Bone 44 (2009) 656–659

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Bone
j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / b o n e

Rate of proximal humeral fractures in older Finnish women between 1970 and 2007
Pekka Kannus a,b,c,⁎, Mika Palvanen a, Seppo Niemi a, Harri Sievänen a, Jari Parkkari d
a
Injury and Osteoporosis Research Center, UKK Institute for Health Promotion Research, Tampere, Finland
b
Medical School, University of Tampere, Tampere, Finland
c
Division of Orthopaedics and Traumatology, Department of Trauma, Musculoskeletal Surgery and Rehabilitation, Tampere University Hospital, Tampere, Finland
d
Tampere Research Center of Sports Medicine, 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

Article history: Low-trauma fractures of older women are a major public health problem. Nevertheless, nationwide
Received 13 November 2008 information on recent trends of proximal humeral fractures is sparse.
Revised 4 December 2008 We assessed the current trend in the number and rate (per 100,000 persons) of low-trauma fractures of the
Accepted 5 December 2008
proximal humerus among 80-year-old or older women in Finland, a European Union country with a well-
Available online 24 December 2008
defined white population of 5.3 million, by taking into account all women who were admitted to our
Edited by: T. Einhorn hospitals for primary treatment of such fracture in 1970–2007.
The number of low-trauma fractures of the proximal humerus among 80-year-old or older Finnish women
Keywords: rose continuously between 1970 (32 fractures) and 2007 (478 fractures), but because of a simultaneous,
Proximal humeral fracture sharper rise in population at risk, the age-adjusted fracture rate (showing a clear rise from 88 fractures per
Older women 100,000 persons in 1970 to 304 fractures in 1995) became stabilized between 1995 and 2007 (298 fractures
Secular trends per 100,000 persons in 2007).
Finland In conclusion, the clear rise in the rate of low-trauma fractures of the proximal humerus in Finnish elderly
Falling
women from early 1970s until mid 1990s has been followed by stabilized fracture rates. Reasons for this are
largely unknown, but a cohort effect toward a healthier aging population with improved functional ability
and reduced risk of injurious falls cannot be ruled out.
© 2009 Elsevier Inc. All rights reserved.

Introduction
Proximal humeral fractures are the third most frequent fracture in
elderly people after hip fracture and distal forearm fracture [1,2]. More
than 70% of patients with a proximal humeral fracture are older than
60 years, about 75% are women, and from 40 years of age the incidence
of fracture begins to increase exponentially [1,3–5].
Treatment of proximal humeral fractures is demanding, time
consuming, and expensive [1–9]. Therefore, exact knowledge on
fracture epidemiology is essential for planning prevention methods
and projecting the number of future fractures. However, epidemiolo-
gic information on proximal humeral fractures is scarce, especially
concerning their recent secular trends [1,6,10–12].
Previously we reported that the number and age-adjusted
incidence of proximal humeral fracture among Finnish persons
60 years of age or older clearly increased from the early 1970s to the
late 1990s [13,14]. We have now been able to follow the highest risk
group of fracture, women 80 years of age or older, to the end of 2007 to
⁎ Corresponding author. Injury and Osteoporosis Research Center, UKK Institute, P.O.
Box 30, FIN-33501 Tampere, Finland. Fax: +358 3 2829 200.
E-mail address: Pekka.Kannus@uta.fi (P. Kannus).
see the fracture development in the new millennium. In other words,
our aim was to assess the most recent secular trends of proximal
humeral fractures among elderly Finnish women.
Materials and methods
In accord with other epidemiologic studies [1,10,14–16], we
defined a low-trauma fracture of the proximal humerus as a fracture
occurring as a consequence of low or moderate energy trauma
(typically a fall from standing height or less) and collected from the
National Hospital Discharge Register (NHDR) all Finnish women
80 years and older who were admitted to our hospitals from 1970 to
2007 for primary treatment of such fracture. Traffic accidents and
other high energy trauma were excluded. During the entire study
period of 38 years, all Finnish hospitals treating fracture patients were
included in the NHDR system, the annual number of hospitals ranging
from 246 to 378.
The Finnish NHDR (established in 1967) is the oldest nationwide
discharge register in the world, and the data provided are well
suited for epidemiologic analyses. This register is well validated
covering the acute injuries in the population adequately (annual
coverage of injuries are ≥90%) and recording them accurately
(annual accuracy of injury diagnoses are also ≥90%). This concerns

