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July 15, 2007 ◆ Volume 76, Number 2 www.aafp.org/afp American Family Physician 273

Clinical Question

Whicholderwomen are athigh riskofhipfracture?

Evidence Summary

Approximatelyonein sixwomenwillhavea hip fracture during her lifetime, and

approximatelyonein35ofallwomenwilldie of complications from hip fracture.1Bonemineraldensityscreeningforwomenis recommended beginning at 65 years ofage,orat60yearsofageinthepresenceofriskfactorssuchaslowerbodymassindex,smoking, or long-term corticosteroid use.2However,lowbonemineraldensityisonlyone ofmany risk factors for hip fracture.Identifying women who are at high risk

allows a family physician to recommendadditionalmeasures thatmight reduce therisk of fracture such as exercise and bal-ance regimens,3 cessation of tobacco oralcoholuse,4andmodificationsofthehomeenvironment.5

Anumberofclinicalriskscoreshavebeen

developed and validated (Table 1).6-11 Twoofthesescoreshavenotbeenprospectivelyvalidatedandthusareinappropriateforuseintheclinicalsetting.9,10Othersaretoolongforoutpatientcare8,11orrequiredatacollec-tionthatisimpractical intheprimarycaresetting.8,9 Two scores have been prospec-tivelyvalidatedinabroadspectrumofolderwomenandaresimpleenoughtouseintheprimarycaresetting.6,7

Predicting Hip Fracture Risk in Older WomenMARKH.EBELL,MD,MS,Athens, Georgia

This guide is one in aseries that offers evidence-based tools to assist familyphysicians in improvingtheir decision making atthe point of care.

A collection of Point-of-Care Guides published inAFP is available at http://www.aafp.org/afp/poc.

Table 1. Studies Used to Develop Clinical Risk Scores for Predicting Hip Fracture in Older Women

Study Population studied

No. of patients

(prospective

validation cohort)

No. of items

in risk score

BMD included

in risk score?

Recommended scores for primary care

Black, et al., 20016 Women older than 65 years 7,575 6 or 7 Optional

Albertsson, et al., 20077 Women older than 70 years 1,498 4 No

Other scores

Colon-Emeric, et al., 20028 Men and women older than

65 years

3,505 9 No

Dargent-Molina, et al., 2002*9 Women older than 75 years

witha T-score of –3.5 to –2.5

— 5 No

McGrother, et al., 2002*10 Women older than 70 years — 6 (three-year risk)

4 (five-year risk)

No

Ahmed, et al., 200611 Women 65 to 74 years of age 1,410 14 Yes

BMD = bone mineral density.

*—Not prospectively validated.

Information from references 6 through 11.

Point-of-Care Guides

Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright ©2007 American Academy of Family Physicians. For the private, noncommer-

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274 American Family Physician www.aafp.org/afp Volume 76, Number 2 ◆ July 15, 2007

The FRAMO (Fracture and Mortality)Index (Table 2), validated in 1,498 Swed-ishwomen,consistsoffouritemsusedinasimplescoringsystem.7Itidentifieslow-andhigh-risk groups and is a good predictor

ofoverallmortality and hip fracture risk.7

The Fracture Index (Table 3) is a six-itemrisk score with an optional seventh item(bone mineral density at the hip).6 Itwasdevelopedin7,782womenusingdatafromtheStudyofOsteoporoticFracturesandwasvalidatedinaseparategroupof7,575Frenchwomen.6

Applying the Evidence

A76-year-oldwomanweighs110lb(49.9kg),isanonsmoker,andhadavertebralfracture

fouryears ago;hermotherneverhadahipfracture.Thepatientisunabletoconsistentlyliftherselfout ofa chairwithout usingherarms,andherT-scoreatthehipis–2.1.What

isthepatient’sriskofhipfractureandoverallmortalityinthenextfewyears?

Answer: Using the FRAMO Index(Table 2 7), she receives one point for herweight, one for being unable to rise from

Table 2. FRAMO (Fracture andMortality) Index for PredictingHip Fracture and Mortality Risk inOlder Women

Patient characteristics Points

Age ≥ 80 years 1

Weight < 132 lb (59.9 kg) 1

Unable to rise five times from a chair

without using the arms

1

Any fracture of the wrist, lower

arm, upper arm, hip, or vertebra

after 40 years of age (or vertebral

compression seen on a radiograph*)

1

Total:

Risk group (score)

Two-year risk

Hipfracture

Overall mortality

Low (0 or 1) 6/789

(0.8%)

25/789

(3.2%)

High (2 or more) 25/459

(5.4%)

109/459

(23.7%)

*—A radiograph is not needed if fracture history is

known.

Adapted with permission from Albertsson DM, Mell-

ström D, Petersson C, Eggertsen R. Validation of a

4-item score predicting hip fracture and mortality risk

among elderly women. Ann Fam Med 2007;5:49, 52.

Table 3. Fracture Index for PredictingHip Fracture Risk in Older Women

The rights holder did not grant the

American Academy of Family Physicians

the right to sublicense this material to a

third party. For the missing item, see the

original print version of this publication.

Adapted with permission from Black DM, Steinbuch

M, Palermo L, Dargent-Molina P, Lindsay R, Hoseyni

MS, et al. An assessment tool for predicting frac-

ture risk in postmenopausal women. Osteoporos Int

2001;12:523, 525.




July 15, 2007 ◆ Volume 76, Number 2 www.aafp.org/afp American Family Physician 275

a chair five timeswithoutusingher arms,andoneforhavingafractureafter40yearsofage.Youdeterminethathertwo-yearhipfractureriskis5.4percent,andhertwo-yearoverallmortalityriskis23.7percent.Using

the Fracture Index (Table 36

), she receivesthree points for her age, one for having afracture after 50 years of age, one for herweight,andtwoforneedingtouseherarmstorisefromachair.Ifbonemineraldensityis considered, she receives three points forher T-score. You determine that her four-year risk of hip fracture, according to theFractureIndex,is10.4percentbasedonriskfactors aloneand7.8percentbasedon riskfactorsplusbonemineraldensityatthehip.

Address correspondence to Mark H. Ebell, MD, MS, at [email protected]. Reprints are not available from theauthor.

REFERENCES

1. Cummings SR, Black DM, Rubin SM. Lifetime risks of

hip, Colles’, or vertebral fracture and coronary heart

disease among white postmenopausal women. Arch

Intern Med 1989;149:2445-8.

2. U.S. Preventive Services Task Force. Recommendations

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pausal women. Accessed May 1, 2007, at: http://www.

ahrq.gov/clinic/3rduspstf/osteoporosis/osteorr.htm.

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Lindsay R, Hoseyni MS, et al. An assessment tool for

predicting fracture risk in postmenopausal women.

Osteoporos Int 2001;12:519-28.

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R. Validation of a 4-item score predicting hip fracture

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9. Dargent-Molina P, Douchin MN, Cormier C, Meunier

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10. McGrother CW, Donaldson MM, Clayton D, Abrams

KR, Clarke M. Evaluation of a hip fracture risk score

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Fracture (MOF) study. Osteoporos Int 2002;13:89-96.

11. Ahmed LA, Schirmer H, Fonnebo V, Joakimsen RM, Ber-

ntsen GK. Validation of the Cummings’ risk score; how

well does it identify women with high risk of hip fracture:

the Tromso Study. Eur J Epidemiol 2006;21:815-22. ■

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