Osteoporosis and bone fractures

You can't feel osteoporosis. People often first find out they have it after fracturing a bone.

The bones that most commonly fracture due to osteoporosis are the vertebrae (bones in the spine). Fractured vertebrae can cause the spine to shrink a little and then people get shorter. They sometimes cause back pain that usually goes away again after a couple of weeks. But many people don't even notice these fractures.

Vertebral fractures can exaggerate the natural curve of the spine (kyphosis). Several vertebral fractures over time can result in a stooped posture or "hump" at the top of the spine.

Osteoporosis fractures are also common in the wrists and the hips (femoral neck). Fractures of the femoral neck can cause serious complications. They mainly occur in people aged over 80 and sometimes mean that they need nursing care after that.

In people who have osteoporosis, simply tripping and falling can already result in bone fractures. Bones can also break because of too much strain or abnormal strain, like when lifting a heavy shopping bag. These kinds of fractures are known as "fragility fractures."

The insides of our bones are made up of fine rods of bone tissue arranged in a certain structure. This "trabecular" structure looks a bit like hard sponge or honeycomb. Bone stability also depends on the shape and density of this bone structure and the minerals inside it. The mineral content can be determined by measuring bone density.

Osteoporosis develops when a large amount of the spongy bone tissue breaks down, leading to bigger spaces and lower bone stability.

Bone density continues to increase until around age 15 in girls and age 20 in boys. It then reaches its maximum level and stays that high until around age 30. After that, bone density gradually decreases. In women, this decrease happens more quickly from about the age of 50. This is because the female hormone estrogen slows the breakdown of bone tissue. When women go through the menopause, their estrogen levels drop and bone tissue is lost more quickly as a result.

Your bone stability depends on a lot of factors. You can influence some of them, but not others. Risk factors for osteoporosis that can be influenced mainly include:

• Low body weight (compared to height)
• Calcium deficiency
• Vitamin D deficiency
• Lack of exercise
• Smoking
• Drinking a lot of alcohol
• Taking steroid medications for a long period of time, such as several months

Osteoporosis usually develops after the age of 50. It becomes more common with age. Women are roughly twice as likely to develop it as men are. In a large-scale study, around 10% of men and 20% of women aged 70 reported that they had been diagnosed with osteoporosis.

According to estimates, around 30% of all fractures in the hip, vertebrae and wrists are due to very low bone density.

Most fractures are caused by falls. That is also true for hip fractures. They are most common in people aged 80 and over. Around 1% to 2% of people in that age group fracture their femoral neck bone within one year.

Osteoporosis is sometimes diagnosed by chance – for instance, if an x-ray is taken of the upper body for a different reason and it shows fractured vertebrae.

It may also first be discovered because a bone is broken following a fall from a normal height when standing. If that happens, doctors can often already diagnose osteoporosis by doing a physical examination and asking a few questions.

This diagnosis is also made for men and women who haven't broken anything, but have low bone density. Then osteoporosis is not a disease but rather a risk factor for bone fractures. Bone density can be measured using a bone density scan (bone densitometry). This scan measures the amount of minerals in the bones.

The results of bone density scans are reported as T-scores. A T-score of 0 describes the typical bone density of a young, healthy adult aged between 20 and 30. The World Health Organization (WHO) currently defines T-scores as follows:

• a T-score above -1 is normal,
• a T-score between -1 and -2.5 is low (this is called osteopenia), and
• a T-score of -2.5 or less means you have osteoporosis.

The best place to measure bone density is at the femoral neck in the hip joint. It is often also measured in the lumbar region of the spine (lower back). But those measurements are less reliable because the vertebrae sometimes change in older age for other reasons.

Bone density measurements can't reliably predict how likely a bone fracture is. The stability of the bone is influenced by the shape and strength of the structure inside the bone, too. And the risk of bone fractures also depends on many other factors, including your overall health.

If someone has osteoporosis, it can be a good idea to do a blood test as well – to rule out the possibility that a different disease is causing the bone tissue to break down.

