Abstract
Background
Detailed analyses of epidemiological data on fractures are an important resource for persons and institutions providing health care services, as they yield information on the effects of current treatment strategies and on the need for preventive measures. The epidemiology of fractures in Germany, however, is unknown. The goal of this study is to determine the nationwide fracture burden from 2009 through 2019, as a function of anatomical site, age, and sex.
Methods
Annual compilations of ICD-10 diagnosis codes for the years 2009–2019 were made available to us by the German Federal Statistical Office. The prevalence and incidence of fractures at 30 different sites were quantified, and standardized sex and age distributions were calculated.
Results
A total of 688 403 fractures was registered in 2019. From 2009 to 2019, the incidence of fractures rose by 14%, to 1014 fractures per 100 000 persons per year. The most common fracture types were femoral neck fractures (120 per 100 000 persons per year), pertrochanteric femoral fractures (109 per 100 000 persons per year), and distal radius fractures (106 per 100 000 persons per year). All types were more common in women, with incidences that rose with age. The highest incidence was of pertrochanteric femoral fractures in women over age 90, with an incidence of 2550 per 100 000 persons per year. The largest rises in incidence were seen with regard to acetabular fractures (+ 58%) and clavicular fractures (+ 44%).
Conclusion
The increasing frequency of fractures, particularly among the elderly, presents a challenge to the health care system. Given the high frequency of geriatric fractures, prophylactic measures against fractures ought to be intensified.
Fracture healing can be a complex and lengthy process, causing a high level of stress for patients. With a lifetime prevalence of 44% in adults aged 55 years or older, fractures remain a major public health problem, with the likelihood of osteoporotic fractures increasing sharply with age (1, 2).
Various treatment strategies have been developed, ranging from conservative management with plaster immobilization to surgical measures such as external fixation, intramedullary nailing or plate fixation. Apart from the stress associated with treatment, which often involves surgery, stays in hospital, and rehabilitation programs, complications can also be particularly challenging for patients. In 5–10% of cases, for example, bone consolidation is impaired, which can lead to nonunion with adverse effects on physical and mental health (3, 4).
In addition, infections occur after fracture fixation at rates of 1–2% in closed fractures and up to 30% in Gustilo-Anderson type III open tibial fractures, which can result in loss of function or even amputation in otherwise healthy patients (5, 6).
With increasing life expectancy of the general population, the incidence of fractures of the long bones is expected to increase, especially in the elderly (7). Demographic changes affect the occurrence of osteoporotic fractures, which are reported to be on the increase (8).
However, current knowledge of the epidemiology of fractures is largely limited to specific anatomical sites (9, 10) or based on relatively small populations of no more than 6000 patients (11, 12). Detailed analysis of epidemiological data is a valuable resource for protagonists in the healthcare system. It provides insights into the impact of current osteoporosis therapy and can support the effectiveness evaluation of prevention strategies. In addition, epidemiological data are of value in assessing the urgency of implementing fall prevention programs (13), in calculating fracture-related costs, and in developing and updating fracture risk assessment tools (14).
The aim of this study was to identify trends in the nationwide fracture burden in relation to age, sex, and anatomical site for Germany between 2009 and 2019.
Methods
The data, comprising annual ICD-10 diagnosis codes from 2009 to 2019 obtained from all German medical institutions, were provided by the Federal Statistical Office (Destatis). The dataset contains only inpatient cases. Patients who presented more than once with the same diagnosis are recorded as one case, so the data do not contain any duplicates.
The total number of fractures was quantified using the ICD-10 codes “S32.1–S92.3” (etable 1) and analyzed according to anatomical site, sex, and age in 10-year increments for patients older than 20 years from 2009 to 2019.
eTABLE 1. ICD-10 codes used and description.
