Beruflich Dokumente
Kultur Dokumente
DOI 10.1007/s00198-005-1887-3
O R I GI N A L A R T IC L E
Rib fractures predict incident limb fractures: results from the European
prospective osteoporosis study
A.A. Ismail A.J. Silman J. Reeve S. Kaptoge
T.W. ONeill
Received: 28 October 2004 / Accepted: 1 March 2005 / Published online: 1 June 2005
International Osteoporosis Foundation and National Osteoporosis Foundation 2005
Abstract Population studies suggest that rib fractures are (range 0.45.9 years), of whom 135 men (2.3%) and 101
associated with a reduction in bone mass. While much is women (1.6%) reported a previous low trauma rib
known about the predictive risk of hip, spine and distal fracture. In total, 138 men and 391 women sustained a
forearm fracture on the risk of future fracture, little is limb fracture during follow-up. In women, after age
known about the impact of rib fracture. The aim of this adjustment, those with a recalled history of low trauma
study was to determine whether a recalled history of rib rib fracture had an increased risk of sustaining any
fracture was associated with an increased risk of future limb fracture [relative hazard (RH) =2.3; 95% CI 1.3,
limb fracture. Men and women aged 50 years and over 4.0]. When stratied by fracture type the predictive risk
were recruited from population registers in 31 European was more marked for hip (RH=7.7; 95% CI 2.3, 25.9)
centres for participation in a screening survey of osteo- and humerus fracture (RH=4.5; 95% CI 1.4, 14.6) than
porosis (European Prospective Osteoporosis Study). other sites (RH=1.6; 95% CI 0.6, 4.3). Additional
Subjects were invited to complete an interviewer- adjustment for prevalent vertebral deformity and pre-
administered questionnaire that included questions vious (non-rib) low trauma fractures at other sites
about previous fractures including rib fracture, the age slightly reduced the strength of the association between
of their rst fracture and also the level of trauma. Lat- rib fracture and subsequent limb fracture. In men, after
eral spine radiographs were performed and the presence age adjustment, there was a small though non-signicant
of vertebral deformity was determined morphometri- association between recalled history of rib fracture and
cally. Following the baseline survey, subjects were future limb fracture. Our data highlight the importance
followed prospectively by annual postal questionnaire to of rib fracture as a marker of bone fragility in women.
determine the occurrence of clinical fractures. The
subjects included 6,344 men, with a mean age of Keywords Epidemiology Incident limb fracture
64.2 years, and 6,788 women, with a mean age of Prospective study Osteoporosis Rib fracture
63.6 years, who were followed for a median of 3 years
This study was carried out in conjunction with the EPOS Study Introduction
Group (see Appendix).
Rib fractures are common in middle-aged and elderly
A.A. Ismail (&) men and women with an estimated incidence of 315 per
Department of Rheumatology,
Stepping Hill Hospital,
100,000 person years at ages 60 years and over [1]. The
Stockport, UK incidence increases with age and is greater in women
E-mail: abbas.ismail@tiscali.co.uk than men [2]. As with vertebral fractures not all rib
Tel.: +44-161-4194798 fractures come to clinical attention and the true inci-
Fax: +44-161-4195548 dence may be higher. Population-based studies suggest
A.J. Silman T.W. ONeill that rib fractures are linked with reduced bone mass [3,
ARC Epidemiology Unit, 4] and thus those who have sustained a low trauma rib
University of Manchester,
Manchester, UK
fracture might be expected to be at increased risk of
further fragility fracture. However, while much is known
J. Reeve S. Kaptoge about the predictive risk of hip, spine and wrist frac-
University Department of Medicine,
Strangeways Research Laboratory, ture on the risk of future fracture [5, 6], we know
Worts Causeway, Cambridge, UK little about the impact of rib fracture. Such data are
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importantevidence that rib fractures are linked with occurrence and site of fracture were not available in 9%
an increased risk of future fracture provides an impor- of cases. In these cases the site of fracture was deter-
tant rationale for considering aected individuals for mined from the area marked by the subject on the
assessment and therapy to prevent bone loss and reduce mannequin [9]. The data coordination for the study was
the risk of further fractures. We used data from the in Manchester (UK) and Lubeck (Germany).
European Prospective Osteoporosis Study (EPOS) to
determine the relationship between a recalled history of
rib fracture and subsequent risk of limb fracture. Analysis
Table 1 Baseline characteristics of study subjects fracture and 1.1 per 1,000 pys in those without. The
Men Women incidence of humerus fracture was 10.2 per 1,000 pys in
(n=6,344) (n=6,788) those with a history of rib fracture and 1.9 per 1,000 pys
in those without.
