Back

International Journal of Anatomical Sciences 2010,1:1-6

Research Paper

Correlation of Anthropometric and Upper Femoral, Morphometrics with Osteoporotic Related Hip Fracture Risk

Prabhu K,a Vathsala V,a Mani R,b Johnson WMS.a

Department of Anatomy; bDepartment of Orthopaedics, Sree Balaji Medical College and  Hospital, Chromepet , Chennai 600 044, India

Key Words: hip fracture, bone mineral density, femoral morphometry

 Abstract: Hip fractures have high morbidity and mortality among people and are generally seen in elderly population. In this study our focus was to know the relation of anthropometric factors and proximal femoral morphometry with fracture risk. Total of 107 women were recruited in this study. Determination of Bone mineral density by DXA scan is gold standard in prediction of osteoporotic related hip fracture. Based on scores of BMD we divide the Participants into two groups.

1. Fracture risk group and

2. Non fracture risk group. Age, BMI, hip axis length (HAL), neck shaft angle (NSA), and   neck   width   (NW),   were   recorded   and   measured   from   the   dual   x-ray absorptiometry (DXA) print out. Age had negative relation with BMD and BMI had positive relation with BMD. HAL and NSA were more in fracture risk group. So our study suggests that, one should strive to use both geometry and BMD to predict the susceptibility to fracture in patients.

 The number of hip  fractures  has  been estimated to rise from 1.7 million in 1990 to 6.26 million by the year 2050, worldwide and this is mostly due to the increasing life expectancy and increasing size of the population in nearly all countries (Cooper et al., 1993). It increases the morbidity and mortality in elderly men and women (Baudoin et al., 1996).

 Many risk factors are there to define the etiology of hip fracture. Age, diseases and trauma are the three main causes that play an important role in the etiopathology of hip fractures. (Alffran et al., 1964). It is also an outcome of age related osteoporosis. Alffran  Correspondence to: Prabhu K, Department of Anatomy, Sri Balaji Medical College, Chrompet, Chennai 600 044, India.

Email: prb_anu@yahoo.co.in

Accepted :26-May-2010 et al., (1964) emphasize the importance of osteoporosis as a predisposing factor in hip fractures. Together with age and gender, bone mineral density measurement is one of the reliable methods to evaluate the risk of osteoporotic –related hip fractures

 The other potential risk factors for hip fracture are lower body weight, cigarette smoking, caffeine intake, use of long acting sedatives and inactivity. Other risk factors such as density also relate to the strength of the bone (Cheng et al., 1997 ).The reduced bone mass during aging alone does not explain this phenomenon (Ramalho et al.,2001), and other factors such as decreased muscle mass (Dargent–Molina et al., 1996), postural instability, bone quality (Cumming et al., 1995; Dargent–Molina et al., 1996), genetic  factors  like  polymorphism  in  the type   2   collagen   synthesizing   gene   that would alter the bone structure (Quershi et al., 2000) and also the geometry of the proximal femur (Gnudi et al., 2002) are also  suggested   to   cause   fracture.   So   Many studies have been carried out to prevent fractures, as most hip fractures follow a fall.

Recently  authors  tried  to  estimate the risk of fracture through measurement of hip geometry like hip axis length, neck shaft angle, neck width with DXA scan. (Pande et al., 2000; Gnudi et al., 2002; Alonso et al.,2000).

 As the great majority have used the densitometry scan image to measure the geometric values mentioned above, we also used DXA scan to measure femoral geometry. To determine whether the geometric measurement of morphological features of the proximal femur are independent predictors of hip fracture and whether   they   improve   the   discriminate ability of the femoral bone mineral density (BMD), we measured and compared the hip axis length, the femoral  neck width, neck shaft angle and the femoral BMD of randomly selected individuals with and without  hip  fracture  risk  by  taking  a  hip scan using dual x- ray absorptiometry (DXA)). The recent interim report from the world health organization (WHO) task force for osteoporosis, recommends using only bone  mineral  density  (BMD)  for determining the fracture risk.

 Earlier  studies  carried  out  in different ethnic groups have found that the incidence   of   hip   fractures   differ   from country to country. This evidence suggests that like others factors, proximal femoral morphometry, may equally be important in determining hip fracture risk.

Materials and Methods

 This  study  was  conducted  on  107 post menopausal women in the age group 50 – 60 years, who visited bone clinic for screening of osteoporosis. The experimental procedure was approved by the local ethics committee. We divided the participants into two groups based on the following criteria.

Control group (n= 57) Women who had normal BMD as per WHO criteria (T >-1 SD) were included in this group. Fracture risk group (n= 50). Women who had osteopenia (T <-1SD TO >-2.5) or osteoporosis (T<-2.5 SD) were included in this group.