| ICD-10 Code | Description |
| S12.0 | Fracture of first cervical vertebra |
| S12.1 | Fracture of second cervical vertebra |
| S12.2 | Fracture of other specified cervical vertebra |
| S22.0 | Fracture of thoracic spine |
| S22.2 | Fracture of sternum |
| S22.3 | Fracture of rib |
| S22.4 | Multiple fractures of ribs |
| S32.0 | Fracture of lumbar spine (L1-L5) |
| S32.1 | Fracture of sacrum |
| S32.2 | Fraktur of coccyx |
| S32.3 | Fracture of ilium |
| S32.4 | Fracture of acetabulum |
| S32.5 | Fracture of pubis |
| S32.6 | Fracture of ischium |
| S32.8 | Fracture of other parts of pelvis |
| S42.0 | Fracture of clavicle |
| S42.1 | Fracture of scapula |
| S42.2 | Fracture of proximal humerus |
| S42.3 | Fracture of shaft of humerus |
| S42.4 | Fracture of distal humerus |
| S52.0 | Fracture of proximal ulna |
| S52.1 | Fracture of proximal radius |
| S52.2 | Fracture of shaft of ulna |
| S52.3 | Fracture of shaft of radius |
| S52.5 | Fracture of distal radius |
| S62.0 | Fracture of scaphoid bone |
| S62.1 | Fracture of carpal bones |
| S62.2 | Fracture of first metacarpal bone |
| S62.3 | Fracture of other metacarpal bones |
| S72.0 | Femoral neck fracture |
| S72.1 | Pertrochanteric fracture of femur |
| S72.2 | Subtrochanteric fracture of femur |
| S72.3 | Fracture of shaft of femur |
| S72.4 | Fracture of distal femur |
| S82.0 | Fracture of patella |
| S82.1 | Fracture of proximal tibia |
| S82.2 | Fracture of shaft of tibia |
| S82.3 | Fracture of distal tibia |
| S82.4 | Fracture of fibula |
| S82.5 | Fracture of medial malleolus |
| S82.6 | Fracture of lateral malleolus |
| S92.0 | Fracture of calcaneus |
| S92.1 | Fracture of talus |
| S92.2 | Fracture of tarsal bones |
| S92.3 | Fracture of metatarsal bones |
ICD-10 codes “S62.1”, “S62.2” and “S62.3” were combined as fractures of carpal and metacarpal bones and ICD-10 codes “S12.0”, “S12.1”, and “S12.2” as fractures of the cervical spine. For calculating the number of pelvic ring fractures, the diagnoses “S32.1”, “S32.2”, “S32.3”, “S32.5”, “S32.6” and “S32.8” were added together. The incidences were calculated based on the population of Germany aged 20 years and older and standardized with respect to age and sex (15). The number of inhabitants per birth cohort for each of the 16 German federal states was taken into account for each year of the period 2009 to 2019. The cut-off date for each year was 31 December.
Results
A total of 688 403 fractures were recorded in 2019. Compared with 2009, the incidence had increased by 14% to 1014/100 000 inhabitants. Females were affected more often than males (64%, 1263/100 000 female population versus 36%, 755/100 000 male population). Fifty-nine percent of all fractures (3059/100 000 population) occurred in patients over 70 years of age. The highest incidence was in females in the age group over 90 years with 10 286/100 000 female inhabitants, followed by males in the age group over 90 years with 4999/100 000 male inhabitants (Table 1, eTable 2, Table 2).
Table 1. Fracture incidences in 2019 in decreasing frequency.