8756-3282/$ – see front matter © 2009 Elsevier Inc. All rights reserved.
doi:10.1016/j.bone.2008.12.007
 P. Kannus et al. / Bone 44 (2009) 656–659 657

especially severe injuries with clear-cut diagnoses, such as bone

fractures [17–21].
Fractures were recorded by evaluating primary and secondary
diagnoses. According to the directives from the Finnish National Board
of Health, the first diagnosis describes the main reason for the hospital
stay. The second, third, and fourth diagnoses indicate other possible
diseases or injuries.
The diagnoses were labeled with a 5-digit code according to the
eighth, ninth, and tenth revisions of the International Classification of
Diseases (ICD) that indicated the type of fracture. From 1970 to 1986,
we used the eighth revision of ICD and its two code classes for
fractures of the proximal humerus (81200 and 81210). From 1987 to
1995, the ICD-9 code classes were 8120A and 8121A, and from 1996 to
2007, the ICD-10 code class was S42.2.
In each study year, the study consisted of the entire Finnish
population (5.3 million people in 2007). Thus, the given absolute
numbers and incidence rates of proximal humeral fractures among
80-year-old or older women were not cohort-based estimates but
final results in the respective total population. Therefore, this study,
similar to our previous epidemiologic investigations [13,14,22], did
not use statistical analyses with probability values and confidence
intervals characteristically needed in cohort or sample-based
estimations.
The annual midyear population figures for each 5-year age group
in 1970–2007 were taken from the Official Statistics of Finland [23]. In
this statutory, computer-based register, every Finn is registered by his
or her personal identification number. The register is quality
controlled continuously and updated by Statistics Finland, the Central
Statistical Office of Finland.
Fracture incidence rates were expressed as the number of cases per
100,000 80-year-old or older women per year. In calculating the age-
adjusted fracture incidence, age adjustment was done by direct
standardization using the mean population from 1970 to 2007 as the
standard population.
The age-specific fracture incidence rates observed in 3 different
age groups over the study period (80–84, 85–89, and 90–) were used
to predict the age-specific incidence rates and absolute number of
proximal humeral fractures in this elderly female population in the
years 2010, 2020, and 2030. The prediction was based on a linear trend
continuation method using ordinary least squares regression and r2
and standard error of estimate (SEE) as descriptors of the fit of the
regression line to the data. The regression lines were first calculated
for each age group and were then used to determine the predicted
age-specific fracture incidence rates until the year 2030. Within each
age group, the predicted absolute number of fractures was then
obtained by multiplying the incidence by the estimate of the number
of inhabitants [24].

