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Injury
journal homepage: www.elsevier.com/locate/injury

The incidence and trauma mechanisms of acetabular fractures: A

nationwide study in Finland between 1997 and 2014
Pasi P. Rinnea,* , Minna K. Laitinenb , Tuomas Huttunenc,d, Pekka Kannusc,e ,
Ville M. Mattilab,c
a
Vaasa Central Hospital, Vaasa, Finland
b
Department of Orthopaedics, Unit of Musculoskeletal Surgery, Tampere University Hospital, Tampere, Finland
c
School of Medicine, Tampere University, Tampere, Finland
d
Department of Anaesthesia, Tampere University Hospital, Tampere, Finland
e
Injury and Osteoporosis Research Centre, UKK Institute for Health Promotion Research, Tampere, Finland

A R T I C L E I N F O A B S T R A C T

Purpose: Information on the incidence of acetabular fractures of the pelvis is limited. Epidemiological
Keywords: data is often based on specific trauma registers, individual trauma centres or on trends of all pelvic
Acetabulum
fractures grouped together. The primary aim of this study was to determine the incidence and trends of
Pelvic
Fracture
hospital-treated acetabular fractures in the Finnish population from 1997 to 2014. The secondary aim was
Incidence to assess the trauma mechanisms involved.
Epidemiology Methods: The Finnish National Hospital Discharge Register collects inpatient data from all public and
Traumatology private medical institutions in Finland and covers the entire Finnish population of 5.5 million. For this
study, we selected all persons 18 years of age or older who were admitted to hospital for the treatment of
an acetabular fracture between 1997 and 2014. The main outcome variable was the annual number of
patients hospitalised with a main or secondary diagnosis of acetabular fracture of the pelvis.
Results: The overall crude incidence of acetabular fractures increased slightly (from 6.4/100 000 persons/
year to 8.1/100 000 persons/year) from 1997 to 2014 while the age-standardised incidence rate remained
at a similar level (7.1/100 000/persons/year in 1997 and 7.2/100 000/persons/year in 2014). An incidence
increase was observed in the elderly population, whereas the incidence of acetabular fractures in the
younger population (mostly high energy traumas) remained stable. The most frequent trauma
mechanism for acetabular fractures was fall on the same level (47%).
Conclusions: The incidence of acetabular fractures increased slightly in Finland between 1997 and 2014.
This increase was observed especially in the elderly population and the ageing of the population largely
explains the rise. The incidence of acetabular fractures in the younger population decreased. The most
common trauma mechanism was falling on the same level.
© 2017 Published by Elsevier Ltd.

Introduction Low energy pelvic fractures mostly occur in elderly patients,

Pelvic fractures are relatively uncommon in the general
population. Such fractures have a great impact on the sufferer,
however, due to significant injury-induced morbidity and mortali-
ty. The incidence of pelvic fractures has varied between 17 and 35/
100000 person-years and fractures constitute about 3%–8% of all
fractures treated in hospitals [1–6]. During recent decades, the
number and incidence of pelvic fractures in elderly people have
increased [1,2,7–12].
* Corresponding author at: Liito-oravankatu 9, FIN-65350 Vaasa, Finland.
E-mail addresses: Pasi.Rinne@fimnet.fi, pasi.rinne@vshp.fi (P.P. Rinne).
and approximately 70% of low energy fracture patients are over 80
years of age [4,11]. High energy pelvic fractures are, in turn, mostly
seen in younger persons aged between 10 and 40 years.
Anatomically, pelvic fractures are divided into pelvic ring
disruptions and acetabular fractures [13]. Combined fractures of
the acetabulum and pelvic ring have been reported to constitute
5%–16% of all pelvic fractures [13].
From 1998 to 2003, the incidence of acetabular fracture
remained at a level of 3 fractures/100000 persons/year [14]. There
is, however, only limited epidemiological data available concerning
these fractures. Data for the frequency and incidence of acetabular
fractures are often based on trauma registers, individual trauma
centres or on trends for all fractures combined [15–19].

http://dx.doi.org/10.1016/j.injury.2017.08.003
0020-1383/© 2017 Published by Elsevier Ltd.

