Doctorb, a chicken or the egg question.

[Jeff]

I could have posted this on the idle thoughts topic, oe on the new mother-in-law topic, but I thought I'd just go ahead and post it here on this board.

You are constantly hearing of older people falling, and when they fall, it seems like the hip is the most likely thing to break, and it seems especially so in elderly woman more then men.  I have a theory based on nothing but idle thoughts, but figured the person that would know if there is a few dots to connect would be doctorb.

Is it possible in some of these cases, that it's not the fall that breaks hips, but the hips breaking that causes the fall?

[Brian_Rhoad]

I saw a TV program where C. Everett Koop thought that the hip broke first, causing the fall. He gave a demonstration of how older people should sit down and stand up to reduce the chances of a hip breaking. He thought that people where putting more weight on one leg as they sat or stood up and twisted at the same time causing hip fractures.

[beenthere]

People talk of hearing the snap of the bone before the fall. Regardless, the results are much the same.

[doctorb]

I'll try and help answer that question, but in reality, for any given situation, we never really know.  Here's some pertinent knowledge....

As we age, we are constantly losing bone mass.  This happens for men and women at about the same rate, up until menopause (early 50's).  After that change, women lose bone mass faster than men.  It's also very race-based as well.  White women have the highest rates of severe osteopenia, so they are the most common person I see with a hip fracture.  Last week, the resident came into the OR where I was working and reported that she had just seen a 60 y.o. woman in the ER with a hip fracture.  I replied that I bet that she was white, and that I bet that she was very thin.  The resident's eyes got a little bigger and she asked me how I knew that.  The answer was easy.  After being in practice for a long while, this pattern of injury is easily apparent.  White men and black women have similar rates of hip fractures, which are less than white women.  It's unusual, but not uncommon, for a black man to have a hip fracture.  When I see a black man with a hip fracture I always think it might be from something else, like spread of a tumor.

Bone is weakest in torsion, i.e. twisting.  We are therefore built to withstand running into the kitchen table, but less able to withstand planting our foot hard and turning in a different direction.  I believe that some of our hip fractures happen on a sudden change of direction, maybe like catching oneself after a mis-step.  That quick loading of the bone, with some twist in the applied force, can cause fracturing of osteopenic bone.

So, when I talk to men with hip fractures, they tell me they tripped over something and fell onto their hip.  Women also say the same thing, but often it's just that they "lost their balance" and fell.  Some certainly fracture upon impact with the ground, others must fracture in the standing position due to an acute loading of very weak bone, making it impossible to stand and then they fall.

No offense to Dr. Koop, but he couldn't have possibly known enough to make an accurate blanket statement like that.  As I said, each situation is different.

The controversy that is arising surrounds all the "bone density" drugs.  They have definitely lowered the rates of hip fractures in this country.  No doubt about it.  That's a huge savings of medical costs and patients' functionality.  But a small number of people who have taken these drugs for long periods of time may be developing very dense, but more brittle bones.  They seem to be prone to getting stress fractures of the lower extremities, which don't heal well in the face of this very dense bone.  So every medical advance has its downside, and the treatment of osteopenia is no different

Long answer with no right answer.  Life is just like that sometimes.

[Left Coast Chris]

Any thoughts regarding diet and excersise habits helping bone density as we age?    We have always heard that eating lots of leafy greens and otherwise getting enough calcium is a help.   Also, does loading the body such as with weight lifting help bone density or bone mass?

[doctorb]

All women, and probably us guys too, need to have an adequate calcium and vitamin D intake in their diet.  If your diet doesn't vary much from week to week, pay attention to the amount of those two items and take supplements if your diet is lacking in that area.  We are now well aware in medicine of the significant percentage of the population that has low vitamin D levels.  This can come from diet issues, or from malabsorption (you can't absorb it from your intestines, or do so poorly.)  Vitamin D helps you absorb calcium and is vital to bone health.

Most people don't realize it, but bones are living organs that respond to the forces placed upon them.  This may be why we don't see a lot of osteopenia in overweight people, as their bones have had increased stress placed upon them.  The astronauts lost a lot of bone mass in their long space flights.

Most people should have exercise in their regimen to maintain bone health.  Weightlifting is often thought of as a upper body exercise.  Most "weight lifting" for lower extremity strength in our elderly population is probably done through walking, which, if done often, will help maintain boney strength.