Results

The annual total number of Finnish 80-year-old or older women

with a low-trauma proximal humeral fracture rose sharply and
steadily during the study period, from 32 in 1970 to 478 in 2007
(Fig. 1A). During 1970-1995, the age-adjusted incidence of these
fractures also rose (from 88 fractures per 100,000 women in 1970 to
304 fractures per 100,000 women in 1995), but thereafter, the fracture
incidence remained rather stable (298 fractures per 100,000 women
in 2007) (Fig. 1B).
If the age-adjusted or age-specific incidence of low-trauma
fractures of the proximal humerus continues to rise at the average
rate observed in 1970–2007 and the size of the 80-year-old or older
female population of Finland increases as predicted (from 0.16 million
in 2007 to 0.30 million in 2030) [24], the number of fractures in this
population will be over three-fold higher in 2030 (1540 fractures) than Fig. 1. The number (A) and age-adjusted incidence (per 100,000 individuals) (B) of
in 2007 (478 fractures) (Fig. 2, curve A). If, however, the incidence proximal humeral fractures in women 80 years of age or older in Finland from 1970 to
rates of fractures were to become stabilized to the 2007 level, the 2007. For comparison, the growth of this population is also demonstrated (C).
658 P. Kannus et al. / Bone 44 (2009) 656–659
Fig. 2. Prediction of the number of proximal humeral fractures in women 80 years of age
or older in Finland until the year 2030, as calculated using a regression model. The
upper curve (A) denotes to a fracture development-model in which the age-adjusted
incidence of fracture continues to rise at the average rate observed in 1970–2007, while
the lower curve (B) to a model in which the incidence becomes stabilized to the 2007
level. The size of the 80-year-old or older female population is predicted to increase
from 0.16 million in 2007 to 0.30 million in 2030.
number of these fractures in Finland would be no more than 920 in
2030 (Fig. 2, curve B).
Discussion
Fractures among elderly people are a worldwide epidemic and
increasingly tighter control of the limited healthcare resources makes
it necessary to predict any fracture change with time
[1,3,4,6,7,12,14,15,25]. Specifically, such a prediction requires knowl-
edge of whether the number of fractures is increasing more rapidly
than can be accounted for by the demographic changes alone. An
understanding of the underlying epidemiologic changes in the
numbers of patients and population also permits assessment of the
efficacy of preventive measures.
We used the Finnish female population 80 years of age and older to
analyze the time trends for the absolute number and incidence of low-
trauma proximal humeral fractures from 1970 to 2007. The results
showed that the long-term rise in the age-adjusted incidence of these
fractures from the early 1970s till the mid part of the 1990s has been
now followed by stabilized fracture rates. In other words, our country
has now faced a clear break in the secular trend of elderly women's
low-trauma fractures of the proximal humerus.
Our humerus fracture statistics, which are the very first full-scale
nationwide data available from 1970 to 2007, are in line with recent
reports on hip, knee and ankle fractures in Finland and elsewhere: the
rates of these fractures have also stabilized or even started to decline
during the recent decade [26–35].
The exact reasons for the secular change in the risk of low-trauma
fractures of elderly people are not known. As speculated previously
[32,34,35], a cohort effect towards healthier elderly populations in
contemporary societies cannot be ruled out: in earlier birth cohorts,
the early-life risk factors for fracture, such as perinatal nutrition, may
have had stronger impact on the late-life fracture risk than in the
others [36]. A second reason could be the improved functional ability
in the elderly populations in the 1990s [37]. Poor neuromuscular
function is a strong risk factor for humeral and other fractures and any
improvement in this predictor, with concomitantly reduced risk for
balance loss, slipping, tripping and fall, is likely to reduce the risk of
fracture [38–44].
A third explanation for stabilizing fracture rates could basically
arise from efforts of recent programs and interventions to prevent
falling and minimize fall severity (strength and balance training,
