Association of Vitamin D with fragility fractures: A hospital based
cross-sectional study
Author: Dr Jaydev Barapatre
PGT, Orthopaedics
JMCH.
Fragility fractures
Definition
• Fragility fracture -- low energy fracture.
• Bone structure undergoes biomechanical failure under specific loading conditions.
• WHO defined this low energy trauma as fall from standing height or less, that
normally would not result in fracture.
Demographics
8.9 million osteoporotic fragility fractures every year
(worldwide)
4th leading cause of chronic disease morbidity.
Vitamin D
• Important regulator of bone metabolism
• Dietary sources of vitamin D – inadequate sun exposure.
• Main function – calcium homeostasis
Metabolism of Vitamin D
Absorbed by 7-Dehydrocholesterol Forms Pre vitamin D3
UVB radiation
(Skin) (unstable)
Dietary Vit D Absorbed in lymphatics
Via chylomicrons
Binds to Vit D binding Vitamin D3
Drawn into capillaries
protein (DBP) (extracellular space)
Forms Transported to liver
Binds to DBP Released into renal Forms 1,25(OH)2D
25(OH)D tubule cell (Active)
Pathophysiology
Low sunshine exposure
Low serum 25 (OH)D Low vitamin D intake
Low serum 1,25 (OH)2D Decreased renal function
Decreased Ca absorption
Higher PTH
Muscle
weakness
Mineral deficit
Hyperosteoidosis High turnover
0 Bone resorption
Falls Osteomalacia
0
Fractures Osteoporosis
Methodology
• Rationale – To determine the prevalence of vitamin D deficiency in patients
with fragility fractures.
Study universe: > 45 years of age with fragility fractures
Study area: Orthopaedics OPD JMCH
Type of study: Hospital based Cross sectional observational study.
Sampling frame: Adult patients more than 45 years of age with fragility fractures
attending Orthopaedics OPD, JMCH.
Sampling technique: Consecutive sampling.
Sample size: 97
• Inclusion criteria:
Patients attending Orthopaedics OPD, JMCH
Consent to participate in study
Age group 45 years and more
Fragility fractures
• Exclusion criteria:
Patient receiving Vit-D supplementation, drug for
osteoporosis, steroids, anti-epileptic drug, diuretics,
heparin, thyroid hormone supplementation, progestins.
Patient with renal and liver disease.
Investigations
Estimation of serum Vit-D level
Serum Calcium, Phosphate, PTH, S. Creatinine and other biochemical tests.
Plain radiographs
Assessment of Singh’s index
Fig: Radiograph showing fragility fracture of proximal femur and distal radius
Pattern of trabecular resorption in the femur due to osteoporosis (Singh index)
DISTRIBUTION OF VITAMIN D STATUS AMONGST SUBJECTS WITH FRAGILITY FRACTURES
Distribution of vitamin D status in subjects with
fragility fracture
20.61%
44.32%
35.05%
Deficent Insufficient Sufficient
Distribution of vitamin D status in subjects with fragility fractures according to sex
Distribution of vitamin D status in patients with
fragility fracture according to sex
30
25
Number of patients 25
20
20 18
15 14 14
10
6
5
0
Male Female
Sex
Deficient Insufficient Sufficient
Distribution of vitamin D status in subjects with fragility
Total fractures according to diet :
Vitamin D status No.
according towith
of patients typefragility
of diet
fractures according to diet
Vitamin D status 18
80
Number of patients
60 33
40
37
20 2
1
6
0
Vegetarian Mixed diet
diet
Types of diet
Deficient Insufficient Sufficient
Distribution of vitamin D status in subjects with fragility fractures
according to behavioural risk factors:
Vitamin D status
Risk Factors Distribution of vitamin D status in subjects with fragility fractures Chi square and p-
according to behavioural risk factors value
12
10
10 9 9
Number of patients
8
8 7
6
6
4 3 3
2
2
0
Smoking Alcoholism Inadequate sun
exposure
Risk factors
Deficient Insufficient Sufficient
Distribution of vitamin D status in subjects with fragility fractures
according to comorbidities
Vitaminin
Distribution of vitamin D status D status
patients with fragility
COMORBITIES fracture according to comorbidities TOTAL
10 9
9 8
Number of patients
8
7 6
6
5 4
4
3 2 2 2
2 1 1 1
1 0 0
0
HTN DM CAD CVA
Comorbidities
Deficient Insufficient Sufficient
Discussion
Out of 97 patients with fragility
Table: Classification of vitamin D fractures,
deficiency(US Endocrine Society classification) 43(44.32%)-- vitamin D deficient,
Vitamin D Status Vitamin D Level 34(35.05%)--vitamin D insufficient
20(20.61%) – vitamin D sufficient.
Deficiency < 20 ng/dl The results similar to –
Suchat Phusunti et al. -- 46.3%
Insufficiency 20-30 ng/dl
vitamin D deficient
Bogunovic et al. -- 40% vitamin D
Sufficiency >30 ng/dl
deficient
Discussion
No significant difference among the male and female subjects with fragility fracture.
The finding similar to -
Gallacher et al., G.S Maier et al., Qinnan wang et al.
Discussion
Out of 43 vitamin D deficient patients
6 out of 9 veg(66.66%) patients -
with fragility fracture –
vitamin D deficiency 7(16.27%)-- smoker,
37(42.04%)out of 88 patients - mixed
10(23.25%)-- alcoholic
diet - vitamin D deficiency. 3(6.97%) -- inadequate sun exposure.
The finding was statistically
insignificant (p-value >0.05) The results were statistically
insignificant (p-value >0.05). The
However, the finding contradictory
finding of contradictory to the finding
to the finding of Javed Altaf Baig et al.
of Eva N Kassi et al.
Discussion
Out of 43 vitamin D deficient patients with fragility fracture,
8(18.60%) patients had hypertension,
9(20.93%) had diabetes mellitus,
1(2.32%) had coronary artery disease
1(2.23%) patient had cerebrovascular accident.
The present study shows vitamin D deficiency is more common among patients with
diabetes mellitus.
Consistent with other studies. Zhao H et al.
Conclusion
• It can be concluded that vitamin D deficiency is highly prevalent
in patients with fragility fracture. Timely diagnosis and vitamin D supplementation can
prevent fragility fracture.
• However, the present study was constrained by the limitation of time and a
relatively smaller sample size. So we recommend a study with larger sample size and a
longer period to get more information regarding the topic.
THANK
