Overview of Epidemiology: Rockwood & Green's Fractures in Adults, 6th Edition

Ovid: Rockwood & Green's Fractures in Adults
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Edit ors: Buchol z, Robert W.; Heckman, James D.; Court-Brown, Charles M . Titl e: Rockwood & Green's Fractures in Ad ults, 6th Edition Copyright 2006 Lippincott Williams & Wilkins
> Ta bl e o f Cont ent s > Vo l ume 1 > S ecti o n O ne - Gene ral P ri nc ipl e s > C ha pter 4 - T he Epi dem i ol o gy o f Fractu re s > Part 1 - Ov ervi ew o f Epi de mi ol o gy
Part 1 Overview of Epidemiology

Char les M. Court-Brown Benjam in C. Caesar Several generations of orthopaedic surgeons have understandably given most of their attention to the constantly evolving treatment methods in orthopaedic trauma. Change has been swift, and as surgeons' primary interest is the optimal care of their patients, their focus has often been on advances in treatment methods, rather than any change in patients or their fractures. T here have been considerable changes not only in the type of patient presenting to orthopaedic surgeons, but also in the health systems of most countries, as well as in the economic ability of many countries to finance health. Because orthopaedic trauma absorbs a considerable proportion of most countries' health budgets, it is important to understand the frequency of musculoskeletal injury, the environment in w hich it occurs, and the treatment costs. T his is the first chapter on fracture epidemiology in six editions of Bucholz's Rockwood and G reen's Fractures in Adults and, given the enormous scope of musculoskeletal trauma, an attempt has been made to define the process of change and to highlight its effect on health care systems. It is divided into two sections. In the first section, the epidemiology of a well-defined population is presented w ith a view to determine the incidence of various fractures and define which section of the population presents with different fracture types. The importance of osteopenic or osteoporotic fractures is highlighted, as are the changing trends. It is shown that a number of fractures that w ere commonly thought of as affecting young people 15 to 20 years ago should now be considered as mainly osteopenic fractures. In the second part of the chapter, there is an in-depth analysis of the epidemiology of fractures in the United States. This information highlights the scale of the problem as it draw s attention to the huge numbers of patients that present with musculoskeletal injury and the considerable strain that they place on the health care system. The requirement for hospitalization is analyzed, as is the associated disability that injury causes. There are also data on the different types of treatment employed in the many parts of the US. The next stage may be to find out why surgeons in different parts of one country use radically different treatment methods. Both sections of the chapter draw attention to the various modes of injury and how they may be directly affected by legislation and public behavior. In some parts of the world, the incidence of serious injury after motor vehicle accidents is falling because of improved legislation regarding speeding and alcohol use. Combined with improved industrial safety legislation, this may change the spectrum of injury seen by orthopaedic surgeons, although increasing leisure time may merely increase the number of sports-related injuries It is important that surgeons understand the epidemiology of the fractures that they treat. T hey often have a skewed view of which fr actures are common and which fractures are merely commonly discussed. Much of the literature concerns the management of difficult fractures such as complex pelvic injuries, unstable spinal fractures, four-part proximal humeral fractures, open tibial fractures or hindfoot fractures, and it is easy to assume that surgeons will generally be required to treat these fractures. Many orthopaedic trauma surgeons work in specialized hospitals where fractures such as distal radial fractures, two-part proximal humeral fr actures, ankle fractures, metacarpal and metatarsal fractures are rarely seen. As a result, they assume that these fractures are less important, easy to treat, and of little importance to the surgical community. This chapter seeks to define the incidence of different fractures and to detail the changing trends in fracture epidemiology, p articularly with regard to the increasing incidence of osteopenic or osteoporotic fractures. T here is no doubt that fracture epidemiology is changing rapidly. In many countries, improvements in social conditions and general health have led to an increasingly elderly population with higher demands and greater political influence. Improvements in workplace legislation and automobile safety have led to a decline in serious fractures in younger patients. This has been helped in many countries by improved road safety legislation and stricter firearm laws. T he overall effect is that osteoporotic fractures are rapidly increasing in incidence in many parts of the world to the extent that orthopaedic trauma surgeons are increasingly treating complex fractures in poor-quality bone. In a relatively short space of time, the young femoral diaphyseal fracture has given way to the periprosthetic femoral fracture, industrial injuries have declined in incidence, and grandmothers are consulting the Internet to see how their distal radial fractures should be treated. T he fracture population used in this chapter is from the Royal Infirmary of Edinburgh, Scotland, which is the only hospital dealing w ith orthopaedic trauma in a well-defined population. All outpatient and inpatient fractures in adults over the age of 12 years during the year 2000 were analyzed. Patients from out of the catchment area and patients who died prior to orthopaedic treatment were excluded. The clinical records and radiographs of all fractures were analyzed to exclude incorrect diagnoses and to document the mode of injury and type of fracture. During the year 2000, there were 5,953 fractures in a population of 534,715. It is accepted that fracture epidemiology fluctuates in different parts of the world and that the spectrum of fractures presenting to different hospitals may vary considerably, but it is likely that the overall population of the Edinburgh area reflects the overall population of many European and North American areas. It is suggested that the data presented in this chapter can be extrapolated for use in other areas, although it is accepted that there will be differences based mainly on the socioeconomic status of the particular area. It is likely, however, that the trends in fracture epidemiology are broadly similar in many parts of the world.
FRACTURE INCIDENCE
T he overall fracture incidence is 11.13 in 1,000 per year. The fracture incidence in males is 11.67 in 1,000 per year, and in females, it is 10.65 in 1,000 per year. These figures are similar P.97 to some other studies but are less than the incidence of fractures recorded in Norw ay, the US, and England (T able 4- 1). It is difficult to know why the incidences shown in Table 4-1 vary so considerably, and it is also difficult to explain why there is such a discrepancy between the incidence of males and females in some of the studies. A number of reasons may well influence the results of the studies shown in Table 4-1. T hese factors are the changing epidemiology of fractures in different parts of the world, the socioeconomic status of the areas in which the studies were undertaken, and the methodology that was used. In the Edinburgh study, all of the fractures were checked by reviewing the radiographs. In other studies, the data have been taken from emergency department records, and the incidence of some fractures may well have been overestimated. It is also important to review both in-patient and
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outpatient records if a true incidence is to be obtained. It is of interest that the incidence of fractures in the population over 65 years of age in Edinburgh is 23.3 in 1,000 per year, which compares with results from England and Australia ( 1,2). The incidence of fractures in patients aged 12 to 19 years is 13.5 in 1,000 per year, and the incidence in patients aged 40 to 49 years is 6.1 in 1,000 per year. The low incidence of fractures in middle age is also show n in Figure 4-1, which shows the age-related incidence for both men and women for all fractures. Female fracture distribution is unimodal; the peak in incidence starts about the time of menopause and rises consistently in later decades. The highest incidence is 49.7 in 1,000 per year between the ages of 90 to 99 years. In males, the fracture distribution is different. It is bimodal w ith peaks between 12 to 19 years (21.9 in 1,000 per year) and between 90 to 99 years ( 23.2 in 1,000 per year). T he rise to the second peak begins later than in females, usually starting between 60 to 69 years of age. The later male peak has become more obvious in recent years because males are now living longer, and they are at greater risk of osteopenic or osteoporotic fractur es.
TABLE 4-1 The Fracture Incidences in Different Studies

Males/1,000 Per Y ear Fem ales/1,000 Per Year Combin ed /1,000 Per Year
Norway (3)
22.9
21.3
22.8
USA (4)
26
16
21
England ( 5)
23.5
18.8
21.1
England ( 4)
10.0
8.1
9.0
Malta (8)
10.0
8.0
9.0
Scotland
11.67
10.65
11.13
Analysis of individual fracture incidence shows that there are eight basic distribution curves (Fig. 4-2) . Most fractures have a unimodal distribution affecting either younger or older patients. Some fractures, however, have a bimodal distribution whereby young and older patients are affected, but there is a lower incidence in middle age. If one analyzes males and females separately, the distribution curves shown in Figure 4-2 can be constructed. The eight distribution curves define all fractures. The relative heights of the curves' peaks differ, but the curves remain appropriate for the overall fracture population. A type A curve is often thought of as a typical fracture curve. Both genders show a unimodal distribution, and the fractures are most commonly seen in young males and older females. Generally, the young male peak is higher than the older female peak although, not in all fractures; an example is metatarsal fractures in which the younger male peak is at a similar height to the older female peak. This type of curve is seen in fractures of the scapula, tibial diaphysis, distal radius, ankle, and metatarsus. In type B curves, there is also a young male unimodal distribution, but fractures in females occur in smaller numbers throughout the decades. Type B fractures are generally seen in the hand affecting the fingers, metacarpus, and carpus. They are usually the result of a direct blow or punch.
FIGURE 4-1 The age- and gender-specific incidence of fractures.
In type C fractures, both males and females show a unimodal distribution; fractures are rare after middle age. The incidence is less in females than males. These fractures tend to occur in the foot and affect the toes, midfoot, and talus. In type D fractures, there is a young male unimodal distribution, but the female distribution is bimodal affecting younger and older females. Generally, the second female peak starts around the time of menopause. Type D curves are seen in proximal forearm fractures, fractures of the forearm diaphyses, and tibial plafond fractures. T ype E fractures are the opposite of type B fractures. There is a unimodal female distribution affecting older females with a relatively constant, lower incidence of fractures in males throughout the decades. The type E pattern is seen in pelvic fractures, distal humeral fractures, distal radius fractures, and distal femoral fractures. This pattern may be surprising to a P.98
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number of surgeons who believe that they see a large number of young male patients with pelvic fractures, distal humeral fractures, and distal femoral fractures; but if the incidence across the community is analyzed, a type E distribution is obtained. Type F fractures are the opposite of type C fractures. In type F fractures, both males and females show a unimodal distribution affecting older patients, and the incidence is higher in females than in males. This pattern is characteristic of fractures of the proximal humerus, humeral diaphysis, proximal femur, femoral diaphysis, and patella. There is some variation regarding when the rise in fracture incidence occurs. Generally, it is earlier in females than in males and usually occurs around the time of P.99 menopause in proximal humeral fractures, humeral diaphyseal fractures, and patellar fractures, but later in femoral diaphyseal fr actures and p roximal femoral fractures.
FIGURE 4-2 AI. The distribution curves for different fractures and causes of fracture.
In type G fractures, females show a unimodal distribution affecting older females, and males show a bimodal distribution affecting both younger and older males (although the incidence is higher in younger males). The two fractures that show this distribution are those of the calcaneus and clavicle. T ype H fractures are unusual in that both males and females show a bimodal distribution. T his distribution is seen in fractures of the humeral diaphysis, tibial plateau, and spine.
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HOW COMMON ARE DIFFERENT FRACTURES?

T here is debate about how common different fractures actually are. Studies that only examine inpatient data will obviously overestimate the frequency with which some fractures occur, and will tend to overestimate the frequency of fractures in males. T able 4-2 shows the relative frequencies of different fractures. It is obvious that fractures of the distal radius are by far the most common, and fractures of the metacarpals and proximal femur occur in approximately equal numbers. Fractures of the distal humerus, distal femur, scapula, talus, and midfoot are rare, and as a result, many surgeons will have little experience in their management. It is interesting to note that if all fractures are considered, the gender ratio is 50/50 despite many fractures having a marked male or female predominance. If the gender ratio in Table 4-2 is compared with the average patient age of the different fractures shown in T able 4- 3, it can be seen that fractures w ith a high female predominance tend to be in patients with an older average age.
WHICH FRACTURES ARE RELATED TO OSTEOPENIA?

Analysis of the fracture distribution curves shown in Figure 4-2 shows that only types B and C are not associated with an increased incidence in older patients. F ractures related to osteopenia or osteoporosis are becoming more frequent. Traditionally, these fractures were always assumed to be those of the proximal femur, distal radius, proximal humerus, or vertebrae, but it is obvious from Table 4-3 that the pattern of osteopenic or osteoporotic fractures in the population is changing. Table 4- 3 shows the different fractures listed by age with percentages of patients aged more than 65 and 75 years. T he results for vertebral fractures should be ignored, as it was impossible to calculate an accurate figure for their frequency in the population. P.100 P.101 P.102 It is often difficult to age a vertebral fracture, and many patients with osteoporotic vertebral fractures never present to a hospital. T he literature indicates that vertebral fractures are common (3) , however, and it seems likely that their incidence may be similar to that of distal radius fractures.
TABLE 4-2 Fractures Arranged in Order of Decreasing Incidence

No. % n/10 5 Gen der/Rati o
Distal Radius
1,044
17.5
195.2
31/69
Metacarpal
697
11.7
130.3
85/15
Proximal Femur
692
11.6
129.4
26/74
Finger Phalanx
574
9.6
107.3
68/32
Ankle
539
9.0
100.8
47/53
Metatarsal
403
6.8
75.4
43/57
Proximal Humerus
337
5.7
63.0
30/70
Proximal Forearm
297
5.0
55.5
46/54
Toe Phalanx
212
3.6
39.6
66/34
Clavicle
195
3.3
36.5
70/30
Carpus
159
2.7
29.7
72/28
Tibial Diaphysis
115
1.9
21.5
61/39
Pelvis
91
1.5
17.0
30/70
Forearm
74
1.2
13.8
64/36
Calcaneus
73
1.2
13.7
78/22
Proximal Tibia
71
1.2
13.3
54/46
Humeral Diaphysis
69
1.2
12.9
42/58
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Patella
57
1.0
10.7
44/56
Femoral Diaphysis
55
0.9
10.3
36/64
Distal Tibia
42
0.7
7.9
57/43
Spine
40
0.7
7.5
62/38
Distal Humerus
31
0.5
5.8
29/71
Midfoot
27
0.4
5.0
48/52
Distal Femur
24
0.4
4.5
33/67
Scapula
17
0.3
3.2
59/41
Talus
17
0.3
3.2
82/18
Sesamoid
0.01
0.2
100/0
5,953
100
1113.3
50/50
The incidence per 100,000 of the population is shown as is the gender ratio of males to females.
TABLE 4-3 Fractures Arranged in Order of Decreasing Age