vitamin D and calcium supplementation, reduction in psychotropic
medication, correction of visual impairment, modification of environ-
mental hazards, and use of hip protectors and gait-stabilizing devices)
[32,38,44]. However, care must be taken when considering these
factors as potential explanation, because there are neither clear signs
nor good evidence for their beneficial secular change in Finland, or the
factor was so uncommon in our elderly population in 1990s that its
role must have been minor in explaining the stabilized fracture
incidence [32].
Finally, the secular change in fracture risk could be explained by
enhanced bone health. In other words, specific actions to prevent and
treat osteoporosis (nonsmoking campaigns, exercise, calcium, vitamin
D, hormone replacement therapy, and bone-specific drugs) may have
started to improve bone mass and strength during the decade of the
1990s. However, the same limitations apply here as noted above for
falling and its potential modifiers [32].
Only the coming years will show whether the above noted
favorable trend in the incidence of low-trauma fractures of the
proximal humerus continues. However, as calculated above, because
the rapid and continuous rise in our aging female population is likely
to increase the absolute number of these fractures in Finland in the
future, intervention studies on potentially cost-effective fracture-
preventing measures, such as prevention of slippings, trippings, and
falls, and use of gait-stabilizing, antislip devices and injury-site
protection, should be urgently initiated.
Conflicts of interest
The authors have no conflicts of interest.
Acknowledgments
The authors thank the Finnish Ministry of Social Affairs and Health
for cooperation and help in conducting the study. The study was
funded by the Competitive Research Funding of the Pirkanmaa
Hospital District, Tampere, Finland and the Finnish Ministry of Social
Affairs and Health, Helsinki, Finland.
References
[1] Lauritzen JB, Schwarz P, Lund B, et al. Changing incidence and residual lifetime risk
of common osteoporosis-related fractures. Osteoporos Int 1993;3:127–32.
[2] Seeley DJ, Browner WS, Genant HK, et al. Which fractures are associated with low
appendicular bone mass in elderly women? Ann Intern Med 1991;115:837–42.
[3] Kristiansen B, Barfod G, Bredesen J, et al. Epidemiology of proximal humeral
fractures. Acta Orthop Scand 1987;58:75–7.
[4] Lind T, Krøner K, Jensen J. The epidemiology of fractures of the proximal humerus.
Arch Orthop Trauma Surg 1989;108:285–7.
[5] Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury
2006;37:691–7.
[6] Bengnér U, Johnell O, Redlund-Johnell I. Changes in the incidence of fracture of the
upper end of the humerus during a 30-year period: a study of 2125 fractures. Clin
Orthop 1988;231:179–82.
[7] Horak J, Nilsson BE. Epidemiology of fracture of the upper end of the humerus. Clin
Orthop 1975;112:250–3.
[8] Kelsey JL, Browner WS, Seeley DG, Nevitt MC, Cummings SR. Risk factors for
fractures of the distal forearm and proximal humerus. Am J Epidemiol
1992;135:477–89.
[9] Rose SH, Melton LJ, Morrey BF, Ilstrup DM, Riggs BL. Epidemiological features of
humeral fractures. Clin Orthop 1982;168:24–30.
[10] Cummings SR, Kelsey JL, Nevitt MC, O'Dowd KJ. Epidemiology of osteoporosis and
osteoporotic fractures. Epidemiol Rev 1985;7:178–208.
[11] Hagino H, Yamamoto K, Ohshiro H, et al. Changing incidence of hip, distal radius,
and proximal humerus fractures in Tottori Prefecture, Japan. Bone 1999;24:265–70.
[12] Obrant KJ, Bengnér U, Johnell O, Nilsson BE, Sernbo I. Increasing age-adjusted risk
of fragility fractures: a sign of increasing osteoporosis in successive generations?
Calcif Tissue Int 1989;44:157–67.
 P. Kannus et al. / Bone 44 (2009) 656–659
[13] Kannus P, Palvanen M, Niemi S, et al. Osteoporotic fractures of the proximal
humerus in elderly Finnish persons. Acta Orthop Scand 2000;71:465–70.
[14] Palvanen M, Kannus P, Niemi S, Parkkari J. Update in the epidemiology of proximal
humeral fractures. Clin Orthop 2006;442:87–92.
[15] Jones G, Nguyen T, Sambrook PN, et al. Symptomatic fracture incidence in
elderly men and women: the Dubbo osteoporosis epidemiologic study (DOES).
Osteoporos Int 1994;4:277–82.
[16] Palvanen M, Kannus P, Parkkari J, et al. The injury mechanisms of osteoporotic