For both the groups age , BMI, HAL,NSA, NW, and BMD were recorded and  measured  from  their DXA  scan  print out. All values were statistically correlated using SPSS statistical package.

Exclusion criteria for the study were hip fracture, any metabolic bone disease, or treatment with sex hormones like calcitonin. The information consent was obtained from the subjects to take secondary data from the DXA print out.

The following parameters were considered and measured for this study:

o BMD values of the proximal femur at neutral  position,  calculated  by  DXA scan (Lunar DPX).

o Age, recorded from patient’s history.

o Body height and weight were measured with        an   anthropometer   and   beam- balance scale.

o Body mass index  was  calculated from height and weight measurements, using the formula Weight / Height in meter2

Following  morphometrics  were  measured   (refer Fig. 1).

 Hip axial length (HAL) was measured as the linear distance from the base of greater trochanter to the apex of the acetabular rim by aligning the ruler manually during the analysis procedure with the software provided with the device.

 Femoral neck width (NW) was measured as the shortest distance within the femoral neck perpendicular to the femoral neck axis.

 The angle between the hip axial length and shaft axis gives neck shaft angle (NSA).

Fig. 1  DXA print out

Observations

The mean values of the anthropometric parameters like age , BMI, and upper femoral morphometric parameters  positive correlation with BMD (r = 0.339  BMD, p = 0.000). HAL had positive correlation  with  age(r=0.303;  p  =  0.002), and NW (r=0.342; p = 0.000). NSA had negative correlation with BMD (r = -0.239; p = 0.013). NSA had negative relation with age (r =-.282 p= .003). BMD had negative correlation with age, (r = – 0.267 p = 0.005), with HAL(r = – 0.389; p = 0.000).

Table 1 The mean and standard deviation of the Physical characteristics namely age, BMI, HAL, NW, NSA and BMD of the participants

 

Mean Std. Deviation

N

AGE

51.93 12.177

107

BMI

26.8741 4.39041

107

HAL(cm) 5.6514 0.31244

107

NW

1.7645 0.17170

107

NSA (degree) 128.29 7.464

107

Area

29.2547 3.42380

107

BMC 24.8940 6.09370

107

BMD 0.85468 0.177891

107

 

Table 2 Averages and standard deviations of anthropometrics and femoral morphometrics of non fracture risk group in women

like HAL, NSA, NW of 57 non fracture risk Chennai  control  group  were  found  to  be

Mean         Std. Deviation          N

 50.44               12.177             57

26.8741         4.39041            57

5.55                .31244               57

1.74              .17170                57

127.8               7.464              57

0.8679          .177891            57

 

Table 3 Averages and standard deviations of anthropometrics and femoral morphometrics  of  fracture  risk group in women

Mean           Std. Deviation            N

53.60                  12.517                50

26.8741             4.3224                 50

1.7800                .17170                50

128.78                    7.265                50

0.6370                 .15789                50

5.6400                .31321                50

Table 4 Correlation between femoral morphometrics, anthropometrics and BMD of both fracture and non fracture groups in women.

 

AGE BMI HAL (cm) NW NSA (degree) AREA BMC QMD
AGE               Person Correlation Sig.(2-tailed)

N

107

0.109 

0.264

107

0.303** 

0.002

107

-0.18 

0.851

107

-0.282**

.003

107

0.375** 

0.000

107

-0.066 

0.501

107

-0.267**

0.005

107

BMI                 Person Correlation Sig. (2-tailed) N 0.109 

0.264

107

 

 

107

-0.182 

0.061

107

0.106 

0.276

107

0.072 

0.464.

107

0.154 

0.113

107

0.380** 

0.000

107

0.339** 

0.000

107

HAL(cm)         Person Correlation Sig.(2-tailed)

N

0-303** 

0.002

107

-0.182 

0.061

107

 

 

107

0.342** 

0.000

107

-0.004 

0.964

107

0.342** 

0.000

107

-0.199* 

0.040

107

-0.389**

0.000

107

NW(cm)           Person Correlation Sig.(2-tailed)

N

-0.018 

0.851

107

0.106 

0.276

107

0.342** 

0.000

107

 

 

107

-0.102 

0.298

107

0.515** 

0.000

107

0.220* 

0.023

107

-0.025 

0.801

107

NSA(degree)    Person Correlation Sig.(2-tailed)

N

-0.282**

0.003

107

0.072 

0.464

107

-0.004 

0.964

107

-0.102 

0.298

107

 

 

107

-0.099 

0.311

107

0.136 

0.163

107

-0.239* 

0.013

107

AREA              Person Correlation Sig.(2-tailed)

