Fall severity and bone mineral density as risk factors for hip fracture in ambulatory elderly

wbldb

Greenspan, Susan L.^1,3,4; Myers, Elizabeth R.²; Maitland, Lauri A.¹; Resnick, Neil M.^4,5; Hayes, Wilson C.^2,3

Fall severity and bone mineral density as risk factors for hip fracture in ambulatory elderly

JAMA. January 12, 1994;271(2):128-133

Affiliations

¹Divisions of Bone and Mineral Metabolism and Gerontology, Department of Medicine, Beth Israel Hospital and Harvard Medical School, Boston, Mass

²Orthopaedic Biomechanics Laboratory, Department of Orthopaedic Surgery, Beth Israel Hospital and Harvard Medical School, Boston, Mass

³Charles A. Dana Research Institute, Beth Israel Hospital and Harvard Medical School, Boston, Mass

⁴Division of Gerontology, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass; and

⁵Geriatric Research, Education and Clinical Center, Brockton/West Roxbury VA Medical Center, West Roxbury, Mass
Abstract

Objective: To determine the relative importance of fall characteristics, body habitus, and femoral bone mineral density (BMD) in predicting hip fracture in community-dwelling elderly.

Design: Prospective case-control study.

Setting: Community-based academic hospital.

Participants: A total of 149 ambulatory, community-dwelling fallers (126 women, 23 men) aged 65 years and older, including 72 case patients (fallers with hip fracture) and 77 control fallers (fallers with no hip fracture).

Main Outcome Measures: Fall characteristics, body habitus, femoral BMD.

Results: Significant and independent risk factors for hip fracture in both sexes were direction of the fall (adjusted odds ratio [OR], 5.7; 95% confidence interval [Cl], 2.3 to 14.0; P<.001); femoral neck BMD (a decrease of 1 SD; adjusted OR, 2.7; 95% Cl, 1.6 to 4.6; P<.001); potential energy of the fall (an increase of 1 SD; adjusted OR, 2.8; 95% CI, 1.5 to 5.2; P<.001); and body mass index (a decrease of 1 SD; adjusted OR, 2.2; 95% Cl, 1.2 to 3.8; P< .01). Importantly, the OR for the fall direction was unaffected by the addition or removal of BMD from the model.

Conclusions: We conclude that among elderly fallers—in most of whom hip BMD is already less than the fracture threshold—fall characteristics and body habitus are important risk factors for hip fracture and touch on a domain entirely missed by knowledge of BMD. These data suggest new targets for preventive therapy. In addition to the maintenance of bone density, reductions in fall severity (eg, by use of trochanteric padding or enhancement of muscle strength) may provide additional strategies for prevention of hip fracture in this age group.
Links

DOI: 10.1001/jama.1994.03510260060029

PubMed: 8264067

WoS: A1994MQ08300022

Cited Works (19)