No. Average Age (yrs) > 65 Yr s (%) > 75 Yr s (%)
Proximal Femur
692
80.5
91.2
78.9
Pelvis
91
69.6
72.5
57.1
Femoral Diaphysis
55
68.0
69.1
58.2
Proximal Humerus
337
64.8
57.0
36.2
Distal Femur
24
61.0
50.0
41.7
Sesamoid
58.0
Patella
57
56.5
49.1
22.8
Distal Humerus
31
56.4
45.2
29.0
Distal Radius
1,044
55.5
45.8
28.2
Humeral Diaphysis
69
54.8
40.5
17.4
Scapula
17
50.5
41.2
29.4
Proximal Tibia
71
48.9
23.9
12.7
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Ankle
539
45.9
20.8
10.2
Proximal Forearm
297
45.7
24.2
13.5
Spine
40
43.5
17.5
12.5
Metatarsal
403
42.8
14.2
5.7
Calcaneus
73
40.4
12.3
4.1
Tibial Diaphysis
115
40.0
17.4
11.3
Distal Tibia
42
39.1
14.3
7.1
Clavicle
195
38.3
17.4
12.3
Finger Phalanges
574
36.2
10.6
5.1
Midfoot
27
36.0
Toe Phalanges
212
35.3
6.5
4.6
Forearm
74
34.6
13.5
12.2
Talus
17
30.5
Metacarpals
697
29.9
5.5
3.6
5,953
49.1
33.0
22.6
The percentages of patients over 65 and 75 years of age are also shown.
If fractures of the proximal radius and proximal humerus are taken as representative of osteoporotic fr actures, we can see from T able 4- 3 that today many fractures that were formerly thought to occur in younger patients can now be thought of as osteopenic or osteoporotic. Table 4-3 shows that fractures of the pelvis, femoral diaphysis, distal femur, patella, distal humerus, humeral diaphysis, and scapula all have descriptive indices that suggest that they are osteopenic. The percentage of patients over 65 and 75 years of age is similar to fractures of the proximal humerus or distal radius. Table 4-3 confirms the very rapid change in the epidemiology of fractures and indicates that fractures that many surgeons now treat occur in older patients as a result of age-related osteopenia rather than in younger p atients as a result of high-energ y injury.
OPEN FRACTURES
T he incidence of open fractures in the Edinburgh population during the year 2000 is shown in Table 4-4. T his shows that open fractures most commonly occur in the leg and foot, and the tibial diaphysis and the distal tibia are most commonly affected. Open fractures of the fingers are also fairly common but are rarely severe. This is in contrast to most of the open fractures of the thigh, leg, and foot, which are associated with a high incidence of Gustilo type III open fractures. Table 4-4 also shows that a number of fractures were not associated with an open wound during the year of the study. This is not to suggest that open fractures in these areas do not occur, but they are clearly very rare, and when they do occur are often associated with very significant soft tissue damage and other musculoskeletal injuries.
ASSOCIATED INJURIES
T he 5,953 fractures occurred in 5,545 patients. Isolated fractures occurred in 94.4% of the patients, and 4.6% presented with tw o fractures. The remaining 1% presented with more than tw o fractures (range, three to nine fractures). Table 4-5 shows the numbers of other fractures that were associated with each index fracture. T he ratio of other fractures to the index fracture is also shown. When this is one, it means that on average, the index fracture is associated with one other fracture. T able 4- 5 lists the fractures according to the average number of other fractures that are associated w ith the index fracture. It is obvious that foot fractures are associated with the highest incidence of other fractures, but that spinal fractures, pelvic fractures, fractures around the knee, distal tibial fractures, and fractures of the humeral diaphysis and distal humerus are associated with a significant number of other fractures. Table 4-5 also lists the P.103 P.104 P.105 three fractures that are most commonly associated with each index fracture. It shows that associated fractures are usually situated near to the index fracture, but that several fractures are associated with spinal fractures. T able 4-5 shows that that the relationship
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between spinal and calcaneal fractures is important, but also shows that spinal fractures are associated with fractures of the talus, midfoot, distal femur, proximal tibia, patella, and pelvis, in particular.
TABLE 4-4 Fractures Arranged in Order of Decreasing Incidence of Open Fractures

No. Open (%) Gustilo III (%)
Tibial Diaphysis
115
19.1
54.5
Distal Tibia
42
16.6
71.3
Finger Phalanges
574
12.5
2.8
Talus
17
11.8
100
Midfoot
27
11.1
100
Forearm
74
9.5
Distal Femur
24
8.3
100
Femoral Diaphysis
55
7.2
75
Toe Phalanges
212
6.6
28.6
Humeral Diaphysis
69
4.3
33.3
Patella
57
3.5
50
Metatarsal
403
3.5
21.4
Proximal Tibia
71
2.8
50
Calcaneus
73
2.7
50
Ankle
539
1.7
33.3
Proximal Forearm
297
1.3
Pelvis
91
1.1
100
Metacarpals
697
1.0
Distal Radius
1,044
0.7
14.3
Spine
40
Clavicle
195
Scapula
17
Proximal Humerus
337
Distal Humerus
31
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Carpus
159
Proximal Femur
692
Sesamoid
5,953
3.1
22.8
The incidence of G ustilo type III open fractures is also shown in this table.
TABLE 4-5 The Numbers of Index Fractures, Associated Fractures, and the Ratio of the Two
Index Fr ac tur e Ot her Fractures Ratio of Other Fractur es/Index
Talus
17
48
2.82
Calcaneus (19.4%) Metatarsal ( 12.9%) Spine ( 6.4%)
Midfoot
27
41
1.52
Metatarsal ( 24.4%) Calcaneus (9.8%) Spine ( 5.9%)
Spine
40
48
1.2
Calcaneus (13.0%) Distal Radius (13.0%) Proximal Forearm ( 9.3%)
Calcaneus
73
31
0.68
Spine ( 14.6%) Metatarsal ( 14.6%) Talus ( 14.6%)
Distal Femur
24
14
0.58
Proximal Tibia (21.4%) Patella (14.3%) Spine ( 14.3%)
Distal Tibia
42
17
0.41
Tibia Diaphysis (41.2%) Distal Radius (17.6%) Proximal Tibia (11.8%)
Pelvis
91
37
0.40
Distal Radius (21.6%) Spine ( 13.5%) Proximal Humerus (13.5%)
Proximal Tibia
71
28
0.39
Spine ( 17.9%) Calcaneus (14.3%) Distal Femur (10.7%)
Humeral Diaphysis
69
22
0.32
Spine ( 13.6%) Distal Radius (13.6%) Proximal Radius (13.6%)
Distal Humerus
31
10
0.32
Proximal Forearm (40%) Distal Radius (20%) Spine ( 20%)
Femoral Diaphysis
55
15
0.27
Forearm Diaphysis (11.8%) Distal Radius (11.8%)
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Patella (11.8%)
Forearm Diaphysis
74
19
0.26
Metacarpal (26.3%) Clavicle ( 10.5%) Humerus Diaphysis (10.5%)
Scapula
17
0.23
Proximal Humerus (50.0%) Proximal Femur (25.0%) Distal Radius (25.0%)
Patella
57
13
0.23
Distal Femur (15.4%) Other Patella (15.4%) Spine ( 15.4%)
Tibial Diaphysis
115
21
0.18
Distal Tibia ( 33.3%) Other Tibia Diaphysis (19.0%) Metatarsal ( 9.5%)
Proximal Forearm
297
50
0.17
Proximal Humerus (16.0%) Proximal Forearm (12.0%) Distal Radius (10.0%)
Proximal Humerus
337
48
0.14
Proximal Femur (18.7%) Proximal Forearm (16.7%) Distal Radius (14.6%)
Carpus
159
16
0.10
Distal Radius (22.2%) Proximal Radius (22.2%) Metacarpal (11.1%)
Metatarsal
403
64
0.11
Other Metatarsals (31.2%) Calcaneus (10.9%) Talus ( 9.4%)
Distal Radius
1044
92
0.09
Other Distal R adius (20.6%) Proximal Femur (13.0%) Proximal Humerus (7.6%)
Clavicle
195
15
0.08
Metatarsal ( 26.7%) Proximal Humerus (20%) Spine ( 13.3%)
Proximal Femur
692
46
0.07
Distal Radius (26.1%) Proximal Humerus (19.6%) Proximal Forearm ( 8.7%)
Metacarpals
697
131
0.04
Other Metacarpals (79.4%) Phalanges ( 6.9%) Forearm Diaphysis (3.8%)
Finger Phalanges
574
100
0.04
Metacarpal (76.0%) Distal Radius (9.0%) Proximal Humerus (4.0%)
Ankle
539
24
0.04
Calcaneus (12.5%) Distal Radius (12.5%)
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Metatarsal ( 12.5%)
Toe Phalanges
212
0.01
Distal Radius (100%)
Sesamoid
5953
973
0.16
Note that any ratio >1 means that there are as many associated fractures as index fractures. The table also shows the three most common associated fractures for each index fracture.
MODE OF INJURY
T here were 12 categories of modes of injury, which were recorded during the study period (Table 4-6). Gunshot fractures are uncommon in Scotland, and only one occurred in the study period. All other common modes of injuries were seen. The section labelled Other in Table 4-6 contains the patients who could not or would not remember the cause of injury. By far, the most common cause of fracture is a fall from a standing height. About 45% of patients sustained a fracture in this way, and Table 4-6 show s that they are generally elderly, and about 70% are female. The other common causes of fracture are a direct blow, an assault, or a sports injury. Direct blows are the opposite of standing falls in that they mainly affect young males. Sports injuries contain a heterogeneous group of injuries caused by twists, falls, and direct blows, but they also predominantly affect young males. Motor vehicle accidents were surprisingly uncommon, causing only 7.2% of the fractures. The United Kingdom has the one of the lowest incidences of mortality related to motor vehicle accidents in the world, and it is likely that the morbidity of motor vehicle accidents in the United Kingdom is also low. It is possible to construct age and gender curves for modes of injury in the same way as can be done for individual fractures. There are nine such curves (Fig. 4-2).
TABLE 4-6 The Average Age, Incidence, and Gender Ratio for Each Mode of Injury
Ave rage Ag e (yr) Incidence (%) Gender Ratio (%)
Twist
45.0
6.5
36/64
Fall from standing height
64.6
45.3
29/71
Fall down stairs or slope
49.1
4.1
40/60
Fall from height
38.2
5.8
72/28
Direct blow/assault/crush
32.3
14.1
79/21
Sport
25.6
12.8
83/17
MVA (vehicle occupant)
37.5
1.8
49/51
MVA (pedestrian)
48.3
1.7
52/48
MVA (motorcyclist)
31.2
1.4
89/11
MVA (cyclist)
29.5
2.3
76/24
Stress/spontaneous
58.9
0.5
30/70
Others
56.9
3.7
46/54
Abbreviation: MVA, motor vehicle accident.
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TABLE 4-7 The Relative Frequencies of Upper Limb, Lower Limb, and Axial Skeleton Fractures for Each Mode of Injury
Upper Limb (%) Lower Limb (%) Axial Skelet on (%)
Twist
2.7
97.3
Fall (standing)
58.7
40.0
2.3
Fall (stairs/slope)
45.6
51.9
2.5
Fall (height)
40.8
51.5
7.7
Direct blow/assault
79.9
19.8
0.3
Sport
78.7
20.9
0.2
MVA (occupant)
42.4
48.5
9.1
MVA (pedestrian)
34.3
55.5
10.1
MVA (motorcyclist)
65.8
32.9
1.3
MVA (cyclist)
90.2
8.3
1.5
Stress/spontaneous
13.3
80.0
6.6
MVA, motor vehicle accident.
Twisting Injuries
T hese are relatively infrequent (T able 4-6), and tend to affect young males or older females. Thus, they have a type A distribution ( Fig. 4-2). Table 4-7 shows that twisting injuries usually cause lower limb fractures, and most upper limb twisting fractures occur in the fingers. The spectrum of fractures caused by twisting injuries is similar in the three age ranges shown in Table 4-8. Metatarsal and ankle fractures are most common, P.106 P.107 representing 80% to 90% of twisting fractures in all three age categories.
TABLE 4-8 The Distribution of the Three Most Common Fractures for Each Mode of Injury
12 to 39 years 40 to 59 ye ars 60 to 99 years
Twist
Metatarsal ( 42.2%)
Ankle (46.0%)
Ankle (51.1%)
Metatarsal ( 48.3%)
Ankle (41.1%)
Metatarsal (37.2%)
Toe (3.8%)
Calcaneus (1.6%)
Proximal Tibia (2.1%)
Fall (standing)
Distal Radius (20.7%)
Proximal Femur (33.1%)
Metacarpal (17.0%)
Ankle (15.9%)
Proximal Forearm (12.0%)
Proximal Humerus (8.3%)
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Fall (stairs/slopes)
Ankle (22.5%)
Metatarsal ( 20.3%)
Metacarpal (15.7%)
Ankle (14.5%)
Metatarsal (11.4%)
Fall (height)
Calcaneus (14.1%)
Metatarsal ( 13.1%)
Calcaneus (13.9%)
Proximal Forearm ( 11.3%)
Ankle (7.0%)
Calcaneus (9.4%)
Direct blow/assault
Metacarpal (53.7%)
Finger (37.7%)
Finger (47.1%)
Finger (17.4%)
Metacarpal (16.0%)
Toe (11.8%)
Toe (6.2%)
Toe (15.1%)
Sports
Finger (29.0%)
Metacarpal (15.6%)
Ankle (15.0%)
Clavicle ( 9.0%)
Finger (10.0%)
MVA (occupants)
Femoral Diaphysis (13.8%)
Distal Femur ( 11.1%)
Distal Radius (21.1%) Spine (10.5%)
Ankle (10.5%)
Metatarsal ( 9.3%)
Ankle (11.1%)
MVA (pedestrians)
Tibial Diaphysis (28.6%)
Ankle (9.5%)
Metatarsal (15.8%)
Spine ( 9.5%)
Ankle (14.3%)
MVA (motorcyclist)
Finger (40.0%)
Clavicle ( 14.3%)
Metacarpal (11.1%)
MVA (cyclist)
Clavicle ( 23.1%)
Clavicle ( 17.5%)
Finger (19.2%)
Stress/spontaneous
Metatarsal ( 50.0%)
Metatarsal ( 60.0%)
Femoral Diaphysis (16.6%)
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Finger (20.0%)
Metatarsal (16.6%)
Note that the fractures are separated by age. MVA, motor vehicle accident.
Falls From a Standing Height

T his is the most common mode of injury, and a Scandinavian study shows that fractures related to falls from a standing height are increasing in frequency ( 4). About 45% of injuries are caused by a simple fall, and about 70% occur in older females. These injuries have a type F distribution pattern. The age and gender incidences are very similar to those of the proximal humerus w ith a rise in the incidence of fall-related fractures in females at about the time of menopause (40 to 49 years of age) with a later rise in males (60 to 69 years). T able 4- 7 shows that the upper limb is more commonly affected than the lower limb, and that fractures of the axial skeleton are rare. Table 4-8 shows that in younger and middle-aged patients, fractures of the distal radius are most common, although in older patients, proximal femoral fractures are the most common fracture to be caused by a fall from a standing height.
Falls Down Stairs or Slopes

T hese fractures are unusual in that they do not correspond to types A through H (Fig. 4- 2). Females present with a linear distribution, whereas males show a unimodal pattern w ith a rise in incidence at about 70 years of age. This pattern has been designated as type I. Fractures down stairs or slopes are relatively uncommon compared with falls from a standing height, and slightly more females than males are affected. There is a similar distribution of upper and lower limb fractures, although there are few fractures in the axial skeleton. Table 4-8 shows that there is a different distribution of fractures depending on the age of the patient; ankle fractures are common in younger patients, and distal radial fractures are common in older patients.
Direct Blows or Assaults

Predictably, these are common in young males ( Table 4-6) and show a type B pattern (Fig. 4-2) . Fractures following direct blows are relatively common, with only falls from a standing height producing more fractures. Most direct blows are either punches or kicks, w hich accounts for the high incidence of metacarpal, finger, and toe fractures detailed in Table 4-8. T he distribution of fractures is similar in the three age categories listed in Table 4-8, although it is interesting to note that finger fractures, rather than metacarpal fractures, become more common in older patients.
Falls From a Height

