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Original Investigation
June 7, 2021

Risk of Subsequent Fractures in Postmenopausal Women After Nontraumatic vs Traumatic Fractures

Author Affiliations
  • 1Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles
  • 2Fred Hutchinson Cancer Research Center, Seattle, Washington
  • 3Department of Epidemiology, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla
  • 4Center for Healthcare Policy and Research, Department of Medicine, UC Davis Medical Center Sacramento, California
  • 5Department of Epidemiology and Environmental Health, University at Buffalo, State University of New York, Buffalo
  • 6Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis
  • 7General Internal Medicine, University of Florida College of Medicine, Gainesville
  • 8California Pacific Medical Center, San Francisco
  • 9Veterans Affairs Palo Alto Health Care System, Palo Alto, California
  • 10Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, California
  • 11The Ohio State University Wexner Medical Center, Department of Internal Medicine, Columbus
  • 12The Ohio State University Wexner Medical Center, General Internal Medicine and Geriatrics, Columbus
  • 13Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
JAMA Intern Med. Published online June 7, 2021. doi:10.1001/jamainternmed.2021.2617
Key Points

Question  What is the risk of fracture subsequent to traumatic fractures vs nontraumatic fractures among postmenopausal women?

Findings  In this large prospective cohort study of 66 874 postmenopausal women, future fracture risk after initial traumatic fracture was similar to that after nontraumatic fracture.

Meaning  Clinical osteoporosis assessment of postmenopausal women should include high-trauma as well as low-trauma fractures.


Importance  The burden of fractures among postmenopausal women is high. Although nontraumatic fractures are strong risk factors for future fracture, current clinical guidelines do not address traumatic fractures.

Objective  To determine how future fracture risk varies according to whether an initial fracture is traumatic or nontraumatic.

Design, Setting, and Participants  We conducted a prospective observational study using data from the Women’s Health Initiative Study (WHI) (enrollment, September 1994-December 1998; data analysis, September 2020 to March 2021), which enrolled postmenopausal women aged 50 to 79 years at baseline at 40 US clinical centers. The WHI Clinical Trials and WHI Bone Density Substudy, conducted at 3 of the clinical centers, asked participants to report the mechanism of incident fractures. Of 75 335 participants, information regarding incident fracture and covariates was available for 66 874 participants (88.8%), who comprised the analytic sample of this study. Mean (SD) follow-up was 8.1 (1.6) years.

Interventions  None.

Main Outcomes and Measures  Incident clinical fractures were self-reported at least annually and confirmed using medical records. Participants reported the mechanism of incident fracture as traumatic or nontraumatic.

Results  Among the 66 874 participants in the analytic sample (mean [SD] age, 63.1 [7.0] years and 65.3 [7.2] years among women without and with clinical fracture, respectively), 7142 participants (10.7%) experienced incident fracture during the study follow-up period. The adjusted hazard ratio (aHR) of subsequent fracture after initial fracture was 1.49 (95% CI, 1.38-1.61). Among women whose initial fracture was traumatic, the association between initial fracture and subsequent fracture was significantly increased (aHR, 1.25; 95% CI, 1.06-1.48). Among women whose initial fracture was nontraumatic, the association between initial fracture and subsequent fracture was also increased (aHR, 1.52; 95% CI, 1.37-1.68). Confidence intervals for associations between initial fracture and subsequent fracture were overlapping for traumatic and nontraumatic initial fracture strata.

Conclusions and Relevance  In this cohort study, among postmenopausal women older than 50 years, fracture was associated with a greater risk of subsequent fracture regardless of whether the fracture was traumatic or nontraumatic. These findings suggest that clinical osteoporosis assessment should include high-trauma as well as low-trauma fractures.

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    1 Comment for this article
    Not convinced that traumatic fractures carry the same risk for subsequent fractures as osteoporotic fractures...
    David Karpf, MD | Stanford University School of Medicine
    The results of this analysis of the WHI data by my esteemed colleagues are compelling, if somewhat surprising. Traumatic fractures increase the risk of a 2nd fracture to the same extent as non-traumatic, osteoporotic fragility fractures?

    Although the 95% CIs of the predictive value of a prior nontraumatic and traumatic fracture for predicting incident fracture overlapped, the point estimate for traumatic fractures predicting second fractures was numerically lower (1.25) than with nontraumatic fragility fractures (1.52), and the adjusted HR for subsequent fracture after traumatic fracture was significantly lower vs nontraumatic fracture [HR 0.82 (95% CI, 0.68-1.00);P = 0.05).
    Suggesting that perhaps fragility fractures may be a greater risk factor than a very traumatic fracture, which makes sense.

    Biomechanical studies have demonstrated that the force generated by falling from a standing height are sufficient to break a normal hip or wrist. This is supported by the incidence of wrist fractures in individuals at peak bone mass in their 20s from falling while skateboarding, rollerblading, or rollerskating, as well as by the Mayo Olmstead County epidemiological data showing a decline in the age-related incidence of wrist fractures coinciding with the hyperbolic increase in hip fracture incidence in women in their 70s to 80s, (1) strongly suggesting that by falling sideways or backwards instead of forwards results in trading a wrist fracture for a hip fracture. And, importantly, by the Study of Osteoporotic Fractures analysis by Dana Seely, et al. (2). In that study, wrist fractures past the age of 45 even in women at least 65 years of age and older barely made the "osteoporotic" cut-off, showing a barely significant HR of 1.3 in the lowest quartile of baseline bone mineral density vs the quartile with the highest baseline bone mineral density. In contrast to the substantially higher HRs with vertebral and hip fractures.

    My question to the authors: did the relative risk of a subsequent fracture following a traumatic fracture differ between those subjects who reported a fall in the preceding 12 months vs those who did not?

    David B. Karpf, MD
    Adj.Clinical Professor of Endocrinology, Gerontology & Metabolism
    Stanford University School of Medicine
    Attending, Osteoporosis & Metabolic Bone Disease Clinic
    Stanford University Hospital & Clinics

    Co-Chair, MSAB
    American Bone Health

    Fellow, ASBMR

    1 L J Melton 3rd, et al. Fracture incidence in Olmsted County, Minnesota: comparison of urban with rural rates and changes in urban rates over time. Osteoporos Int. 1999;9(1):29-37.
    2 Seeley DG, et al. Which fractures are associated with low appendicular bone mass in elderly women? Ann Int Med 1991;115(11):837-842.