Year	Entry
1993	Lauritzen JB, Petersen MM, Lund B. Effect of external hip protectors on hip fractures. Lancet. January 2, 1993;341(8836):11-13.
1990	Cummings SR, Black DM, Nevitt MC, Browner WS, Cauley JA, Genant HK, Mascioli SR, Scott JC, Seeley DG, Steiger P, Vogt TM; The Study of Osteoporotic Fractures Research Group. Appendicular bone density and age predict hip fracture in women. JAMA. February 2, 1990;263(5):665-668.
1985	Cummings SR. Are patients with hip fractures more osteoporotic? review of the evidence. Am J Med. March 1985;78(3):487-494.
1983	Bohr H, Schaadt O. Bone mineral content of femoral bone and the lumbar spine measured in women with fracture of the femoral neck by dual photon absorptiometry. Clin Orthop Relat Res. October 1983;179:240-245.
1991	Chrischilles EA, Butler CD, Davis CS, Wallace RB. A model of lifetime osteoporosis impact. Arch Intern Med. October 1991;151(10):2026-2032.
1990	Melton LJ III, Eddy DM, Johnston C Jr. Screening for osteoporosis. Ann Intern Med. April 1, 1990;112(7):516-528.
1988	Melton LJ III, Chao EYS, Lane J. Biomechanical aspects of fractures. In: Riggs BL, Melton LJ III, eds. Osteoporosis: Etiology, Diagnosis, and Management. New York, NY: Raven Press; 1988:111-131.
1985	Melton LJ, Riggs BL. Risk factors for injury after a fall. Clin Geriatr Med. August 1985;1(3):525-539.
1993	Hayes WC, Myers ER, Morris JN, Gerhart TN, Yett HS, Lipsitz LA. Impact near the hip dominates fracture risk in elderly nursing home residents who fall. Calcif Tiss Int. March 1993;52(3):192-198.
1993	Cummings SR, Black DM, Nevitt MC, Browner W, Cauley J, Ensrud K, Genant HK, Palmero L, Scott J, Vogt TM; Study of Osteoporotic Fractures Research Group. Bone density at various sites for prediction of hip fractures. Lancet. January 9, 1993;341(8837):72-75.
1991	Grisso JA, Kelsey JL, Strom BL, Chiu GY, Maislin G, O'Brien LA, Hoffman S, Kaplan F; Northeast Hip Fracture Study Group. Risk factors for falls as a cause of hip fracture in women. NEJM. May 9, 1991;324(19):1326-1331.
1989	Hosmer DW Jr, Lemeshow S. Applied Logistic Regression. New York, NY: John Wiley & Sons; 1989.
1982	Riggs BL, Wahner HW, Seeman E, Offord KP, Dunn WL, Mazess RB, Johnson KA, Melton LJ III. Changes in bone mineral density of the proximal femur and spine with aging: differences between the postmenopausal and senile osteoporosis syndromes. J Clin Invest. October 1982;70(4):716-723.
1986	Riggs BL, Melton LJ III. Involutional osteoporosis. NEJM. June 26, 1986;314(26):1676-1686.
1988	Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. NEJM. December 29, 1988;319(26):1701-1707.
1989	Nevitt MC, Cummings SR, Kidd S, Black D. Risk factors for recurrent nonsyncopal falls: a prospective study. JAMA. May 12, 1989;261(18):2663-2668.
1992	Melton LJ III, Chrischilles EA, Cooper C, Lane AW, Riggs BL. How many women have osteoporosis? J Bone Miner Res. September 1992;7(9):1005-1010.
1985	Cummings SR, Kelsey JL, Nevitt MC, O'Dowd KJ. Epidemiology of osteoporosis and osteoporotic fractures. Epidemiol Rev. 1985;7:178-208.
1990	Ross PD, Davis JW, Vogel JM, Wasnich RD. A critical review of bone mass and the risk of fractures in osteoporosis. Calcif Tiss Int. March 1990;46(3):149-161.

Cited By (82)