| Anatomical site | Total | Incidence per 100 000 inhabitants | Change from 2009 to 2019 | Ratiofemale/male | Incidence female/male | Ratio < 70 years/≥ 70 years | Incidence < 70 years/≥ 70 years |
| Total | 688 403 | 1014.4 | + 14% | 64/36 | 1262.5/754.7 | 41/59 | 519.4/3059.3 |
| Femoral neck | 81 570 | 120.2 | + 23% | 68/32 | 157.3/81.3 | 18/82 | 26.2/508.2 |
| Femur pertrochanteric | 73 785 | 108.7 | + 24% | 69/31 | 148.2/67.4 | 13/87 | 17.2/486.5 |
| Distal radius | 72 087 | 106.2 | – 3% | 78/22 | 162.7/47.0 | 57/43 | 75.0/235.4 |
| Proximal humerus | 61 606 | 90.8 | + 10% | 75/25 | 133.4/46.1 | 38/62 | 42.9/288.4 |
| Lumbar spine | 47 874 | 70.5 | + 21% | 62/38 | 85.0/55.5 | 32/68 | 28.1/254.7 |
| Pelvic ring | 40 571 | 59.8 | + 39% | 81/19 | 94.4/23.5 | 17/83 | 12.5/255.2 |
| Lateral malleolus | 33 226 | 49.0 | – 20% | 56/44 | 53.6/44.1 | 76/24 | 46.0/61.2 |
| Multiple ribs | 31 499 | 46.4 | + 40% | 43/57 | 38.7/54.5 | 39/61 | 22.2/146.4 |
| Thoracic spine | 28 057 | 41.3 | + 32% | 64/36 | 51.4/30.8 | 35/65 | 18.1/137.4 |
| Clavicle | 22 752 | 33.5 | + 44% | 30/70 | 19.7/48.0 | 82/18 | 34.3/30.5 |
| Proximal tibia | 19 455 | 28.7 | + 9% | 63/37 | 35.0/22.0 | 71/29 | 25.3/42.5 |
| Shaft of femur | 13 901 | 20.5 | + 38% | 66/34 | 26.6/14.1 | 27/73 | 6.9/76.5 |
| Femur subtrochanteric | 13 817 | 20.4 | + 30% | 69/31 | 27.4/13.0 | 17/83 | 4.4/86.4 |
| Shaft of humerus | 12 368 | 18.2 | + 14% | 68/32 | 24.3/10.7 | 43/57 | 9.6/53.7 |
| Cervical spine | 11 179 | 16.5 | + 94% | 48/52 | 15.5/17.5 | 30/70 | 6.1/59.3 |
| Metatarsal bones | 10 567 | 15.6 | + 11% | 56/44 | 17.0/14.0 | 81/19 | 15.6/15.5 |
| Proximal ulna | 10 554 | 15.6 | + 13% | 66/34 | 20.1/10.8 | 54/46 | 10.3/37.1 |
| Patella | 9590 | 14.1 | 0% | 68/32 | 18.7/9.3 | 49/51 | 8.5/37.3 |
| Distal tibia | 9111 | 13.5 | – 20% | 49/51 | 12.9/14.0 | 77/23 | 12.8/15.9 |
| Distal femur | 9077 | 13.4 | + 30% | 77/23 | 20.1/6.3 | 31/69 | 5.2/47.3 |
| Shaft of tibia | 9077 | 13.4 | – 22% | 40/60 | 10.4/16.5 | 83/17 | 13.8/11.7 |
| Proximal radius | 8423 | 12.4 | + 19% | 58/42 | 14.1/10.7 | 87/13 | 13.3/8.6 |
| Carpal and metacarpal bones | 8412 | 12.4 | + 9% | 31/69 | 7.5/17.5 | 82/18 | 12.6/11.6 |
| Acetabulum | 8142 | 12.0 | + 58% | 46/54 | 10.8/13.3 | 29/71 | 4.3/43.9 |
| Rib | 7355 | 10.8 | + 5% | 46/54 | 9.6/12.1 | 42/58 | 5.7/32.1 |
| Distal humerus | 7192 | 10.6 | + 9% | 71/29 | 14.8/6.2 | 42/58 | 5.6/31.3 |
| Calcaneus | 6010 | 8.9 | – 16% | 30/70 | 5.2/12.7 | 84/16 | 9.3/7.1 |
| Scapula | 3364 | 5.0 | + 31% | 38/62 | 3.7/6.3 | 64/36 | 3.9/9.2 |
| Medial malleolus | 3235 | 4.8 | – 6% | 43/57 | 4.0/5.6 | 79/21 | 4.7/5.0 |
| Sternum | 3134 | 4.6 | + 15% | 55/44 | 5.0/4.2 | 53/47 | 3.1/11.1 |
| Shaft of radius | 2877 | 4.2 | – 6% | 58/42 | 4.8/3.7 | 65/35 | 3.4/7.6 |
| Shaft of ulna | 2798 | 4.1 | + 15% | 54/46 | 4.3/3.9 | 70/30 | 3.6/6.3 |
| Tarsal bones | 1191 | 1.8 | + 28% | 43/57 | 1.5/2.1 | 87/13 | 1.9/1.2 |
| Fibula | 1741 | 2.6 | – 10% | 50/50 | 2.5/2.8 | 65/35 | 2.1/4.6 |
| Scaphoid | 1551 | 2.3 | – 17% | 25/75 | 1.1/3.5 | 92/8 | 2.6/0.9 |
| Talus | 1266 | 1.9 | + 3% | 34/66 | 1.2/2.5 | 92/8 | 2.1/0.7 |
Table 2. Age- and sex-standardized incidence of fractures in 2019, presented for the total number and for the 10 most common fractures.