T his category contains all falls from more than 6 feet, so the type of injury will vary, depending on the height from which the patient falls. Overall, these account for approximately 6% of all fractures (Table 4-6) and have a type B distribution that is more common in younger males (Fig. 4- 2). The fractures caused by falls from a height tend to be more severe than those produced by twists, standing falls, or a direct blow, but T able 4- 8 shows that the most common fractures that are caused by falls from a height are in the feet, ankle, and forearms. Falls from a height are the principal cause of calcaneal fractures, and Table 4-7 show s that they are associated w ith a sig nificant incidence of fractures to the pelvis and spine.
Sports Injuries
T his is a very heterogeneous group of patients w ho present after twisting injuries, falls, direct blows, motor vehicle accidents, and cycling accidents. T hey can also present w ith stress fractures. It could be argued that it is, in fact, the least w orthwhile category, but sports injuries are common (T able 4-6). In general, they show a type C pattern, and young males and females are mainly affected, although Table 4-6 shows that overall more males than females sustain sports- related fractures. Table 4-7 shows that almost 80% of sports fractures are in the upper limb, and Table 4- 8 indicates that almost all of the common sports-related fractures are in the upp er limb, with ankle fractures occurring more commonly in older sportsmen and women.
Motor Vehicle Accidents

It is often assumed that motor vehicle accidents cause most fractures, but Table 4-6 shows that this is not the case. As has already been pointed out, the United Kingdom has a low mortality rate related to motor vehicle accidents, and it may well also have a low morbidity rate. Other countries have less stringent legislation concerning speeding and alcohol abuse and may have a higher incidence of motor vehicle accidents, although, as in Scotland, it is still probably falls, direct blows, and sports that will cause most fractur es.
Vehicle Occupants
T able 4- 6 shows that there is an equal gender distribution in fractures seen in vehicle occupants. Both males and females show a bimodal distribution with younger and older vehicle occupants being affected, which is a type H pattern. There is a high incidence of pelvic and spinal fractures ( Table 4- 7), and slightly more lower limb fractures are seen than upper limb fractures. Table 4-8 indicates that the fractures tend to be severe with a high incidence of femoral diaphyseal fractures, distal femoral fractures, and proximal tibial fractures.
Pedestrians
Pedestrians tend to be older than vehicle occupants (Table 4-6) . There is an approximately equal gender ratio, and a review of the distribution of fractures shown in Table 4-7 shows that pedestrians have the highest incidence of pelvic and spinal fractures. Lower limb fractures are more common than upper limb fractures. As with vehicle occupants, the fractures are often severe, with a high
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incidence of tibial diaphyseal fractures and proximal tibial fractures.
Motorcyclists
Predictably, motorcyclists have a type B distribution predominantly affecting young males. Table 4-6 shows that about nine P.108 males are injured for every female. The incidence of pelvic and spinal fractures is low, and it is interesting to observe that the incidence of upper limb fractures is consistently higher than the incidence of lower limb fractures. T his is probably because motorcyclists that have spinal, pelvic, and/or a severe lower limb injury often die at the scene of the accident. Motorcyclists over the age of 60 are relatively uncommon, but analysis of the common fractures in the two younger age groups shows a fairly wid espread spectrum of injuries.
Cyclists
As with motorcyclists, cycle injuries mainly affect young males, but about 25% of the injuries are in young females; therefore, the distribution is type C. The majority of fractures are in the upper limb, and fractures of the axial skeleton are very rare. T able 4-8 shows a similar distribution of fracture in younger and middle-aged patients. There were insufficient elderly cyclists to justify an analysis of their injuries.
Stress/Spontaneous Fractures
T hese have been combined, as many spontaneous fractures are actually insufficiency fractures occurring in older patients. The combined fracture groups have a type H distribution with a bimodal distribution in both males and females. Fatigue fractures have a type C distribution with younger males and females being affected, and insufficiency fractures have a type E pattern mainly affecting older females. The fractures are usually in the lower limb, and Table 4-8 shows that the proximal femur, metatarsus, and femoral and tib ial diaphyses are commonly affected.
Other Modes of Injury

Approximately 4% of patients either had a different mode of injury or had no definite history, usually because of dementia, intoxication, or epileptic fits. There were 41 (19.4%) finger fractures secondary to hyperextension or cutting injuries. Most of the rest of the unspecified mode of injury group probably sustained their fracture in simple falls, and 25.9% of the patients presented w ith distal radial fr actures, 19.9% with proximal femoral fractures, and 5.1% presented with proximal humeral fractures.
GUNSHOT INJURIES
Information regarding the epidemiology of fractures caused by firearms is sparse. They are relatively uncommon in Europe, but the North American literature strongly suggests that they have a type B distribution and are the most common in young males. Gunshot mortality and morbidity rates are greatest in the US where the large urban level I trauma centers see a disproportionate number of fr actures caused by firearms. In one level I trauma center, a 1-year analysis showed that firearms caused 15% of all fractures requiring surgical intervention ( 5). Most fractures involved the femur ( 22%) , hand (18%), tibia (14%), forearm (14%), and humerus ( 10%) . I t would seem that the pr oblem of firearm-related fractures is worsening.
TABLE 4-9 Descriptive Indices for the Different Types of Clavicle Fracture
% Ave rage Ag e (yrs) Gender Ratio (M/F) Distribution Curve
Medial
4.1
53.5
75/25
T ype A
Diaphyseal
68.2
33.2
70/30
Type G
Lateral
27.7
48.6
68/32
T ype A
SPECIFIC FRACTURE TYPES Clavicle

F ractures of the clavicle are most commonly seen in young males, but they are increasingly seen in older patients, and overall, clavicle fractures actually have a type G distribution with an increasing incidence in older males and females. Clavicle fractures are usually subdivided according to their location, and the different characteristics of fractures of the diaphysis and medial and lateral ends of the clavicle are shown in Table 4-9. This shows that medial clavicle fractures are uncommon, and that both medial and lateral clavicle fractures have a type A pattern affecting younger males and older females. Diaphyseal fractures predominantly occur in young males, but there is a late increase in incidence in older males and females. T hey therefore show a type G pattern. Clavicle fractures usually follow low-energy injuries with 31% caused by falls from a standing height, 31% by sports injuries, and 12% in cycling accidents.
Scapula
T hese are very rare fractures and have a type A distribution. In young males, they tend to be high-energy injuries, and in older females, they usually follow low-energy injuries. Table 4-10 shows the descriptive indices for extra-articular scapular fractures and for intra- articular fractures involving the glenoid. It shows that both fracture types have a type A pattern affecting young males and older females, but extra- articular fractures are P.109
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more common. The majority of glenoid fractures actually occur in older females following low-energy injuries.
TABLE 4-10 Descriptive Indices for Extra- and Intra-articular Scapular Fractures
Extra-articular
64.7
44.2
73/27
T ype A
Intra-articular
35.3
62.0
50/50
T ype A
Proximal Humerus
T hese are common fractures (Table 4-2) that usually occur in older females and have a type F distribution. Most are low-energy injuries, and if it is assumed that the unspecified modes of injuries were mainly falls from a standing height, it is likely that about 78% of proximal humeral fractures are caused by simple falls.
Humeral Diaphysis
Humeral diaphyseal fractures also have a type H distribution mainly with a bimodal distribution in both males and females. T he peaks in older patients are higher than those in younger patients, and Table 4-3 indicates that a high proportion of patients are over 65 years of age at the time of fracture. About 62% of these fractures are caused by falls from a standing height, and approximately 4% are pathological, secondary to a metastatic deposit.
Distal Humerus
Distal humeral fractures are relatively uncommon. Surgeons may be surprised that they have a type E distribution mainly affecting older females, but there is a high incidence of OT A type A transcondylar distal humeral fractures in this age group. The type C bicondylar fracture is rare in comparison. Table 4-3 shows a high incidence of fractures in patients over the age of 65 years, and the distal humerus must be regarded as an osteopenic fracture, as its age distribution is very similar to that of the distal radius. About 68% of distal humeral fractures are caused by falls from a standing height. A further 13% are sports-related injuries occurring in younger p atients.
Proximal Forearm
T hese common fractures comprise 5% of all fractures. Overall, they show a type D distribution, but T able 4-11 shows that if they are subdivided into their different fracture types, their distribution changes. Olecranon fractures and fractures affecting both the proximal radius and ulna occur more commonly in older patients, and therefore have a type F pattern. Radial head fractures have a type H pattern with bimodal curves for both males and females, and radial neck fractures show a type A pattern with younger males and older females being affected. T able 4- 11 also shows that radial head fractures account for about 56% of all proximal forearm fractures, with olecranon and radial neck fractures occurring in about 20% of patients. Fractures of both the proximal radius and ulna are relatively unusual.
TABLE 4-11 Descriptive Indices for the Different Types of Proximal Forearm Fractures
% Age (yrs) Gender Ratio (M/F) Distribution Curve
Olecranon
19.9
59.1
47/53
Type F
Radial Head
56.2
40.5
46/54
Type H
Radial Neck
19.9
48.5
44/56
T ype A
Radius and Ulna
4.0
61.3
36/64
Type F
Forearm Diaphysis
F ractures of the diaphysis of the radius and ulna account for 1.2% of all fractures. Overall, they have a type D pattern. Analysis of the three different forearm fractures, the isolated ulna, isolated radius, and both radius and ulna shows that each has a different fracture pattern (Table 4-12). Isolated ulna fractures have a type H pattern w ith a bimodal distribution in both males and females,
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w hereas isolated radial fractures have a type A pattern with young males and older females presenting with these injuries. Fractures of both the radius and ulna occur mainly in young males, and they show a type B pattern. Sports injuries are the most common cause of forearm fractures (26%) followed by a direct blow to the forearm (20%) and falls from a standing height (19%).
Distal Radius and Ulna

T hese are the most common fractures encountered by orthopaedic surgeons (T able 4-2), and they have a Type A pattern. Level I trauma centers will see a number of young males w ith high-energy distal radial fractures, but most occur in older females. Altogether, approximately 75% of distal radial fractures occur in falls from a standing height with about 13% occurring in sports injuries.
TABLE 4-12 Descriptive Indices for the Different Types of Forearm Diaphyseal Fracture
Ulna
51.3
39.0
45/55
Type H
Radius
23.0
36.1
76/24
T ype A
Radius and Ulna
25.7
24.7
63/37
T ype B
P.110
Carpus
Most carpal fractures involve the scaphoid (carpal navicular) bone. Table 4-13 shows a breakdown of carpal fractures according to w hether or not they involve the scaphoid. It can be seen that patients with scaphoid fractures tend to be younger than those with other carpal fractures. The gender ratio is similar, but scaphoid fractures have a type B pattern with a unimodal young male distribution, whereas nonscaphoid carpal fractures show a type A pattern with fractures also occurring older females.
TABLE 4-13 Descriptive Indices for Carpal Fractures

Scaphoid
82.4
30.1
72/28
T ype B
Non-scaphoid
17.6
46.7
71/29
T ype A
Metacarpal Fractures
Metacarpal fractures are the second most common fractures seen by orthopaedic surgeons (Table 4-2). They have a type B distribution, and most fractures occur in young men. About 55% occur as a result of a punch or direct blow to the hand. About 6% of patients have multiple metacarpal fractures, and the rest have isolated fractures. Sixty percent of the fractures are in the little finger, 15% in the ring finger, 7% in the middle finger, 8% in the index finger and 10% are in the thumb.
Finger Fractures
As with metacarpal fractures, these are common fractures with a type B pattern. Most finger fractures present in young males. About 34% occur following a punch or direct blow to the fingers, and 21% occur in a fall from a standing height. As with metacarpal fractures, 6% of these fractures are multiple, and the rest are isolated. Thirty percent occur in the little finger, 22% in the ring finger, 18% in the middle finger, 12% in the index finger, and 18% occur in the thumb.
Proximal Femoral Fractures

T hese are common fractures, and it is generally accepted that, as with other osteopenic fractures, they are increasing in frequency in many parts of the w orld. The fractures have been subdivided into femoral head fractures, subcapital fractures, and intertrochanteric fr actures. Basicervical fractures are included in the subcapital group, and subtrochanteric fractures are combined with femoral diaphyseal fractures.
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F emoral head fractures are extremely rare, and the average age and gender ratio shown in Table 4-14 have been taken from the literature. The literature also suggests that femoral head fractures have a type B pattern, but there are insufficient data to measure these statistics precisely. Both subcapital and intertrochanteric fractures have a type F pattern with an increasing incidence in both older males and females. Until relatively recently, proximal femoral fractures were assumed to be a problem predominantly in females, but with increasing male life expectancy, the incidence in older males is now higher and likely to become greater in years to come. Analysis of the data indicates that about 92% of proximal femoral fractures occur as a result of a fall from a standing height.
TABLE 4-14 Descriptive Indices for the Different Types of Proximal Femoral Fracture
% Aver age Age (yrs) Gender Ratio (M/F) Distribution Curve
Femoral Head
0.3
40.5
73/ 27
T ype B
Sub-capital
46.3
77.9
27/ 73
Type F
Inter-trochanteric
53.4
82.1
25/ 75
Type F
The average, gender ratio, and distribution curve for femoral head fractures has b een taken from the literature.
Femoral Fractures
T his category includes both subtrochanteric fractures and femoral diaphyseal fr actures. Their descriptive indices are shown in Table 4-15. Subtrochanteric fractures affect older males and females, are similar to subcapital and intertrochanteric fractures, and have a type F pattern. Falls from a standing height cause 70% of subtrochanteric fractures. F emoral diaphyseal fractures have a type A pattern mainly affecting young males and older females. T he early male peak is not very pronounced, and there seems no doubt that the epidemiology of femoral diaphyseal fractures is changing rapidly. P.111 T able 4- 15 shows that the average age of patients with femoral diaphyseal fractures is 62.4 years and that the majority of patients are female. This is because periprosthetic and insufficiency femoral fr actures are becoming common and are tending to replace the young femoral fracture, which is declining in incidence in many parts of the world due to improved car design and better road safety legislation. Clearly, this does not apply uniformly throughout the world, but presumably many countries that currently have a high incidence of femoral fractures in younger patients will experience change over the next few decades. The mode of injury in younger patients remains motor vehicle accidents; falls from a standing height cause the majority of femoral diaphyseal fractures in the elderly.
TABLE 4-15 Descriptive Indices for Femoral Diaphyseal Fractures

Sub-trochanteric
30.1
76.5
47/53
Type F
Diaphysis
69.9
62.4
32/68
T ype A
Distal Femoral Fractures

Distal femoral fractures are relatively uncommon and, as with femoral diaphyseal fractures, they now tend to occur in older patients. T able 4- 3 shows that 50% occur in patients over 65 years of age. The age-related descriptive indices are very similar to those of the proximal humerus, and the distal femoral fracture must now be regarded as an osteopenic fracture. They have a type E pattern. About 50% are caused by falls, but in younger patients, motor vehicle accidents and sports accidents cause distal femoral fractures.
Patella Fractures
T able 4- 3 shows that patellar fractures should also be regarded as osteopenic fractures. Approximately 50% of patellar fractures occur in patients over 65 years of age, although the gender ratio is more even than in most osteopenic fractures. They have a type F pattern, and patellar fractures present in both older males and females. About 75% of patellar fractures are caused by falls from a standing height. The majority of the rest are caused by falls down stairs or from a height.
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Tibial Plateau Fractures