Two things are out of our control in this equation.  Our genetic makeup can predispose us to osteopenia and fractures, regardless of how diligent we try to fight it.  Secondly, we can not control the level of our peak bone mass, which occurs in your 20's.  The higher you peak bone mass is, the longer it takes for the erosive effects of age to weaken your bones.  The peak bone mass is undoubtedly affected by diet, exercise, and heredity.  Not many of us worry about bone mass when we are in our teens, but maybe we should.

[pineywoods]

DocB, you sure my wife isn't one of your patients ?  ;D Your explanation fits her to a T. Early 60's white, slight build. She fell and broke a hip. I was with her when it happened and I'll always believe the joint broke before the fall. Awkward twisting step backwards. Local bone doc says, I can patch it with bolts, but guarantee it won't last a year, recommend a total replacement. We concurred. A bone density scan showed lower back and hips to be less than 50% normal, despite the fact she had been on calcium and vitamin D supplements for over a decade. He recommended a hormone regimen, in addition to calcium and vitamin D, which appears to be working. She now gets a density scan as part of a yearly physical. There's undoubtedly some side effects, but it's hard to say what they are because she's on some other meds (like thyroid treatment) that also have side effects.

BTW, the replacement, titanium and teflon, has been mostly trouble free for 12 years, but she isn't very active.

Your comment about one side effect being brittle bones is spot on. Last year she sat down hard and fractured her pelvic bone in 2 places..despite the bone density scans showing almost normal...Last session with the bone doc, he said "at your age and condition, if you fall, probably gonna break something". I ordered a medical alert pendant tonite, something I recommend.

[Gary_C]

The controversy that is arising surrounds all the "bone density" drugs.  They have definitely lowered the rates of hip fractures in this country.  No doubt about it.  That's a huge savings of medical costs and patients' functionality.  But a small number of people who have taken these drugs for long periods of time may be developing very dense, but more brittle bones.  They seem to be prone to getting stress fractures of the lower extremities, which don't heal well in the face of this very dense bone.  So every medical advance has its downside, and the treatment of osteopenia is no different

As an former dairy farmer, I have to ask if consuming dairy products through out your life and particularly in later years will have a positive effect on bone density. I've always heard that milk, cheese, and ice cream consumption were far better for you than all the bone density drugs because they are "good" sources of calcium and Vitamin D. I know that many doctors do not like to recommend dairy products, probably because of the high fat content and the obesity problems it can cause. And of course digesting lactose can become problematic in later life too.

What are your thoughts on this?

[WH_Conley]

After my wife had her thyroid taken out the Doctors told her to OD on dairy. She takes daily calcium supplements. They said it was for the muscles, they come first, the bones get what is left over.

[doctorb]

Calcium is a very tightly controlled mineral in the body.  Blood calcium levels that are too high or too low cause tetany (uncontrolled muscle contraction) or paralysis.  So taking huge amounts of calcium, when your body does not need it, just means you don't absorb it through the intestines and it passes through.  Dietary calcium should be maximuized, up to a point.  Beyond that, you simply can not absorb more.  Furthermore, your body is physiologically made to store calcium in the bones.  So while we are now "programmed" to try to maximize our calcium bone health, your body was built to do that from a long time ago.  The calcium that's measured in your blood is ionized calcium.  The calcium you absorb  from your diet is not.  The former is the usable form for muscles and bones.

That being said, I think that growing up with a high dairy dietary intake will maximize your bone mass, if you are active.  While it's a generalization, my times on farms were active times.  If you grew up on a farm and had a diet rich in dairy products, I think that you would have maximized your bone health.  The uncotrollable factor, without some other problem or disease like malabsorption syndrome or parathyroidism, is your genetic makeup.  Some people are simply predetermined to have low bone mass and become osteopenic.  I am not of the opinion that the classic farm diet and activity can overcome bad genetics in this instance.

[Sprucegum]

An article in our local newspaper claimed two drinks, of any type of alcoholic beverage, was very effective in building bone mass. I have embraced that theory and aim to prove it  ;D

[Raider Bill]

An article in our local newspaper claimed two drinks, of any type of alcoholic beverage, was very effective in building bone mass. I have embraced that theory and aim to prove it  ;D

So if 2 are good the 6 has to be better right! 8)

[Sprucegum]

Sorry Bill, any more than 2 just thickens the bone in your head