Foot, Ankle Fractures in Older Women Caused by Different Factors

Foot and ankle fractures are the second most commonly occurring fractures, after those in the spine, in older women. Many are thought to be caused by osteoporosis, the thinning or reduction of bone density that often accompanies aging. Yet in some older women, ankle fractures are often the same kinds of fractures that occur in younger persons. Previous reports have suggested that fractures of both the foot and ankle in elderly people are the result of osteoporosis, and other studies have suggested that food and ankle fractures are not related to bone density.

Foot and ankle fractures can have a significant impact on the older patient's quality of life and often carry a poor prognosis. Due to the presence of coexisting medical conditions, treating lower extremity fractures in this group of women can present a real challenge to physicians. Thus, identifying risk factors of foot and ankle fractures and devising methods to prevent them are major goals in the health care of the growing number of older women.

A study to determine the incidence and risk factors of foot and ankle fractures in older women was conducted at the University of Pittsburgh by Carl T. Hasselman, MD, Molly T. Vogt, PhD, Katie L. Stone, PhD, Jane A. Cauley, DrPH, and Stephen Conti, MD and published in the May 2003 issue of The Journal of Bone and Joint Surgery (JBJS). The study followed more than 9700 women, 65 years or older, for ten years. The investigators selected women who were able to walk and perform six specific activities of daily living, all of which are important to an active life-style: (1) walk two to three blocks outside on level ground, (2) climb ten steps without stopping, (3) walk down ten steps, (4) prepare meals, (5) do strenuous housework, and (6) shop for clothes and food. The researchers also assessed each woman's psychological outlook. The physical examination included height and weight measurement, body mass index (weight divided by height) calculation, and bone density evaluation.

This study showed that risk factors for foot fractures are different from those for ankle fractures. Women who had a foot fracture were generally older; had lower bone density (osteoporosis changes); were less likely to be physically active; and were more likely to have had a previous fracture after age 50 -- and a history of past fracture(s) is a major predictor of future osteoporotic fractures.

Interestingly, the use of both long and short-acting benzodiazepines (sedatives) significantly increased the risk for foot fractures in this population, even though they did not have more falls, suggesting a different reason for this increased risk not identified in this study.

Women with an ankle fracture were more inclined to be overweight, were more likely to have fallen within the year before joining the study, more likely to be physically active, and were slightly younger when they enrolled in the study. Obesity was shown to be highly associated with ankle fractures in both this study and previous studies.

Osteoporosis was shown not to be a significant factor in ankle fractures; as Dr. Conti states, "If you are an older woman with no osteoporosis, then you are probably at no greater risk for an ankle fracture than anyone else." Dr. Conti does recommend, however, that every woman have a baseline bone density test to compare to later test results, since one in two women will experience a bone density-related fracture in her lifetime.

Older women should consult their physicians about eliminating or minimizing risk factors associated with foot and ankle fractures:

*women (and men) who have sustained one or more fractures after the age of 50 should have a bone density test to see whether osteoporosis is a contributing factor*women should have periodic, routine bone density tests as they grow older*postmenopausal women who are overweight should discuss a weight loss program with their physicians*older women at risk for foot or ankle fractures should avoid high-impact activities or exercises ( skip aerobics classes)*older women at risk for foot fractures should wear energy-absorbing shoes, such as walking shoes or sneakers that fit well

The investigators plan that future research on these subjects will examine the characteristics of falls associated with bone fractures. To evaluate the impact of fractures on patients' lives and their daily activities, investigators also intend to make before and after comparisons of mobility and function.

The Journal of Bone and Joint Surgery (JBJS) is a publication of the 26,047-member American Academy of Orthopaedic Surgeons (www.aaos.org or http://orthoinfo.aaos.org), a not-for-profit organization that provides education programs for orthopaedic surgeons, allied health professionals and the public. An advocate for improved patient care, the Academy is participating in the Bone and Joint Decade (www.usbjd.org) the global initiative in the years 2002-2011 to raise awareness of musculoskeletal health, stimulate research and improve people's quality of life. President Bush has declared the years 2002-2011 National Bone and Joint Decade in support of these objectives.

The peer-reviewed JBJS, located in Needham, Massachusetts, is published monthly. Abstracts are available online at http://www.jbjs.org.

An orthopaedic surgeon is a medical doctor with extensive training in the diagnosis and nonsurgical as well as surgical treatment of the musculoskeletal system including bones, joints, ligaments, tendons, and nerves.