T ibial plateau fractures have a type H pattern with a bimodal distribution in both male and female patients. T hey account for 1.2% of all fractures. In younger patients, they are usually high-energy injuries caused by motor vehicle accidents, falls from a height, or sports injuries. In older patients, the most common cause of tibial plateau fractures is a motor vehicle accident when the patient is a pedestrian struck by an automobile.
Tibial Diaphyseal Fractures

Despite the considerable number of articles written about the management of tibial diaphyseal fractures, they are comparatively uncommon, accounting for only 1.9% of all fractures. They do have the highest incidence of open fractures, however (Table 4-4). T hey have a type A pattern that is more common in younger males and older females. The young male peak is higher than the older female peak, and the fracture is therefore more common in males. In younger patients, tibial fractures are usually caused by motor vehicle accidents and sports injuries, and in older patients, they often occur in pedestrians or as a result of a fall from a standing height. The epidemiology of tibial diaphyseal fractures is discussed in more detail in Chapter 52 w here data from the Edinburgh Unit collected between 1988 to 1999 are shown. The incidence of tibial fractures has decreased in the last decade because of a decrease in the incidence of tibial fractures in young men. Otherwise, the earlier data are very similar.
Distal Tibial Fractures

Distal tibial fractures are comparatively unusual fractures accounting for only 0.7% of all fractures. T hey are common in younger patients, but have a type D pattern indicating that there is a second peak in older female patients. As w ith tibial diaphyseal fractures, there is a high incidence of open fractures, and the majority are Gustilo type III in severity. Distal tibial fractures are usually the result of high- energy injuries. In younger patients, they are caused by falls from a height, sports injuries, or motor vehicle accidents. In older patients, they are caused by falls from a standing height or motor vehicle accidents.
Ankle Fractures
Ankle fractures are very common, accounting for 9% of all fractures. Overall, they have a type A pattern, but conventionally, ankle fractures are classified according to the number of malleoli involved and the location of the fibular fracture. T able 4- 16 shows the descriptive indices of medial malleolar, lateral malleolar, bimalleolar, trimalleolar, and suprasyndesmotic fractures. They are somewhat different, and only the lateral malleolar fractures have a type A pattern affecting young males and older females. Medial malleolar fractures have a type D pattern affecting younger adults of both genders, with a higher incidence in young males. There is, however, a second peak in older females.
TABLE 4-16 Descriptive Indices for the Different Types of Ankle Fractures
Medial Malleolus
4.9
34.0
64/36
Type D
Lateral Malleolus
63.5
44.4
52/48
T ype A
Bimalleolar
11.6
43.1
29/71
Type E
Trimalleolar
7.3
52.7
33/67
Type E
Suprasyndesmotic
7.6
39.0
66/34
Type C
Note that fractures with a posteromedial tibial component have not been included.
P.112 Both bimalleolar and trimalleolar fractures have a type E pattern affecting older females in particular. Table 4-16 shows that the average age of patients with trimalleolar fractures is higher than those who have bimalleolar fractures. Suprasyndesmotic fractures have a type C pattern affecting young males and females, with a higher incidence in young males. The majority of ankle fractures are caused by twisting injuries (31%), falls from a standing height (37%), or sports injuries (10%).
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TABLE 4-17 Descriptive Indices for Calcaneal Fractures

Intra-articular
60.1
45.6
73/27
Type G
Extra-articular
39.9
34.4
75/25
T ype B
Calcaneal Fractures
C alcaneal fractures account for 1.2% of all fractures. They have a type G pattern with a bimodal male curve and a unimodal curve in older women. Table 4-17 shows the descriptive indices for intra-articular and extra- articular calcaneal fractures. Both occur mainly in males, but the average age of patients with intra-articular fractures is higher. The intra-articular fractures show a type G pattern, but the extra- articular fractures have a type B pattern that is more common in younger males. Falls from a height are the most common cause of both types of calcaneal fracture and occur in 64% of intra-articular fractures and 47% of extra-articular fractures.
Talar Fractures
T alar fractures are very rare. They have a type C pattern mainly affecting young males. They can be subdivided into neck, body, and head fractures, although the latter are extremely rare and none was encountered during the study period. Table 4- 18 gives the descriptive indices for talar neck and body fractures. They are both seen in young adults and both have a type C pattern. Talar body fr actures are rare in females. Most talar fractures occur as a result of a fall from a height (59%).
TABLE 4-18 Descriptive Indices for Talar Fractures

Neck
29.4
28.4
60/40
Type C
Body
70.6
32.1
92/8
Type C
Midfoot
Midfoot injuries are rare and involve the cuboid (44.4%) , the navicular ( 48.1%), or the cuneiform bones (7.4%). Like the talus, they have a type C pattern mainly affecting young males. Table 4-4 shows that they are associated with a high incidence of open fractures, which tend to be very severe. Most cuboid fractures are caused but low- energy injuries but cuneiform, and navicular fractures tend to be caused by high-energy injuries such as falls from a height or motor vehicle accidents.
Metatarsus
T hese are common injuries showing a type A pattern that is more common in younger males and older females. Nine percent of fractures involve more than one metatarsal, but of the isolated metatarsal fractures, 75% involve the fifth metatarsal, 3% the fourth metatarsal, 5% the third metatarsal, 6% the second metatarsal and only 1% involve the hallux metatarsal. The most common cause is a twisting injury ( 40%) , followed by a fall from a standing height (13.6%) , and a direct blow to the foot (11.7%).
Toes
T oe fractures are relatively common and have a type C pattern affecting young males and females. About 57% of these fractures are caused by a kick or direct blow to the foot.
Pelvis
T able 4- 2 shows that pelvic fractures are relatively uncommon. Due to the difficulty of treating these fractures, they have received considerable attention in the literature, and the implication is that they occur more frequently than they actually do. Patients with pelvic fractures tend to be referred to specialist centers, but if the true incidence is calculated for the overall population, it becomes clear that they occur infrequently. Most pelvic fractures are pubic rami fractures in elderly patients, and comparatively few young
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patients present with unstable pelvic or acetabular fractures. Table 4-3 shows that if all pelvic fractures are considered, the average age is about 70 years, and more than 70% of patients are at least 65 years of age. Table 4-19 shows the separate descriptive indices for pelvic and acetabular P.113 fractures and that the average age of patients with pelvic fractures is, in fact, similar to the average age of patients with proximal femoral fractures. These fractures show a type E pattern. About 67% of pelvic fractures occur in simple falls, but in younger patients, they are high-energy fracture usually occurring in motor vehicle accidents and falls from a height.
TABLE 4-19 Descriptive Indices for Pelvic and Acetabular Fractures

% Average Age (yrs) Gender Ratio (M/F) Distribution Curve
Pelvis
92.3
78.3
74/26
Type E
Acetabulum
7.7
59.1
71/29
Type G
Acetabular fractures are uncommon. The Edinburgh Unit, like other major trauma units, admits patients with acetabular fractures from a wide area, but if the population is accurately defined, it becomes clear that they are relatively rare injuries. They have a type G distribution w ith a bimodal male distribution and unimodal older female distribution. In younger patients, pelvic fractures are highenergy injuries usually caused by motor vehicle accidents or falls from a height, whereas in older patients, these fractures frequently follow a fall from standing height.
Spine
T able 4- 20 shows the descriptive indices for spinal fractures. T hese are only traumatic fractures resulting from a well-defined inj ury. It is accepted that most thoracolumbar fractures are probably osteoporotic in origin, but it is often difficult to know just how old the fracture is w hen seen on a radiograph. It is also likely that many, if not most, osteoporotic vertebral fractures remain undetected in the community, and it has been estimated that less than 10% of vertebral fractures necessitate hospital admission (3) . It has been estimated that the age- and gender-adjusted incidence of clinically diagnosed vertebral fractures is 117 per 100,000 per year (3), but figures vary in different parts of the world. If osteoporotic vertebral fractures are not considered, Table 4- 20 shows that cervical fractures are most common. They have a type H pattern w ith a bimodal male and female distribution. In younger patients, spinal fractures tend to be the result of high-energy injuries, mainly motor vehicle accidents (47%) and falls from a height ( 21%) . In the elderly, they usually occur as a result of simple falls such as falls down stairs. Thoracolumbar fractures tend to occur in young males and have a type B distribution. If osteoporotic thoracolumbar fractures are included, the distribution is type A.
TABLE 4-20 Descriptive Indices for the Different Types of Spinal Fractures
% A verage Age (yrs) Ge nder Ratio (M/F) Distribution Cur ve
Cervical
51.3
43.4
58/ 42
Type H
Thoracolumbar
48.7
43.5
66/ 33
Type B
It is probable that if osteoporotic thoracolumbar fractures are included, the distribution curve is type A.
REFERENCES
1. J ones G, Ng uyen PN, Sambr ooke PN, et al. Symptomatic fracture incidence in elderly men and women: The Dubb o Osteoporosis Epidemiology Study (DOES). Osteop oros Int 1994;4:277281.
2. O'Neill TW, C ooper C, Finn JD, et al. Incidence of distal forearm fracture in British men and women. Osteoporos Int 2001;12:555558.
3. C ooper C, Atkinson EJ, O'Fallon WM, et al. Incidence of clinically diagnosed vertebral fractures: a population-based study in
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Rochester, Minnesota, 1985-1989. J Bone Miner Res 1992; 7:221227.
4. Kannus P, Niemi S, Parkkari J, et al. Epidemiology of adulthood injuries: a quickly changing injury profile in Finland. J Clin Epidemiol 2001;54:597 602.
5. Brown TD, Michas P, Williams RE, et al. The impact of gunshot wounds on an orthopaedic surgical service in an urban trauma center. J O rthop T rauma 1997; 11:149 153.
Edit ors: Buchol z, Robert W.; Heckman, James D.; Court-Brown, Charles M . Titl e: Rockwood & Green's Fractures in Ad ults, 6th Edition Copyright 2006 Lippincott Williams & Wilkins
> Ta bl e o f Cont ent s > Vo l ume 1 > S ecti o n O ne - Gene ral P ri nc ipl e s > C ha pter 4 - The Epi dem i ol o gy o f Fr actu re s > Part 2 - Expe rie nc e in the U ni ted St ate s
Part 2 Experience in the United States

Kenneth J. Kova l Michael Cooley Musculoskeletal injuriesincluding fractures, dislocations and sprains, crushing injuries, open wounds, contusions, and other injuriesoccur frequently, resulting in substantial morbidity and use of health care resources. There are categorical differences for each musculoskeletal injury type, and they reveal d ifferences in gender and age groups afflicted, setting in which the injury occurred, mechanism of injury, treatment and recovery times, and associated mortality rates. F urthermore, epidemiological data demonstrate that considerable regional variation exists across the US in treatment philosophy, particularly regarding the use of surgical intervention. This chapter reviews data current epidemiological trends in musculoskeletal injury from the National Trauma Data Bank R eport 2003 (1), American Academy of Orthopaedic Surgeons ( 2), and The Dartmouth Atlas of Musculoskeletal Health Care ( 3). Enhanced understanding of current musculoskeletal injury patterns is necessary to facilitate improved allocation of health care resources and to achieve better outcomes. P.114
DATA FROM THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Overview

In 1995, the incidence rate for musculoskeletal injuries w as 109.2 injuries per thousand persons (Table 4-21), totaling more than 28 million injuries in the US. Men had a higher incidence rate than women, and age correlated inversely w ith injury rate for musculoskeletal injuries. Sprains or dislocations, the most common category of musculoskeletal injury, accounted for 44% of musculoskeletal injuries and serve as a model of general epidemiological trends. The highest incidence rates occurred in persons aged 18 to 44 and 45 to 64, reflecting the inverse relation of age and injury rate that, at least in this injury category, may be partially influenced by occupational injuries that occur in the younger, employed, age groups. Fractures, the second most common injury, comprised 22% of musculoskeletal injuries, and also had a declining incidence rate as age increased. This, however, was true only to age 65, at which point incidence rates again rose, likely reflecting the increasing rate of hip fracture in the elderly.
TABLE 4-21 Incidence of Persons Injured by Gender and Age: US, 1995
Pe rsons Injured per 1,000 Population All Injuries Musculoskeletal Inju ries Fr act ure s Sprains and Disloc ations
Male
228.5
128.5
28.2
52.6
Female
168.7
90.9
20.3
43.0
Less than 18 years
241.1
124.8
29.9
45.9
1844 years
202.0
118.0
21.2
57.8
4564 years
165.9
93.1
22.1
46.0
65 years and over
139.0
70.7
24.7
19.6
Total
197.9
109.2
24.2
47.7
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All injuries include ICD-9-CM 800999. Musculoskeletal injuries include ICD -9- CM 805829, 831847, 848.3848.9, 874877, 879.2884, 885897, 922924, 926928, 954956, 957.1 957.9, and 959. Fractures include ICD -9- CM 805829. Sprains and dislocations include ICD -9- CM 831847 and 848.3848.9. Source: National Center for Health Statistics, National Health Interview Survey, 1995. (Reprinted with permission from Praemer A, Furner S, Rice D. Musculoskeletal Conditions in the United States . Rosemont: American Academy of Orthopaedic Surgeons, 1999.)
Inpatient hospitalization, a measure of the use of health care resources, was required for 3 million musculoskeletal conditions in 1995, approximately 11.1% of all hospital stays. Traumaresulting in musculoskeletal injury including fractures, dislocations and sprains, and other musculoskeletal injuryaccounted for 40% of the musculoskeletal conditions requiring hospitalization. Fractures, the leading category of musculoskeletal injury resulting P.115 in hospitalization, accounted for 896,000 inpatient stays, while dislocations or sprains and other injuries caused an additional 306,000 hospitalizations. By age, the distribution of musculoskeletal conditions resulting in hospitalizations varied as seen in T able 4-22. Among those under 18, trauma (fractures, dislocations and sprains, and other musculoskeletal injuries) encompassed 55% of hospitalizations for musculoskeletal conditions, while in those age 18 to 44, trauma accounted for only 44% of hospitalizations. In persons 45 to 65 years old, trauma accounted for 28% of hospitalizations. The inverse relation between age and injury rate no longer was valid among those 65 and older, however, where fractures accounted for an increasing proportion of musculoskeletal hospitalizations. Thirty-six percent of musculoskeletal- related hospitalizations in those 65 years of age and older were fracture related. Within the 65 and older group, 38.1% of hospitalizations in those 75 to 84 years old were fracture related and in the 85 and older age group, 61.6% resulted from fracture. Given the bimodal distribution of musculoskeletal injury, as well as predictions that the percent of the population age 65 and over will increase from 12.8% to 20.0% over the next 30 years, it is probable that the impact of musculoskeletal injury in the U S will continue to increase dramatically.
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TABLE 4-22 Hospitalizations Resulting from Musculoskeletal Conditions by Age Groups: US, 1995*
Distribution by Age Group (in per cents) <18 1844 4564 65 & Over 65 74 7584 85 & Over Total
Musculoskeletal Diseases and Connective Tissue Disorders
27.7
48.0
59.7
47.9
60.2
46.5
27.3
49.2
Fractures
37.2
26.0
19.6
36.3
20.6
38.1
61.6
29.8
Dislocations and Sprains
4.9
7.2
5.4
2.7
3.6
2.1
2.5
4.6
Other Musculoskeletal Inj uries
13.1
10.9
3.2
2.8
2.7
2.2
3.9
5.6
Complications or Reactions**
1.1
2.8
4.2
4.3
4.8
4.6
2.5
3.7
Congenital Malformations
8.6
0.7
0.3
0.1
0.2
0.9
Neoplasms
1.5
2.1
5.1
3.9
5.0
3.9
1.7
3.5
Other Musculoskeletal Conditions
5.9
2.4
2.6
2.3
2.8
2.4
0.5
2.7
*First listed diagnosis for inpatients discharged from short-stay hospitals. **Mechanical or other complication or infection and inflammatory reaction to internal orthopaedic or prosthetic device, implant or gr aft. Estimate does not meet standards of reliability or precision. Sour ce: National Center for Health Statistics. National Hospital Discharge Survey, 1995. (Reprinted with permission from Praemer A, Furner S, Rice D. Musculoskeletal Conditions in the United States . Rosemont: American Academy of Orthopaedic Surgeons, 1999.)
Frequency of Musculoskeletal Injury

