Injury, Int. J.

Care Injured (2006) 37, 691—697

www.elsevier.com/locate/injury

REVIEW

Epidemiology of adult fractures: A review

Charles M. Court-Brown *, Ben Caesar

Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, UK

Accepted 20 April 2006

KEYWORDS Summary The epidemiology of adult fractures is changing quickly. An analysis of

Osteoporosis; 5953 fractures reviewed in a single orthopaedic trauma unit in 2000 showed that there
Osteopenia; are eight different fracture distribution curves into which all fractures can be placed.
Fractures; Only two fracture curves involve predominantly young patients; the other six show an
Epidemiology increased incidence of fractures in older patients. It is popularly assumed that
osteoporotic fractures are mainly seen in the thoracolumbar spine, proximal femur,
proximal humerus and distal radius, but analysis of the data indicates that 14 different
fractures should now be considered to be potentially osteoporotic. About 30% of
fractures in men, 66% of fractures in women and 70% of inpatient fractures are
potentially osteoporotic.
# 2006 Elsevier Ltd. All rights reserved.

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 691
Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 692
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 692
Fracture distribution curves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 694
Is the epidemiology of fractures changing? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 694
Osteoporotic fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 695
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 697
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 697

Introduction issue. They are relatively common and treatment has

In recent years fractures, particularly those occurring
in osteoporotic bone, have become a major health
* Corresponding author. Tel.: +44 131 242 3516;
fax: +44 131 660 328.
E-mail address: courtbrown@aol.com (C.M. Court-Brown).
become increasingly expensive and complicated.
Despite this, there is little known about their epide-
miology. Buhr and Cooke1 published their classic
paper on fracture epidemiology in 1959, and a
number of studies have been undertaken since
then,4—6,11,12,14 but the results are somewhat contra-
dictory. We believe that the changing epidemiology

0020–1383/$ — see front matter # 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2006.04.130
692 C.M. Court-Brown, B. Caesar

of fractures has not generally been fully appreciated.

The studies that have been undertaken suggest a
world incidence of 9.0—22.8/1000/year.4,11 We
believe it likely that there are variations in fracture
incidence in different parts of the world, but studies
within England and Wales have also shown wide
variations, the reasons for which are not fully under-
stood. Some studies have used data from Accident
and Emergency Departments, and possibly this
resulted in over-estimations, as inexperienced doc-
tors frequently over-diagnose certain fractures.
Other studies have used data from orthopaedic frac-
ture clinics, but not all fractures are referred to these
clinics, resulting in under-estimations. Another pro- Figure 1 Overall fracture age and gender distribution
blem is in that in many large cities orthopaedic curves.
trauma is managed in a number of hospitals, and
the analysis of data from a single hospital may give
skewed results. 11.67/1000/year and in women was 10.65/1000/
In an attempt to correctly define the epidemiol- year. The overall age and gender incidence curves
ogy of fractures in the local population, a retro- are shown in Fig. 1. This demonstrates a relatively
spective study of all individuals presenting to the uniform incidence in women up to the menopause
Orthopaedic Trauma Unit of the Royal Infirmary of and a rapid increase thereafter. In men the pattern
Edinburgh in the year 2000 was undertaken.3 is different; there is an increased incidence in young