Year	Entry
1998	Greenspan SL, Myers ER, Kiel DP, Parker RA, Hayes WC, Resnick NM. Fall direction, bone mineral density, and function: risk factors for hip fracture in frail nursing home elderly. Am J Med. June 1998;104(6):539-545.
2003	Frost HM. Bone's mechanostat: a 2003 update. Anat Rec. 2003;275A(2):1081-1101.
1997	Robinovitch SN, Hayes WC, McMahon TA. Distribution of contact force during impact to the hip. Ann Biomed Eng. May 1997;25(3):499-508.
2000	Cody DD, Hou FJ, Divine GW, Fyhrie DP. Short term in vivo precision of proximal femoral finite element modeling. Ann Biomed Eng. April 2000;28(4):408-414.
1996	Marshall D, Johnell O, Wedel H. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ. May 18, 1996;312(7041):1254-1259.
1995	Riggs BL, Melton LJ III. The worldwide problem of osteoporosis: insights afforded by epidemiology. Bone. November 1995;17(5)(suppl 1):S505-S511.
1996	Hayes WC, Myers ER, Robinovitch SN, Van Den Kroonenberg A, Courtney AC, McMahon TA. Etiology and prevention of age-related hip fractures. Bone. January 1996;18(1)(suppl):77S-86S.
1996	Melton LJ III. Epidemiology of hip fractures: implications of the exponential increase with age. Bone. March 1996;18(3)(suppl 1):S121-S125.
1997	Cheng XG, Lowet G, Boonen S, Nicholson PHF, Brys P, Nijs J, Dequeker J. Assessment of the strength of proximal femur in vitro: relationship to femoral bone mineral density and femoral geometry. Bone. March 1997;20(3):213-218.
1999	Bouxsein ML, Coan BS, Lee SC. Prediction of the strength of the elderly proximal femur by bone mineral density and quantitative ultrasound measurements of the heel and tibia. Bone. July 1999;25(1):49-54.
2002	Homminga J, McCreadie BR, Ciarelli TE, Weinans H, Goldstein SA, Huiskes R. Cancellous bone mechanical properties from normals and patients with hip fractures differ on the structure level, not on the bone hard tissue level. Bone. May 2002;30(5):759-764.
2017	Johannesdottir F, Thrall E, Muller J, Keaveny TM, Kopperdahl DL, Bouxsein ML. Comparison of non-invasive assessments of strength of the proximal femur. Bone. December 1, 2017;105:93-102.
2020	Jin Y, Zhang T, Cheung JPY, Wong TM, Feng X, Sun T, Zu H, Sze KY, Lu WW. A novel mechanical parameter to quantify the microarchitecture effect on apparent modulus of trabecular bone: a computational analysis of ineffective bone mass. Bone. June 2020;135:115314.
1994	Courtney AC, Wachtel EF, Myers ER, Hayes WC. Effects of loading rate on strength of the proximal femur. Calcif Tiss Int. 1994;55(1):53-58.
1995	Bouxsein ML, Courtney AC, Hayes WC. Ultrasound and densitometry of the calcaneus correlate with the failure loads of cadaveric femurs. Calcif Tiss Int. February 1995;56(2):99-103.
1996	Pinilla TP, Boardman KC, Bouxsein ML, Myers ER, Hayes WC. Impact direction from a fall influences the failure load of the proximal femur as much as age-related bone loss. Calcif Tiss Int. April 1996;58(4):231-235.
1999	Parkkari J, Kannus P, Palvanen M, Natri A, Vainio J, Aho H, Vuori I, Järvinen M. Majority of hip fractures occur as a result of a fall and impact on the greater trochanter of the femur: a prospective controlled hip fracture study with 206 consecutive patients. Calcif Tiss Int. July 1999;65(3):183-187.
2017	Fuchs RK, Kersh ME, Carballido-Gamio J, Thompson WR, Keyak JH, Warden SJ. Physical activity for strengthening fracture prone regions of the proximal femur. Curr Osteoporos Rep. February 2017;15(1):43-52.
1996	van den Kroonenberg AJ, Hayes WC, McMahon TA. Hip impact velocities and body configurations for voluntary falls from standing height. J Biomech. June 1996;29(6):807-811.
1996	Zysset PK, Curnier A. A 3D damage model for trabecular bone based on fabric tensors. J Biomech. December 1996;29(12):1549-1558.