F rom 1992 to 1994, the average annual number of persons injured in the US was 57.9 million, and is displayed categorically by age, gender, and type of injury in T ables 4-23 and 4-24. Compared with women, men had a higher total injury rate (16.4 vs.12.7 per 100 persons), a higher rate of dislocations and sprains (5.7 vs. 5.1 per 100 persons), and a higher rate of fracture (2.7 vs. 2.0 per 100 persons) (Table 4-24) . Figure 4-3, Figure 4-4, Figure 4- 5 further demonstrate the effect of gender and age on the average annual rate of persons injured for all musculoskeletal injuries, dislocations and sprains, and fractures. Young men had higher rates than young women (those under age 45) in all musculoskeletal injuries, a differential that equalized in the 45 to 64 age category. After age 65, women surpassed men as the predominant victims of injury (F ig. 4-3). A subcategory of musculoskeletal injury, fractures, had similar trends, with male rates clearly higher than female rates for those under age 45. Comparable rates were seen between the ages of 45 and 64. Men had substantially lower rates than women in persons 65 years of age and older (Fig. 4- 4), a pattern that reflects the higher incidence of osteoporosis-related fractures in older women. For dislocations and sprains, there was virtually no difference by gender in more elderly age groups, although males under age 45 had higher rates (Fig. 4-5).
Place of Occurrence
As illustrated in Figure 4-6, the most frequently reported place for fractures to occur from 1992 to 1994 w as inside and outside P.116 the home (22.5% and 19.1%, respectively). Fracture occurrence was also commonly reported in streets and highways (12.7%), sports and recreational facilities (12.2%), and schools (11.3%). Industrial settings accounted for only 9.5% of fractures, but were associated with a relatively higher proportion of other musculoskeletal injuries. For example, 11.4% of all injuries, 13.6% of musculoskeletal injuries, and nearly 14% of dislocations and sprains occurred in an industrial setting.
TABLE 4-23 Average Annual Number of Episodes of Persons Injured by Type of Injury: US, 1992 to 1994
Average Annual Episodes (in thousands) Male Fe male Less than 1 8 Year s 1844 Y ear s 4564 Y ear s 65 Years & Over Total
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Fractures
3,321
2,625
1,921
2,344
777
904
5,946
Neck and Trunk
362
333
253
*198
243
695
Humerus, Radius, and Ulna
232
238
253
*78
*18
*122
471
Femur
*46
*100
*17
*129
*146
Tibia, Fibula, and Ankle
320
262
*152
300
*85
*45
581
Other Limbs
1,760
1,331
1,314
1,198
348
230
3,091
7,121
6,663
2,746
7,850
2,174
1,014
13,784
Crushing Injury
*241
*102
*53
*229
*61
343
Open Wound
5,060
2,492
2,152
3,983
1,009
408
7,552
Contusions
2,928
3,103
1,659
2,635
751
986
6,032
Other Musculoskeletal Injuries
1,628
1,616
919
1,363
584
378
3,244
Total Musculoskeletal Injuries**
20,299
16,601
9,450
18,404
5,356
3,690
36,901
Total Injuries
31,159
26,726
17,117
26,922
8,034
5,808
57,885
*Estimate does not meet standards of reliability or precision. **Musculoskeletal injuries include IC D-9-C M 805829, 831847, 848.3848.9, 874877, 879.2884, 885887, 890894, 895897, 922924, 926928, 954956, 957.1957.9, and 959. Totals do not add up, due to other categories of fractures not included in the subgroups listed. Source: National Center for Health Statistics, National Health Interview Survey, 19921994. (Reprinted with permission from Praemer A, Furner S, Rice D. Musculoskeletal Conditions in the United States . Rosemont: American Academy of Orthopaedic Surgeons, 1999.)
Occupational Injury
Occupational injury, defined by the Bureau of Labor Services, is any injury that results from a work-related accident or exposure involving a sudden event in the workplace. T he workplace is a common site of injury, and these events result in substantial illness and disability. In 1997, there were 6.1 million occupational injuries and illnesses reported, resulting in a rate of 7.1 cases per 100 full-time equivalent workers. Ninety-three percent, or 5.7 million cases, resulted from occupational injury, while the remaining 7%, or 430,000 cases, resulted from occupational illness. Of the injuries and illnesses resulting in lost workdays, those affecting the musculoskeletal system accounted for the majority of lost workdays in both men and women. The most frequent injury to result in work loss, accounting for 43.6% of cases, was injury related to sprains and strains (Table 4-25). Other musculoskeletal injury categories resulting in work loss included fractures, causing 6.4% of cases; dislocations, 1.0%; tendonitis, 0.9%; and amputations, 0.5%. Crushing injuries, lacerations, contusions and other injuries also accounted for some work loss. When gauging morbidity using median number of work loss days, dislocations resulted in the greatest loss (28 days). Other injuries associated with substantial work loss days were carpal tunnel syndrome (25 days), amputations (20 days), and fractures ( 17 days). Sprains and strains, w ith a median work loss of 6 days, was associated with fewer lost days, but still exceeded the median for all occupational injuries and illnesses. Average w orkers' compensation claims, an indication of the costs associated with occupational injuries and illnesses, w ere highest for amputations ($19,272) and fractures ($15,528) . The P.117 P.118 average cost per workers' compensation claim filed in 1995 to 1996 was $11,033.
TABLE 4-24 Average Annual Number of Episodes of Persons Injured by Type of Injury: US, 1992 to 1994
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A verage Annual Episodes (r ate per 100 pe rsons) All Injuries Musculoskelet al Injuri es Dislocations and Spr ains Fr actur es
Male
25.1
16.4
5.7
2.7
Female
20.4
12.7
5.1
2.0
Less than 18 years
25.2
13.9
4.0
2.8
1844 years
25.3
17.2
7.4
2.2
4564 years
16.2
10.8
4.4
1.6
65 years & over
18.7
11.9
3.3
2.9
6574 years
14.9
3.6
2.3
75 years & over
24.8
2.8
3.9
Total
22.7
14.5
5.4
2.3
*Information not available. Source: National Center for Health Statistics, National Health Interview Survey, 19921994. (Reprinted with permission from Praemer A, Furner S, Rice D. Musculoskeletal Conditions in the United States . Rosemont: American Academy of Orthopaedic Surgeons, 1999).
FIGURE 4-3 Average annual rate of episodes of persons injured by age and gender, all musculoskeletal injuries: US, 1992 to 1994. (Reprinted with permission from Fildes J, et al. National Trauma Data Bank Report 2003, Version 3.0. American C ollege of Surgeons, 2003. Available at: http://www.facs.org/trauma/ntdbannualreport2003.pdf.)
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FIGURE 4-4 Average annual rate of episodes of persons injured by age and gender, fractures: US, 1992 to 1994. (R eprinted with permission from Fildes J, et al. National Trauma Data Bank Report 2003, Version 3.0. American College of Surgeons, 2003. Available at: http://w ww.facs.org/ trauma/ntdbannualreport2003.pdf.)
FIGURE 4-5 Average annual rate of episodes of persons injured by age and gender, dislocations and sprains: US, 1992 to 1994. (Reprinted with permission from Fildes J, et al. National Trauma Data Bank Report 2003, Version 3.0. American C ollege of Surgeons, 2003. Available at: http://www.facs.org/trauma/ntdbannualreport2003.pdf.)
Motor Vehicle Accidents

Motor vehicle accidents are a substantial source of trauma to the musculoskeletal system. In 1996, the police reported approximately 6.8 million motor vehicle accidents (US Dept. of Transportation), resulting in death or injury of 3.6 million motor vehicle occupants, and 147,000 pedestrians and cyclists. T he percentage of musculoskeletal injuries resulting from motor vehicle accidents from the 1992 through 1994 National Health Interview Surveys are shown by type of injury in Table 4-26. Injuries resulting from motor vehicle accidents accounted for 11.6% of all injuries; men reported that their injury involved a motor vehicle more often (13.1%) than women (9.9%). Reporting of musculoskeletal injuries resulting from motor vehicle involvement (13.7%) was comparable to that reported for all injuries resulting from motor vehicle involvement (11.6%), with men, again, reporting motor vehicle involvement more often than females (15.1% vs. 11.9%). Overall, it is apparent that men reported higher incidence rates for all injuries related to motor vehicle accidents than women, with an even higher differential for musculoskeletal injuries than women. In addition, there was substantial variability among injury types. The greatest difference occurred w ith fracturesmen reported sustaining a motor vehicle-related fracture more than twice as often as women. Dislocations and sprains also had gender differences, although it w as minimal (13.6% for men and 12.0% for women) .
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FIGURE 4-6 Percent distribution of fracture location: US, 1992 to 1994. ( Reprinted with permission from Fildes J, et al. National Trauma Data Bank Report 2003, Version 3.0. American College of Surgeons, 2003. Available at: http://www.facs.org/trauma/ntdbannualreport2003.pdf.)
Associated Disability
Of the 36.9 million annual musculoskeletal injuries reported between 1992 and 1994, 33.1 million received medical treatment; over half resulted in activity restriction (defined as one-half day of a reduction in a person's normal activity level following injury) and one-fifth resulted in bed-disability (defined as at least one-half day of bed- disability resulting from injury). The categories of injury most likely to be treated were fractures and open wounds ( 97.4% and 94.5%, respectively). Fracture, which was also the injury most likely to result in bed-disability (27.5%) or activity restriction (64%), had a varying impact on P.119 activity restriction based on anatomic site. Fractures of the tibia, fibula, and ankle resulted in both the most activity restriction and the most bed- disability, w hereas fractures of the humerus, radius, and ulna were more likely to result in activity restriction, though w ere less likely to result in bed- disability. After fracture, the second greatest impact on activity restriction occurred with dislocations and sprains, resulting in activity restrictions in 59.4% of patients and bed-disability in 26.9%.
TABLE 4-25 Distribution of Type of Occupational Injury or Illness by Gender and Median Days Away from Work per Injury or Illness, 1996
Injuries or Illnesses (perc ents) Male Female Total Median Wor k-Loss Days
Dislocation
1.2
0.7
1.0
28
Fracture
7.2
4.9
6.4
17
Sprains & Strains
42.1
46.6
43.6
Amputation
0.7
0.2
0.5
20
Crushing Injuries
1.5
0.6
1.2
Cuts, Lacerations
8.6
4.1
7.1
Bruises, Contusions
8.6
10.8
9.3
Heat Burns
1.5
1.7
1.5
Tendinitis
0.5
1.7
0.9
Carpal Tunnel Syndrome
0.7
3.3
1.6
25
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Multiple Injuries
3.3
3.1
3.2
All Other
24.1
22.3
23.7
100.0
100.0
100.0
Source: Department of Labor, Bureau of Labor Statistics, Case and Demographic Characteristics for Workplace Injuries and Illnesses Involving Days Away F rom Work, 1996; Supplemental Tables, 1998. (Reprinted with permission from Praemer A, Furner S, Rice D. Musculoskeletal Conditions in the United States. Rosemont: American Academy of Orthopaedic Surgeons, 1999.)
Duration of restricted activity days was also greatest for fracture, which accounted for 145.6 million days of restricted activity and the longest duration of restricted activity per episode among all injury categories (24.5 days). Patient age was an important factor in determining the length of restricted activity. Persons under the age of 65 had 107.3 million restricted-activity days associated with fracture, with duration of 21.3 days per fracture. Among those 65 and older, the number of restricted-activity days was far less (38.3 million), but the duration was significantly greater ( 42.3 days). These trends are likely due to the higher incidence in younger populations, and the slower recovery time associated with older age. By gender, women with fractures reported 75.1 million days of restricted activity for an average of 28.6 days per fracture, while men had less morbidity using this measure, with corresponding numbers of 70.4 million days and 21.2 days per fracture. T he proportion of total restricted-activity days due to musculoskeletal injury was highest for dislocations and sprains, not fractures. F orty-one percent of the total restricted-activity days were due to dislocations and sprains, compared to 26.6% for fractures. C ontusions accounted for 13.4% of total restricted- activity days and smaller percentages were attributable to open wounds, other musculoskeletal injuries, and crushing injuries. Substantial work-loss and school-loss days were associated with musculoskeletal injury. Among those currently employed, more than 147 million work-loss days were attributable to musculoskeletal injuries. As percentages of work- loss days by injury category, fractures caused 24.7% of work-loss days, and open P.120 wounds were responsible for 11.8% of work-loss days. Among school children ages 5 to 17, 21.2 million school-loss days resulted from musculoskeletal injuries, whereas fractures accounted for 34.7% of school-loss days, dislocations and sprains resulted in 27.9% of school- loss days, and open wounds caused 21.3% of school-loss days. Overall, fracture w as the number one cause of activity restriction, bed-disability, and duration of restricted-activity days, as well as the leading cause of work loss and school loss.
TABLE 4-26 Percentage of Injuries with Motor Vehicle Involvement by Type of Injury and Gender: US, 1992 to 1994
Injurie s with Mot or Vehicle Involvement (percent) Injur y Male Fe male Total
All Injuries
13.1
9.9
11.6
Fractures
16.6
6.8
12.3
Neck and Trunk
*27.3
*14.2
Tibia, Fibula, and Ankle
*22.9
*12.6
Humerus, Radius, and Ulna
*7.5
*3.8
Other Fractures
15.1
*10.9
13.3
13.6
12.0
12.9
Open Wounds
8.1
*3.3
6.5
Contusions
25.1
20.7
22.8
Other Injuries
20.5
14.6
17.6
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All Musculoskeletal Injuries
15.1
11.9
13.7
*Estimate does not meet standards of reliability or precision. Source: National Center for Health Statistics, National Health Interview Survey, 19921994. (Reprinted with permission from Praemer A, Furner S, Rice D. Musculoskeletal Conditions in the United States. Rosemont: American Academy of Orthopaedic Surgeons, 1999.)
Health Care Utilization

