Context Absolute fracture risk in nursing home patients is the highest among the communities studied. Screening for high risk patients in such an environment is usually difficult.

Objective To investigate whether quantitative bone ultrasound measurements and/or markers of bone turnover/metabolism help in predicting which patients will incur hip- or non-vertebral fractures.

Design, Setting, and Participants In this prospective study, mobile teams enrolled 1664 female patients from 95 nursing homes in Austria.

Main Outcome Measures Calcaneal stiffness (n=1117), radial SOS (n=1332) and phalangeal SOS (n=1498) measurements were performed at baseline. Serum samples (n=960) were analyzed for serum calcium and phosphate, 25 hydroxyvitamin D, parathyroid hormone, osteocalcin, C-terminal telopeptide crosslinks and osteoprotegerin. Patients were prospectively followed for hip and other non-vertebral fractures for two years.

Results A total of 117 hip- and 269 non-vertebral fractures developed during a mean observation period of 2 years. Prevalence of Vitamin D deficiency and secondary hyperparathyroidism was high. A history of a past fracture was significantly associated with a hazard ratio (HR) of 1.47 (95%CI 1.01-2.15) and 1.65 (1.26-2.16) for the development of hip- and non-vertebral fractures, respectively. Cox regression analysis revealed a multivariate adjusted elevation in both hip [HR 1.30 (1.12-1.43)] and non-vertebral fracture risk [HR 1.14 (1.02-1.25)] for each standard deviation (SD) decrease in calcaneal stiffness. Patients in the lowest quartile for calcaneal stiffness Z-score had a 2.5 and 1.2 times higher rate of hip and non-vertebral fractures when compared to patients in the highest quartile. Fracture rates were not statistically associated with baseline radial or phalangeal SOS measurements or with serum osteocalcin, C-terminal telopeptide crosslinks and osteoprotegerin concentrations. When adjusted for bone mass, higher serum osteoprotegerin levels were associated with fewer hip as well as non-vertebral fractures [HR 0.85 (0.73-0.99) and 0.89 (0.80-0.99) per increment of 1]. Higher serum phosphate levels indicated an increased hip [HR 1.54 (1.07-2.21)] and non-vertebral fracture risk [HR 1.40 (1.10-1.78) per increase of 1 mg/dL]. BMI was protective of hip fractures [HR 0.94 (0.90-0.98) per increase of 1] as well as medication with acetylsalicylic acid [HR 0.59 (0.36-0.95) for hip and 0.72 (0.52-0.99) for non-vertebral fractures]. In contrast, current use of glucocorticoids [HR 5.65 (1.77-18.0)] and opiates [HR 1.85 (1.18-2.92)] exerted a negative effect on prospective hip fracture risk.

Conclusion Calcaneal stiffness measurements proved to be useful in predicting hip and to a lesser extent non-vertebral fractures in nursing home residents. Radial and phalangeal bone ultrasound measurements and baseline markers of bone turnover, however, were not indicative of future fracture risk in this population.