Osteoporosis and fragility fractures may become the most important public heath issue in the United States in the next 20 years.

Osteoporosis is a condition where the body loses bone mineral over time, leading to weakened bones and a higher risk for fractures. A fragility fracture is a fracture of the wrist, shoulder, spine, or hip that results from minimal trauma. These are not fractures related to car crashes or sporting events or falls from a height -- they are the injuries that occur from everyday activities and don't happen very often to people with normal bone strength. A fragility fracture is usually the end result of many years of osteoporosis development.

Fragility fractures have become epidemic in the United States. The U.S. Surgeon General reported in 2004 that 40 percent of elderly women (and up to 33 percent of men) will experience a fragility fracture in their lifetime. There are more than 1.5 million fragility fractures in the United States each year.

What is really amazing is that there are three times more fragility fractures each year than cases of heart attack, six times more fragility fractures than cases of stroke, and seven times more fragility fractures than cases of breast cancer each year in the United States.

While we often hears about research and prevention to solve heart disease, stroke and breast cancer, we hear very little about the prevention and treatment of fragility fractures. The rate of growth of fragility fractures and osteoporosis -- increasing from 23 million Americans in 2002 to an estimated 61 million in 2020 -- is far higher than the rates of growth projected for heart disease and stroke and breast cancer. Fragility fractures really are the public health problem of the future in the United States

What makes this issue difficult is that osteoporosis develops silently over a number of years.

While our medical system has been rather effective at treating the fragility fracture, it has not been particularly effective at managing the underlying osteoporosis. In a review conducted in 2004 of a Medicare population, it was determined that only 18 percent of patients with a fragility fracture had appropriate osteoporosis management after their fracture. Why the poor performance? It's largely because there has not, until recently, been a large effort to education patients and physicians about osteoporosis and fragility fractures.

Recently, the American Orthopaedic Association (AOA) initiated an "Own the Bone Program" in an effort to improve awareness of and management of fragility fractures and the underlying bone disease. The crux of the program's philosophy is that a fragility fracture provides the physician a 'teachable moment' -- a small window in which the physician can engage the patient and his or her family to better understand and manage the underlying osteoporosis.

The AOA conducted a pilot program in 14 hospitals nationwide (including UNC Hospitals) in which it applied an easy-to-use series of educational prompts to change physician behaviors in eight important areas related to the management of osteoporosis in patients who sustained a fragility fracture. The results of the program were very compelling, with a four-fold improvement in performance in six of the eight measures.

Examples of areas where dramatic improvement was observed was in the education of the patient about the effects of calcium, exercise and smoking on osteoporosis, in the ordering of a bone scan to measure bone density, and in communication with the patient's primary care physician about the need to institute medical treatment for osteoporosis.

What can you do to help "own the bone"? Be aware of the slow, inexorable process of osteoporosis, aware of the link between osteoporosis and fragility fractures, and aware that testing and treatment for these conditions are now available. Talk with your primary care physician or your orthopaedist about these issues, and insist on their advice regarding evaluation and treatment.

For information, see www.ejbjs.org/cgi/content/full/87/6/1389 or www.aoassn.org/otb_pilotstudy.pdf. For more information on osteoporosis screening and treatment, visit www.nof.org or orthoinfo.aaos.org.