1997	Hoshaw SJ, Cody DD, Saad AM, Fyhrie DP. Decrease in canine proximal femoral ultimate strength and stiffness due to fatigue damage. J Biomech. April 1997;30(3):323-329.
1998	Hsiao ET, Robinovitch SN. Common protective movements govern unexpected falls from standing height. J Biomech. January 1998;31(1):1-9.
2001	Smeesters C, Hayes WC, McMahon TA. Disturbance type and gait speed affect fall direction and impact location. J Biomech. March 2001;34(3):309-317.
2007	Feldman F, Robinovitch SN. Reducing hip fracture risk during sideways falls: evidence in young adults of the protective effects of impact to the hands and stepping. J Biomech. 2007;40(12):2612-2618.
2015	Zani L, Erani P, Grassi L, Taddei F, Cristofolini L. Strain distribution in the proximal human femur during in vitro simulated sideways fall. J Biomech. July 16, 2015;48(10):2130-2143.
1995	Robinovitch SN, Hayes WC, McMahon TA. Energy-shunting hip padding system attenuates femoral impact force in a simulated fall. J Biomech Eng. November 1995;117(4):409-413.
2013	Gilchrist S, Guy P, Cripton PA. Development of an inertia-driven model of sideways fall for detailed study of femur fracture mechanics. J Biomech Eng. December 2013;135(12):121001.
1995	Courtney AC, Wachtel EF, Myers ER, Hayes WC. Age-related reductions in the strength of the femur tested in a fall-loading configuration. J Bone Joint Surg. March 1995;77A(3):387-395.
2010	Unnanuntana A, Gladnick BP, Donnelly E, Lane JM. The assessment of fracture risk. J Bone Joint Surg. March 2010;92A(3):743-753.
1995	Looker AC, Johnston CC Jr, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP, Lindsay RL. Prevalence of low femoral bone density in older U.S. women from NHANES III. J Bone Miner Res. May 1995;10(5):796-802.
1996	Hipp JA, Jansujwicz A, Simmons CA, Snyder BD. Trabecular bone morphology from micro-magnetic resonance imaging. J Bone Miner Res. February 1996;11(2):286-292.
1996	Ford CM, Keaveny TM, Hayes WC. The effect of impact direction on the structural capacity of the proximal femur during falls. J Bone Miner Res. March 1996;11(3):377-383.
1997	Burr DB, Forwood MR, Fyhrie DP, Martin RB, Schaffler MB, Turner CH. Bone microdamage and skeletal fragility in osteoporotic and stress fractures. J Bone Miner Res. January 1997;12(1):6-15.
1997	Melton LJ III, Thamer M, Ray NF, Chan JK, Chesnut CH III, Einhorn TA, Johnston CC, Raisz LG, Silverman SL, Siris ES. Fractures attributable to osteoporosis: report from the National Osteoporosis Foundation. J Bone Miner Res. January 1997;12(1):16-23.
1997	Ray NF, Chan JK, Thamer M, Melton LJ III. Medical expenditures for the treatment of osteoporotic fractures in the United States in 1995: report from the National Osteoporosis Foundation. J Bone Miner Res. January 1997;12(1):24-35.
1997	Looker AC, Orwoll ES, Johnston CC Jr, Lindsay RL, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP. Prevalence of low femoral bone density in older U.S. adults from NHANES III. J Bone Miner Res. November 1997;12(11):1761-1768.
2000	Ciarelli TE, Fyhrie DP, Schaffler MB, Goldstein SA. Variations in three‐dimensional cancellous bone architecture of the proximal femur in female hip fractures and in controls. J Bone Miner Res. 2000;15(1):32-40.
2000	McCreadie BR, Goldstein SA. Biomechanics of fracture: is bone mineral density sufficient to assess risk? J Bone Miner Res. December 2000;15(12):2305-2308.
2007	Bouxsein ML, Szulc P, Munoz F, Thrall E, Sornay‐Rendu E, Delmas PD. Contribution of trochanteric soft tissues to fall force estimates, the factor of risk, and prediction of hip fracture risk. J Bone Miner Res*. June 2007;22(6):825-831.