Musculoskeletal injury is a substantial burden on health care resources and accounts for 40.8% of hospitalizations due to musculoskeletal conditions. From 1993 through 1995, almost 1.3 million inpatient hospitalizations, averaging 6.0 days each, occurred annually in the US for all types of musculoskeletal injuries (Table 4-27), resulting in more than 7.5 million patient days per year. By injury type, fracture dominated the use of inpatient services compared with other categories of musculoskeletal injury, requiring the longest average stay (7.0 days) and 84.9% of patient days (Tables 4-27 and 4-28). As a result, 71.9% of hospitalizations for musculoskeletal injuries in short-stay hospitals were due to fractures, with an average of 906,000 hospitalizations occurring each year (Table 4-28). F ractures also led to a substantial differential in the overall utilization of inpatient resources by gender (Table 4-27). Epidemiological data indicate that women utilize inpatient services much more than men for musculoskeletal injuries. This is likely due to two main factors, both related to fracture epidemiology. First, the majority of hospitalizations resulted from fractures and occurred predominantly among women (59.5%); and second, women had a longer length of stay following fractures (7.5 days) than men (6.5 days). When these two factors were combined, patient days resulting from fractures accounted for 89.3% of the patient days associated with musculoskeletal injuries among women, compared with 78.2% among men. This was the dominant factor contributing to the overall greater utilization of inpatient resources by females. Selected anatomic sites of fractures and sprains or dislocations resulted in hospitalization as displayed in T ables 4-29 and 4-30. The fractures are most likely to lead to hospitalizations involving the neck of the femur, ankle, vertebral column, and the tibia and fibula. Women (primarily 65 and older) sustained the majority of fractures of the neck of the femur, as well as the pelvis and the humerus, a disproportional representation that likely reflects P.121 both the larger female population among the elderly and the susceptibility to fracture of these bones among the older, more osteoporotic female population. The best example occurred in fractures of the neck of the femur: 90.1% of fractures occurred in patients 65 and older, 78.0% of which were in w omen.
TABLE 4-27 Average Annual Hospitalizations Resulting from Musculoskeletal Injuries, by Age and Gender: US 1993 to 1995
Number of Hospit alizations 1 Gender <18 18 44 45 64 65 & Over Total 3 Number of Patient Days 2 Ave rage Length of Stay (days)
Fractures
87,000
203,000
137,000
478,000
906,000
6,402,000
7.1
Male
55,000
137,000
64,000
110,000
367,000
2,374,000
6.5
Female
32,000
66,000
72,000
368,000
539,000
4,028,000
7.5
Dislocations
6,000
21,000
9,000
7,000
42,000
120,000
2.8
Male
4,000
15,000
6,000
2,000
27,000
74,000
2.7
Female
2,000
5,000
3,000
4,000
15,000
46,000
3.1
Sprains and Strains Male
9,000
48,000
35,000
29,000
122,000
341,000
2.8
5,000
33,000
20,000
11,000
69,000
171,000
2.5
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Female
4,000
15,000
16,000
18,000
53,000
170,000
3.2
Crushing Injuries Male
53,000*
3,000
53,000
23,000
4.7
3,000
4,000
20,000
4.7
Female
Contusions
2,000
13,000
8,000
23,000
47,000
195,000
4.1
Male
1,000
6,000
4,000
8,000
20,000
77,000
3.9
Female
7,000
5,000
15,000
27,000
118,000
4.3
Open Wounds
14,000
59,000
13,000
8,000
94,000
331,000
3.5
Male
11,000
49,000
10,000
5,000
75,000
252,000
3.4
Female
4,000
10,000
3,000
3,000
19,000
79,000
4.1
Other
6,000
21,000
9,000
8,000
44,000
132,000
3.0
Male
3,000
13,000
6,000
3,000
25,000
67,000
2.6
Female
3,000
8,000
3,000
5,000
19,000
65,000
3.5
Total, All
126,000
368,000
213,000
554,000
1,260,000
7,544,000
6.0
Musculoskeletal
Male
80,000
257,000
110,000
140,000
588,000
3,035,000
5.2
Injuries
Female
46,000
111,000
102,000
414,000
672,000
4,509,000
6.7
First listed diagnosis for inpatient discharged from short-stay hospitals. average. 3 Because of rounding, totals may not equal sum of the individual components. *Estimate does not meet standards of reliability or precision. (Reprinted with permission from Praemer A, Furner S, Rice D. Musculoskeletal Conditions in the United States. Rosemont: American Academy of Orthopaedic Surgeons, 1999.)
1 2 Annual
F or fractures, the average length of hospital stay was affected most by injury site (Table 4-29) . Hospital stays were generally shorter for fractures in the upper extremity than for fractures of the trunk or lower extremities. T he longest lengths of stay occurred in patients with femoral fractures other than the neck of the femur (10.3 days), fractures of the neck of the femur (9.4 days), fractures of the vertebral column ( 8.1 days), and fractures of the pelvis (7.9 days). Of note, average lengths of stay reflect both the seriousness of the injury as well as the comorbidities of the persons most at risk for sustaining the injury. Hospitalizations for dislocations were generally shorter, and were predominantly due to dislocations of the knee ( 22,000) or shoulder ( 6,000), with respective lengths of stay of 2.1 and 2.3 days (Table 4-30). Hip dislocations, although less frequent (4,000), had a longer average length of stay of 4.7 days. In addition to hospitalizations, musculoskeletal injuries also resulted in a large number of outpatient physician visits. From 1993 through 1995, there were more than 38.7 million annual visits to physicians in office-based practice as a result of musculoskeletal injuries. The distribution of injury types in outpatient practices differed from that seen at the inpatient care level, and P.122 sprains and strains, not fractures, were the most frequently occurring musculoskeletal injury category. Sprains and strains caused approximately 16.1 million physician visits per year, whereas fractures (still the second most frequent category) resulted in 9.4 million visits, followed by open wounds (3,796,000), contusions (3,148,000), and dislocations (1,993,000).
TABLE 4-28 Distribution of Hospitalizations and Patient Days Resulting From Musculoskeletal Injuries, by Age and Gender: US, 1993 to 1995
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Distribution (in per cent) Hospitalizations* Patient Days
Fractures
71.9
84.9
Dislocations
3.3
1.6
Sprains and Strains
9.7
4.5
Crushing Injury
0.4
0.3
Contusions
3.7
2.6
Open Wound
7.5
4.4
Other Injury
3.5
1.7
*First listed diagnosis for inpatients discharged from short-stay hospitals. Annual average. Source: National Center for Health Statistics, National Hospital Discharge Survey, 19931995. (Reprinted with permission from Praemer A, Furner S, Rice D. Musculoskeletal Conditions in the United States. Rosemont: American Academy of Orthopaedic Surgeons, 1999.)
Financial Costs
T he cost of musculoskeletal injuries, including injuries related to fractures, dislocations and sprains, open wounds, crushing injury, traumatic amputation, and other selected injuries affecting the musculoskeletal system, amounted to $41.3 billion in 1995. Seventeen percent ($7.1 billion) were indirect costs, with morbidity costs related to reduced or lost productivity amounting to $2.7 billion, and mortality costs related to the loss of expected earnings in an individual's future totalling $4.4 billion. The remaining 83% of total costs were direct costs related to health care. F ractures, a costly category of musculoskeletal injuries, were estimated to have utilized $19.3 billion in 1995. Direct costs comprised more than two-thirds of this figure, in large part due to lengthy hospitalizations. Almost 900,000 persons were hospitalized with fractures and the average length of stay was 6.5 days, giving a total of 5.8 million days. As a result, hospital inpatient costs amounted to $7.0 billion and made up the majority of the $13.2 billion in direct costs related to fracture. Indirect costs were $6.2 billion, of which $3.8 billion were mortality costs and $2.4 billion were morbidity costs.
NATIONAL TRAUMA DATA BANK 2003

T he National Trauma Data Bank ( NTDB) is a trauma registry that contains 731,824 records from 268 US trauma centers. The Annual R eport 2003, consisting of 548,735 records from 255 US trauma centers, reviews the combined data set for the period 1997 to 2002 and evaluates the NTDB data, giving insight into the state of trauma care and general characteristics of patients treated at trauma centers in the US (1). Specifically, it contains detailed epidemiological data on age and gender distributions, mechanisms of injury, and mortality.
National Trauma Data Bank Hospitals

T wo hundred and sixty-eight hospitals submitted data to the NTDB, 223 (83%) of which met the American College of Surgeons C ommittee on Trauma criteria to be verified as a trauma center. Sixty-nine hospitals were designated as Level I, 71 as Level II, 34 as Level III, and 49 w ere either Level IV or V. Sixty-five ( 24%) were university hospitals and 144 (54%) were community teaching hospitals.
Patient Characteristics
F rom 1997 to 2002, 548,735 trauma cases were submitted to The NTDB, contributing to the data bank's accrued total of 731,824 records. Persons 17 to 24 years old represented the peak age group of patients in the NTDB, with men injured in motor vehicle accidents and by violence ( gunshots, shotguns, stabs, and fights) predominating (Figs. 4-7 and 4-8) . A second peak in the age distribution occurred in patients 35 to 44 years old, again including mostly males injured in motor vehicle accidents. A smaller third peak occurred between ages 72 and 85, representing mostly women injured in falls and motor vehicle accidents. Overall, the gender pattern observed was that by ages 20 to 24, men outnumbered women by 3: 1 in the trauma registry until after age 40. Men thereafter continued to represent the majority of victims through age 68, at which point w omen sustained the majority of trauma.
Mechanism of Injury
T he most prevalent mechanism of injury in the registry was motor vehicle accidents, which accounted for 39% of cases in the data bank (Fig. 4-9), w as responsible for 39.5% of mortalities (Figure 4-10), and was associated with the greatest number of hospital ( Fig. 4-11) and ICU days (Fig. 4- 12). Younger age groups were most affected, with a dramatic rise in motor vehicle accident cases observed beginning at age 14 and peaking at age 20. F alls, the second most prevalent source of trauma, accounted P.123 P.124
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for an additional 27% of cases in the NT DB (Fig. 4-9) . Peak incidence occurred at age 81 (F ig. 4-13), a factor that likely contributed to the high mortality rate (18.3% of total deaths). Falls were also associated with the second largest number of hospital (Fig. 4- 11) and ICU days (Fig. 4-12), partly reflecting the increased comorbidities in the elderly.
TABLE 4-29 Average Annual Hospitalizations Resulting from Fractures at Selected Anatomic Sites, by Age and Gender: US, 1993 to 1995
Nu mber of Hospit alizations 1 65 & Over Number of Patient Days 2 Avera ge Length of St ay
Gender
<18
1844
4564
Total 3
Fracture of Hand Male
2,000
11,000
4,000
2,000
18,000
46,000
2.6
2,000
9,000
3,000
14,000
32,000
2.3
Female
2,000
4,000
15,000
3.6
Fracture of Carpals Male
1,000
1,000
7,000
3,000
14,000
4.6
2,000
7,000
3.8
Female
1,000
7,000
5.9
Fracture of Radius and Ulna Male
15,000
17,000
12,000
15,000
59,000
185,000
3.1
9,000
13,000
5,000
3,000
29,000
88,000
3.0
Female
5,000
5,000
7,000
13,000
30,000
97,000
3.2
Fracture of Humerus Male
15,000
9,000
9,000
27,000
61,000
254,000
4.2
9,000
5,000
3,000
6,000
22,000
79,000
3.5
Female
6,000
4,000
6,000
22,000
38,000
175,000
4.6
Fracture of Clavicle or Scapula Male
4,000
2,000
1,000
7,000
26,000
3.6
3,000
4,000
14,000
3.4
Female
1,000
3,000
12,000
3.9
Fracture of Ribs and Sternum Male
1,000
11,000
10,000
19,000
42,000
233,000
5.6
1,000
7,000
6,000
7,000
21,000
109,000
5.2
Female
3,000
4,000
13,000
21,000
124,000
5.9
Fracture of Vertebral Column Male
5,000
24,000
10,000
35,000
74,000
604,000
8.1
2,000
19,000
6,000
11,000
37,000
315,000
8.4
Female
3,000
5,000
5,000
25,000
37,000
298,000
7.8
Fracture of Pelvis Male
3,000
11,000
6,000
35,000
55,000
431,000
7.9
1,000
6,000
4,000
8,000
19,000
176,000
9.1
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Female
1,000
4,000
3,000
27,000
35,000
255,000
7.2
Fracture of Neck of Femur Male
3,000
6,000
20,000
273,000
303,000
2,831,000
9.4
1,000
4,000
10,000
60,000
77,000
710,000
9.3
Female
1,000
1,000
10,000
213,000
226,000
2,122,000
9.4
Other Fracture of Femur Male
18,000
15,000
6,000
23,000
62,000
633,000
10.3
12,000
10,000
3,000
4,000
28,000
273,000
9.6
Female
6,000
4,000
3,000
20,000
33,000
360,000
10.9
Fracture of Tibia and Fibula Male
12,000
29,000
17,000
15,000
72,000
476,000
6.6
8,000
22,000
9,000
4,000
42,000
270,000
6.4
Female
4,000
7,000
8,000
12,000
30,000
206,000
6.8
Fracture of Ankle Male
9,000
47,000
31,000
21,000
108,000
454,000
4.2
6,000
25,000
11,000
4,000
46,000
179,000
3.9
Female
3,000
22,000
20,000
17,000
62,000
275,000
4.4
Fracture of Foot
2,000
14,000
6,000
2,000
24,000
114,000
4.7
Male
1,000
11,000
4,000
17,000
77,000
4.6
Female
4,000
2,000
8,000
37,000
4.9
Fracture of Other and Unspecified Sites
1,000
6,000
4,000
8,000
18,000
101,000
5.6
Male
3,000
1,000
3,000
8,000
45,000
5.5
Female
2,000
2,000
5,000
10,000
55,000
5.6
listed diagnosis for inpatients discharged from short-stay hospitals. average. 3 Because of rounding, totals may not equal sum of the individual components. *Estimate does not meet standards of reliability or precision. Source: National Center for Health Statistics, National Hospital Discharge Survey, 1993 to 1995. (Reprinted with permission from Praemer A, Furner S, Rice D. Musculoskeletal Conditions in the United States. Rosemont: American Academy of Orthopaedic Surgeons, 1999.)
2 Annual
1 First
TABLE 4-30 Average Annual Hospitalizations Resulting from Sprains or Dislocations at Selected Anatomic Sites, by Age and Gender: US, 1993 to 1995
Number of Hospitalizations 1 65 & Over Number of Patie nt Days 2 Avera ge Leng th of St ay
Gender
<18
1844
4564
Total 3
Sprains
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Ankle and Foot Male
4,000
2,000
1,000
8,000
22,000
2.7
3,000
5,000
8,000
1.8
F emale
1,000
1,000
4,000
14,000
3.9
Knee and Leg
6,000
18,000
4,000
2,000
30,000
68,000
2.3
Male
3,000
13,000
2,000
19,000
41,000
2.2
F emale
3,000
5,000
2,000
2,000
11,000
27,000
2.5
Shoulder
9,000
21,000
15,000
45,000
92,000
2.0
Male
7,000
13,000
7,000
27,000
54,000
2.0
F emale
7,000
4,000
5,000
17,000
79,000
2.2
Back
2,000
15,000
7,000
8,000
30,000
134,000
4.4
Male
1,000
8,000
2,000
3,000
13,000
55,000
4.1
F emale
7,000
4,000
5,000
17,000
79,000
4.6
Other and Unspecified Sites Male
2,000
2,000
3,000
8,000
24,000
3.0
2,000
1,000
1,000
5,000
13,000
2.8
F emale
1,000
2,000
3,000
11,000
3.3
Dislocations
Shoulder
3,000
1,000
1,000
6,000
14,000
2.3
Male
3,000
4,000
7,000
1.6
F emale
1,000
2,000
7,000
4.1
Knee
4,000
1,000
5,000
2,000
22,000
47,000
2.1
Male
2,000
8,000
3,000
14,000
32,000
2.2
F emale
1,000
3,000
2,000
2,000
8,000
15,000
1.9
Hip
1,000
4,000
17,000
4.7
Male
1,000
2,000
9,000
4.0
F emale
1,000
8,000
5.9
Other and Unspecified Sites Male
1,000
4,000
3,000
2,000
10,000
42,000
4.1
1,000
3,000
2,000
1,000
7,000
26,000
4.0
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F emale
1,000
1,000
1,000
4,000
16,000
4.2
listed diagnosis for inpatients discharg ed from short-stay hospitals. average. 3 Because of rounding, totals may not equal sum of the individual components. *Estimate does not meet standards of reliability of precision. Source: National Center for Health Statistics, National Hospital Discharge Survey, 19931995. (Reprinted with permission from Praemer A, Furner S, Rice D. Musculoskeletal Conditions in the United States. Rosemont: American Academy of Orthopaedic Surgeons, 1999.)
2 Annual
1 First
G unshot w ounds, the third most common injury category (6.5%), accounted for 20.7% of mortalities (Figures 4-9 and 4-10). The number of gunshot wound cases increased abruptly at age 12, but peaked earlier than motor vehicle accident at 19 years, then steadily decreased. Violent injuries overall, including gunshot w ounds, stab wounds and assaults/fights, accounted P.125 for 13.4% of hospital days (Fig. 4-11) and 13.1% of IC U days (F ig. 4-12).
FIGURE 4-7 Number of patients at each age from 0 to 89 in the NTDB. Total N = 548,735. (Reprinted with permission from Praemer A, Furner S, Rice D. Musculoskeletal Conditions in the United States. R osemont: American Academy of Orthopaedic Surgeons, 1999.)
Mortality
T he greatest number of deaths in the NTDB resulted from motor vehicle accidents, followed by gunshot wounds and falls (Fig. 4-10). Death occurred in 5% of motor vehicle crashes in the data bank; crash rates rose dramatically in victims 12 to 20 years old. Deaths from motor vehicle accidents, however, remained relatively stable until age 75, after which they declined (Fig. 4-13), possibly due to infrequent driving among the very elderly. Gunshot wound injuries, although less pr evalent than motor vehicle accidents, were associated with death in 16.71% of cases, the highest percentage of any penetrating injury. Falls, the second most prevalent source of trauma and third most common cause of death, resulted in death in 3.6% of cases, a slightly lower percentage than for motor vehicle accidents. Other injuries with high mortality rates included pedestrian injuries, which were associated with death in 8.56% of cases, and burns, which were associated with death in 5.93% of cases.
FIGURE 4-8 Number of men and women at each age from 0 to 89 in the NTDB. Total N = 548,735. (Reprinted with permission from Praemer A, Furner S, Rice D. Musculoskeletal Conditions in the United States. Rosemont: American Academy of
03.05.2010
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Orthopaedic Surgeons, 1999.)
R egarding age, the percentage of death was highest in those aged 65 to 89 years, due largely to deaths after falls or motor vehicle accident in the elderly. A bimodal distribution was noted in the number of deaths, however, with peaks at 20 and 80 years ( Fig. 14). Men who died in motor vehicle accidents and by gunshot wounds, stabbings, assaults, and fights, contributed to the first peak, with the prevalence of violent deaths rising dramatically among those 12 to 20 years old and peaking at 25 to 30 years. P.126
MEDICARE DATA FROM THE DARTMOUTH ATLAS

