What are the three fractures typically associated with osteoporosis? Which of these might be considered “worst”?

The three fractures typically associated with osteoporosis are wrist fractures (distal radius/Colles; Figure 1), vertebral body compression fractures (Figure 2), and hip fractures (femoral neck and intertrochanteric; Figure 3).

Please note that when patients present with one of these fractures, they may not know they have osteoporosis. Thus, the presence of one of these fractures after a low energy injury mechanism should be considered as an alert to consider the possibility (indeed probability) of undiagnosed osteoporosis.

In these cases, the patient should undergo a workup for osteoporosis (DEXA scan). This recommendation is especially (but not exclusively) applicable to wrist fractures, as they tend to occur at a younger age than the other two, and are thereby associated with a longer time window during which the osteoporosis might work.

Figure 1: Colles fracture. (From radiopaedia.org http://bit.ly/1P0PjGJ)
Figure 2: Vertebral compression fracture at T12 (from Wikipedia) The vertebral body’s (collapsed) superior surface is outlined in red.
Figure 3: CT scan of a femoral neck fracture (Case courtesy of Dr. David Cuete, Radiopaedia.org, rID: 29323)

Which is the worst? Although the Mel Brooks rule** would suggest that the worst of these three fractures is the one that you (or your loved one) sustains, a fair standard for “worst” is the effect on mortality and function. Among the common osteoporotic fractures, hip fracture is associated with the greatest mortality risk: the one year mortality following a geriatric hip fracture after a fall is approximately 30%. Moreover, an additional 1/3 of patients lose a level of independence.

Note that we cannot be sure if the increased mortality risk is produced by the hip fracture itself, or rather the fracture might merely be a manifestation of underlying disease or senescence. A patient with “the dwindles” *** might both sustain a fracture, and have as well other independent risk factors for looming demise.

Additional Points to Consider

Regarding possible neurological complications from vertebral body compression fractures, remember that neurological complications from spine fractures generally are caused by retropulsion of bone fragments into the spinal canal. Here, with osteoporosis-related vertebral body compression fracture, the bone basically collapses on itself because of a lack of bone. Thus, there are no bone fragments to be pushed into the canal and compress the cord or nerve roots ****. The risk of neurological compromise from an osteoporosis-related vertebral body compression fracture is vanishingly small.

** For some reason, Mel Brooks does not get quoted in medical forums. That implicit rule won’t be broken here. You may find his rule, basically a statement about externalizing costs, here: https://www.brainyquote.com/quotes/mel_brooks_161275

*** apparently, a medical term of art. See https://pubmed.ncbi.nlm.nih.gov/8919675/

**** recall that the cord terminates at ~L2. Accordingly, distal to L2, the central canal is filled with the cauda equina, the nerve roots that have not yet exited their respective foramina. That is, even if there were piece of body to fill the canal (as might be seen in high energy trauma in a younger person), below L2 a fracture by definition cannot cause cord compression, per se.

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