Method Table 1 Fractures arranged in order of decreasing

incidence
The Royal Infirmary of Edinburgh is the only ortho- Fracture n % n/10 5 Men:
paedic trauma unit treating adults in Midlothian and women
East Lothian. All orthopaedic trauma patients in the Distal radius 1044 17.5 195.2 31:69
area attend the hospital, and all outpatient frac- Metacarpal 697 11.7 130.3 85:15
tures are reviewed at outpatient clinics. Children Proximal femur 692 11.6 129.4 26:74
under the age of 12 years attend the local paediatric Finger phalanx 574 9.6 107.3 68:32
hospital and were excluded from analysis. The over- Ankle 539 9.0 100.8 47:53
Metatarsal 403 6.8 75.4 43:57
all population served by the Royal Infirmary of
Proximal humerus 337 5.7 63.0 30:70
Edinburgh in 2000 was 534,715. All inpatients and
Proximal forearm 297 5.0 55.5 46:54
outpatients were included, and all diagnoses were Toe phalanx 212 3.6 39.6 66:34
made from relevant radiographs by the authors, to Clavicle 195 3.3 36.5 70:30
prevent over-diagnosis. All soft-tissue injuries and Carpus 159 2.7 29.7 72:28
other diagnoses were excluded from the analysis. In Tibial diaphysis 115 1.9 21.5 61:39
previous epidemiological studies, fractures have Pelvis 91 1.5 17.0 30:70
frequently been grouped into anatomical areas such Forearm 74 1.2 13.8 64:36
as ankle, hand, foot and forearm/wrist.6,14 This Calcaneus 73 1.2 13.7 78:22
does not provide orthopaedic surgeons with suffi- Proximal tibia 71 1.2 13.3 54:46
cient information, and we have subdivided fractures Humeral diaphysis 69 1.2 12.9 42:58
Patella 57 1.0 10.7 44:56
into the anatomical areas that are commonly recog-
Femoral diaphysis 55 0.9 10.3 36:64
nised by orthopaedic surgeons.
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
Results Midfoot 27 0.4 5.0 48:52
Distal femur 24 0.4 4.5 33:67
Analysis of the fractures that presented in the year Scapula 17 0.3 3.2 59:41
2000 showed that there were 5953 inpatient and Talus 17 0.3 3.2 82:18
outpatient fractures. The average age of the Sesamoid 1 0.01 0.2 100:0
patients was 49.1 years, with a gender ratio of Total 5953 100 1113.3 50:50
50:50. The incidence of fractures in men was
Epidemiology of adult fractures 693

men that gradually falls until about 60 years of age.
It then rises again, although the older male peak is
lower than the older female peak. The highest
incidence of fracture in women is 49.7/1000/year
between 90 and 99 years of age. In men there are
two similar peaks, with an incidence of 21.9/1000/
year between 12 and 19 years and 23.2/1000/year
between 90 and 99 years. Table 1 shows the pre-
valence, incidence and gender ratio of the different
fractures seen in 2000, and it is interesting to note
that fractures of the distal radius, metacarpus,
proximal femur, finger phalanges and ankle com-
prise 60% of the fractures that orthopaedic surgeons
see. It is also notable that the fractures of the
femoral diaphysis, distal femur, proximal tibia,
tibial diaphysis, tibial plafond, talus and calcaneus,
which have received considerable attention in the
literature, account for only 6.6% of all fractures, and

Figure 2 The eight fracture distribution curves: (A) unimodal young man, unimodal older woman, (B) unimodal young
man, (C) unimodal young man, unimodal young woman, (D) unimodal young man, bimodal woman, (E) unimodal older
woman, (F) unimodal older man, unimodal older woman, (G) bimodal man, unimodal older woman, (H) bimodal man,
bimodal woman.
694 C.M. Court-Brown, B. Caesar

Table 2 Fracture curves pelvic fractures comprise only 1.5% of all fractures
Fracture Curve seen by orthopaedic surgeons.
Clavicle G
Medial A Fracture distribution curves
Diaphyseal G
Lateral A Analysis of the different fractures shows that there
are eight different curves, which are depicted in
Scapula A
Intra-articular A Fig. 2. Type A fractures have a unimodal distribution
Extra-articular A in young men and older women. Types B and C affect
young patients, type B having a unimodal distribu-
Proximal humerus F
tion in young men, and type C a unimodal distribu-
Humeral diaphysis H
tion in young men and women. Type D fractures have
Distal humerus E
a unimodal distribution in young men and a bimodal
Proximal forearm D distribution in women. Types E and F are osteoporo-
Radial head H
tic fractures, with type E showing a unimodal dis-
Radial neck A
tribution in older women and type F a unimodal
Olecranon F
Radius and ulna B distribution in older men and women. Type G frac-
tures have a bimodal distribution in men and a
Distal radius A unimodal distribution in older women. In type H
Carpus B fractures there is a bimodal distribution in both
Scaphoid B men and women. These curves can be applied to
Non-scaphoid A all fractures, and a list of the different distribution
Metacarpus B curves for different fractures is given in Table 2. The
Hand phalanges B curve types for femoral head and thoracolumbar
Proximal femur F spine fractures shown in Table 2 have been calcu-
Head B lated from data in the world literature. There were
Neck F too few femoral head fractures to permit analysis,
Inter-trochanteric F and most osteoporotic thoracolumbar fractures are
Sub-trochanteric F not admitted to hospital. It has been estimated that
Multiple fractures E the overall incidence of spinal fractures is 117/105/
Patella F year,2 which is only slightly less than that of prox-
Tibial plateau H imal femoral fractures (Table 1).
Tibial diaphysis A There is a common belief that most fractures
Tibial plafond D have a type A distribution (Fig. 2) affecting younger
Ankle A men and older women. Table 2 shows that a number
Medial malleolus D of fractures, such as those of the scapula, distal
Lateral malleolus A radius, femoral and tibial diaphyses and ankle, do
Bi-malleolar E have this fracture distribution. However, analysis of
Tri-malleolar E our data demonstrates that there are seven other
Supra-syndesmotic C distinct distribution curves. It is important to realise
Talus C that the curves shown in Fig. 2 are diagrammatic,
Neck C and the height of the curve will vary between
Body C fractures. Thus, whereas both distal radial and tibial
Calcaneus G diaphyseal fractures have a type A distribution, the
Intra-articular G relative heights of the young male and older female
Extra-articular B curves are different. However, we believe that all
Midfoot C fractures conform to the eight basic types that we
Metatarsus A have presented.
Toe phalanges C
Pelvis E Is the epidemiology of fractures changing?
Spine E
Thoracolumbar E It would seem clear that the epidemiology of frac-
Cervical H tures is changing. In the 1970s and 1980s, the revolu-
tion in fracture management concerned young,
Femoral diaphysis A
multiply-injured people, and in a number of countries
Distal femur E
specialised trauma centres were set up to treat these
Epidemiology of adult fractures 695

