Calcified Tissue International

, Volume 53, Supplement 1, pp S23–S26 | Cite as

The epidemiology of fragility fractures: Is there a role for bone quality?

  • Cyrus Cooper
Session I


Fragility fractures, particularly those of the hip, vertebrae, and distal forearm, constitute a major public health problem. The two ultimate determinants of fracture are bone strength and propensity to trauma. Bone strength depends not only upon bone mass but also upon a variety of qualitative aspects of bone structure. These include its architecture, the amount of fatigue damage it has sustained, and changes in its bulk material properties, indices that are collectively subsumed into the term “bone quality” Fragility fractures show differences in their patterns of incidence by age, sex, ethnic group, geographic area, and season. Many of these differences are currently unexplained, and disorders of bone quality might contribute to them. There are two fracture sites at which evidence implicates bone quality more directly—the spine and proximal femur. Many vertebral compression fractures follow minimal trauma, and controlled studies suggest that vertebral microarchitecture contributes to fracture risk independently of vertebral bone mass. At the hip, observational studies have pointed to a role for disordered trabecular architecture, accumulation of microfractures (fatigue damage), and the accumulation of osteoid. The extent to which these phenomena act independently of bone mass, however, remains uncertain.

Key words

Osteoporosis Epidemiology Hip fracture 


  1. 1.
    Anonymous (1990) Osteoporosis. In: Berg RL, Cassells JS (eds) The second fifty years: promoting health and preventing disability. National Academy Press, Washington, DC, pp 76–100Google Scholar
  2. 2.
    Johnston CC, Slemenda CW, Melton LJ (1991) Clinical use of bone densitometry. N Engl J Med 324:1105–1109Google Scholar
  3. 3.
    Wahner HW (1989) Measurements of bone mass and bone density. Endocrinol Metab Clin North Am 18:995–1012Google Scholar
  4. 4.
    Melton LJ, Chao EYS, Lane J (1988) Biomechanical aspects of fractures. In: Riggs BL, Melton LJ (eds) Osteoporosis: etiology, diagnosis and management. Raven, New York, pp 111–131Google Scholar
  5. 5.
    Cooper C, Melton LJ (1992) Epidemiology of osteoporosis. Trends Endocrinol Metab 3:224–229Google Scholar
  6. 6.
    Melton LJ (1988) Epidemiology of fractures. In: Riggs BL, Melton LJ (eds) Osteoporosis: etiology, diagnosis and management. Raven, New York, pp 133–154Google Scholar
  7. 7.
    Seeley DG, Browner WS, Nevitt MC, Genant HK, Scott JC, Cummings SR, for the Study of Osteoporotic Fractures Research Group (1991) Which fractures are associated with low appendicular bone mass in elderly women? Ann Intern Med 115:837–842Google Scholar
  8. 8.
    Cooper C, Atkinson EJ, O'Fallon WM, Melton LJ (1992) The incidence of clinically diagnosed vertebral fractures: a population-based study in Rochester, Minnesota, 1985–1989. J Bone Miner Res 7:221–227Google Scholar
  9. 9.
    Hayes WC, Piazza SJ, Zysset PK (1991) Biomechanics of fracture risk prediction of the hip and spine by quantitated computed tomography. Radiol Clin North Am 29:1–18Google Scholar
  10. 10.
    Melton LJ, Ilstrup DS, Riggs BL, Beckenbaugh RD (1982) Fifty year trend in hip fracture incidence. Clin Orthop 162:144–149Google Scholar
  11. 11.
    Riggs BL, Melton LJ (1990) Clinical heterogeneity of involutional osteoporosis: implications for preventive therapy. J Clin Endocrinol Metab 70:1229–1232Google Scholar
  12. 12.
