A cross-sectional view of data from this large international, observational study shows that women aged 55 years and older with a history of fracture at any of 9 different locations have a lower HRQL than women without such a history. Lower scores were most apparent for prior fractures of the hip and spine, but also for the upper leg. Dimensions of HRQL that were notably affected included mobility, self-care, and performance of usual activities. Lower fracture-associated quality-of-life values were similar to those experienced by women who reported having chronic health conditions such as arthritis, asthma or emphysema, or type 1 diabetes. Impaired HRQL was particularly evident for women with more than 1 prior fracture.
As is often seen in clinical practice, multiple clinical fractures can occur in an individual. These fractures have an additive effect, resulting in disability similar to a single hip (0.07) or vertebral (0.09) fracture. For example, the combination of a pelvic (0.04) and rib (0.03) or arm (0.03) fracture has the same effect as a hip fracture. In addition, fractures occur in women with other comorbidities. In a patient with arthritis (0.12), sustaining a hip (0.07) or vertebral (0.09) fracture is particularly devastating, with reductions ranging from 0.19 to 0.21. Moreover, reductions in EQ-5D resulting from most combinations of multiple fractures that include hip or spine (but exclude wrist) fractures match or exceed reductions due to type 1 diabetes or lung disease.
Our data are consistent with the findings of others who reported that HRQL is affected adversely by several types of fractures. After a hip fracture, mobility, ambulation, and self-care are significantly affected.4,18-21
This reduction in quality of life has been shown to persist for several years.20
Spine fractures result in severe pain and reductions in general health and vitality. In contrast to hip fractures, the negative impact of spine fractures occurs primarily in those who experienced fracture more recently.20
Although some improvement in HRQL may occur over time, reductions in quality of life are long-term.18,22
In the current study, wrist fractures had a minimal long-term impact on HRQL, a finding that concurs with some other reports.20,23
During the acute period after a wrist fracture, substantial pain may develop, and movement may be limited. However, individuals with wrist fractures may experience chronic loss of function.24
In one study, older people with wrist fractures were reported to have trouble ascending and descending stairs, which may have been due to difficulty in holding onto the banister.21
Less well recognized is the long-term impact of previous fractures at other bone locations. Our survey did not ascertain when prior fractures occurred (other than after age 45 years); the fracture could have occurred in the preceding year or many years in the past. Still, as a group, those reporting fractures of 9 of the 10 bones evaluated had diminished HRQL compared with their nonfracture counterparts.20
The importance of this finding is underscored by the fact that the impact on HRQL was similar to that of 2 medical conditions (lung disease and arthritis) that are more likely than past fractures to produce symptoms at the time of survey completion.
Few detailed data are available that establish the association between fractures and utility measures. As in the current study, these studies focused on hip, spine, and wrist fractures.18,25
One study demonstrated that hip and vertebral fractures had a negative impact on quality-adjusted life years as estimated with time trade-off values using an automated computer-based instrument.26
In another study using the EQ-5D, Colles fractures appeared to have a minimal impact on quality-adjusted life years.27
The authors suggested that the loss associated with a Colles fracture was about 2%.
Assessments of HRQL are important for evaluating patients with osteoporosis.18,28,29
These measurements provide data that are necessary to better describe osteoporosis and the functional outcomes of this condition. Our study examines a wide variety of fractures in a population-based international sample of postmenopausal women.
The major limitation of the current study was that fractures were self-reported and were not confirmed radiographically. Nonetheless, hip and wrist fractures are generally reported accurately, whereas spine fractures are reported less accurately.30
We did not report on subclinical vertebral deformities because x-ray films were not a part of this study. It has been postulated that only severe vertebral deformities are associated with pain and pain-related dysfunction31
and that subclinical deformities may tend to be less severe. Compared with a clinically recognized deformity, subclinical deformities have been shown to result in only a modest increase in morbidity.18
Because no specific date of fracture was recorded, we were unable to account for the effect of time on quality of life since the fracture occurred. If we had been able to distinguish fractures that occurred more recently from those that occurred several years earlier, and had adjusted results on that basis, the effect of fractures on quality of life would probably have been more pronounced.
We report quality of life associated with fractures and cannot infer causation or poorer health leading to fractures or fractures leading to poorer health. Because data on previous fractures since age 45 years were collected as a single checklist, we are unable to determine whether multiple fractures occurred on single or multiple occasions. Similarly, because some women may have experienced more than 1 fracture at a specific bone location (eg, multiple rib fractures in a single episode or multiple spine fractures over time), which would have been tallied as a single fracture, the rate of multiple fractures is probably underestimated. We compare women with or without fractures (single or multiple) with women with medical conditions, but we are unable to determine whether these medical conditions were accompanied by any fractures.
Misclassification of the comparison medical conditions is also possible and would likely result in an underestimation of their effect on quality of life. One reason for combining rheumatoid arthritis and osteoarthritis was concern that many respondents who report the former may have the latter. Some patients with type 2 diabetes may have reported type 1 diabetes. If this were the case, the effect of diabetes on HRQL would likely be underestimated. Because this study is cross-sectional, we cannot make inferences about the causality of these associations. Moreover, many comparisons were performed, and some results with little a priori evidence might have arisen by chance. Although several potential confounding variables were included in the analysis, not all risk factors may have been captured adequately in the GLOW data set.