and Related Fractures: The Risk of Undiagnosed
Falls are serious at any age,
and breaking a bone after a fall becomes more
likely as a person ages. Everyone knows someone
who has fallen and broken or fractured a bone.
While healing, the fracture limited activities
and sometimes required surgery, and, often, the
person wore a heavy cast to support the broken
bone and needed physical therapy to resume
normal activities. People are unaware that there
is often a link between the broken bone and
osteoporosis, a silent disease in which there is
a gradual loss of bone tissue or bone density
that makes bones so fragile they break under the
slightest strain. Because osteoporosis
progresses without symptoms, falls are
especially dangerous for people who are unaware
that they have low bone density. If the patient
and the physician fail to connect the broken
bone to osteoporosis, the chance to make a
diagnosis with a bone density test and begin a
prevention or treatment program is lost. Bone
loss continues until another bone breaks.
Even though bones do not break
after every fall, the person who has fallen and
broken a bone almost always becomes fearful of
falling again. As a result, she or he may limit
activities for the sake of "safety." Among
Americans age 65 and older, fall-related
injuries are the leading cause of death due to
There are 5 main factors which affect the
risk of fracture in patients with osteoporosis:
life expectancy, age, bone density, previous
fracture history, and the underlying condition
responsible for the osteoporosis (if known).
Fracture Triangle includes the following three
factors that play a role in the breaking of a
- More than 90% of hip
fractures are associated with osteoporosis?
- Nine out of ten hip
fractures in older Americans are the result
of a fall?
- Individuals who have a
hip fracture are 5-20% more likely to die in
the first year following that injury than
others in this age group?
- For those living
independently before a hip fracture, 15-25%
will still be in long-term care institutions
a year after their fracture?
- Most falls happen to
women in their homes in the afternoon?
of these factors is modified, the chances of
breaking a bone are greatly reduced.
There are several factors that
can lead to a fall. Loss of footing or loss of
traction are common causes of falls. Loss of
footing occurs when there is less than total
contact between the person's foot and the ground
or floor. Loss of traction occurs when the
ground upon which the person is stepping is wet
or slippery, and the person's feet fly out from
under her or him. Other examples of loss of
traction include tripping, especially over
uneven surfaces such as sidewalks, curbs or
floor elevations that result from carpeting,
risers or scatter rugs. Loss of footing also
happens from using household items for
unintended purposes, such as trying to gain
height climbing on kitchen chairs or balancing
on boxes or books.
A fall may occur because a
person's reflexes have changed. As people age,
reflexes slow down. Reflexes are automatic
responses to stimuli in the environment.
Examples of reflexes include quickly slamming on
the car brakes when a child runs into the
street, or quickly moving out of the way when
something accidentally falls. Aging slows a
person's reaction time and makes it harder to
regain one's balance following a sudden movement
or shift of body weight.
muscle mass and body fat also can play a role in
falls. As people get older, they lose muscle
mass because they have become less active over
time. Loss of muscle mass, especially in the
legs, reduces a person's strength to the point
where she or he is often unable to get up from a
chair without assistance. In addition, as people
age, they lose body fat that has cushioned and
protected bony areas, such as the hips. This
loss of cushioning also affects the soles of the
feet, which upsets the person's ability to
balance. The gradual loss of muscle strength,
which is common in older people but not
inevitable, also plays a role in falling. Muscle
strengthening exercises, however, can help
people regain their balance, level of activity
and alertness no matter what their age.
Changes in vision also
increase risk of falling. Diminished vision can
be corrected with glasses, but often, these
glasses are bifocal or trifocal so that when the
person looks down through the lower half of
her/his glasses, depth perception is altered.
This makes it easy to lose one's balance and
fall. To prevent this from happening, people who
wear bifocals or trifocals must practice looking
straight ahead and lowering their head. For many
other older people, vision changes cannot be
corrected completely, making even the home
As people get older, they also
are more likely to suffer from a variety of
chronic medical conditions that often require
taking several medications. People with chronic
illnesses that affect their circulation,
sensation, mobility or mental alertness or those
taking medications (see chart) are more likely
to fall as a result of drug-related side effects
such as dizziness, confusion, disorientation or
Drinking alcoholic beverages
also increases the risk of falling. Alcohol
slows reflexes and response time, causes
dizziness, sleepiness or lightheadedness, alters
balance and encourages risky behaviors that can
lead to falls.
Force and Direction of a Fall
The force of a fall (how hard
a person lands) plays a major role in
determining whether a person will fracture or
not. For example, the greater the distance of
the hip bone to the floor, the greater the risk
of fracturing a hip so tall people seem to have
an increased risk of fractures when they fall.
The angle at which a person falls also is
important. Falling sideways or straight down is
more risky than falling backwards, for example.
Did you know that:
- Being tall
increases your risk of a hip
- How you land
increases fracture risk?