Mean age (SD) 64.2 (8.4) 63.6 (8.4) In men, after age adjustment, there was a small
Prevalence of vertebral 743 (11.7%) 799 (11.8%) though not signicant association between recalled his-
deformity
History of low trauma 135 (2.3%) 101 (1.6%) tory of rib fracture and future limb fracture: age-ad-
rib fracture (%) justed RH=2.0 (95% CI 0.94.5). Additional
History of low trauma 275 (4.3%) 873 (12.9%) adjustment for BMI and centre did not alter the results
fractures (>50 years)* (%) in both men and women (results not presented).
*Excluding rib fracture
Discussion
deformity was similar in men and women (11.7 vs.
11.8%). In this study, women with a recalled history of low
trauma rib fractures had a signicantly increased risk of
future limb fracture, particularly hip and humerus
Limb fractures at follow-up
fracture. Our study had several advantagesit was
population based and included both men and women.
In total, 138 men and 391 women sustained a limb
There are, however, several limitations that need to be
fracture during the follow-up period (Table 2). Of these
considered when interpreting the results. Classication
fractures the most frequent individual fracture site was
of rib fracture at the baseline survey was based on self
the distal forearm. Ten subjects sustained more than one
report, which is subject to errors of recall both of under-
type of limb fracture.
and over-reporting. Under-reporting may have occurred
if aected individuals did not come to medical attention,
Rib fracture and incident limb fractures or alternatively if they did and the diagnosis was missed.
Over-reporting may have occurred if individuals or their
In women the incidence of any limb fracture was 47.4 medical attendants ascribed chest pain, usually follow-
per 1,000 patient years (pys) in those with a history of ing an episode of trauma or coughing episode, as due to
rib fracture and 18.9 per 1,000 pys in those without. For rib fracture without conrmation by chest radiograph.
men the corresponding gures were 14.5 per 1,000 pys In a previous study in elderly women 23% of self-re-
and 7.2 per 1,000 pys. Table 3 presents the adjusted ported rib fractures were false positives [11]. In our study
relative hazards (RH) for the association between there were more self-reported fractures in men compared
baseline rib fracture and future limb fracture in men and to women (2.3 vs. 1.6%). A possible explanation is that
women. In women, after age adjustment, those with a men, due to sports or occupational hazard, may have
history of low trauma rib fracture had a modestly in- had more frequent chest trauma causing rib fracture
creased risk of sustaining any limb fracture: age-ad- than women. Alternatively chest wall pain in men may
justed relative hazard (RH)=2.3 (95% CI 1.34.0). have been more likely to be attributed to rib fracture
When stratied by fracture type the risk was more when actually no fracture had occurred. We repeated the
marked for the hip (RH=7.7; 95% CI 2.3, 25.9) and analysis excluding those subjects with rib fractures that
humerus fracture (RH=4.5; 95% CI 1.4, 14.6). Addi- occurred under the age of 40 years and the results were
tional adjustment for prevalent vertebral deformity and broadly similar though condence intervals were wide.
previous low trauma fractures slightly reduced the Errors may also have occurred in the classication of
strength of the association between rib fracture and incident fractures. To reduce the risk of over-reporting,
subsequent limb fracture. The incidence of hip fracture fractures were where possible conrmed by either review
was 10.2 per 1,000 pys in those with a history of rib of the radiograph or contemporary medical records or
subject interview. In a small proportion of cases (9%) it
Table 2 Number (%) of subjects with incident limb fracture by was not possible to conrm fracture by any of these
gender methods. It is possible therefore that subjects who were
more likely to over-report rib fractures at baseline may
Type of incident Men Women also have been more likely to over-report incident limb
limb fracture
fractures during follow-up (systematic bias). Restricting
Hip 19 (14%) 28 (7%) the analysis, however, to those individuals in whom
Distal forearm 32 (23%) 150 (38%) incident limb fractures were conrmed (by radiograph,
Humerus 15 (11%) 43 (11%) medical records or subject interview) did not aect the
Other limb 74 (53%) 178 (45%)
Any limb fracture* 138 (100%) 391 (100%)
results (data not shown). Given the study design it was
not possible to assess the degree of under-reporting.
