Dem Bones, Dem Bones – how to stop fractures

Osteoporosis means ‘bone with holes in it’ and is the cause of significant later life problems.

The figures are that 1 in 3 women and 1 in 5 men suffer osteoporotic ‘fragility fractures ‘of the hip, spine ribs or limbs. The fractures usually occur over age 65 unless someone has additional risk factors such as taking corticosteroids, a history of anorexia [so bones thinned at an early stage of adulthood] or alcoholism.

There were 100,000 hip fractures in the UK in 2020 [up from 44,000 in 2006]* so this is a growing problem. Osteoporotic fragility fractures can cause substantial pain and severe disability, often leading to a reduced quality of life: infact hip and vertebral fractures are associated with decreased life expectancy. Hip fracture nearly always requires hospitalisation, is fatal in 20% of cases and permanently disables 50% of those affected; only 30% of patients recover full function and completely independent living. So osteoporosis is a condition to be aware of and take effective steps to avoid. Importantly, it is entirely preventable – a fact rarely advertised or discussed.

Bone strength: cortex and spongy bone

The strength of bones comes from both its structural features , the outer shell or cortex and the spongy inner structure that is rather like reinforced concrete with bone surrounding blood vessels and connective tissue elements. Both types of bone are important in maintaining strength and the flexible resistance to stress that prevents fracture. Osteoporosis thins the cortex and increases the size of the holes in the bone due to loss of bone in the ‘struts’ of the sponge, known as trabeculae.

Bone loss is the problem

Bone is constantly being tidied up and renewed [remodelling]. As we age, that process slows down and the degree of bone loss is not perfectly matched by bone replacement. However this age-related bone loss is dwarfed by the changes due to sex hormone changes: oestrogen and testosterone loss in women post menopause and testosterone loss in men that occurs somewhat later [60+], but inevitably. So women after 50 and men after 60 lose bone mass at a rate of between 1% and 3% per year. Fracture risk increases significantly when around 15% of bone has been lost but this depends to some extent of how strong that persons’ bones were to start with and this varies genetically, by sex and because of exercise.

What should you do?

The most important thing to do is to find out your risk and the best way to do this is by getting a Dexa scan that measures your bone density in spine and hip and calculates your risk of fracture. Dexa scans are cheap and in some circumstances [eg in parts of the UK] are provided free.

There is a risk prediction tool called Frax that can be used to predict fracture risk fairly accurately but it is most useful when the bone density is known. It is worth paying to have a test around the age of 60-65 if no free service is available and if you are high risk then treatment can be started.

A person taking HRT or TRT [in men] will probably be protected. More accurate measurement of fracture risk can be established using a clever CT scan called HRpQCT that can show the structure as well as the density.

This is mainly a research tool right now but will be a game changer in years to come.

Most importantly the risk to men has usually been seriously underrated. Men need to know their bone density too, though many family practitioners are not aware of this!