T he Dartmouth Atlas, an analysis of Medicare data (3) from 1996 to 1997, documents regional variation in the rates of fracture and operative treatment for different musculoskeletal conditions. Various databases were analyzed to determine health care demands and utilization across the US. Databases, including the Denominator File, were provided through the Health Care Financing Administration and were analyzed to determine the number of possible Medicare beneficiaries in a designated region, as well as demographic data for these individuals (age, gender, and race). The MEDPAR File (hospital claims data) contained data on the rates of hospital services usage. Physician visit rates and the rates of certain diagnostic procedures and preventative services were obtained from analyzing the Part B Standard Analytical Variable Length File.
FIGURE 4-9 Proportional distribution of patients, grouped by mechanism of injury in the NTDB. Total N = 453,806. MVC, motor vehicle crash; GSW, gunshot wound; MCC, motorcycle crash. ( Reprinted with permission from Praemer A, Furner S, Rice D. Musculoskeletal Conditions in the United States. Rosemont: American Academy of Orthopaedic Surgeons, 1999.)
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FIGURE 4-10 Proportional distribution of deaths, grouped by mechanism of injury in the NTDB. T otal N = 23,730. MVC , motor vehicle crash; GSW, gunshot wound; MCC, motorcycle crash. ( Reprinted with permission from Praemer A, Furner S, Rice D. Musculoskeletal Conditions in the United States. Rosemont: American Academy of Orthopaedic Surgeons, 1999.)
T o define regions of health care delivery, 3,436 hospital service areas were defined, each comprising a region in w hich an acute care health facility w as located with inpatient capabilities. These facilities w ere identified through the American Hospital Association Annual Survey of Hospitals and the Medicare Provider of Services files. Hospital referral regions were also defined according to the 19961999 Dartmouth Atlas of Health C are guidelines, and represent tertiary care facilities in which there was delivery of specific cardiovascular and neurosurgical procedures. All hospital service areas w ere then assig ned to a specific hospital referral region based on the g reatest proportion of p atients in a designated hospital service area utilizing service in that hospital r eferral region. Some hospital service areas were reassigned to achieve geographic contiguity, a minimum population size of 120,000, or a high localization index. T he most common musculoskeletal condition requiring hospitalization in the Medicare population w as fracturemore than 450,000 patients sustained fractures in 1996 alone. Among fracture types, the most common were hip fractures (femoral neck and intertrochanteric) (45%), followed by fractures of the wrist (20%), ankle (10%), proximal humerus (9%), forearm (5%), femur ( thigh bone) ( 4%), distal humerus/shaft (upper arm) (4%), and proximal tibia/shaft (lower leg) ( 4%) (Fig. 4-15).
Hip Fracture
F racture of the proximal femur was the most common fracture type. Incidence increased with age and was highest in white women, likely due to the higher prevalence of osteoporosis in this group. F rom 1996 to 1997, hip fracture occurred in approximately 420,000 Medicare patients, 98% of whom were treated surgically. The average hip fracture rate was 7.7 per 1,000 Medicare enrollees from 1996 to 1997, but varied twofold, from 4.9 per 1,000 Medicare enrollees in Honolulu to 10.5 in Rome, Georgia. Other hospital referral regions where hip fracture rates w ere substantially higher than average included Lubbock, Texas (10.0); Nashville, T ennessee (9.5); Winston-Salem, North Carolina (9.5); Chattanoog a, Tennessee (9.2); and Cincinnati (9.1) (Fig. 16). In addition to Honolulu, hospital referral regions where hip fracture rates per 1,000 Medicare enrollees were substantially lower than average included San Francisco ( 5.6); Eugene, Oregon (5.9); San Jose, California (6.0) ; Newark, New Jersey (6.0); and Manhattan (6.3).
Wrist Fracture
Wrist fracture, the second most common fracture type, occurred in approximately 96,000 Medicare patients in 1996, 85% of whom w ere women. Wrist fracture rates varied almost four-fold, from 1.5 per 1,000 Medicare enrollees to 5.7. Hospital referral regions w ith high rates of wrist fracture per 1,000 Medicare enrollees were Huntsville, Alabama (5.7); Tuscaloosa, Alabama P.127 P.128 ( 5.6); Birmingham, Alabama (5.4); Philadelphia, Pennsylvania (5.0); Winston-Salem, North Carolina (4.9); and Ann Arbor, Michigan ( 4.7) (Fig. 4-17). Hospital referral regions with lower than average rates per 1,000 Medicare enrollees were Everett, Washington ( 1.5); San Francisco, California (1.6); Stockton, California (1.7); San Jose, Californi a (1.8) ; Portland, Oregon (1.9); and Sacramento, California (2.0).
FIGURE 4-11 Hospital length of stay grouped by mechanism of injury in the NTDB. T otal N = 453,806. Total hospital length of stay = 2,562,282 days. Blue bars represent blunt mechanism of injury. Green bars represent violent mechanisms of injury. Red bar represents burns. MVC, motor vehicle crash; GSW, gunshot wound; MCC, motorcycle crash. (Reprinted with permission from Praemer A, Furner S, Rice D. Musculoskeletal Conditions in the United States. R osemont: American Academy of Orthopaedic Surgeons, 1999.)
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FIGURE 4-12 T otal ICU length of stay grouped by mechanism of injury in the NTDB. T otal N = 412,687, total ICU length of stay = 644,627 days. Blue bars represent blunt mechanism of injury, green bars represent violent mechanism of injury, and red bars represent burns. MVC, motor vehicle crash; GSW, gunshot wound; MCC, motorcycle crash. (Reprinted with permission from Praemer A, Furner S, Rice D. Musculoskeletal Conditions in the United States. R osemont: American Academy of Orthopaedic Surgeons, 1999.)
FIGURE 4-13 Number of deaths due to injuries from the most common mechanism of injury categories at each age from 0 to 89 in the NT DB, total N = 18,902. MVC, motor vehicle crash. ( Reprinted with permission from Praemer A, Furner S, Rice D. Musculoskeletal Conditions in the United States. Rosemont: American Academy of Orthopaedic Surgeons, 1999.)
FIGURE 4-14 Number of deaths at each age from 0 to 89 in the NTDB, total N = 27,052. (From Praemer A, Furner S, Rice D. Musculoskeletal Conditions in the United States. Rosemont: American Academy of Orthopaedic Surgeons, 1999.)
Surgical repair rates of wrist fracture varied almost tenfold, as a proportion of all wrist fractures, from 5.1% of all wrist fractures to 50.7% ( Fig. 4-18). The US average was 16.5%. Hospital referral regions with relatively high rates of surgical repair of wrist fr actures included Olympia, Washington (50.7%) ; C asper, Wyoming (48.3%); Joplin, Missouri (41.3%); Little R ock, Arkansas (38.2%); Anchorage, Alaska (36.7%); and Seattle, Washington ( 36.0%). Hospital referral regions with lower than average surgical repair rates
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w ere Greenville, North Carolina (5.1%); White Plains, New York (6.4%); Detroit, Michigan (7.7%) ; Hackensack, New Jersey (7.9%) ; Morristown, New J ersey (8.6%); and Royal Oak, Michig an (9.1%) .
FIGURE 4-15 T he relative frequency of eight different types of fractures in Medicare patients. The number of Medicare enrollees with each fracture is in parentheses. (Reprinted with permission from Wennberg J, Cooper MC, eds. The Dartmouth Atlas of Musculoskeletal Health Care. Chicago: American Hospital Association Press, 2000.)
Ankle Fracture
R ates of ankle fracture, the third most common fracture type, varied almost sixfold in 1996 and 1997, from 0.5 to 3.1 per 1,000 Medicare enrollees. The US average rate of ankle fracture was 1.7 per 1,000 Medicare enrollees. Hospital referral regions where rates of ankle fracture per 1,000 Medicare enrollees were higher than the national average included Danville, Pennsylvania ( 3.1); Altoona, Pennsylvania (2.9); Reading, Pennsylvania ( 2.8); Allentown, Pennsylvania (2.7); Birmingham, Alabama (2.5); Ann Arbor, Michigan ( 2.5); and Cincinnati, Ohio (2.4) ( Fig. 4-19) . Hospital referral regions where rates per 1,000 Medicare enrollees were lower than the national average included Honolulu, Hawaii (0.5); San Jose, California (0.7) ; New Orleans, Louisiana ( 0.8); Los Angeles, California ( 0.8); Sacramento, California (0.8) ; and Phoenix, Arizona (0.9) . T he US average for the proportion of ankle fractures repaired surgically in 1996 and 1997 was 37.2%, and varied from 20.8% to 77.1% ( Fig. 4-20), a greater than threefold difference. Hospital referral regions where the proportion of surgical repair of ankle fracture was higher than average included Chico, California (77.1%); Tacoma, Washington ( 71.4%); Spokane, Washington (70.9%); Eugene, Oregon ( 69.7%); Little Rock, Arkansas (68.1%) ; and Phoenix, Arizona (67.9%). Hospital referral regions with a lower than average proportion of ankle fractures treated surgically included Altoona, Pennsylvania ( 20.8%); Buffalo, New Y ork (21.9%); C harleston, South Carolina (23.1%); White Plains, New Y ork (23.4%); Philadelphia, Pennsylvania P.129 P.130 P.131 P.132 P.133 P.134 ( 24.6%); Detroit, Michigan (24.7%); and Albany, New York (25.6%).
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FIGURE 4-16 R atio of rates of hip fracture treatment to the US average by hospital referral region ( 1996 to 1997). (R eprinted with permission from Wennberg J, Cooper MC, eds. The Dartmouth Atlas of Musculoskeletal Health Care. C hicago: American Hospital Association Press, 2000.)
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FIGURE 4-17 R atio of rates of wrist fracture treatment to the US average by hospital referral region (1996 to 1997). (Reprinted with permission from Wennberg J, Cooper MC , eds. T he Dartmouth Atlas of Musculoskeletal Health Care. Chicago: American Hospital Association Press, 2000.)
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FIGURE 4-18 Proportion of wrist fractures treated surgically by hospital referral region (1996 to 1997). (Reprinted with permission from Wennberg J, C ooper MC, eds. T he Dartmouth Atlas of Musculoskeletal Health Care. Chicago: American Hospital Association Press, 2000.)
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FIGURE 4-19 R atio of rates of ankle fracture treatment to the US average by hospital referral region (1996 to 1997). (Reprinted with permission from Wennberg J, Cooper MC , eds. T he Dartmouth Atlas of Musculoskeletal Health Care. Chicago: American Hospital Association Press, 2000.)
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FIGURE 4-20 Proportion of ankle fractures treated surgically by hospital referral region ( 1996 to 1997). ( Reprinted with permission from Wennberg J, C ooper MC, eds. T he Dartmouth Atlas of Musculoskeletal Health Care. Chicago: American Hospital Association Press, 2000.)
Proximal Humerus Fracture