*Numbers in cells do not add up because ten subjects incurred However, in a separate study at three of the participat-
more than one type of limb fracture ing centers, amongst 174 subjects with a known history
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Table 3 Relationship between history of rib fracture and incident limb fracture in men and women.RH relative hazard; CI condence
interval
Any limb fracture* 138 2.0 (0.94.5) 1.9 (0.84.2) 391 2.3 (1.34.0) 2.0 (1.13.5)
Hip 19 28 7.7 (2.325.9) 5.5 (1.618.8)
Humerus 15 43 4.5 (1.414.6) 4.0 (1.213.2)
Colles 32 1.4 (0.29.9) 1.3 (0.29.3) 150 1.7 (0.64.5) 1.6 (0.64.3)
Other 74 2.4 (0.96.5) 2.3 (0.86.2) 178 1.6 (0.64.3) 1.4 (0.53.7)
*Numbers do not add up because ten subjects incurred more than one type of limb fracture. Too few fracture events in men. Multi-
variate: adjusted for age, baseline vertebral deformity, history of low trauma fracture (excluding rib fracture)
of previous fracture, only 12 (7%) did not recall the may be explained by non-skeletal factors such as an
event, and only 3% of subjects did not recall a hip or increased tendency to fall among those with prevalent
distal forearm fracture [9]. The eect of any under- rib fracture. Further studies are required in order to
reporting would again tend to reduce the chance of tease out the relative contribution of bone mass, qual-
nding any signicant association between rib fracture ity, bone turnover and falls in explaining the associa-
and future limb fracture. In our study we did not include tion.
fractures that occurred following rib fracture and prior What are the implications of our ndings? The
to the baseline survey. The eect of this would be to treatment for rib fracture is largely symptomatic and
underestimate the strength of the associations. Finally supportive and among individuals with low trauma rib
our results were derived from a predominantly Cauca- fracture, radiographs are sometimes not performed. Our
sian population in Europe, and the data should be data highlight the importance of rib fracture as a marker
extrapolated beyond this population with caution. of bone fragility in women. Women presenting with
It is well established that hip, wrist and vertebral musculoskeletal chest pain following relatively minor
fractures are associated with an increased risk of future trauma or in whom rib fracture is suspected should be
limb fracture [6, 12, 13, 14]. Studies have also suggested referred for chest radiography to conrm whether or not
an increased risk of fracture among those with a history a rib fracture has occurred. Furthermore, women with
of any previous fracture [5, 15]. To our knowledge, low trauma rib fracture should be considered for bone
however, there are no data concerning the relationship mineral densitometry to assess their underlying osteo-
between rib fracture and future limb fracture. Our re- porosis risk and if osteoporosis is conrmed given
sults suggest that women with rib fracture are at in- appropriate treatment.
creased risk of future limb fracture, particularly of the In conclusion this study shows that women with low
hip and humerus though the condence limits are wide. trauma rib fracture are at signicantly increased risk of
The strength of the association between rib and future future limb fracture, particularly hip and humerus
limb fracture was broadly similar in men though the fractures. The detection of rib fracture in women may
condence intervals around the eect estimates included help identify those at risk of future limb fracture.
unity. This almost certainly reects reduced statistical
power because of the smaller number of incident limb Acknowledgements The study was nancially supported by a
fractures. European Union Concerted Action Grant under Biomed-1
(BMH1CT920182), and also EU grants C1PDCT925102,
What is the explanation for the association between ERBC1PDCT 930105 and 940229. The central coordination was
prevalent rib fracture and future limb fractures? At also supported by the UK Arthritis Research Campaign, the
least part of the explanation is that both fractures are Medical Research Council (G9321536) and the European Foun-
associated with low bone mass [3, 4]. In our study bone dation for Osteoporosis and Bone Disease. The EUs PECO pro-
mass measurements were undertaken in a sub sample of gram linked to BIOMED 1 funded in part the participation of the
Budapest, Warsaw, Prague, Piestany, Szczecin and Moscow cen-
the study cohort at baseline; however, because of the ters. Data collection from Croatia was supported by a grant from
relatively small numbers of individuals with complete the Wellcome Trust. The central X-ray evaluation was generously
data concerning incident limb fractures and bone den- sponsored by the Bundesministerium fuer Forschung and Tech-
sity, we were unable to determine whether adjustment nologie, Germany. Individual centers acknowledge the receipt of
locally acquired support for their data collection. Dr. Abbas Ismail
for bone mass inuenced or explained our ndings. In was a Wellcome Trust Clinical Research Fellow. We would like to
studies of fractures at other skeletal sites, adjustment thank the following individuals: Rita Smith, Aberdeen, UK; Uday
for bone mass did not signicantly inuence the risk of Bhonsle, Anna Martin, Judith Walton, Bridget Wardley-Smith,
future fracture [16, 17]. It is possible that the occur- Cambridge and Harrow, UK; Mrs. Joanna Parsons, Truro, UK; J.
Bernardino Diaz Lopez, Ana Rodriguez Rebollar, Oviedo, Spain.
rence of a previous rib fracture may also be a marker of We would like also to thank the individuals who took part in the
impaired bone quality, or increased bone turnover, study and the many individuals who helped access our population
which inuences fracture risk. Alternatively, the risk samples.
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