| Anatomical site |
20–29
years |
30–39
years |
40–49
years |
50–59
years |
60–69
years |
70–79
years |
80–89
years |
≥ 90
years |
|
Percentage female/male
Incidence female/male | ||||||||
| Total | 1.3/3.0 195.9/415.2 |
1.4/3.2 185.6/394.2 |
2.1/3.6 285.1/481.5 |
6.3/5.8 644.8/598.6 |
9.0/5.4 1146.7/731.4 |
14.2/6.0 2391.3/1203.3 |
21.4/7.3 4927.2/2646.2 |
7.9/1.9 10 284.5/4999.1 |
| Femur femoral neck | 0.1/0.1 1.1/2.4 |
0.1/0.3 2.1/4.8 |
0.4/0.8 6.5/12.6 |
2.8/2.4 33.5/29.1 |
6.2/4.3 95.1/68.7 |
15.6/8.2 310.4/192.7 |
29.9/12.9 816.6/554.9 |
11.9/4.0 1828.3/1224.4 |
| Femur pertrochanteric | 0/0.1 0.4/1.9 |
0.1/0.3 1.1/4.5 |
0.2/0.6 2.6/9.0 |
1.4/2.1 14.8/23.0 |
4.1/3.9 55.3/56.1 |
12.6/6.9 226.9/147.5 |
33.1/12.0 818.2/4 67.7 |
18.4/4.2 2549.9/1181.7 |
| Distal radius | 1.6/2.3 24.3/33.0 |
2.1/2.7 18.7/35.6 |
3.5/3.4 50.3/47.9 |
12.8/5.0 136.9/54.0 |
19.4/3.9 258.3/55.5 |
20.1/2.5 352.7/52.4 |
16.0/1.5 387.3/56.8 |
2.9/0.2 393.9/57.5 |
| Proximal humerus | 0.3/0.5 4.5/6.2 |
0.7/1.3 7.6/15.0 |
1.5/2.2 18.6/26.3 |
7.7/4.5 70.7/41.1 |
14.3/5.0 162.8/60.4 |
21.7/5.3 326.7/94.9 |
23.3/4.9 478.1/158.8 |
5.7/1.1 666.7/247.6 |
| Lumbar spine | 1.3/1.7 13.2/16.1 |
0.9/1.7 8.1/14.4 |
1.3/2.4 11.9/22.4 |
4.6/4.8 32.8/34.6 |
7.5/6.0 66.0/56.2 |
16.3/8.7 190.1/121.1 |
23.9/10.9 383.4/274.8 |
6.0/2.1 537.4/385.2 |
| Pelvic ring | 0.8/0.6 7.4/4.8 |
0.7/0.7 5.1/5.1 |
0.9/0.9 7.0/6.9 |
2.9/1.9 17.6/11.5 |
4.9/2.5 36.9/19.8 |
16.7/3.9 165.1/45.4 |
38.2/6.7 518.6/142.7 |
15.8/2.1 1203.4/316.8 |
| Lateral malleolus | 8.5/16.1 27.0/46.4 |
9.6/14.0 26.7/37.9 |
15.8/14.9 45.6/42.5 |
31.1/21.2 67.3/46.3 |
25.2/15.6 67.9/44.8 |
21.0/11.4 74.9/48.4 |
13.9/6.1 67.9/47.0 |
2.3/0.7 63.1/36.7 |
| Multiple ribs | 0.3/0.7 2.3/4.6 |
0.6/2.1 3.5/12.1 |
1.2/4.5 7.6/27.6 |
3.5/11.2 16.3/52.8 |
2.7/10.6 21.5/65.7 |
7.9/11.7 60.6/106.4 |
17.1/13.3 179.9/220.1 |
8.4/3.2 500.5/377.3 |
| Thoracic spine | 1.5/2.5 9.3/13.8 |
1.2/2.7 6.2/13.6 |
1.4/2.9 7.7/16.2 |
4.9/5.3 20.3/22.1 |
7.3/5.5 37.8/30.4 |
16.5/7.3 112.7/59.2 |
24.6/8.6 231.0/127.0 |
6.3/1.6 331.6/168.2 |
| Clavicle | 2.8/13.5 13.6/60.9 |
2.4/12.5 10.3/51.7 |
2.5/12.7 11.2/56.6 |
6.2/16.3 20.8/55.2 |
5.1/8.3 21.5/37.1 |
4.6/3.9 25.7/25.9 |
4.9/3.3 37.4/26.1 |
1.6/0.4 70.0/38.2 |
* The incidence values of the male and female population per 100 000 inhabitants are presented for the age groups in 10-year increments as well as in percent proportion of the total number of fractures at the respective anatomical site
The most common fractures were femoral neck fractures with 81 570 registered cases and an incidence of 120/100 000 inhabitants. The incidence was higher in females than in males (158/100 000 female inhabitants versus 81/100 000 male inhabitants), with the highest incidence in female patients in the age group 90 years or older at 1828/100 000 female inhabitants. The second highest incidence was found in pertrochanteric fractures of the femur (109/100 000 population), followed by distal radius fractures (106/100 000 population), proximal humerus fractures (91/100 000 population), lumbar spine fractures (71/100 000 population), and pelvic ring fractures (60/100 000 population). The age and sex distribution was even for these fractures. The majority involved women, with incidences increasing with age. Of all fractures, the highest incidence was for pertrochanteric femur fractures in women in the over 90 age group, with 2550/100 000 female inhabitants (Table 1, Table 2, eTable 3).