Table 3 Numbers of fractures found in order of decreasing age in years, with prevalences in patients over 50, 65 and
75 years of age
Fracture n Average age >50 years (%) >65 (%) >75 (%)
Proximal femur 692 80.5 97.2 91.2 78.9
Pelvis 91 69.6 80.2 72.5 57.1
Femoral diaphysis 55 68.0 78.2 69.1 58.2
Proximal humerus 337 64.8 77.7 57.0 36.2
Distal femur 24 61.0 62.5 50.0 41.7
Sesamoid 1 58.0 100 0 0
Patella 57 56.5 68.4 49.1 22.8
Distal humerus 31 56.4 54.8 45.2 29.0
Distal radius 1044 55.5 62.5 45.8 28.2
Humeral diaphysis 69 54.8 66.6 40.5 17.4
Scapula 17 50.5 41.2 41.2 29.4
Proximal tibia 71 48.9 43.7 23.9 12.7
Ankle 539 45.9 42.3 20.8 10.2
Proximal forearm 297 45.7 39.4 24.2 13.5
Spine 40 43.5 35.0 17.5 12.5
Metatarsal 403 42.8 34.9 14.2 5.7
Calcaneus 73 40.4 28.8 12.3 4.1
Tibial diaphysis 115 40.0 26.9 17.4 11.3
Distal tibia 42 39.1 26.2 14.3 7.1
Clavicle 195 38.3 27.2 17.4 12.3
Finger phalanges 574 36.2 22.3 10.6 5.1
Midfoot 27 36.0 14.8 0 0
Toe phalanges 212 35.3 14.6 6.5 4.6
Forearm 74 34.6 24.3 13.5 12.2
Carpus 159 33.6 18.2 7.5 2.5
Talus 17 30.5 5.9 0 0
Metacarpals 697 29.9 9.2 5.5 3.6
Total 5953 49.1 46.2 33.0 22.6

