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Fragility fractures in fragile people: epidemiology of the age quake
Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences, Orthopaedics.
2009 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Osteoporosis-related fracture is already today a major public health problem and the number of hip fractures is expected to double to 2030. Sweden has one of the highest hip fracture incidences worldwide. This may be explained by several factors: e.g. age, genetic, climatologic, geographic and a relative vitamin D deficiency, secondary to the limited sunlight exposure especially during winter months. Intrinsic and extrinsic factors contribute to a fracture, although a prior low energy fracture is one of the strongest predictors for a subsequent one and this should be a target for secondary fracture prevention in an orthopaedic setting.

Since 1993 all injured patients admitted to the emergency floor and all in-hospital fractures at Umeå University Hospital, Sweden, were registered according to the Injury Data Base, former EHLASS. There were 31,173 fracture events (one or more fractures at the same time), of which 13,931 were in patients’ ≥ 50 years old. The fracture database was co analyzed with the Northern Sweden Health and Disease Study cohort in a nested case-control study for investigations of associations between osteoporotic fracture and serum markers, lifestyle data, nutrition etc. We found that there were differences in fracture pattern depending on age and sex. Both injury mechanism and fracture site were strongly dependent of age. The most severe fragility fracture, hip fracture, had a decreasing incidence. However, the incidence curve was right-shifting leading to an increase, both in numbers and in incidence of hip fractures among the oldest female. To identify people at high risk for fractures, re-fracture patients are useful. No less than 21% of the fracture patients had suffered more than one fracture event, accounting for 38% of all fracture events. The total risk ratio for a subsequent fracture was 2.2 (2.1-2.3 95% CI). In males the highest risk for re fracture was in the age cohort 70-79 years (RR 2.7, 2.3-3.2 95% CI), in females > 90 years (RR 3.9, 3.2-4.8 95% CI). Another possible risk factor in this subarctic population is the lack of sunlight, leading to a vitamin D deficit. The overall adjusted risk of sustaining a hip fracture in this population was 2.7 (95%CI:1.3-5.4) in subjects with a serum 25 hydroxyvitamin D below 50 nmol/l. The association was, however, different according to age at baseline. Thus in subjects aged 60 years and above at baseline, the adjusted odds ratio of sustaining a hip fracture was 6.2 (1.2-32.5 95%CI) for the group of individuals with a serum 25OHD below 50 nmol/l, whereas no significant association was found in the youngest age group.

In the next 30 years the ongoing demographic changes will accelerate. The World War II baby boomers will cause an age quake. We can already see signs heralding a new fracture pattern: an increasing cohort of mobile but fragile elderly, with considerable co-morbidity is now at risk for fragility fractures. In fracture patients, clinical information is sufficient to pinpoint patients with a high risk for re-fractures. It is therefore clinically important to use the information provided by the fracture event. We suggest that trauma units and primary care units should screen for risk factors and inform patients about the treatment options, and to organize fracture liaison services. This seems to be especially cost-efficient for our oldest and frailest patients. Secondary prophylaxis and follow-up treatment after cardiovascular disorders are now a matter of course worldwide, but the screening for risk factors, in order to prevent a second fracture, is often neglected. This is one of the most important issues of fracture care in the future in order to improve general health.

Place, publisher, year, edition, pages
Umeå: Institutionen för kirurgi och perioperativ vetenskap , 2009. , 54 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1249
Keyword [en]
Fragility, fractures, elderly, epidemiology, age quake, population based, Vitamin D.
National Category
Surgery
Research subject
Orthopaedics
Identifiers
URN: urn:nbn:se:umu:diva-22729ISBN: 978-91-7264-739-8 (print)OAI: oai:DiVA.org:umu-22729DiVA: diva2:217871
Distributor:
Ortopedi, 901 87, Umeå
Public defence
2009-06-12, Sal B 9tr, Tandläkarhögskolan, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2009-05-19 Created: 2009-05-17 Last updated: 2010-01-18Bibliographically approved
List of papers
1. Fracture mechanisms and fracture pattern in men and women aged 50 years and older: a study of a 12-year population-based injury register, Umeå, Sweden
Open this publication in new window or tab >>Fracture mechanisms and fracture pattern in men and women aged 50 years and older: a study of a 12-year population-based injury register, Umeå, Sweden
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2008 (English)In: Osteoporosis International, ISSN 0937-941X, E-ISSN 1433-2965, Vol. 19, no 9, 1267-1273 p.Article in journal (Refereed) Published
Abstract [en]

Summary: In a study of a 12-year population-based injury register, Umeå, Sweden, we analyzed the fracture mechanisms and fracture pattern in men and women 50 years and older. Low-energy trauma was responsible for the major and costliest part of the fracture panorama, but the pattern differs between age groups.