On comparing fracture incidences for 2009 with those for 2019, the highest increase is evident for acetabular fractures (+ 58%) and clavicular fractures (+ 44%), followed by pelvic ring fractures (+ 39%), femoral shaft fractures (+ 38%), and scapula fractures (+ 31%). The figures for distal femur fractures (+ 30%), subtrochanteric femur fractures (+ 30%), tarsal bone fractures (+ 28%), pertrochanteric femur fractures (+ 24%), and femoral neck fractures (+ 23%) were also significantly increased. A continual rise in these fractures over the years has been recorded. A decrease over the years was observed in tibial shaft fractures (– 22%), distal tibial fractures (– 20%), lateral malleolus fractures (– 20%), scaphoid fractures (– 17%), calcaneal fractures (– 16%), fibular shaft fractures (– 10%), medial malleolus fractures (– 6%), radial shaft fractures (– 6%), and distal radius fractures (– 3%) (Table 1, eTable 2). The decrease in these fractures was consistent over the examined period.
Discussion
The incidence of fractures in relation to age and sex is reported here for 30 different anatomical sites. A striking feature of the present article is that the analysis is based on registry data, comprising ICD-10 diagnosis codes from all German medical institutions. While studies based on data from individual departments provide results for which conclusions are limited, the present article reports the total fracture burden for Germany nationwide, including the development of fracture rates over the past ten years.
A total of 688 403 fractures were recorded in 2019, which is a rise of 14% since 2009. The identified increase in total fracture incidence was higher in comparison with that reflected in the available literature. For example, fractures in residents of Olmsted County, Minnesota, USA, over the age of 50 years were analyzed for the years 2009 to 2011 against data from 1989 to 1991. Prevalence increased by 11% during this period (12). A study conducted in the Netherlands with 14 613 participants observed no secular trend differences in fracture incidence between the years 1989 to 2001 and 2001 to 2013 (16). In contrast, an analysis of national registries for 2004 to 2012 in the Netherlands showed a significant rise in extremity fractures from 129 188 to 176 129 (26.7%) (17). The increase in fracture frequency can be attributed to demographic change and the ageing general population. An impact on the figures by changes in the applied diagnostic investigations may be assumed unlikely, as the gold standard of imaging procedures, such as X-ray, computed tomography, and magnetic resonance imaging, has become firmly established over the years (18).
The present study shows that the most common fractures were at the femoral neck and the pertrochanteric femur, with females forming the majority and incidence increasing with age. The greatest rise over the period under investigation was found for acetabular fractures. In keeping with these findings, increasing numbers of hip and pelvic fractures have also been reported by other studies from Germany (7, 8), while hip fractures seem to be decreasing in the USA as well as in Finland (19, 20).
Court-Brown and Caesar analyzed 5953 fractures treated in Edinburgh and divided the fractures into eight different categories based on distribution of age and sex. They concluded that 30% of fractures in men and 66% of fractures in women are potentially osteoporotic (11).
The present article shows that 59% of all fractures occurred in patients aged 70 years or older, which is a higher prevalence than previously reported for other countries (1, 2). The highest incidence values for Germany were in the age group over 90 years with 10 285/100 000 female and 4999/100 000 male inhabitants. These increased incidence rates associated with older age suggest that osteoporosis is a key factor in the development of fracture incidence.