N

0.375** 

0.000

107

0.154 

0.113

107

0.342** 

0.000

107

0.515** 

0.000

107

-0.099 

0.311

107

 

 

107

0.512** 

0.000

107

0.036 

0.716

107

BMC               Person Correlation Sig.(2-tailed)

N

-0.066 

0.501

107

0.380** 

0.000

107

-0.199* 

0.040

107

0.220 

0.023

107

0.136 

0.163

107

0.512** 

0.000

107

 

 

107

0.862** 

0.000

107

BMD               Person Correlation Sig.(2-tailed)

N

-0267** 

0.005

107

0.339** 

0.000

107

-0.389**

0.000

107

-0.025 

0.801

107

-0.239* 

0.013

107

0.036 

0.716

107

0.862** 

0.000

107

 

 

107

**        Correlation Is significant at the 0.01 level (2-tailed)

*          Correlation is significant at the 0.05 level (2-tailed)

Discussion

 India is a large country with a wide variety of environmental conditions. It shows ethnic multiplicity and is characterized by an interracial mixing rarely seen in other countries. Taking into account of these factors the data base obtained in our study may  not  be  representative  of  the  entire Indian    population    and    therefore    our normative data should be used only for a population  sharing  the  same  genetic potential and living under similar environmental conditions. One limitation of our study was the recruitment of volunteers. The study sample was not population based but recruited from the subjects who visited bone clinic. It is possible that this may introduce a selection bias focusing on the wealthier  and  better  educated  part  of  the   population or alternatively on those who through  life style or living conditions are prone to osteoporosis.  To our knowledge, this is the first study of BMD in a large south Indian population using DXA measurements. In the present study we cannot exclude cohort effects such as socio economic status, life time exercise patterns or nutritional habitat. A survival bias may also have occurred since we made bone measurements only in the individuals able to come to the outpatient clinic.

 The hip axis length has been found to be correlated with the risk of fracture (Nakamura et al., 1994). Our result also shows higher value of HAL in fracture risk group ref table 3.The precise physical mechanism of this is unknown. However Faulkner is of the opinion that a longer hip axis length leads to a higher probability of impacting the great trochanter and to lower impact  absorption  after  a  fall.  (Faulkner,1995; Schwartz et al., 1999).

 In  our  study  the  neck  shaft  angle also  discriminated  healthy  from osteoporotic subjects. Neck –shaft angle varies among the published studies on fracture risk. In every comparison study except those of Cody and Nahigian in 1993 (a CT study) and Ferris et al., in 1989, (where hips were held in maximum internal rotation), the NSA is larger in the fracture – prone group. Our method of femoral NSA measurement proved both reliable and precise. Furthermore the mean values and ranges are similar to those reported in other studies (Alonso et al., 2000; Gnudi et al.,2002; Faulkner et al., 1993; Quershii et al.,2001). Our study also anticipates that larger NSA to be associated to an increased hip fracture risk in later life. But our data regarding NSA was in contrast to those of Faulkner et al., (1993) who report no association  between  neck  shaft  angle  and hip fracture risk.

 Ex vivo biomechanical tests also shows   that   neck   shaft   angle   does   not   correlate with femoral neck strength (Cheng et al., 1997; Schwartz et al., 1999). So it correlation  to  fracture  risk  may  involve other mechanism.  It may be hypothesized that neck shaft angle or the ante version angles interact with the direction of the fall, thus affecting the femoral neck loading angle. This angle, according to Pinilla et al., (1996) is inversely related to fracture load and its variation may therefore be associated with different fracture risk.

 These discrepancies may be due to racial differences in the neck shaft angle Nakamura et al., (1994) or to different compensations of the anteversion angle during positioning of patients on the scan bed producing different effects on this measurement.  The  occurrence  of  hip fracture may also be influenced by anthropoimetric   factors   (Farmer   et   al.,1989).   Aging   is   one   of   the   important reasons for hip fracture. It increases exponentially  with  age  (Cumming  et  al.,1989). Many studies show that short individuals have a lower risk of hip fracture compared to tall individuals (Hemenway et al., 1995).

 Conclusion

Non  invasive  imaging   techniques can provide measures of geometry and a correlate to macroscopic material properties (BMD).  Until  we  have  effective  methods for  measuring  micro  architecture  and genetic or other biomarkers for individual response dynamics, we should strive to use both geometry and BMD to predict the susceptibility to type of fracture in patients

References

Alffram PA (1964) An epidemiological study of cervical and trochanteric fractures of the femur in  an  urban  population.  Acta  Orthop  Scand Suppl 65.

Alonso  CG,  Curiel  MD,  Caranza  FH,  Cano  RP, Perez AD (2000) Femoral bone mineral density, neck –shaft angle and mean femoral neck width as predictor of hip fractures in men and women.