- Catching yourself
so you land on your hands or
grabbing onto an object as you fall
can prevent a hip fracture?
Protective responses, such
as reflexes and changes in posture that break
the fall, can reduce the risk of fracturing a
bone as a result of a fall. Individuals who land
on their hands or grab an object on their
descent are less likely to fracture their hip,
but they may fracture their wrist or arm. While
these fractures are painful and interfere with
daily activities, they do not carry the same
risks that are associated with a fractured hip.
The type of surface on which one lands can also
affect whether a bone breaks or not. Landing on
a soft surface is less likely to cause a broken
bone than landing on a hard surface.
Preliminary research has
suggested that trochanteric (hip) padding can
decrease the chances of fracturing a hip after a
fall. The energy created by the fall is
distributed throughout the pad, lessening the
impact to the hip. Further research is needed to
fully evaluate the role of these devices in
decreasing the risk of a hip fracture following
While most serious falls
happen when people are older, steps to prevent
and/or treat bone loss and falls can never begin
too early. Many people begin adulthood with less
than optimal bone mass, so the fact that bone
mass or density is lost slowly over time puts
them at increased risk for fractures. Bones that
once were strong become so fragile and thin that
they easily break. Activities that once were
done without a second thought are now avoided
for fear they will lead to breaking another
Steps to prevent fragile bones
- Take in adequate
amounts of calcium and vitamin D
- Exercise several
times a week
- Ask your doctor
about a Bone Density Test
- Ask about
medications to slow bone loss and
reduce fracture risk
Prevention of Falls and Fractures
First to Prevent Falls
At any age, people can improve
their environments in ways that reduce their
risk of falling and breaking a bone.
- In nasty weather, use a
walker or cane for added stability.
- Wear warm boots with
rubber soles for added traction.
- Look carefully at floor
surfaces in public buildings. Many floors
are made of highly polished marble or tile
that can be very slippery. When floors have
plastic or carpet runners in place, stay on
them whenever possible.
- Identify community
services that can provide assistance, such
as 24 hour pharmacies that deliver, grocery
stores that take orders over the phone and
deliver, especially in poor weather.
- Use a shoulder bag, fanny
pack or backpack to leave hands free.
- Stop at curbs and check
height before stepping up or down. Be
cautious at curbs that have been cut away to
allow access for bikes or wheelchairs. The
incline up or down, may lead to a fall.
- Keep all rooms free from
clutter, especially the floors.
- Keep floor surfaces
smooth but not slippery. When entering
rooms, be aware of differences in floor
levels and thresholds.
- Wear supportive,
low-heeled shoes even at home. Avoid walking
around in socks, stockings or floppy,
- Check that all carpets
and area rugs have skid-proof backing or are
tacked to the floor, including carpeting on
- Keep electrical cords and
telephone lines out of walkways.
- Be sure that all
stairwells are well lit and that stairs have
handrails on both sides. Consider placing
fluorescent tape on edges of top and bottom
- For optimal safety,
install grab bars on bathroom walls beside
tubs, showers and toilets. If you are
unstable on your feet, consider using a
plastic chair with a back and non-skid leg
tips in the shower.
- Use a rubber bath mat in
the shower or tub.
- Keep a flashlight with
fresh batteries beside your bed.
- Add ceiling fixtures to
rooms lit by lamps only; or install lamps
that can be turned on by a switch near the
entry point into the room. Another option is
to install voice- or sound-activated lamps.
- Use at least 100-watt
bulbs in your home.
- If you must use a step
stool for hard to reach areas, use a sturdy
one with a handrail and wide steps. A better
option is to reorganize work and storage
areas to minimize the need for stooping or
- Consider purchasing a
portable phone that you can take with you
from room to room. It provides security
because not only can you answer the phone
without rushing for it, but you can also
call for help should an accident occur.
- Don't let prescriptions
run low. Always keep at least one week's
worth of medications on hand at home. Check
prescriptions with your physician and
pharmacist to see if they may be increasing
your risk of falling. If you take multiple
medications, check with your physician and
pharmacist about possible interactions
between the different medications.
- Arrange with a family
member or friend for daily contact. Always
have at least one person who knows where you
- If you live alone, you
may wish to contract with a monitoring
company that will respond to your call 24
hours a day.
- Watch yourself in a
mirror. Does your body lean or sway back and
forth or side to side? People with decreased
ability to balance often have a high degree
of body sway and are more likely to fall.
Reducing the Force of a Fall
steps to lessen your chances of breaking a bone
in the event that you do fall.
- Remember that falling
sideways or straight down is more likely to
result in a hip fracture than falling in
other directions. If possible, try to fall
forward or to land on your buttocks.
- If possible, land on your
hands or use objects around you to break a
- Walk carefully,
especially on hard surfaces.
- When possible, wear
protective clothing for padding.
- Talk to your doctor about
whether you may be a candidate for hip