Multiple simultaneous fractures are associated with higher all-cause mortality: results from a province-wide fracture liaison service

  • R. SujicEmail author
  • J. Luo
  • D.E. Beaton
  • E.R. Bogoch
  • J.E.M. Sale
  • S. Jaglal
  • R. Jain
  • M. Mamdani
  • the Ontario Osteoporosis Strategy Fracture Screening and Prevention Program Evaluation Team
Original Article



Mortality rates in our fracture liaison service ranged from 2.7% at year 1 to 14.8% at year 5 post-screening. Presentation with multiple simultaneous fractures at screening was associated with higher risk of death. This finding indicates the need for increased focus on this high-risk group.


To examine all-cause mortality rates in a provincial fracture liaison service (FLS) and the association between the index fracture type, particularly multiple simultaneous fractures, and the risk of death at follow-up.


This cohort study includes fragility fracture patients aged 50+, enrolled in a provincial FLS in Ontario, Canada, between 2007 and 2010. All-cause mortality was assessed using administrative data. Multivariable Cox proportional hazards model was used to examine the risk of death 5 years after screening.


Crude mortality rates for 6543 fragility fracture patients were 2.7% at year 1, 5.6% at year 2, and 14.8% at year 5 after screening. After adjusting for age and sex, and relative to distal radius fracture, patients with multiple (simultaneous) fractures at screening had a higher risk of dying (HR = 1.8, 95%CI 1.3–2.4), followed by those with a hip fracture (HR = 1.5, 95%CI 1.3–1.8), a proximal humerus fracture (HR = 1.4, 95%CI 1.2–1.7), and other single fractures (HR = 1.4, 95%CI 1.1–1.7). Having an index ankle fracture was not associated with the risk of death over a distal radius fracture. As compared to the 50–65 age group, patients 66 years and older had a higher risk of death (for 66–70 age group: HR = 2.5, 95%CI 1.9–3.3; for 71–80: HR = 4.3, 95%CI 3.5–5.4; and for 81+: HR = 10.6, 95%CI 8.7–13.0). Females had a lower risk of death (HR = 0.5, 95%CI 0.5–0.6) than males.


Presenting with multiple fractures was an indicator of higher risk of death relative to a distal radius fracture. This finding indicates the need for increased focus on this high-risk group.


Fracture liaison service Fragility fracture Mortality rates Multiple fractures Risk of death 


Funding information

This project was supported by funding from the Ontario Ministry of Health and Long Term Care (MOHLTC) through the Ontario Osteoporosis Strategy. The views expressed are those of the researchers and do not necessarily reflect those of the MOHLTC. This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. The data used in this study were linked using unique encoded identifiers and analyzed at ICES Central. The authors gratefully acknowledge the support of Osteoporosis Canada and the Fracture Screening and Prevention Program Evaluation Team for their overall evaluation of the program.

Compliance with ethical standards

This project received a Research Ethics Board (REB) approval of the principal investigators’ home institution St. Michael’s hospital, Toronto (REB#08-304), the Sunnybrook Health Sciences Centre, Toronto REB, and approvals from each fracture clinic’s REB for research use of patients’ data.

Conflict of interest

Rebeka Sujic, Jin Luo, Dorcas E Beaton, Joanna EM Sale, Susan Jaglal, and Ravi Jain declare that they have no conflict of interest. Earl R Bogoch received an unrestricted research grant and speaker fees from Amgen Canada Inc, and is an Editorial Board member for the Journal of Rheumatology. Muhammad Mamdani received Honoraria and served as a consultant/advisory board of Novo Nordisk, Allergan, and Amgen.


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Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2019

Authors and Affiliations

  • R. Sujic
    • 1
    Email author
  • J. Luo
    • 2
  • D.E. Beaton
    • 1
    • 3
    • 4
  • E.R. Bogoch
    • 5
    • 6
  • J.E.M. Sale
    • 1
    • 3
  • S. Jaglal
    • 2
    • 7
    • 8
  • R. Jain
    • 9
  • M. Mamdani
    • 2
    • 3
    • 10
  • the Ontario Osteoporosis Strategy Fracture Screening and Prevention Program Evaluation Team
  1. 1.Musculoskeletal Health and Outcomes ResearchLi Ka Shing Knowledge Institute of St. Michael’s HospitalTorontoCanada
  2. 2.ICESTorontoCanada
  3. 3.Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoCanada
  4. 4.Institute for Work & HealthTorontoCanada
  5. 5.Division of Orthopaedic Surgery, Department of SurgeryUniversity of TorontoTorontoCanada
  6. 6.Mobility ProgramSt. Michael’s HospitalTorontoCanada
  7. 7.Toronto Rehabilitation Institute – University Health NetworkTorontoCanada
  8. 8.Department of Physical TherapyUniversity of TorontoTorontoCanada
  9. 9.Ontario Osteoporosis StrategyOsteoporosis CanadaTorontoCanada
  10. 10.Li Ka Shing Centre for Healthcare Analytics Research & TrainingLi Ka Shing Knowledge Institute of St. Michael’s HospitalTorontoCanada

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