No one would argue with the concept that a person suffering a low-trauma hip/femur neck fracture has osteoporosis and needs therapy to prevent future fractures. But does this apply to a relatively young patient with a low-trauma radius fracture? Should we automatically diagnose and treat this patient in a similar way? It is actually a difficult question to answer in haste. The current debate started with a study from Norway  that examined cases of distal radius fractures (218 men, 1576 women, age > 50 years). The authors concluded that, because a large proportion of these patients, who also had a high 10-year fracture risk calculated by the WHO assessment tool FRAX(R), did not have osteoporosis by bone mineral density (BMD) criteria, all distal radius fracture patients above the age of 50 years should be routinely referred for BMD testing; only those with low bone mass should be offered medical treatment.
A group of key-opinion bone experts representing the International Osteoporosis Foundation and the National Osteoporosis Foundation now defy these conclusions in a short, but angry manuscript placed in the same journal . They put forward the following known key points: (1) bone density measures only one of several important factors that contribute to skeletal fragility; (2) individuals with osteopenia may fracture, whereas others with a [i]T[/i] score lower than -2 or even -2.5 standard deviations (SD) may never fracture; (3) in fact, most fractures occur in those who do not have a [i]T[/i] score in the osteoporosis range. The authors claim that, since fragility fracture is the very definition of osteoporosis, there is no need for any further tests or surrogate markers to prove it. The conclusion of the group was that they disagree with the notion that a densitometric threshold for treatment should be applied to patients over age 50 years who suffer low-trauma distal radius fracture.
Department of Medicine T, Ichilov Hospital, Tel-Aviv, Israel
Oyen J, Gjesdal CG, Brudvik C, et al. Low-energy distal radius fractures in middle-aged and elderly men and women the burden of osteoporosis and fracture risk: A study of 1794 consecutive patients. Osteoporos Int 2009 Oct 8. Epub ahead of print.
Blank RD, Bilezikian JP, Bonnick SL, et al. “Evidence-based” or “logic-based” medicine? Osteoporos Int 2010 May 13. Epub ahead of print.
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