Risk factors for fracture and fracture severity of the distal radius and ankle : What about osteoporosis, celiac disease and obesity?
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Background: Fractures are a substantial burden for both individuals and society. For the individual it leads to pain, reduced quality of life, disability and increased mortality. For society, it carries a great cost and requires substantial resources. With the increasing age in the population, this burden is expected to increase. There is potential to prevent more fractures than we do today by increased knowledge about groups at risk and individual risk factors, both through awareness, case finding in defined populations, and targeted treatment in the case of osteoporosis. Aim: The overall aim of this thesis is to contribute to better fracture prevention through increased knowledge of risk factors and patient groups at risk, focusing on celiac disease, osteoporosis and obesity as risk factors for peripheral fractures. Materials and methods: The dissertation is based on a case control study of consecutive patients with acute ankle- or distal radius fracture treated at the Helse Førde Hospital Trust in Norway, March 2014- January 2017, and community-based controls. Results: Our findings are presented in four papers. The first paper is a review on celiac disease and risk of fractures in adults. Previous studies performed on the subject were heterogeneous and difficult to compare, but the overall findings indicate a positive association between celiac disease and risk of fracture. We concluded that adult patients with celiac disease should be considered for bone densitometry in order to estimate fracture risk, thus enabling fracture prevention. In the second paper we report the prevalence of positive IgA transglutaminase 2 (TG2), a marker for both subclinical and clinically active celiac disease, and celiac disease in patients with distal radius or ankle fracture compared to community-based controls. We found that 2.5 % of the fracture patients had positive TG2, compared to 1 % in the control group, but the results did not show significantly increased odds of fracture. This study indicates that universal screening for celiac disease in fracture patients is not warranted, but that diagnostic tests should be performed in case of additional factors present increasing the patients’ risk of having celiac disease. The aim of the study reported in the third paper was to determine whether radiographic complexity of a distal radius fracture can be used to see if different distal radius fracture subtypes differ with regard to the prevalence of osteoporosis. When classifying the fractures according to the AO-classification system, we found no association between the severity of distal radius fractures and osteoporosis, hereby challenging a common perception that such an association exists. The study reported in the fourth paper investigated associations of overweight, obesity and osteoporosis with ankle fracture and the Danis-Weber (D-W) ankle fracture classification. We concluded that overweight increased the odds of ankle fractures and the odds of sustaining an ankle fracture with possible instability (D-W type B and C). Osteoporosis did not significantly increase the odds of ankle fracture, nor the odds of an instable distal fibula fracture. Conclusion: Understanding the impact common medical conditions such as osteoporosis, celiac disease and obesity have on fracture risk is important in order to identify and treat people at risk. This dissertation aims to expand the knowledge in this research landscape, look into and challenge the perception of common clinical beliefs, and contribute to the path towards new clinical practice guidelines for clinicians.
Består avPaper I: Hjelle, AM, Apalset E, Mielnik P, Bollerslev J, Lundin KEA, Tell GS: “Celiac disease and risk of fracture in adults- a review”. Osteoporosis Int. 2014 Jun; 25(6): 1667-76. The article is not available in BORA due to publisher restrictions. The published version is available at: https://doi.org/10.1007/s00198-014-2683-8
Paper II: Hjelle, AM, Apalset E, Mielnik P, Nilsen RM, Lundin KEA, Tell GS: “Positive IgA against transglutaminase 2 in patients with distal radius and ankle fracture compared to community-based controls”. Scand J Gastroenterol, 2018 Oct-Nov; 53(10-11): 1212-1216. The article is not available in BORA due to publisher restrictions. The published version is available at: https://doi.org/10.1080/00365521.2018.1509122
Paper III: Hjelle, AM, Gjertsen JE, Apalset E, Nilsen RM, Tell GS, Lober A, Mielnik P: “No association between osteoporosis and AO classification severity of distal radius fractures: an observational study of 289 patients”. BMC Musculoskeletal Disorders, 2020 Dec; 21(1): 811. The article is available at: https://hdl.handle.net/11250/2727531
Paper IV: Hjelle, AM, Gjertsen JE, Apalset E, Nilsen RM, Tell GS, Mielnik P: “Associations of overweight, obesity and osteoporosis with ankle fractures”. The article is not available in BORA.