Please cite this article in press as: P.P. Rinne, et al., The incidence and trauma mechanisms of acetabular fractures: A nationwide study in
Finland between 1997 and 2014, Injury (2017), http://dx.doi.org/10.1016/j.injury.2017.08.003
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The primary aim of this study was to determine the incidence of
acetabular fractures leading to hospitalisation in Finland from
1997 to 2014. A secondary aim was to assess the trauma
mechanisms of such fractures.
Material and methods
The Finnish National Hospital Discharge Register (NHDR)
provides an opportunity to investigate descriptive numbers of
hospital-admitted injuries and diseases that cover the whole
Finnish population. The register is the responsibility of the
National Institute for Health and Welfare – a research and
development institute under the Finnish Ministry of Social Affairs
and Health. The registering of data in the NHDR is mandatory for
both public and private healthcare providers.
The NHDR contains data on age, sex, domicile of the patient,
length of hospital stay, primary and secondary diagnoses, the
surgical operations performed during the hospital stay and trauma
mechanisms. Hospitals in Finland receive financing based on this
information, and thus the motivation to register all patient data is
enhanced. Since 1996, diagnoses in the NHDR, have been coded
according to the 10th revision of the International Classification of
Diseases (ICD).
The main outcome variable for this study was the number of
patients hospitalised in Finland with a main or secondary
diagnosis of acetabular fracture of the pelvis (ICD-10 code
S32.4) from 1997 to 2014. All patients 18 years of age or older
were included in the study.
During the years 1997 to 2014, there were 8941 hospitalisation
events with an acetabular fracture diagnosis. In case of multiple
hospitalisation episodes of a single patient, only the first episode
was included. In total, 5022 patients with acetabular fracture were
included in the analysis.
The population was categorised into two groups: 1. younger
patients including adults under general retirement age (18 to 64
years) and 2. elderly patients over the general retirement age (over
65 years).
Trauma mechanisms were analysed and three groups of trauma
mechanisms based on the ICD-10 external causes were formed. The
group ‘fall on the same level’ included the ICD-10 diagnosis codes
W00 (fall on the same level involving ice and snow) and W01 (fall
Fig. 1. The age specific number and incidence of acetabular fractures in Finland from 1997 to 2014.
Please cite this article in press as: P.P. Rinne, et al., The incidence and trauma mechanisms of acetabular fractures: A nationwide study in
Finland between 1997 and 2014, Injury (2017), http://dx.doi.org/10.1016/j.injury.2017.08.003
on the same level from slipping, tripping and stumbling). The
group ‘fall from one level to another’ included the ICD-10 codes
W10 (fall on and from stairs and steps), W11 (fall on and from
ladder), W17 (other fall from one level to another) and W19
(unspecified fall). Motor car (V49.9) and motor bike (V29.9) crashes
were included in the third group entitled ‘motor vehicle crashes’.
Statistical analysis
To compute the incidence ratios of acetabular fractures leading
to hospitalisation, the annual mid-population was obtained from
Official Statistics of Finland, a computer-based national population
register. Crude and age-standardised incidence rates of acetabular
fracture were calculated for both genders and were expressed as
the number of cases per 100,000 persons per year. In the
calculation of the age-standardised incidence rates, age adjust-
ment was carried out by direct standardisation using the mean
population of Finland between 1997 and 2014 as the standard
population. For the entire time period, one person was counted
only once. Since the study was nationwide and comprised the
entire adult Finnish population and the incidence of acetabular
fractures, the results were true final numbers of frequency and
incidence – not estimates based on sampling or cohort. Thus, in full
agreement with our previous investigations [7,20], 95% confidence
intervals were not calculated.
Results
During the study period between 1997 and 2014, a total of 5022
patients were hospitalised due to acetabular fracture. The annual
number of fractures was 256 in 1997 and 357 in 2014 (Fig. 1). The
age distribution of the patients was bimodal (Fig. 2). The major
mode comprised older patients (mostly low energy injuries) and
the minor mode comprised younger patients (mostly high energy
injuries).
The overall crude incidence of acetabular fractures increased
slightly (from 6.4/100 000/persons/year to 8.1/100 000/persons/
year) from 1997 to 2014, while the age-standardised incidence
ratio remained at a similar level (7.1/100 000/persons/year in 1997
and 7.2/100 000/persons/year in 2014) (Fig. 3). The incidence of
acetabular fractures in elderly patients over 65 years of age
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Fig. 2. Distribution of age in adult acetabular fracture patients in Finland from 1997 to 2014.