2008	Keaveny TM, Hoffmann PF, Singh M, Palermo L, Bilezikian JP, Greenspan SL, Black DM. Femoral bone strength and its relation to cortical and trabecular changes after treatment with PTH, alendronate, and their combination as assessed by finite element analysis of quantitative CT scans. J Bone Miner Res. December 2008;23(12):1974-1982.
2009	Orwoll ES, Marshall LM, Nielson CM, Cummings SR, Lapidus J, Cauley JA, Ensrud K, Lane N, Hoffmann PR, Kopperdahl DL, Keaveny TM; Osteoporotic Fractures in Men (MrOS) Study Group. Finite element analysis of the proximal femur and hip fracture risk in older men. J Bone Miner Res. March 2009;24(3):475-483.
2020	Yang Y, Komisar V, Shishov N, Lo B, Korall AM, Feldman F, Robinovitch SN. The effect of fall biomechanics on risk for hip fracture in older adults: a cohort study of video‐captured falls in long‐term care. J Bone Miner Res. October 2020;35(10):1914-1922.
1995	Robinovitch SN, McMahon TA, Hayes WC. Force attenuation in trochanteric soft tissues during impact from a fall. J Orthop Res. November 1995;13(6):956-962.
2019	Haider IT, Frei H. Previous damage accumulation can influence femoral fracture strength: a finite element study. J Orthop Res. October 2019;37(10):2197-2203.
2002	Cummings SR, Melton LJ III. Epidemiology and outcomes of osteoporotic fractures. Lancet. May 18, 2002;359(9319):1761-1767.
1995	Lotz JC, Cheal EJ, Hayes WC. Stress distributions within the proximal femur during gait and falls: implications for osteoporotic fracture. Osteoporos Int. July 1995;5(3):252-261.
1997	Li B, Aspden R. Material properties of bone from the femoral neck and calcar femorale of patients with osteoporosis or osteoarthritis. Osteoporos Int. September 1997;7(5):450-456.
1998	Schwartz AV, Kelsey JL, Sidney S, Grisso JA. Characteristics of falls and risk of hip fracture in elderly men. Osteoporos Int. May 1998;8(3):240-246.
2001	Black DM, Steinbuch M, Palermo L, Dargent-Molina P, Lindsay R, Hoseyni MS, Johnell O. An assessment tool for predicting fracture risk in postmenopausal women. Osteoporos Int. August 2001;12(7):519-528.
2003	Muller ME, Webber CE, Bouxsein ML. Predicting the failure load of the distal radius. Osteoporos Int. June 2003;14(4):345-352.
2008	Cui W-Q, Won Y-Y, Baek M-H, Lee D-H, Chung Y-S, Hur J-H, Ma Y-Z. Age-and region-dependent changes in three-dimensional microstructural properties of proximal femoral trabeculae. Osteoporos Int. 2008;19(11):1579-1587.
1997	Myers ER, Wilson SE. Biomechanics of osteoporosis and vertebral fracture. Spine. December 15, 1997;22(24)(suppl):25S-31S.
2016	Haider IT. An Investigation on the Influence of Stumbling Loads on Femoral Fracture Risk, Using a Novel Gradient Enhanced Quasibrittle Finite Element Model [PhD thesis]. Carleton University; 2016.
1997	Samelson EJ. Reproductive and Related Risk Factors for Hip Fracture in White and Black Women [PhD thesis]. Columbia University; 1997.
2006	Fritton JC. Mechanical Loading Induced Adaptation of the Mouse Tibia [PhD thesis]. Ithaca, NY: Cornell University; January 2006.
2015	Brock GR Jr. Changes in Bone Tissue Properties With Osteoporosis Treatment [PhD thesis]. Ithaca, NY: Cornell University; January 2015.
2018	Enns-Bray WS. Identifying Individuals Predisposed to Hip Fracture [PhD thesis]. Swiss Federal Institute of Technology Zürich; 2018.
2019	Fleps I. Assessing the Risk of Hip Fracture: Subject-Specific Dynamic Models for the Simulation of Sideways Fall Impact [PhD thesis]. Swiss Federal Institute of Technology Zürich; 2019.
1999	Smeesters C. Fall Biomechanics and Hip Fracture Risk [PhD thesis]. Cambridge, MA: Harvard University; August 1999.
2018	Deng C. Femur/femoral Neck Load Estimation During Stair Navigation [PhD thesis]. Iowa State University; 2018.
