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Impact of osteoporotic fracture type and subsequent fracture on mortality: the Tromsø Study



Less is known about the impact of non-hip non-vertebral fractures (NHNV) on early death. This study demonstrated increased risk of dying following hip and NHNV fractures which was further increased by a subsequent fracture. This highlights the importance of early intervention to prevent both initial and subsequent fractures and improve survival.


Osteoporotic fractures are a major health concern. Limited evidence exists on their impact on mortality in ageing populations. This study examined the contribution of initial fracture type and subsequent fracture on mortality in a Norwegian population that has one of the highest rates of fractures.


The Tromsø Study is a prospective population-based cohort in Norway. Women and men aged 50+ years were followed from 1994 to 2010. All incident hip and non-hip non-vertebral (NHNV) fractures were registered. NHNV fractures were classified as either proximal or distal. Information on self-reported co-morbidities, lifestyle factors, general health and education level was collected. Multivariable Cox models were used to quantify mortality risk with incident and subsequent fractures analysed as time-dependent variables.


Of 5214 women and 4620 men, 1549 (30%) and 504 (11%) sustained a fracture, followed by 589 (38%) and 254 (51%) deaths over 10,523 and 2821 person-years, respectively. There were 403 (26%) subsequent fractures in women and 68 (13%) in men. Hip fracture was associated with a two-fold increase in mortality risk (HR 2.05, 95% CI 1.73–2.42 in women and 2.49, 95% CI 2.00–3.11 in men). Proximal NHNV fractures were associated with 49% and 81% increased mortality risk in women and men (HR 1.49, 95% CI 1.21–1.84 and 1.81, 95% CI 1.37–2.41), respectively. Distal NHNV fractures were not associated with mortality. Subsequent fracture was associated with 89% and 77% increased mortality risk in women and men (HR 1.89, 95% CI 1.52–2.35 and 1.77, 95% CI 1.16–2.71), respectively.


Hip, proximal NHNV and subsequent fractures were significantly associated with increased mortality risk in the elderly, highlighting the importance of early intervention.

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We are grateful to Professor Ragnar Joakimsen for his great contribution to The Tromsø Study.


The Tromsø Study was funded by the University of Tromsø and from contributions by the National Screening Services, the Research Council of Norway, Northern Norway Regional Health Authority, Norwegian Council on Cardiovascular Diseases and Norwegian Foundation for Health and Rehabilitation. This work was supported by the National Health Medical Research Council Australia (NHMRC project ID; DA 1114676, DB 1073430, TT 1070187 and JRC 1008219). Other funding bodies were the Bupa Health Foundation (formerly MBF Foundation) and the Mrs. Gibson and Ernst Heine Family Foundation.

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Correspondence to D. Alarkawi.

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DA, DB, TT, LAA, NE, ÅB, LJ and TC have no competing interests to declare. JRC has consulted for and/or given educational talks for Merck Sharp and Dohme, Amgen, Actavis and Sanofi-Aventis. JAE has consulted for and/or received research funding from Amgen, deCode, Merck Sharp and Dohme and Sanofi-Aventis.


The study sponsors had no role in the study design; collection, analyses and interpretation of the data; the writing of this report; or the decision to submit this manuscript for publication.

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Supplementary Table S1.

Multivariable adjusted mortality risk following subsequent fracture by gender in fracture cohort – a paired comparison for each fracture type (DOCX 15 kb)

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Alarkawi, D., Bliuc, D., Tran, T. et al. Impact of osteoporotic fracture type and subsequent fracture on mortality: the Tromsø Study. Osteoporos Int 31, 119–130 (2020).

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  • Non-hip non-vertebral fractures
  • Mortality
  • Tromsø Study
  • Subsequent fracture