Some doctors offer bone density scans as an individual health care service (known as "IGeL services" in Germany). The aim is to detect osteoporosis at an early stage. But the screening can have more disadvantages than advantages, especially for women under 65 who don't have any risk factors: The bone density scan exposes the body to a small amount of x-ray radiation. If the test detects low bone density, that can be worrying and make people avoid physical activity for fear of breaking a bone. Screening is then even harmful.

Statutory health insurers in Germany cover the costs of the bone density test if there are good medical reasons to do the test. For example, if

• you have a type of bone fracture that is typically caused by osteoporosis,
• you have an increased risk of osteoporosis, for instance after taking steroid medications for a long period of time, or
• treatment with osteoporosis medications is being considered.

Three large studies looked into whether screening is useful in women over 65 years of age. The results suggest that screening might slightly reduce the risk of bone fractures – as long as treatment with bone-strengthening medication is started if needed. But there's an overall lack of research on the benefits of screening here, and it's generally still a matter of debate.

There is not enough good-quality research on the pros and cons of screening in younger women, women with no risk factors, and men.

There are various things you can do to strengthen your bones, reduce the risk of falls and prevent fractures. They include the following:

• Get enough movement and do specific exercises: This strengthens your muscles and bones, improves your coordination and helps you to walk with more confidence. That prevents fractures and also reduces the risk of falls. Strain can be taken off the spine by lifting and carrying things properly.
• Get enough calcium and protein in your diet: This is important because it prevents the breakdown of bone and muscle tissue in older age. The risk of not getting enough calcium and protein is particularly high in older people who are in need of nursing care.
• Get enough vitamin D: Vitamin D helps your bones to absorb calcium. Because vitamin D is made in the skin with the help of UV light, it is important to spend enough time outdoors in natural daylight. About 15 minutes a day are usually enough.
• Remove tripping hazards from your home: This includes things like loose cables and rugs, door thresholds and the like.
• Quit smoking: People who smoke have an increased risk of bone fractures. This is because tobacco smoke contains harmful substances that speed up the breakdown of bone tissue. People who manage to quit smoking reduce their risk of bone fractures.
• Limit your alcohol consumption: Larger amounts of alcohol increase the risk of falls and bone fractures. For this reason, it's important to stick to recommendations for low-risk alcohol consumption.

Most people do not benefit from taking dietary supplements with calcium and/or vitamin D. But these supplements can increase the risk of conditions like kidney stones and can cause digestive problems such as constipation. Independent medical societies don’t usually recommend them for the prevention of bone fractures.

Dietary supplements with calcium and vitamin D are mainly useful for people in need of nursing care who only get little exercise and hardly spend any time in the sun. They often have a vitamin D deficiency.

Remaining active, strengthening your bones and preventing falls are an important part of treating osteoporosis, too. It can also be treated with special medications that slow down the breakdown of bone tissue. Medications called bisphosphonates (alendronate, risedronate or zoledronic acid) are typically used here.

Treatment with medication is considered if someone has already broken a bone, or if they have a high risk of bone fractures – for example, because they have very low bone density or a combination of different risk factors. If you decide to have treatment with medication, doctors usually recommend taking it for several years. But there is currently no known medical need to take it for longer than five years.

Whether or not you would like to use preventive medication is your own personal decision. It is worth talking to your doctor about the pros and cons of taking it. Medications can have side effects, and taking them can be bothersome in everyday life.

When taken over the long term, hormone medications (like those used to treat menopause-related problems) can also lower the risk of bone fractures caused by osteoporosis. But long-term hormone therapy for menopause-related problems increases the risk of cardiovascular disease and breast cancer. Because of this, it is only rarely recommended for the treatment of osteoporosis.

Osteoporosis-related vertebral fractures are sometimes treated with surgical procedures known as vertebroplasty and kyphoplasty. Both procedures involve putting a special cement mixture into the broken spinal bone to stabilize it. But good-quality research has shown that most people do not benefit from these procedures. The treatment can help a little in some people who have very severe pain. It can also lead to serious complications, though. So it's a good idea to carefully weigh the pros and cons of bone cement treatment before making a decision.

When people are ill or need medical advice, they usually go to see their family doctor first. In our topic "Health care in Germany" you can read about how to find the right doctor – and our list of questions can help you to prepare for your appointment.