Health Matters: Hip fractures and osteoporosis

Conway McLean, DPM, Journal columnist

It’s common knowledge: hip fractures are dangerous. Every year, approximately 300,000 seniors are hospitalized for hip fractures. And though there are a multitude of factors, fractures of the hip bone have a one year mortality rate of 15 to 30 percent. Even those who survive the first year will tend to have a shorter life expectancy. Another risk is the surgery often required to repair the damage: complications from hip fracture surgery are common.

We have established this traumatic event is life-changing. Why are there so many? Due to the aging population, the number of hip fractures per year is expected to double in the next few decades, since these are a recognized consequence of aging. Bone loss is a common finding amongst the elderly, occurring when either the body loses too much bone, makes too little bone, or both. This process leads to weakened bones, making a fracture easier to occur. In serious cases of bone loss, a broken hip bone can happen from something as simple as a sneeze.

This process, of a progressive weakening of bone, is termed osteopenia, although most of us are more familiar with the term osteoporosis. What is the difference and how are they related? These are important questions, being asked by many aging Americans. The health care costs associated with these injuries means that some major players, like the insurance companies, even the federal government, are asking these same questions.

Osteopenia is the first phase someone goes through when their bones are thinning. Both osteoporosis and osteopenia represent varying degrees of bone loss, becoming less dense. Osteoporosis is the more severe form of the two. In this process, the body is breaking down more bone than it is creating. When viewed under a microscope, healthy bone looks like a honeycomb, while osteoporotic bone has more space and less bone.

You can think of osteopenia as a midpoint between healthy bone and osteoporotic bone. Osteopenia is present when your bones are weaker than normal but not so much that they break easily. Osteopenia affects about half of Americans over age 50. The occurrence of fractures with even slight trauma is a hallmark of osteoporosis.

As a generalization, our bones are usually densest when we are about 30 years of age. Osteopenia, when it happens, and it doesn’t always, typically occurs after the age of 50. There are many variables in this process, with the strength of your bones when you’re young being a critical factor. Good bone strength as a youth usually indicates minimal osteopenia in the later years. As in most things, your genetic make-up is also tremendously important.

Bone density is a function of many things besides your genetics. It has been well established: the stresses of weight bearing change one’s bone density. Bone tissue responds to physical stress by laying down more bone, altering that constant balance of bone deposition and resorption. A weightlifter is going to have denser, and therefore stronger, bone than their genetic constitution might otherwise have dictated.

Many strategies have been documented allowing us to intervene in this process. As with so many aspects of health, exercise is a powerful tool in reducing osteopenia. Physical stress will trigger a shift in the deposition-resorption equation. Diet also can be altered to reduce these dangerous changes. Additionally, certain medications have been developed to slow this process, helping to keep your bones stronger.

As to the question of the symptoms associated with osteopenia and osteoporosis, the answer is simple: there are none. It is considered a silent killer because one can’t feel their bones weakening. There is no pain or discomfort. That is always the situation until one has experienced the most significant consequence of the disease, a painful broken bone.

Many risk factors for osteopenia have been identified, from your sex to your diet. The disease has a clear predilection for women (3 to 1), and the age factor has already been mentioned. Naturally, there is a genetic component, in which case a family history of the condition is often reported. Some diseases can lead to the development of osteoporosis, such as rheumatoid arthritis and others of the auto-immune diseases, as well as many gastro-intestinal disorders. Smoking cigarettes encourages this process, as does being a heavy drinker.

Certain drugs are known for their ability to impair bone health. One class of drug used to treat heartburn (eg. omeprazole and pantoprazole) has this effect. Corticosteroids, like prednisone and cortisone, can also lead to osteopenic changes when taken for more than three months. Some of the newer antidepressants, which includes some commonly prescribed medications like Prozac and Paxil, can have this action.

It is a relatively simple concept: your fracture risk increases as your bone density wanes. Bone density testing is more precise than ever with the development of the DEXA scan, a unique type of X-ray. Plain films provide an impression of the changes of osteopenia but it’s difficult to measure accurately. Many get a DEXA scan regularly if they have some risk factors in an effort to find bone loss before it becomes serious.

Hip fractures are typically the result of osteoporosis, although many other bones can be broken like the spine or wrist. Osteoporosis causes some patients to lose height when it affects the bones of the spine, leading to the characteristic hunched posture. Limitations in mobility resulting from these traumatic injuries often leads to feeling isolated or depressed. As mentioned, the ultimate complication is death, an uncomfortably common event following a hip fracture, related to either the broken bone or the surgery to repair it.

As mentioned, exercise is a key to bone health. Mild bone loss is best treated with exercise, studies revealing resistance training to be the most effective, although any kind of physical stress results in improved bone density. Simply walking more, carrying your body around, working against gravity to stay upright, is an excellent method for many seniors.

Nutritional therapies are beneficial. Vitamin D supplementation has been well-documented to improve bone density in many studies. Diets low in protein are a risk factor for osteoporosis, since a protein deficiency reduces calcium absorption, accelerating the demineralization of bone. Calcium also is known to benefit bone density, with roughly 1,200 mg of calcium a day a common recommendation. Foods high in calcium include many dairy products, leafy green vegetables, and certain types of fish. A common suggestion for vitamin D is to take 800 units a day, especially if you are female going through menopause or get very little sun.

More than 95% of hip fractures are caused by a fall, so reducing the risk factors for falls is an effective approach. Many techniques can assist the human body in being more stable and balanced. From specialized physical therapy techniques to better foot support, fall prevention is a worthwhile endeavor. A very different approach is through improving bone health, which has obvious benefits. Fracture prevention by increasing bone density has many positives. Thus, the old adage rings true: an ounce of prevention is worth its weight in gold, or something like that. But you get the idea: exercise and better nutrition as means of reducing fracture risk. It’s a fine prescription for health.

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments atdrcmclean@outlook.com.


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