What is the risk of fracture subsequent to traumatic fractures vs nontraumatic fractures among postmenopausal women?
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.
Clinical osteoporosis assessment of postmenopausal women should include high-trauma as well as low-trauma fractures.
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.
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.
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.
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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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
American Bone Health
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.
Crandall CJ, Larson JC, LaCroix AZ, et al. Risk of Subsequent Fractures in Postmenopausal Women After Nontraumatic vs Traumatic Fractures. JAMA Intern Med. 2021;181(8):1055–1063. doi:10.1001/jamainternmed.2021.2617
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