Fig. 3. Crude and age-standardised incidence of acetabular fractures in Finland from 1997 to 2014.

Fig. 4. Age and sex adjusted incidence of acetabular fractures in Finland from 1997 to 2014.

Please cite this article in press as: P.P. Rinne, et al., The incidence and trauma mechanisms of acetabular fractures: A nationwide study in
Finland between 1997 and 2014, Injury (2017), http://dx.doi.org/10.1016/j.injury.2017.08.003
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increased by 30% (from 17/100 000/persons/year to 23/100 000/
persons/year) during the study period, while the incidence in
younger patients slightly decreased (from 3.8/100 000/persons/
year to 3.3/100 000/persons/year) (Fig. 1). There was a steady
increase in the incidence of acetabular fractures in both elderly
male and elderly female patients during the study period (Fig. 4).
Fall on the same level (ICD-10 code W01) was the most frequent
trauma mechanism for acetabular fractures (47%) (Table 1). During
the study period, the absolute number and proportion of
acetabular fractures caused by motor vehicle crashes decreased
from 159 (10%) to 108 (5%). Motor cycle injuries were an
uncommon trauma mechanism of acetabular fractures in Finland
(1997–2002: 0.9%, n = 13, vs. 2009–2014: 1.4%, n = 28).
There were differences in trauma mechanism between female
and male patients (Table 1). The most common cause for
acetabular fracture was fall on the same level in 58% of female
patients but in just 38% of male patients (Table 2). Fall from one
level to another was the trauma mechanism in 10% of female
patients and in 20% of their male counterparts. Trauma mechanism
and age were associated in that acetabular fractures in younger
patients were caused by high energy trauma, while falling on the
same level was the most common cause for low energy acetabular
fractures in elderly patients (Table 2).
Discussion
The literature provides a limited amount of information on the
incidence of acetabular fractures. Our results show a 30% increase
in the crude incidence of acetabular fracture hospitalisations in
Finland from 1997 to 2014. Furthermore, our incidence of
acetabular fractures was higher when compared with the steady
incidence of 3/100 000 persons/year reported in a Scottish single
centre study from between 1998 and 2003 [14]. However, our
cohort comprised the whole population of Finland while the
Scottish study was based on a single centre study setting.
In our study, the incidence of acetabular fractures among
younger patients, mostly caused by high energy trauma, remained
the same during the entire 18-year study period. Thus, the increase
in overall incidence was mainly the result of the crude incidence
increase in low energy acetabular fractures among elderly people.
There was a difference between the trend of crude incidence rate
and the trend of age-standardised incidence rate, although both
trends were rising. The difference reflects the influence of
population ageing during the study period, which, in turn, is
typical for all developed countries. There was only a slight increase
in the age standardised incidence indicating that change in the age
distribution of the Finnish population largely explained the
increase in the crude incidence of acetabular fractures.
Table 1
The most common trauma mechanisms for acetabular fractures in Finland between
1997 and 2014 (%).
Male Female
Fall on the same level involving ice and snow (W00) 4,9 3,2
Fall on the same level (W01) 33 55
Fall on and from stairs and steps (W10) 2,0 2,1
Fall on and from ladder (W11) 3,2 0,3
Other fall from one level to another (W17) 11 3,9
Unspecified fall (W19) 3,9 4,0
Car occupant injured (V499) 9,7 5,6
Motorcycle rider injured (V299) 2,7 0,8
Striking against or struck by other objects (W22) 0,9 0,3
Exposure to other specified factors (X58) 1,9 1,2
Exposure to unspecified factor (X59) 2,2 2,3
Other 17 11
Missing data 7,6 0,3
Total 100 100
Please cite this article in press as: P.P. Rinne, et al., The incidence and trauma mechanisms of acetabular fractures: A nationwide study in