Introduction: Osteoporosis-related fracture is a major health problem: the number of hip fractures is expected to double to 2030. While osteoporosis is one of many risk factors, trauma is almost always involved. Therefore, we analyzed injury mechanisms in patients aged over 50.

Methods: We registered injury mechanism, cause, diagnosis in all trauma patients at Umeå University hospital, Sweden. This population-based register (1993–2004) comprises a total of 113,668 injuries (29,189 fractures). Patients ≥50 years contributed to 13,279 fractures.

Results: Low-energy trauma (fall <1 m) caused 53% of all fractures ≥50 years and older. In those over 75 low-energy trauma caused >80%. The seasonal variation of fractures was maximally 25%. With increasing age, proximal fractures became more common, in both upper and lower extremities. Proximal locations predominate in older age groups.

Conclusions: Low-energy trauma was responsible for the largest and costliest part of the fracture panorama. In fact, almost all fractures in middle-aged and old people were caused by low-energy mechanisms; thus, most fractures in these patients have a fragility component, and the contribution of osteoporosis-related fractures is more important than previously thought. A better understanding of injury mechanisms also in low-energy trauma is a prerequisite for preventive interventions.

Place, publisher, year, edition, pages
London: Springer International, 2008
Keyword
Epidemiology, Fracture, Mechanisms, Osteoporosis, Population-based
Identifiers
urn:nbn:se:umu:diva-20895 (URN)10.1007/s00198-007-0549-z (DOI)
Available from: 2009-03-27 Created: 2009-03-27 Last updated: 2011-08-24Bibliographically approved
2. The hip fracture incidence curve is shifting to the right: a forecast of the age-quake
Open this publication in new window or tab >>The hip fracture incidence curve is shifting to the right: a forecast of the age-quake
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2009 (English)In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 80, no 5, 520-524 p.Article in journal (Refereed) Published
Abstract [en]

Background The number of hip fractures has doubled in the last 30–40 years in many countries. Age-adjusted incidence has been reported to be decreasing in Europe and North America, but is there a decreasing trend in all age groups? Patients and methods This population-based study included all hip-fracture patients over 50 years of age (a total of 2,919 individuals, 31% of whom were men) admitted to Umeå University Hospital, Sweden, from 1993 through 2005. Results The incidence of hip fracture declined between the periods 1993–1996 and 2001–2005: from 706 to 625 hip fractures per 105 women and from 390 to 317 hip fractures per 105 men. However, there was a 114% increase in the number of fractures in women aged 90 or older (12 and 25 hip fractures/year, respectively, in the two time periods). For the period 2001–05, women ≥ 90 years of age accounted for almost the same numbers of hip fractures as women aged 75–79 (27 fractures/year). The rate increased during this period, from 2,700 per 105 women to 3,900 per 105 women > 90 years. In men there were declining trends for both relative and absolute numbers. Interpretation Although age-adjusted incidence declined in the population > 50 years of age, absolute fracture rate and incidence increased in the very old. Women over 90 now have the same absolute number of hip fractures every year as women aged 75–79 years. There was a right-shift in hip fracture distribution towards the oldest old, probably due to an increased number of octo/nonagenarians, a new population of particularly frail old people that hardly existed earlier. Better health among septuagenarians may also have delayed the age at which fractures occurred. This changing pattern will strain orthopedic and geriatric resources even more.

Keyword
age Factors, aged, aged, 80 and over, female, hip fractures/epidemiology, humans, incidence, male, middle aged, registries, Sweden/epidemiology
Identifiers
urn:nbn:se:umu:diva-22883 (URN)10.3109/17453670903278282 (DOI)19916682 (PubMedID)
Note
Vid publiceringen av doktorsavhandlingen med titeln: Hip fracture incidence curve is right-shifting - drastic increase in hip fractures among the oldest old: a forecast of the age quake. Available from: 2009-05-19 Created: 2009-05-19 Last updated: 2011-08-24Bibliographically approved
3. Serial fractures - age and fracture site important predictors for a second fracture: results from 13-years population based data
Open this publication in new window or tab >>Serial fractures - age and fracture site important predictors for a second fracture: results from 13-years population based data
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(English)Manuscript (Other academic)
National Category
Geriatrics
Identifiers
urn:nbn:se:umu:diva-22885 (URN)
Available from: 2009-05-19 Created: 2009-05-19 Last updated: 2013-09-04Bibliographically approved
4. Vitamin-D levels and risk for hip fractures in northern Sweden: the UFO study
Open this publication in new window or tab >>Vitamin-D levels and risk for hip fractures in northern Sweden: the UFO study
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(English)Manuscript (Other academic)
Identifiers
urn:nbn:se:umu:diva-22886 (URN)
Available from: 2009-05-19 Created: 2009-05-19 Last updated: 2010-01-14

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