Fractures of the wrist and hip in elderly patients are so common and so costly that these fractures rank high on the list of national public health concerns in the United States. Prevention is perhaps the most effective way to attack this problem, and a prevention strategy relies in part upon identifying the risk factors that predispose elderly patients to these injuries. With this perspective, the article “Evaluation of Physical Performance Level as a Fall Risk Factor in Women with a Distal Radial Fracture,” by Dr. Young Jae Cho et al., is particularly relevant to contemporary orthopaedic care and public health. The authors attempted to identify aspects of physical performance and muscle strength as variables that might predispose women over the age of fifty years to distal radial fracture. Cho et al. compared forty postmenopausal women who broke their wrists with forty age-matched controls. Physical performance was measured by assessing walking speed, chair stand ability, standing balance, grip strength, and time spent walking during the day. The authors were also able to collate data about other health information, such as body mass index; the use of certain medications (including sedatives and antihypertensive drugs); and the presence of osteoarthritis, arrhythmias, vertigo, hypotension, and depression.

Interestingly enough, the only variables that showed any significant difference between the two groups of patients were the chair stand ability and grip strength. Of note is that even for these two variables, the degree of significance was not particularly dramatic, and, as the authors point out, the power of this study was limited by the relatively small sample population. So although this project was thoughtfully constructed and is presented in a well-written text, the reader might be underwhelmed by its value. Despite a careful attempt to identify risk fractures in a typical at-risk population for distal radial fracture, only two factors stood out, and quite slightly at that.

However, with a little bit of added perspective, this article is actually quite interesting. It is all too easy in the world of orthopaedic surgery to become obsessed with the “how” and less so with the “why.” Our field has advanced enormously in terms of scientific knowledge concerning fracture fixation; distal radial fracture care, for example, has changed completely from the external fixators of a previous era to the use of contemporary internal fixation systems. Yet there is frustratingly little objective information as to why so many elderly patients fall in the first place. Hip and wrist fractures in the elderly are such a common occurrence that it seems somehow accepted as a normal process of aging. Although we have dramatically improved the quality of life through better fracture care, how to find effective ways to prevent those fractures from occurring still remains a mystery.

As much as the authors have been true to their data and can only identify two areas of possible correlation for fracture risk, it is particularly interesting that both are in the realm of physical performance. Chair stand ability likely relates to both strength and balance factors, and grip strength has been shown to have some correlation with overall strength in older patients. The relationship of physical activity and general health has a commonsense appeal, in particular because, with the higher life expectancies and the advancements in orthopaedic care, increasingly more Americans are living longer and are doing more. This fact is not just supported with census data; it has also been endorsed by the public at large, in part because maintaining a high activity status in later years has become such an obvious and popular feature of our culture.

For years, the American Academy of Orthopaedic Surgeons has focused on public health by stressing physical activity as the key. “Get Up, Get Out, Get Moving” has been a campaign slogan for many years and stresses the importance of physical activity as a strategy to improve body mass index and overall physical fitness. A current public education program uses the phrase “A Nation in Motion” to highlight the benefits of orthopaedic care in maintaining active lifestyles at every age. The web site http://anationinmotion.org features personal stories that patients voluntarily contribute about their orthopaedic care and how it has maintained their mobility. It does not take much time visiting this web site to see the enormous number of posted stories and the fact that many elderly patients use the words “I’ve gotten my life back” in describing their recovery from joint replacement or fracture surgery. “Getting their life back” for these older patients is often characterized as resuming a sport, returning to regular physical activity, or, in some cases, climbing mountains again.

The point here is that physical activity might really be the magic potion that keeps our skeletons strong and our bodies younger. Is physical activity later in life just increasing our risk of injury—or, as our inner voice might suggest, does exercise heal at any age? What would be nice, as with every other hypothesis that seems intuitively obvious, is some real proof. The article by Dr. Cho et al. brings us a baby step closer to this proof. A logical extension of this project would include larger sample sizes and more objective strength and balance measurements. However, at a very basic level, this article starts to answer the “why” of fragility fractures and identifies a few clues that might confirm what everyone, both doctors and patients, suspects is true: physical activity is the holy grail of orthopaedic health. Now it is time to for me to go jogging with my dog—and with my wrist guards.