    Parfitt AM, Mathews CHE, Villaneuva AR, Kleerekoper M, Frame B, Rao DS (1983) Relationship between surface, volume and thickness of iliac trabecular bone in aging and in osteoporosis. Implications for the microanatomic and cellular mechanism of bone loss. J Clin Invest 72:1396–1409Google Scholar
  13. 13.
    Melton LJ (1991) Differing patterns of osteoporosis across the world. In: Chesnut CH (ed) New dimensions in osteoporosis in the 1990's. Excerpta Medica, Hong Kong, pp 13–18Google Scholar
  14. 14.
    Maggi S, Kelsey JL, Litvak J, Heyse SP (1991) Incidence of hip fractures in the elderly: a cross-national analysis. Osteoporosis Int 1:232–241Google Scholar
  15. 15.
    Jacobsen SJ, Goldberg J, Miles TP, Brody JA, Stiers W, Rimm AA (1990) Regional variation in the incidence of hip fracture: US white women aged 65 years and older. JAMA 264:500–502Google Scholar
  16. 16.
    Cooper C, Jacobsen SJ, Wickham C, Barker DJP (1991) Water fluoridation and hip fractures. JAMA 266:513–514Google Scholar
  17. 17.
    Sernbo I, Johnell O, Andersson T (1988) Differences in the incidence of hip fracture. Comparison of an urban and a rural population in southern Sweden. Acta Orthop Scand 59:382–385Google Scholar
  18. 18.
    Ralis ZA (1981) Epidemic of fractures during period of snow and ice. Br Med J 282:603–605Google Scholar
  19. 19.
    Jacobsen SJ, Goldberg J, Miles TP, Brody JA, Stiers W, Rimm AA (1991) Seasonal variation in the incidence of hip fracture among white persons aged 65 years and older in the United States, 1984–1989. Am J Epidemiol 133:996–1004Google Scholar
  20. 20.
    Melton LJ, O'Fallon WM, Riggs BL (1987) Secular trends in the incidence of hip fractures. Calcif Tissue Int 41:57–64Google Scholar
  21. 21.
    Spector TD, Cooper C, Fenton AF (1990) Trends in admissions for hip fracture in England and Wales 1968–1985. BMJ 300:1178–1184Google Scholar
  22. 22.
    Cooper C, Atkinson EJ, Kotowicz M, O'Fallon WM, Melton LJ (in press) Secular trends in the incidence of postmenopausal vertebral fractures. Calcif Tissue IntGoogle Scholar
  23. 23.
    Kleerekoper M, Villaneuva AR, Stanciu J, Rao DS, Parfitt AM (1985) The role of three-dimensional trabecular microstructure in the pathogenesis of vertebral compression fractures. Calcif Tissue Int 37:594–597Google Scholar
  24. 24.
    Recker RR, Kimmel DB (1991) Changes in trabecular microstructure in osteoporosis occur with normal bone remodelling dynamics. J Bone Miner Res 6(suppl 1):S225Google Scholar
  25. 25.
    Ross PD, Davis JW, Epstein RS, Wasnich RD (1991) Preexisting fractures and bone mass predict vertebral fracture incidence in women. Ann Intern Med 114:919–923Google Scholar
  26. 26.
    Cooper C, Barker DJP, Morris J, Briggs RSJ (1987) Osteoporosis, falls and age in fracture of the proximal femur. BMJ 295:13–15Google Scholar
  27. 27.
    Cooper C, Barker DJP, Hall AJ (1986) Evaluation of the Singh index and femoral calcar width as epidemiological methods for measuring bone mass in the femoral neck. Clin Radiol 37:123–125Google Scholar
  28. 28.
    Freeman MAR, Todd RC, Pirie CJ (1974) The role of fatigue in the pathogenesis of senile femoral neck fractures. J Bone Jt Surg 56B:698–702Google Scholar
  29. 29.
    Chapuy MC, Arlot ME, Duboeuf F, Brun J, Crouzet B, Arnaud S, Delmas PD, Meunier PJ (1992) Vitamin D3 and calcium to prevent hip fractures. N Engl J Med 327:1637–1642Google Scholar

Copyright information

© Springer-Verlag New York Inc. 1993

Authors and Affiliations

  • Cyrus Cooper
    • 1
  1. 1.The MRC Environmental Epidemiology UnitSouthampton General HospitalSouthamptonEngland

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