regardless of how you broke that bone. If you have not had your bone density tested, you need to have that done with a DEXA. You should also make sure that you are getting 1,200 mg of calcium a day and that you are taking a vitamin D supplement, typically 800-1,000 international units a day and that you are doing weight bearing exercises. If you smoke, do your best to quit, and if you are drinking 3 or more units of alcohol a day, think of ways you might be able to cut back. If you are like me and have already had your bone density tested, then it is probably time to have a consultation with an endocrinologist about your bones.

Rib fractures suck. Having another risk factor for osteoporosis also sucks. But I am going to look on the positive side, because of my rib fractures I now know I am at higher risk for osteoporosis than I had previously believed. This gives me the opportunity to seek expert advice that will hopefully help lower my risk of breaking any more bones. Also, I had been thinking about reducing the dose of my menopausal hormone therapy as my hot flashes have been pretty well controlled for a year, but now I don’t think I will as it seems pretty clear that I need all the osteoporosis prevention that I can get.

References

1. W. D. Leslie, J. T. Schousboe, S. N. Morin, et al. Osteoporosis International. 2020;31. Fracture risk following high-trauma versus low-trauma fracture: a registry-based cohort study

2. Dawn C. Mackey, MSc; Li-Yung Lui, MA, MS; Peggy M. Cawthon, PhD; et al. High-Trauma Fractures and Low Bone Mineral Density in Older Women and MenJAMA. 2007;298.

3. Management of osteoporosis in postmenopausal women: the 2021 position statement of The North American Menopause Society. Menopause: The Journal of The North American Menopause Society 2021;28.