1994	Robinovitch SN. Hip Fracture and Fall Impact Biomechanics [PhD thesis]. Cambridge, MA: Massachusetts Institute of Technology; September 1994.
1995	van den Kroonenberg A. Dynamic Models of Human Falls for Prediction of Hip Fracture Risk [PhD thesis]. Cambridge, MA: Massachusetts Institute of Technology; January 1995.
1996	Ford CM. Failure of the Human Proximal Femur: Material and Structural Perspectives [PhD thesis]. Cambridge, MA: Massachusetts Institute of Technology; September 1996.
1996	Silva MJ. Predicting the Failure Behavior of the Human Vertebral Body [PhD thesis]. Cambridge, MA: Massachusetts Institute of Technology; February 1996.
2014	Ellman R. Skeletal Adaptation to Reduced Mechanical Loading [PhD thesis]. Cambridge, MA: Massachusetts Institute of Technology; September 2014.
2002	Henley JD. A Kinematic and Kinetic Analysis of Postural Perturbation [PhD thesis]. State College, PA: Pennsylvania State University; May 2002.
2008	Laing ACT. Biomechanical Testing of Hip Protectors and Energy-Absorbing Floors for the Prevention of Fall-Related Hip Fractures [PhD thesis]. Simon Fraser University; 2008.
2009	Feldman F. Neuromuscular and Behavioural Influences on Balance and Falls [PhD thesis]. Simon Fraser University; 2009.
2013	Choi WJ. Biomechanics of Falls and Hip Fractures in Older Adults [PhD thesis]. Simon Fraser University; F 2013.
2015	Yang Y. Video Analysis of the Circumstances of Falls in Long-Term Care [PhD thesis]. Simon Fraser University; Spring 2015.
2006	Carpenter RD. Mechanobiology of Bone Cross-Sectional Development, Adaptation, and Strength [PhD thesis]. Stanford University; June 2006.
2009	Varga P. Prediction of Distal Radius Fracture Load Using HR-PQCT-Based Finite Element Analysis [PhD thesis]. Vienna University of Technology; December 2009.
2005	Manske SL. Magnetic Resonance Imaging as an Instrument to Assess the Association Between Femoral Neck Bone Geometry and Strength of the Proximal Femur [Master's thesis]. Vancouver, BC: University of British Columbia; October 2005.
2014	Ariza OR. A Novel Approach to Finite Element Analysis of Hip Fractures Due to Sideways Falls [Master's thesis]. Vancouver, BC: University of British Columbia; April 2014.
2014	Gilchrist SM. Comparison of Proximal Femur Deformations, Failures and Fractures in Quasi-Static and Inertially-Driven Simulations of a Sideways Fall from Standing: An Experimental Study Utilizing Novel Fall Simulation, Digital Image Correlation, and Development of Digital Volume Correlation Techniques [PhD thesis]. Vancouver, BC: University of British Columbia; January 2014.
2000	Hsiao ET. Biomechanical Analysis of Movement Strategies During Falls from Standing Height [PhD thesis]. Berkeley, CA: Berkeley, University of California; 2000.
1997	Sabick MB. The Effects of Fall Direction and Protective Responses on the Likelihood of Hip Fracture in Falls [PhD thesis]. University of Iowa; August 1997.
1998	Ciarelli TE. Architectural and Material Contributions to Fracture of the Spine and Proximal Femur [PhD thesis]. University of Michigan; 1998.
2011	Telonio A. Effets de l'âge et de la direction de la perte d'équilibre sur l'habileté a rétablir l'équilibre et éviter une chute [PhD thesis]. Université de Sherbrooke; November 2011.
1998	Vajda EG. Age-Related Changes in the Microstructure and Mineralization of the Female Proximal Femur [PhD thesis]. University of Utah; March 1998.
2022	Martel DR. Contributors to Proximal Femur Fracture Force: Multiscale Considerations of Rate, Toughness, and Bone Composition [PhD thesis]. University of Waterloo; 2022.
2020	Hamandi FMRA. Hierarchical Structure, Properties and Bone Mechanics At Macro, Micro, and Nano Levels [PhD thesis]. Dayton, OH: Wright State University; 2020.