Finland between 1997 and 2014, Injury (2017), http://dx.doi.org/10.1016/j.injury.2017.08.003
Table 2
The three main causes of trauma mechanism in acetabular fractures of Finnish
adults divided by trauma energy (%).
Male Female All
Fall on the same level 38 58 46
Fall from one level to another, ladder or stairs 20 10 16
Traffic accident (car, motor bike) 12 6,4 9,9
Contrary to hip fractures where a decrease in incidence has
been seen [20,21], the incidence of acetabular and other pelvic
fractures has increased [11]. The exact reasons for this increase are,
however, unknown. It has been suggested that instead of a hip
fracture, elderly women today are more likely to suffer from
acetabular and other pelvic fractures when falling, and thus the
increase in these low energy fractures could partly explain the
decreasing incidence of proximal femoral fractures [20,21].
However, this explanation needs further confirmation.
The age distribution of acetabular fracture patients is clearly
bimodal. Older female patients commonly sustain an acetabular
fracture after a simple fall, whereas high energy traumas occur
mainly in younger males. Our results show that the incidence of
high energy trauma fractures in young patients remained at a
steady level during the study period (approximately 3/100 000
persons/year) despite the fact that during the study period the
number of registered motorbikes in Finland increased by more
than three-fold from 68 552 in 1997 to 257 094 in 2014 [22].
Epidemiological studies based on a single trauma centre or
trauma registry may be prone to selection bias, and thus high
energy trauma cases may be over presented in these selected
cohorts. Our nationwide results of the incidence of acetabular
fractures in younger patients are similar to the results of the
Scottish study [14]. The strength of the present study is that it was
based on national NHDR data that covers all healthcare for the
entire Finnish population of 5.5 million. The NHDR has been
extensively studied and validated and found to be a reliable
register for epidemiological research [23–25].
The most common cause for acetabular fracture in our material
was fall on the same level (42% of all acetabular fractures).
However, there is a wide variation in the previous literature
concerning the trauma mechanisms for acetabular fractures. Gary
et al. reported that fall from standing was the main mechanism in
49% of acetabular fractures, and that motor vehicle collision was
the second most common mechanism in 30% of injuries [26]. Bible
et al., in turn, reported motor vehicle collision as the most common
trauma mechanism for acetabular fractures in 67% of the fractures
and fall from height as the second most common trauma
mechanism accounting for 14% of the fractures [27]. Laird and
Keating also reported motor vehicle collision as the most common
mechanism for acetabular fractures with 38% of injuries, falls from
heights < 3 m in 27% and falls from heights > 3 m in 13% of
acetabular fractures [14].
In summary, we observed that in Finnish adults the overall
All incidence of hospitalisation for an acetabular fracture increased
4,2
from 6.4 to 8.1/100 000 persons/year between 1997 and 2014. This
42 increase was observed especially in low-energy fragility fractures
2,0 in the elderly population, an increase largely explained by the
2,0 ageing of the population. The incidence of acetabular fractures in
7,9
the younger population (mostly high energy fractures) remained
3,9
8,0 stable. The most common mechanism for an acetabular fracture
1,9 was fall on the same level and resulted in the majority of acetabular
0,7 fractures among the elderly Finnish population.
1,6
2,2
15
Conflict of interest statement
8,6
100 The authors declare that they have no conflict of interest.
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Acknowledgements
This study was funded by the Jussi Lalli and Eeva Mariapori-Lalli
Foundation and the Vappu Uuspää Foundation.
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