T he fourth most common fracture type, proximal humerus fracture, had rates that varied by a factor of 10 in 1996 and 1997, from 0.3 per 1,000 Medicare enrollees to 3.4. The US average was 1.6 per 1,000 Medicare enrollees. Substantially higher than average rates per 1,000 Medicare enrollees w ere observed among the following hospital referral regions: Covington, Kentucky (3.4); Allentown, Pennsylvania (2.8); Philadelphia, Pennsylvania (2.8) ; Harrisburg, Pennsylvania (2.5); Columbia, South Carolina ( 2.5); C incinnati, Ohio (2.4); and Baltimore, Maryland (2.3) ( Fig. 4-21) . Hospital referral regions with proximal humerus fracture rates lower than average per 1,000 Medicare enrollees were Jackson, Tennessee (0.3) ; Honolulu, Hawaii (0.4); Tacoma, Washington (0.5) ; San Jose, C alifornia (0.6); Spokane, Washington (0.6); San Francisco, California (0.7) ; and San Bernardino, California (0.8). Surgical repair of proximal humerus fracture in 1996 and 1997 varied tenfold, from 6.4% of all proximal humerus fractures to 60.0%. T he US average was 14.3% (F igure 4-22). Hospital referral regions with higher than average surgical repair rates included Tacoma, Washington ( 60.0%); Little Rock, Arkansas (34.8%) ; Spokane, Washington (33.3%); Phoenix, Arizona ( 29.8%); San Diego, California ( 27.5%); and Minneapolis, Minnesota (22.9%). Hospital referral regions where the proportion of proximal humerus fractures treated surgically was lower than average were Takoma Park, Maryland (6.4%); Detroit, Michigan ( 8.5%); Buffalo, New York (8.8%) ; East Long Island, New York ( 8.9%); Cleveland, Ohio (9.3%); and Milwaukee, Wisconsin ( 9.8%) .
Proximal Forearm and Shaft Fracture

R ates of proximal forearm and shaft(s) fracture varied sixfold in 1996, from 0.3 per 1,000 Medicare enrollees to 1.8. T he U S average was 0.9 per 1,000 Medicare enrollees. Hospital referral regions where rates of proximal forearm and shaft(s) fracture were substantially higher than this average included Binghamton, New York (1.8); Takoma Park, Maryland (1.4); Detroit, Michigan (1.4); Philadelphia, Pennsylvania (1.3); Providence, Rhode Island (1.2); and Cleveland, Ohio (1.2) (F ig. 4-23). Hospital referral regions w here rates were lower than average per 1,000 Medicare enrollees included Honolulu, Hawaii (0.3); Seattle, Washington (0.4); Portland, Oregon ( 0.4); Little Rock, Arkansas (0.5); Knoxville, Tennessee ( 0.5); and Spokane, Washington (0.6).
Femur Fracture
F orty thousand Medicare patients sustained a femur fracture in 1996 and 1997, making it the sixth most common fracture type. I n the US, the average rate of femur fracture per 1,000 Medicare enrollees was 0.7, and rates varied fourfold from 0.3 to 1.2. Seventythree percent of these patients were treated surgically. Hospital referral regions where the rate of femur fracture per 1,000 Medicare enrollees was substantially higher than the national average included T uscaloosa, Alabama (1.2); Lubbock, Texas (1.1); Cincinnati, Ohio (1.0); Toledo, Ohio (1.0); Atlanta (1.0); Kansas C ity, Missouri (0.9); and Philadelphia, Philad elphia (0.9) (Fig. 4-24). Rates per
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1,000 Medicare enrollees weresubstantially lower than average in the hospital referral regions of Salem, Oregon ( 0.3); San Francisco, Californai (0.4); Lebanon, New Hampshire ( 0.4); Boise, Idaho (0.5); Sacramento, California ( 0.5); and New Brunswick, New Jersey ( 0.5).
Humeral Shaft and Distal Humerus Fracture

Medicare enrollees experienced 35,000 fractures of the humeral shaft or distal humerus from 1996 to 1997, giving an average rate in the US of 0.6 per 1,000 enrollees, making it the seventh most common fracture category. A sixfold difference in incidence was observed among hospital referral regions. Hospital referral regions where rates of humeral shaft and distal humerus fracture were higher than the US average per 1,000 Medicare enrollees included Hinsdale, Illinois (1.4); Takoma Park, Maryland (1.2); Corpus Christi, Texas (1.1); Tuscaloosa, Alabama (1.1); Norfolk, Virginia (0.9); and Philadelphia, Pennsylvania (0.9) (Fig. 4-25). Hospital referral regions with lower than average rates of humeral shaft and distal humerus fracture per 1,000 Medicare enrollees w ere San Angelo, Texas (0.3); Eugene, Oregon (0.3); San Francisco, California (0.3); Portland, Oregon (0.3); Seattle, Washington (0.3) ; and T ucson, Arizona (0.4). Surgical intervention was used in 38.7% of Medicare patients with fractures of the humeral shaft and distal humerus in 1996 and 1997, with the proportion undergoing surgical repair varying almost fourfold, from 18.6% to 70.1% of all proximal humerus fractures ( Fig. 4-26) . Hospital referral regions with relatively high surgery rates for humeral shaft and distal humerus fracture included San F rancisco, California (70.1%); Seattle, Washington (64.1%); Little Rock, Arkansas (63.6%) ; Los Angeles, California (55.3%); K noxville, Tennessee (53.2%); and Peoria, Illinois (50.9%). Hospital referral regions with a low proportion of humeral shaft and distal humerus fractures treated surgically included Paterson, New Jersey (18.6%); Hartford, C onnecticut (22.9%); Buffalo, New Y ork, (25.6%); Evanston, Illinois (27.0%) ; Milwaukee, Wisconsin ( 27.3%); Washington, D.C. (27.7%); and East Long Island, New Y ork (28.7%).
Lower Leg Fracture

In 1996 and 1997, the average rate of lower leg fracture in the US was 0.6 per 1,000 Medicare enrollees, with rates varying from 0.2 per 1,000 Medicare enrollees to 1.1, more than a fivefold variation. Among hospital referral regions where rates of lower leg fracture per 1,000 Medicare enrollees w ere higher than average included Spartanburg, South C arolina (1.1); Cincinnati, Ohio (1.1); Toledo, Ohio (1.0); Philadelphia, Pennsylvania (1.0); Pittsburgh, Pennsylvania (0.9); and Birmingham, Alabama (0.9) (Fig. 4-27). Hospital referral regions where rates P.135 P.136 P.137 P.138 P.139 P.140 P.141 P.142 P.143 of proximal tibia and tibia shaft fracture were lower than average per 1,000 Medicare enrollees included Honolulu, Hawaii (0.2); Sun C ity, Arizona (0.2) ; San Francisco, California (0.2) ; Eugene, Oregon (0.3); Seattle, Washington (0.3); and Orange County, California ( 0.3).
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FIGURE 4-21 R ates of proximal humerus fracture treatment to the US average by hospital referral region (1996 to 1997). (Reprinted with permission from Wennberg J, Cooper MC , eds. T he Dartmouth Atlas of Musculoskeletal Health Care. Chicago: American Hospital Association Press, 2000.)
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FIGURE 4-22 Proportion of proximal humerus fractures treated surgically by hospital referral region (1996 to 1997). (Reprinted with permission from Wennberg J, Cooper MC , eds. T he Dartmouth Atlas of Musculoskeletal Health Care. Chicago: American Hospital Association Press, 2000.)
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FIGURE 4-23 R atio of forearm fracture treatment to the US average by hospital referral region ( 1996 to 1997). (R eprinted with permission from Wennberg J, Cooper MC, eds. The Dartmouth Atlas of Musculoskeletal Health Care. C hicago: American Hospital Association Press, 2000.)
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FIGURE 4-24 R atio of rates of femur fracture treatment to the US average by hospital referral region (1996 to 1997). (Reprinted with permission from Wennberg J, Cooper MC , eds. T he Dartmouth Atlas of Musculoskeletal Health Care. Chicago: American Hospital Association Press, 2000.)
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FIGURE 4-25 R atio of rate of humeral shaft/distal humerus fracture treatment to the US average by hospital referral region (1996 to 1997). (Reprinted with permission from Wennberg J, C ooper MC, eds. T he Dartmouth Atlas of Musculoskeletal Health Care. C hicago: American Hospital Association Press, 2000.)
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FIGURE 4-26 Proportion of humeral shaft/distal humerus fractures treated surgically by hospital referral region ( 1996 to 1997). (Reprinted with permission from Wennberg J, Cooper MC, eds. The Dartmouth Atlas of Musculoskeletal Health C are. Chicago: American Hospital Association Press, 2000.)
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FIGURE 4-27 R atio of rates of tibia fracture treatment to the US average by hospital referral region (1996 to 1997). (Reprinted with permission from Wennberg J, Cooper MC , eds. T he Dartmouth Atlas of Musculoskeletal Health Care. Chicago: American Hospital Association Press, 2000.)
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FIGURE 4-28 Proportion of tibial fractures treated surgically in the US by hospital referral region (1996 to 1997). (Reprinted with permission from Wennberg J, Cooper MC, eds. The Dartmouth Atlas of Musculoskeletal Health Care. C hicago: American Hospital Association Press, 2000.)
Surgical repair of tibia fracture in the US averaged 30.3% from 1996 to 1997. Great variation was observed across hospital referral regions in the proportion of patients treated surgically ( Fig. 4-28) , however, with the proportion ranging from 13.7% to 69.4%. Hospital referral regions where the proportion of surgical repair of tibia fracture was significantly higher included Duluth, Minnesota ( 69.4%); San Francisco, California (68.6%); Seattle, Washington (58.3%); Billings, Montana (56.7%) ; Phoenix, Arizona (53.3%); Los Angeles, California (45.3%) ; and Houston, Texas (41.7%) . Hospital referral regions where the proportion of surgical repair of tibia fracture was significantly lower than average w ere Buffalo, New York (13.7%); Rochester, New York (14.9%); Syracuse, New Y ork (16.2%); Washington, D.C. (17.4%); Allentown, Pennsylvania (19.5%) ; and Fort Lauderdale, Florida (21.7%) .
CONCLUSION
Musculoskeletal injury is a substantial source of morbidity and financial burden. To optimize treatment and health care resource allocation, study of demographic and epidemiological trends in musculoskeletal injury will continue to be necessary. Improved understanding of injury victim characteristics, as well regional outcome variation, is necessary to enhance future prevention and treatment programs, allowing specific populations to be addressed separately to improve overall outcomes. F urthermore, the differing proportions of injury treated surgically across the country w arrant future study and may provide pertinent data on how to minimize morbidity of injury while optimizing both direct and indirect costs.
REFERENCES
1. F ildes J , et al. National T rauma Data Bank Report 2003, Version 3.0. American College of Surgeons, 2003. Available at: http: //www.facs.org/trauma/ntdbannualreport2003.pdf .
2. Praemer A, Furner S, Rice D. Musculoskeletal Conditions in the United States. Rosemont: American Academy of Orthopaedic Surgeons, 1999.
3. Wennberg J, Cooper MC, eds. The Dartmouth Atlas of Musculoskeletal Health C are. Chicago: American Hospital Association Press, 2000.
03.05.2010

Overview of Epidemiology: Rockwood & Green's Fractures in Adults, 6th Edition

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Ovid: Rockwood & Green's Fractures in Adults

Part 1 Overview of Epidemiology

Ovid: Rockwood & Green's Fractures in Adults

TABLE 4-1 The Fracture Incidences in Different Studies

FIGURE 4-1 The age- and gender-specific incidence of fractures.

Ovid: Rockwood & Green's Fractures in Adults

Ovid: Rockwood & Green's Fractures in Adults

HOW COMMON ARE DIFFERENT FRACTURES?

WHICH FRACTURES ARE RELATED TO OSTEOPENIA?

TABLE 4-2 Fractures Arranged in Order of Decreasing Incidence

Ovid: Rockwood & Green's Fractures in Adults

TABLE 4-3 Fractures Arranged in Order of Decreasing Age

Ovid: Rockwood & Green's Fractures in Adults

Ovid: Rockwood & Green's Fractures in Adults

TABLE 4-4 Fractures Arranged in Order of Decreasing Incidence of Open Fractures

Ovid: Rockwood & Green's Fractures in Adults

Calcaneus (19.4%) Metatarsal ( 12.9%) Spine ( 6.4%)

Metatarsal ( 24.4%) Calcaneus (9.8%) Spine ( 5.9%)

Calcaneus (13.0%) Distal Radius (13.0%) Proximal Forearm ( 9.3%)

Spine ( 14.6%) Metatarsal ( 14.6%) Talus ( 14.6%)

Proximal Tibia (21.4%) Patella (14.3%) Spine ( 14.3%)

Tibia Diaphysis (41.2%) Distal Radius (17.6%) Proximal Tibia (11.8%)

Distal Radius (21.6%) Spine ( 13.5%) Proximal Humerus (13.5%)

Spine ( 17.9%) Calcaneus (14.3%) Distal Femur (10.7%)

Spine ( 13.6%) Distal Radius (13.6%) Proximal Radius (13.6%)

Proximal Forearm (40%) Distal Radius (20%) Spine ( 20%)

Forearm Diaphysis (11.8%) Distal Radius (11.8%)

Ovid: Rockwood & Green's Fractures in Adults

Metacarpal (26.3%) Clavicle ( 10.5%) Humerus Diaphysis (10.5%)

Proximal Humerus (50.0%) Proximal Femur (25.0%) Distal Radius (25.0%)

Distal Femur (15.4%) Other Patella (15.4%) Spine ( 15.4%)

Distal Tibia ( 33.3%) Other Tibia Diaphysis (19.0%) Metatarsal ( 9.5%)

Proximal Humerus (16.0%) Proximal Forearm (12.0%) Distal Radius (10.0%)

Proximal Femur (18.7%) Proximal Forearm (16.7%) Distal Radius (14.6%)

Distal Radius (22.2%) Proximal Radius (22.2%) Metacarpal (11.1%)

Other Metatarsals (31.2%) Calcaneus (10.9%) Talus ( 9.4%)

Metatarsal ( 26.7%) Proximal Humerus (20%) Spine ( 13.3%)

Distal Radius (26.1%) Proximal Humerus (19.6%) Proximal Forearm ( 8.7%)

Other Metacarpals (79.4%) Phalanges ( 6.9%) Forearm Diaphysis (3.8%)

Metacarpal (76.0%) Distal Radius (9.0%) Proximal Humerus (4.0%)

Calcaneus (12.5%) Distal Radius (12.5%)

Ovid: Rockwood & Green's Fractures in Adults

Distal Radius (100%)

Fall from standing height

Fall down stairs or slope

Fall from height

MVA (vehicle occupant)

Abbreviation: MVA, motor vehicle accident.

Ovid: Rockwood & Green's Fractures in Adults

MVA, motor vehicle accident.

Proximal Tibia (2.1%)

Distal Radius (20.7%)

Distal Radius (25.1%)

Proximal Femur (33.1%)

Distal Radius (25.7%)

Proximal Forearm (12.0%)

Proximal Forearm (10.3%)

Proximal Humerus (8.3%)

Ovid: Rockwood & Green's Fractures in Adults