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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. 2021;181(8):1055-1063. 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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    3 Comments 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.

    Reply to Dr. David Karpf
    Carolyn Crandall, MD, MS, FACP | David Geffen School of Medicine at University of California, Los Angeles
    We read with interest the question raised by Dr. Karpf's comment. Because of how our study questionnaires were worded, we cannot ascertain the sequence of falls and fractures in the prior 12 months. That is, both falls and fractures in the prior 12 months were reported concurrently on annual questionnaires, and we cannot know whether falls preceded fracture or vice versa within a given year.

    Carolyn J. Crandall, MD, MS, FACP, Fellow ASBMR
    Professor of Medicine
    David Geffen School of Medicine at University of California, Los Angeles
    A fracture is a fracture is a fracture?
    Olle Svensson, Professor emeritus | Umeå University, Sweden
    Crandall & al argue that the distinction between high energy and low energy fracture is not relevant when predicting the risk for subsequent fractures.1 This is probably true, but their terminology—traumatic versus non traumatic fracture—is problematic. Almost all fractures, even pathological ones, are preceded by an injury event. Since kinetic energy is proportional to mass * (velocity)2, even falls from standing height and less can break any bone.
    In vivo, protective neuromuscular reflexes are not less important than bone strength to distribute kinetic energy at injuries.2 Any trauma can be regarded as a natural biomechanical experiment with three possible outcomes:
    death, injury (about 20% fractures in most emergency department materials), and no injury at all. The neuromuscular mechanical forces are immensely complex and cannot yet be captured in biomechanical computer animations.3
    Mechanically, bones, like all biological tissues, are highly anisotropic, i.e., much stronger in physiological directions—for the femur axially. Moreover, nature has not over-dimensioned tissue strength very much above the loads exerted by the activities of daily life.4 In fact, in biomechanical bench tests even moderate impacts can fracture bone, e.g. vertebrae, using forces that overlap with physiological loads. On the other hand, there are anecdotal reports of falls from very large heights, even from air planes, causing only minor injuries.5 And the kinetic energy released when two American football players collide—and then continue the match—would kill most octogenarians.
    This leads us to another weakness in the study. Only 6% of the subjects were over 75, whereas some 75% of the hip fracture patients are. Hip fracture incidence increases 40-fold between 50 and 80+, with a morbidity and mortality comparable with metastatic cancer6, not only because of the injury per se, but also because of the patients’ general condition.
    In fact, only some 20% of postmenopausal women with fragility fracture do have osteoporosis7-10, and due to natural ageing effects about half of the hip fracture patients, most have osteopenia. This calls for new strategies in osteoporosis and falls prevention.11,12 All fractures are not equal.


    1. Crandall CJ, Larson JC, LaCroix AZ, et al. Risk of Subsequent Fractures in Postmenopausal Women After Nontraumatic vs Traumatic Fractures. JAMA internal medicine. 2021.

    2. Currey J. How well are bones designed to resist fracture? J Bone Miner Res. 2003;8:591-598.

    3. Luo Y. On challenges in clinical assessment of hip fracture risk using image-based biomechanical modelling: a critical review. J Bone Miner Metab. 2021;39(4):523-533.

    4. Dobzhansky T. Nothing in Biology Makes Sense except in the Light of Evolution. National Association of Biology Teachers. http://www.jstor.org/stable/4444260. Published 1973. Accessed April 4, 2020.

    5. De Haven H. Mechanical analysis of survival in falls from heights of fifty to one hundred and fifty feet. Inj Prev. 2000;6:62–68.

    6. Michaelsson K, Nordstrom P, Nordstrom A, et al. Impact of hip fracture on mortality: a cohort study in hip fracture discordant identical twins. J Bone Miner Res. 2014;29(2):424-431.

    7. Siris EC, YT. Abbott, TA. Barrett-Connor, E. Miller, PD. Wehren, LE. Berger, ML. Bone mineral density thresholds for pharmacological intervention to prevent fractures. Arch Int Med. 2004;164:1108–1112.

    8. Trajanoska K, Schoufour JD, de Jonge EAL, et al. Fracture incidence and secular trends between 1989 and 2013 in a population based cohort: The Rotterdam Study.

    9. Tei RMH, Ramlau-Hansen CH, Plana-Ripoll O, Brink O, Langdahl BL. OFELIA: Prevalence of Osteoporosis in Fragility Fracture Patients. Calcif Tissue Int. 2019;104(1):102-114.

    10. Mai HT, Tran TS, Ho-Le TP, Center JR, Eisman JA, Nguyen TV. Two-Thirds of All Fractures Are Not Attributable to Osteoporosis and Advancing Age: Implications for Fracture Prevention. J Clin Endocrinol Metab. 2019;104(8):3514-3520.

    11. Castle SC. New Strategies for Falls Prevention. Clin Geriatr Med. 2019;35(2):xi-xiv. Reid IR. A broader strategy for osteoporosis interventions. Nat Rev Endocrinol.2020;Jun;16(6):333-339.

    12. Reid IR. A broader strategy for osteoporosis interventions. Nat Rev Endocrinol. 2020;Jun;16(6):333-339.