patients. As much of the literature on fractures and
their management has come from these specialised
centres, the concentration has been on the treat-
ment of high-energy fractures in severely injured
people, and the significant changes in the epidemiol-
ogy of fractures that have occurred over the last few
decades have been appreciated only comparatively
recently. There is no doubt that the population is now
ageing quickly and, with dramatic improvements in
the diagnosis and medical care of patients, it seems
likely that the incidence of osteopenic or osteoporo-
tic fractures will increase, and most authorities now
agree that there will be a significant rise in the next
20—30 years.9 In the United States it has been esti-
mated that there are about 1.5 million osteoporotic
fractures each year13 and that about 10 million Amer-
icans have densitometrically diagnosed osteoporosis.
Currently the lifetime risk of an osteoporotic fracture
in women is between 40 and 50% and between 13 and
22% in men.7
Osteoporotic fractures
It seems clear that not only is the incidence of
osteoporotic fractures increasing quickly, but the
spectrum of fractures presenting in the older popu-
lation is changing. The traditional osteoporotic frac-
tures were fractures of the thoracolumbar
vertebrae, distal radius, proximal femur and prox-
imal humerus, but in recent years it has been sug-
gested that pelvic fractures10 and fractures around
the knee9 should also be considered to be osteo-
porotic. Indeed, Kanis et al.8 have suggested that
other femoral fractures, apart from those of the
proximal femur, should also be considered to be
osteoporotic, together with fractures of the ribs,
clavicle, scapula and sternum. They also suggested
that diaphyseal fractures of the tibia and fibula in
women were osteoporotic. These views are vindi-
cated by the review in Table 3, which shows the
fractures detailed in Table 1 in order of decreasing
age. It also shows the prevalences in patients over
50, 65 and 75 years of age.
Fig. 2 suggests that there are only two fracture
distribution curves where involvement of elderly
patients is unusual. These are type B and C curves,
and Table 2 shows that these occur mainly in frac-
tures of the hand and foot, although fractures of
both bones of the forearm and supra-syndesmotic
ankle fractures are also unusual in elderly patients.
696
All the other six distribution curves indicate involve-
ment of elderly women in types A, D, E, F, G and H and
of elderly men in types F, G and H. This argues that
there are considerably more osteoporotic fractures
than had been previously realised. It is accepted that
fractures of the thoracolumbar vertebrae, distal
radius, proximal femur and proximal humerus are
predominantly osteoporotic, but Tables 2 and 3 sup-
port the belief of Kanis et al.8 that many fractures
around the knee are also osteoporotic.
There has been discussion as to whether ankle
fractures are osteoporotic, but Table 2 reveals that,
overall, ankle fractures have a type A distribution.
However, it is inappropriate to combine all ankle
fractures together, as orthopaedic surgeons know
that different types of ankle fractures present in
different patients. Table 2 makes it clear that,
although in total ankle fractures have a type A dis-
tribution, only lateral malleolar fractures actually
have this distribution; medial malleolar fractures
have a type D distribution and supra-syndesmotic
fractures a type C distribution. Bi-malleolar and
tri-malleolar fractures are osteoporotic, both pre-
senting with a type E distribution. Table 2 shows that
fractures in other anatomical areas can also be sub-
divided. Overall, proximal forearm fractures have a
type D distribution but radial head and neck fractures
show type H and A distribution, respectively, whereas
fractures of the olecranon, proximal radius and prox-
imal ulna are osteoporotic with a type F distribution.
If we accept that distal radial fractures are pre-
dominantly osteoporotic, then an analysis of Table 3
shows that a number of other fractures must be
considered to be osteoporotic as well, as they have a
higher average age and a greater prevalence of
older patients than distal radial fractures. Combin-
ing the fractures that lie above the distal radius in
Table 3 with those fractures that have a type E or F
distribution in Table 2 will indicate which fractures
should now be considered to be osteoporotic. These
are shown in Table 4.
There are a number of surprising inclusions in
Table 4, including fractures of the distal humerus
and femoral diaphysis and multiple fractures. Many
surgeons working in level 1 trauma centres will be
Table 4 Fractures that should be regarded as predo-
minantly osteoporotic, in descending anatomical order
Proximal humerus Femoral diaphysis
Distal humerus Patella distal femur
Olecranon Bi-malleolar ankle
Proximal radius and ulna Tri-malleolar ankle
Distal radius Thoracolumbar vertebrae
Proximal femoral Pelvis
Sub-trochanteric Multiple fractures
C.M. Court-Brown, B. Caesar
used to treating these fractures in young patients
but, if the general community is examined, it is
apparent that the majority of these fractures actu-
ally occur in elderly people. We fully accept that
many multiple injuries occur in younger people after
high-energy trauma, but a considerable number of
older people present with a combination of proximal
femoral and distal radial fractures or other fracture
combinations. For the purposes of analysis we have
excluded multiple metacarpal, metatarsal, phalan-
geal or vertebral fractures, but the multiple fracture
