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Risk Factors

BMD assessed by DXA is currently the best single predictor of the risk of  future fracture of an individual; it is also, most often, the only diagnostic tool available for clinicians in daily practice(1). However, several other determinants should be considered when assessing the fracture probability (2). Skeletal and non-skeletal risk factors may be combined to identify individuals at the highest risk of fracture through case-finding strategies (3).

Non-skeletal factors

  • Cigarette smoking (4)
  • Excessive alcohol consumption (5)
  • Low body mass index (BMI)
  • Low dietary calcium intake
  • Vitamin D deficiency
  • Prolonged immobilisation – Little or no physical activity
  • Visual impairment
  • Frequent falls

Skeletal factors

  • Female gender
  • Premature menopause
  • Primary or secondary amenorrhoea
  • Primary and secondary hypogonadism in men
  • Age(6)
  • Asian or Caucasian race
  • Previous fragility fracture (7)
  • Family history of hip fracture (8)
  • Low BMD
  • High bone turnover
  • Neuromuscular disorders
  • Glucocorticoid long-term therapy (9)
  • Rheumatoid arthritis

Contribution of risk factors in fracture risk assessment

The use of risk factors provides additional information on fracture risk, independently of BMD. An algorithm, combining some of them, together with BMD assessment providing the absolute 10-year fracture risk in an individual may soon be released by a WHO Working Group. These risks factors are also used to assess fracture risk in countries where DXA machines are not easily available for patients (cost of BMD test, low number of machines…). Further information about this model is available here.

References

  1. World Health Organisation. Assessment of fracture risk and its implication to screening for postmenopausal osteoporosis: Technical report series 843. Geneva: WHO,1994.
  2. Kanis J A, Borgstrom F, De Laet C, Johansson H, Johnell O, Jönsson B, Odén A, Zethraeus N, Pfleger B, Khaltaev N. Assessment of fracture risk. Osteoporos Int 2005; 16: 581–589
  3. De Laet C, Odén A, Johansson H, Johnell O, Jönsson B, Kanis J A. The impact of the use of multiple risk indicators for fracture on case-finding strategies: a mathematical approach. Osteoporosis Int. 2005;16:313-18
  4. Kanis JA, Johnell O, Odén A, Johansson H, De Laet C, Eisman JA, Fujiwara S, Kroger H, McCloskey, Mellstrom D, Melton LJ III, Pols H, Reeve J, Silman A, Tenehouse A. Smoking and fracture risk: a meta-analysis. Osteoporosis Int. 2005;16:155-62
  5. Kanis JA. Johansso H, Johnell O, Odén A, De Laet C, Eisman J, Pols H, Tenenhouse A. Alcohol intake as a risk factor for fracture. Osteoporosis Int 2005;16:737-42
  6. Kanis JA, Johnell O, Odén A, Dawson A, De LAet C, Jonsson B. Ten year probabilities of osteoporotic fractures according to BMD and diagnosis thresholds. Osteoporosis Int 2001;12:989-95
  7. Kanis JA, De LAet C, Delmas P, Garnero P, Johansson H, Johnell O, Kriger H, McCloskey EV, Mellstrom D, Melton LJ III, Odén A, Pols H, Reeve J, Silman A, tenehouse A. A meta-analysis of previous fracture and fracture risk. Bone 2004 35;375-82
  8. Kanis JA, Johansson H, Odén A, Johnell O, De LAet C, Eisman JA, McCloskey EV, Mellström D, Melton LJ III, Pols HA, Reeve J, Silman AJ, Tenenhouse A. A familiy history of fracture and fracture risk: a meta-analysis. Bone 2004;35:1029-37
  9. Kanis J A, Johansson H, Odén A, Johnell O, De Laet C, Melton LJ III, Tenenhouse A, Reeve J, Silman AJ, Pols H, Eisman JA, McCliskey EV, Mellström D. A meta-analysis of prior corticosteroid use and fracture risk. J Bone and Miner Res 2004;19.893-99
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