upper extremity fractures among older adults: a controlled study of 287
consecutive patients and their 108 controls. Osteoporos Int 2000;11:822–31.
[17] Keskimäki I, Aro S. Accuracy of data on diagnosis, procedures and accidents in the
Finnish hospital discharge register. Int J Health Sci 1991;2:15–21.
[18] Lüthje P, Nurmi I, Kataja M, et al. Incidence of pelvic fractures in Finland in 1988.
Acta Orthop Scand 1995;66:245–8.
[19] Salmela R, Koistinen V. Coverage and accuracy of the Hospital Discharge Register.
[Finnish]Hospital 1987;49:480–2.
[20] Sund R, Nurmi-Luthje I, Luthje P, Tanninen S, Narinen A, Keskimäki I. Comparing
properties of audit data and routinely collected register data in case of
performance assessment of hip fracture treatment in Finland. Methods Inf Med
2007;46:558–66.
[21] Mattila V, Sillanpää P, Iivonen T, Parkkari J, Kannus P, Pihlajamäki H. Coverage and
accuracy of diagnosis of serious knee injury in a Finnish National Hospital
Discharge Register. Injury 2008 Aug. 12, Epub ahead of print.
[22] Kannus P, Parkkari J, Koskinen S, et al. Fall-induced injuries and deaths among
older adults. JAMA 1999;281:1895–9.
[23] Official Statistics of Finland. Population structure 1970–2007. Helsinki, Finland:
Statistics Finland; 2008.
[24] Official Statistics of Finland. Population projection by municipalities 2008–2030.
Helsinki, Finland: Statistics Finland; 2008.
[25] Melton III LJ. Epidemiology of hip fractures: implications of the exponential
increase with age. Bone 1996;18:S121–5.
[26] Rogmark C, Sernbo I, Johnell O, Nilsson JÅ. Incidence of hip fractures in Malmö,
Sweden, 1992–1995. A trend-break. Acta Orthop Scand 1999;70:19–22.
[27] Lofthus CM, Osnes EK, Falch JA, et al. Epidemiology of hip fractures in Oslo,
Norway. Bone 2001;29:413–8.
[28] Finsen V, Johnsen LG, Trano G, Hansen B, Sneve KS. Hip fracture incidence in cenral
Norway: a followup study. Clin Orthop 2004;419:173–8.
659
[29] Rosengren BE, Ahlborg HG, Karlsson MK, Mellström D. Secular trends in Swedish
hip fracture incidence 1987–2002. J Bone Miner Res 2008;23:S47.
[30] Giversen IM. Time trends of age-adjusted incidence rates of first hip fractures: a
register-based study among older people in Viborg County, Denmark, 1987–1997.
Osteoporos Int 2006;17:552–64.
[31] Nymark T, Lauritsen JM, Ovesen O, Röck ND, Jeune B. Decreasing incidence of hip
fracture in the Funen County, Denmark. Acta Orthop Scand 2006;77:109–13.
[32] Kannus P, Niemi S, Parkkari J, Palvanen M, Vuori I, Jarvinen M. Nationwide decline
in incidence of hip fracture. J Bone Miner Res 2006;21:1836–8.
[33] Jaglal S. Letter to the editor. Falling hip fracture rates. J Bone Miner Res
2007;22:1098.
[34] Kannus P, Palvanen M, Niemi S, Parkkari J, Järvinen M. Stabilizing incidence of low-
trauma ankle fractures in elderly people. Bone 2008;43:340–2.
[35] Kannus P, Niemi S, Parkkari J, Sievänen H, Palvanen M. Declining incidence of low-
trauma knee fractures in elderly women. Osteoporos Int 2008 May 14, Epub ahead
of print.
[36] Cummings SR, Melton III LJ. Epidemiology and outcomes of osteoporotic fractures.
Lancet 2002;359:1761–7.
[37] Sulander TT, Rahkonen OJ, Uutela AK. Functional ability in the elderly Finnish
population: time period differences and associations, 1985–1999. Scand J Public
Health 2003;31:100–6.
[38] Kannus P, Sievänen H, Palvanen M, Järvinen T, Parkkari J. Prevention of falls and
consequent injuries in elderly people. Lancet 2005;366:1885–993.
[39] Guggenbuhl P, Meadeb J, Chales G. Osteoporotic fractures of the proximal
humerus, pelvis and ankle: epidemiology and diagnosis. J Bone Spine
2005;72:372–5.
[40] Delmas PD, Marin F, Marcus R, Misurski DA, Mitlak BH. Beyond hip: importance of
other nonspinal fractures. Am J Med 2007;120:381–7.
[41] Seeley DG, Kelsey J, Jergas M, Nevitt MC, for the Study of Osteoporotic Fractures
Research Group. Predictors of ankle and foot fractures in older women. J Bone
Miner Res 1996;11:1347–55.
[42] Hasselman CT, Vogt MT, Stone KL, Cauley JA, Conti SF. Foot and ankle fractures in
elderly white women. Incidence and risk factors. J Bone Joint Surg 2003;85-A:820–4.
[43] Cummings SR, Nevitt MC, Browner WS, et al. Risk factors for hip fracture in white
women. N Engl J Med 1995;332:767–73.
[44] Järvinen TLN, Sievänen H, Khan KM, Heinonen A, Kannus P. Shifting the focus in
fracture prevention from osteoporosis to falls. BMJ 2008;336:124–6.