Hospitalizations for Osteoporosis-Related Fractures: Analysis from Eastern Saudi Arabia

Background and Objectives: Osteoporosis causes fragility fractures which increase the morbidity and mortality in the elderly. Our objective was to look at the hospital admissions due to fragility fractures and site of fractures. Methods: This is a retrospective study of a 2-year period (2017-2018), in which we evaluated all the admissions of fragility fractures at King Fahd Hospital of the University, Al Khobar, Saudi Arabia. A Fragility Fracture is a fracture which occurs in patients with low bone mass due to a fall from a standing height. The data were gathered from the Quadru Med patient care system for patients over the age of 50 years: sex, site of fracture, previous fractures, and treatment meted out. The hospitalization rate for fragility fractures was calculated by taking into consideration of all the adult admissions to the orthopaedic department. Ethical approval was obtained from the Institutional Review Board of the Hospital and the Imam Abdul Rahman Bin Faisal University, Dammam. Results: During the study period 187 patients with fragility fractures were admitted. The mean age was 68.55 ± 12.43 years; fracture femur was the most common with 136 (72.7%), tibia 15 (8%) and spine 14 (7.5%). At the time of discharge based on the T score of spine 50 were osteo-penic and 45 were osteoporotic. Overall adult admission for the study period was 1410 patients and 13.26% were patients with fragility fractures. There were 3 (1.6%) deaths within the first 30 days in the hospital. Conclusions: Fracture femur was the most common fragility fracture seen in our study. Orthopaedic surgeons should be ready to treat all fragility fractures and treat osteoporosis appropriately so that a second fracture is prevented.


Introduction
Osteoporosis is a clinical syndrome of loss of bone, and deterioration of the micro-architectural structure of the bone leading to fractures with minimal trauma.
The prevalence of osteoporosis among Saudi Arabians is reported to be in the range of 30% -35% [1] [2] [3] [4] and the incidence of fracture femur rose from 2.91/1000 to 6/1000 in a decade [5] [6] [7]. Recent study has shown the overall cost of treating osteoporosis related femur fractures is Saudi Riyals 564.75 million yearly as direct costs and the yearly total cost goes up to 2.359 billion Saudi riyals [7]. Still many patients with osteoporosis in Saudi Arabia are neither diagnosed nor treated which could increase the incidence of osteoporosis related fractures and a fragility fracture is the first indication of osteoporosis.
It has been proved beyond doubt that osteoporosis enhances the risk of fractures [8] and only the prevalence of hip and vertebral fractures have been sporadically reported from Saudi Arabia. The prevalence of vertebral fractures in the men is reported to be 13.1% and in women it was found to be 20.3% [9] [10].
Apart from hip and vertebral fractures, there is no data from Saudi Arabia of the other fragility fractures like wrist, humerus and forearm which predicts subsequent hip fractures [11] [12]. It was found that a prior proximal humeral fracture could increase by over 5 times for a risk of hip fracture within the 12 months period [13].
Our objective was to look retrospectively at all admissions with fragility fractures and site of fractures in Saudi Arabian citizens at our center.

Methods
This retrospective study for the 2-year period between 2017-2018, at the tertiary care King Fahd Hospital of the University Al Khobar, Saudi Arabia was conducted. We evaluated all the admissions of all fractures, which occurred due to fall from ground level (Fragility Fracture). The data was gathered from the Qua-druMed patient care system for patients over the age of 50 years, sex, site of fracture, previous fractures, treatment meted out. Patients were stratified into 50 -60, 61 -70, 71 -80 and >81 years or older. The hospitalization rate for fragility fractures was calculated by taking into consideration of all the adult admissions to the orthopaedic department. Ethical approval was obtained from the Institutional Review Board of the Hospital and the Imam Abdul Rahman Bin Faisal University, Dammam.
The data was entered in the database and analyzed using SPSS Inc. version 21.
The data were expressed as mean ± SD. Statistically significant differences between the different groups were determined with the Student's t-test using a ratio of P < 0.05, which is considered to be significant, and was ascertained at a CI of 95%.

Results
During the study period 187 patients with fragility fractures were admitted. The were females. Table 1 gives the demographic data of all patients. One-third 58 (31.1%) were below the age of 60 years. Fracture femur was the most common with 136 (72.7%), Tibia 15 (8%) and Spine 14 (7.5%). Figure 1 gives the comparison between the male and female patients and different fractures. Table 2 shows the fracture pattern in male and versus female patients.

Discussion
Our study shows that hip fractures are still the most common fragility fractures seen in our country with 72.7% of all fragility fractures; secondly the age at which these fractures occurred in this study was younger than reported in other countries. The reported mean age for fragility femoral fractures is between 75 -80 years [14]. In this study the average age was 68.5 years. Secondly we observed that pattern of other fragility fractures requiring admission was different than reported elsewhere. The distal radius and proximal humerus fractures were the most common reported apart from femur in elderly due to osteoporosis [15] [16]. Melton et al. (1992) [17] reported that 16% in women and 5% in men, and in Sweden it was 20.8% and 4.6% in women and men [18]. In our patients fractures of the distal radius were quite low of 3.2%. This could be our limitation that we only considered the admissions and other acceptable cases of distal radius fractures could have been manipulated, reduced and discharged in cast from emergency room.
Osteoporotic fractures are generally classified as vertebral or non-vertebral. This study has some limitations that it was not possible to analyze all fragility fractures which came through the emergency room and we analyzed only hospitalized fractures but we believe our sample is representative one which could at least give a cue for other researchers to conduct studies including emergency room patients; otherwise there will concern potential underestimation of such fractures. The importance of this study is that it has given different type of fragility years.
In conclusion based on this 2-year study we found that fragility fractures are occurring at a younger age and fracture femur is the most common fragility fractures in our society and in 28% fractures occur at other sites such as Tibia and fibula 15 (8%) and spine 14 (7.5%). Our results confirm that fragility fractures occupy about 14% of all hospital admissions raising serious concerns for Ministry of health the largest stakeholder that provides free treatment to all citizens to implement appropriate strategies in the early diagnosis, and appropriate treatment and prevent all fragility fractures.