group has a type E distribution, an average age of 66.8
years and 66% of patients older than 65 years of age.
Many surgeons will also feel that femoral diaphy-
seal fractures are common in younger patients and
usually follow high-energy injuries. This was
undoubtedly true, and it was the femoral diaphyseal
fracture that mainly stimulated the change to
operative fracture surgery in the 1970s and the
1980s. However, in recent years in many countries
there has been a decline in the incidence of femoral
diaphyseal fractures in young adults because of
tougher drink driving laws, improved car safety
and speed restrictions. At the same time, the inci-
dence of peri-prosthetic fractures, metastatic frac-
tures and insufficiency fractures of the femur in the
elderly has increased considerably. It is interesting
to note that the average age of femoral diaphyseal
fractures in the Edinburgh Orthopaedic Trauma Unit
in 1990 was 44 years, compared with 68 years in the
year 2000. The femoral diaphyseal fractures
detailed in Table 3 include sub-trochanteric frac-
tures but, if these are excluded, the average age of
patients with diaphyseal fractures is still 62.4 years.
The increase in osteoporotic fractures is high-
lighted by the fact that the fractures listed in
Table 4 account for 42.4% of the fractures treated
in 2000. It is obvious that there are yet more osteo-
porotic fractures, as types A, D. G and H all show
increased incidence in older men and women. Kanis
et al.8 have defined osteoporotic fractures as those
that occur at a site of low bone density and where
there is an increased incidence of fracture over the
age of 50 years. If we accept that older people with
types A, D, G and H fractures are osteoporotic, then
we must examine fractures of the clavicle, scapula,
humeral diaphysis, radial head and neck, forearm
diaphysis, tibial plateau, tibial diaphysis, tibial pla-
fond, medial and lateral malleoli, calcaneus and
cervical vertebrae in more detail. If we take an
arbitrary age limit of 50 years and assume that, above
this age, fractures are potentially associated with
osteoporosis, then another 9.7% of fractures are
implicated. It would therefore seem that, overall,
about 52% of fractures should be considered to be
potentially osteoporotic. Using these criteria, analy-
Epidemiology of adult fractures
sis of our data shows that 30.1% of fractures in men
are potentially osteoporotic compared with 66.3% of
fractures in women. In addition, 34.7% of outpatient
and 70.4% of inpatient fractures are potentially
osteoporotic.
It is interesting to compare the epidemiology of
fractures in 2000 with the study of Buhr and Cooke in
1959.1 They pointed out that at that time smallpox,
diphtheria, enteric fevers and rickets had virtually
been eliminated but that, in the elderly, cardiovas-
cular disease, strokes, diabetes, osteoarthritis and
fractures had taken their place. They analysed frac-
tures around Oxford, UK, between 1953 and 1957 and
found that there were six different basic fracture
distribution curves which correspond to our type A, B,
C, D, F and H curves. They did not find any fractures
that showed a type E or G distribution. They analysed
22 different fractures and, although a number of
fractures such as those of the hand, foot, distal radius
and proximal femur showed a similar distribution to
those plotted in 2000, other fractures clearly showed
a different distribution. In the 1950s fractures of the
clavicle, tibial diaphysis and distal humerus had a
type C distribution, being designated ‘‘pre-wage-
earning fractures’’. Buhr and Cooke recognised that
proximal humeral fractures, humeral diaphyseal
fractures, proximal femoral fractures, bi-malleolar
ankle fractures and pelvic fractures were osteoporo-
tic and had a type F distribution. However, they found
that medial malleolar fractures had a type B distribu-
tion, affecting wage-earning men.
We believe that the fact that Buhr and Cooke found
no fractures which showed a type E or G distribution
indicates two things. First, it indicates the significant
rise in osteoporotic fractures in elderly women in the
last few decades and, secondly, it suggests that older
people are now much more active than in previous
generations. Type G fractures involve the clavicle and
calcaneus and tend to be activity related. It is the
increased activity of older people that has caused
some fractures that had a type C distribution in the
1950s to now have a type G curve. This is also true of
fractures of the tibial diaphysis, distal humerus and
medial malleolus, which predominantly involved
young people in the 1950s. Increased activity and
longevity have converted these fractures from types
C, C and B to types A, E and D, respectively.
Conclusions
Our results show that the epidemiology of fractures
is changing quickly. Improved social conditions and
697
medical treatment have led to an increasingly aged
population with an increasing number of fractures in
both men and women. It seems likely that this trend
will continue, that there will be further changes in
fracture epidemiology and that some of the other
fractures listed in Table 3 will soon have to be
regarded as osteoporotic. We believe that this par-
ticularly applies to humeral diaphyseal and proximal
tibial fractures. However, Table 4 shows that many
of the common fractures should already be regarded
as osteoporotic. This clearly has significant implica-
tions for the detection, prevention and treatment of
osteoporosis and the prevention and treatment of
osteoporotic fractures.
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