Stephen Robinovitch

Etiology and Prevention of Age-Related Hip Fractures

Falls and fall-related injuries are among the most serious and common medical problems experienced by the elderly. Hip fracture, one of the most severe consequences of falling in the elderly, occurs in only about 1% of falls. Despite this, hip fracture accounts for a large share of the disability, death, and medical costs associated with falls. As measured by their frequency, influence on quality of life, and economic cost, hip fractures are a public health problem of crisis proportions. Without successful international initiatives aimed at reducing the incidence of falls and hip fractures, the implications for allocations of health resources in this and the next century are staggering. Identifying those at risk for harmful falls requires an understanding of what kinds of falls result in injury and fracture. In elderly persons who fall, in most of whom hip bone mineral density is already several standard deviations below peak values, fall severity (as reflected in falling to the side and impacting the hip) and body habitus are important risk factors for hip fracture and touch on a domain of risk entirely missed by knowledge of bone mineral density. These findings clearly suggest that factors related to both loading and bone fragility play important roles in the etiology of hip fracture. We provide a strategy, based on engineering approaches to fracture risk prediction, for determining the relative etiologic importance of loading and bone fragility and to summarize some of what is known about both sets of factors. We define a factor of risk, phi, as the ratio of the loads applied to the hip divided by the loads necessary to cause fracture and summarize available data on the numerator and the denominator of phi. We then provide an overview of the complex interplay between the risks associated with the initiation, descent, and impact phases of a fall, thereby suggesting an organized approach for evaluating intervention efforts being used to prevent hip fractures. The findings emphasize the continuing need for combined intervention strategies that focus on fall prevention, reductions in fall severity, and maintaining or increasing femoral bone mass and strength, either through targeted exercise programs, optimal nutrition (Ca, Vitamin D), and/or in the use of osteodynamic agents. By developing and refining the factor of risk, a property that captures both the contributions of bone density and the confounding influences of body habitus and fall severity, we believe these intervention strategies can be targeted more appropriately.

Distribution of Contact Force during Impact to the Hip

Hip fracture is a common, costly, and debilitating injury occurring primarily in the elderly. Commonly viewed as a consequence of osteoporosis, it is less often appreciated that >90% of hip fractures are caused by falls, and that fracture risk is governed not only by bone fragility, but also by the mechanics of the fall. Our goal is to develop experimental and mathematical models that describe the dynamics of impact to the hip during a fall, and explain the factors that influence hip contact force and fracture risk during a fall. In the current study, we used “pelvis release experiments” to test the hypothesis that, during a fall on the hip, two pathways exist for energy absorption and force generation at contact: a compressive load path directly in line with the hip, and a flexural load path due to deformation of muscles and ligaments peripheral to the hip. We also explored whether trunk position or muscle contraction influence the bodys impact response and the magnitude of force applied to the hip during a fall. Our results suggest that only 15% of total impact force is distributed to structures peripheral to the hip and that peak forces directly applied to the hip are well within the fracture range of the elderly femur. We also found that impacting with the trunk upright significantly increases peak force applied to the hip, whereas muscle contraction has little effect. These results should have application in the development of fracture risk indices that incorporate both fall severity and bone fragility, and the design of interventions such as hip pads and energy-absorbing floors that attempt to reduce fracture risk by decreasing in-line stiffness and hip contact force during a fall.