Multi center project for research in osteoporosis.

Oteoporos Int, 11: 714 -720.

Baudoin C Fardellone P, Bean K, Ostertag-Ezembe, Hervy F (1996) Clinical outcomes and mortality after  hip  fracture;  a  2-year  follow  up  study. Bone, 18: 1495-1575.

Cheng XG, Lowet G, Boonen S, Nicholson PH, Brys P, Hijs J (1997) Assessment of the strength of Proximal femur in vitro; relationship to femoral bone mineral density and femoral geometry. Bone, 20: 213-218.

Cody DD, Nahigian KK, Divine G, Ciarelli J, Sard B (1993) Does bone density or bone shape discriminate between subjects at high and low risk of hip fracture? Proceedings of the Thirty – ninth annual meeting of the Orthopaedic Research Society. San Francisco, CA. p. 19

Cooper C (1998) A case finding strategy: European

Perspective. Osteoporos Int, 7 Suppl 1:S70-S74;

Cooper  C,  Campion  G,  Melton  LJ  (1992)  Hip fracture in the elderly: world wide projection. Osteoporosis Int, 12: 285-289.

Cummings SR, Nevitt MC (1989) A hyphothesis: the cause of Hip fractures. J Gerentol, 44: M107-M111.

Dargent–Molina P, Favier F, Grandjean H, Baudoin C, Schott AM, Hausherr E, Meunier PJ, Breart G (1996) For EPIDOS group. Fall – related factors and  risk of  hip  fractures: the  EPIDOS prospective study. Lancet, 348: 145 – 149.

Farmer ME, Harris T, Madans JH, Wallace RB, Cornoni- Huntley J, White LR (1989) Anthro pometric indicators and hip fracture. The NHANES / epidemiologic follow up study, JAM Geriatr Soc, 37: 9-16.

Faulkner K G, Cummings S R, Black D, Palermo L, Gluer CC,and Genant HK (1993) Simple measurment of Femoral Geometry predicts hip fracture: The study of Osteoporotic fractures. J Bone Miner Res, 10: 1211-1217.

Faulkner KG, Letter to the editor; (1995). Hip axis length and osteoporotic fractures. J Bone Miner Res, 10; 1211-1217.

Ferris BD, Kennedy C, Bhamra M, Muirhead- Allwood W (1989) Morphology of the femur in proximal femoral fractures. J Bone Joint Surg Br, 71: 475-477.

Hemenway D, Feskanich D, Coldits GA (1995) Body height and hip fracture: a Cohort study of 90000 women. Int J Epidemiol, 24: 783-786.

Gnudi S, Ripamonti C, Lisi L, Fini M, Giardino R, Giavaresi G (2002) Proximal femur geometry to detect  and  distinguish  femoral  neck  fracture from trochanteric in postmenopausal women. Osteoporos Int, 13: 69 – 73.

Hoaglund FT, Low WD (1980) Anatomy of the femoral neck and head, with comparative data from Caucasians and Hong Kong Chinese. Clinical Orthopaedics and Related Res, 152: 10-16.

Nakamura T, Turner CH, Yoshikawa T, Slemenda CW, Peacock M, Burr D, Mizuno Y, Orimo H, Ouchi Y, Johnston CC Jr (1994) Do variations in hip geometry explain differences in hip fracture risk between Japanese and white Americans? J Bone Miner Res, 9: 1071-1076.

Pande I, O’Neill TW, Pritchard C, Scott DL, Woolf AD (2000) Bone mineral density hip axis length and risk of hip fracture in men. From the Cornwall hip  fracture study.  Osteoporosis Int,11: 866-870.

Pinilla TP, Boardman KC, Hayes WC  (1996) Impact direction from a fall influences the failure load of the proximal femur as much as age –related bone loss. Calcif Tissue Int, 58: 231-235.

Qureshi AM, Mcguigan FEA, Seymour DG, Hutchison JD,Reid DM, & Ralston SH (2001).Association between COLIA1 Sp1 alleles and  femoral neck  geometry. Calcif tissue  Int,69:67-72.

Ramalho AC, Lazaretti-Castro M, Hauache O, Vieira JG,Takata E, Cafalli F, Tavares F (2001) Osteoporotic fratures of proximal femur, clinical and epidemiological features in a population of the city of Sao Paulo. Rev Paul Med, 119: 48-53.

Schwartz AV, Sellmeyer DE, Ensrud KE, Cauley JA, Tabor HK, Schreiner PJ, Jamal SA, Black DM, Cummings SR (2001) Older women with diabetes have an  increased risk of  fracture: a prospective study. J Clin Endocrinol Metab 86:32 – 38.

Back