A figure of 928 000 fractures is forecast for 2025, with an estimated socioeconomic burden of 11 261 million euros (21). Increasing risk factors for osteoporotic fractures contribute to this development, including diabetes type 2, which affects 5.8 million Germans, and a high proportion of smokers in the German population (22– 25).
In general, it is reported that the burden from fractures is decreasing worldwide, while an increase in fragility fractures is expected, which is why authors call for an intensification of resources in fracture care (26, 27). Research into the epidemiological trends of fractures or even the creation of a patient-centered fracture registry in Germany (28) would therefore be beneficial for the modification of preventive measures in society and optimization of care management.
Limitations
The study is limited by the fact that, although ICD-10 codes were available according to age and sex, neither identification of the cause of the fracture nor differentiation of possible contributing comorbidities, such as osteoporosis or diabetes mellitus, was possible.
It may be assumed that the diagnoses were coded correctly since the DRG-based flat-rate funding scheme depends on it and is strictly controlled by the health insurance funds. Possible “upcoding”, on the other hand, cannot be excluded. Furthermore, the calculations were based only on inpatient data. Therefore, the reported fracture incidences may be underestimated and fragmentary since fractures treated on an outpatient basis were not included in the analysis. This limitation refers in particular to fractures which are often also treated in the outpatient sector, such as radius fractures or carpal and metacarpal bone fractures.
Summary
In summary, the rising incidence of fractures is a major public health problem. Fifty-nine percent of all fractures occurred in patients aged 70 years or older. The highest prevalence was found for proximal femur fractures, with case figures increasing sharply with age. Therefore, a development towards more osteoporosis-related fractures may be assumed, especially in geriatric patients. Since other developed countries are facing similar demographic trends, the present article can help protagonists in health systems worldwide to adapt their resource management.
eTable 2. Incidence of fractures in 2019, subdivided according to anatomical site.
| Anatomical site | Total | Incidence per 100 000 inhabitants | Change from 2009 to 2019 | Ratio female/male | Incidence female/ male | Ratio < 70 years/ ≥ 70 years | Incidence < 70 years/ ≥ 70 years |
| Total | 688 403 | 1014.4 | + 14% | 64/36 | 1262.5/754.7 | 41/59 | 519.4/3059.3 |
| Shoulder and upper arm | |||||||
| Clavicle | 22 752 | 33.5 | + 44% | 30/70 | 19.7/48.0 | 82/18 | 34.3/30.5 |
| Scapula | 3364 | 5.0 | + 31% | 38/62 | 3.7/6.3 | 64/36 | 3.9/9.2 |
| Proximal humerus | 61 606 | 90.8 | + 10% | 75/25 | 133.4/46.1 | 38/62 | 42.9/288.4 |
| Shaft of humerus | 12 368 | 18.2 | + 14% | 68/32 | 24.3/10.7 | 43/57 | 9.6/53.7 |
| Distal humerus | 7192 | 10.6 | + 9% | 71/29 | 14.8/6.2 | 42/58 | 5.6/31.3 |
| Lower arm | |||||||
| Proximal ulna | 10 554 | 15.6 | + 13% | 66/34 | 20.1/10.8 | 54/46 | 10.3/37.1 |
| Shaft of ulna | 2798 | 4.1 | + 15% | 54/46 | 4.3/3.9 | 70/30 | 3.6/6.3 |
| Proximal radius | 8423 | 12.4 | + 19% | 58/42 | 14.1/10.7 | 87/13 | 13.3/8.6 |
| Shaft of radius | 2877 | 4.2 | – 6% | 58/42 | 4.8/3.7 | 65/35 | 3.4/7.6 |
| Distal radius | 72 087 | 106.2 | – 3% | 78/22 | 162.7/47.0 | 57/43 | 75.0/235.4 |
| Hand and wrist | |||||||
| Scaphoid | 1551 | 2.3 | – 17% | 25/75 | 1.1/3.5 | 92/8 | 2.6/0.9 |
| Carpal and metacarpal bones | 8412 | 12.4 | + 9% | 31/69 | 7.5/17.5 | 82/18 | 12.6/11.6 |
| Spine and thorax | |||||||
| Lumbar spine | 47 874 | 70.5 | + 21% | 62/38 | 85.0/55.5 | 32/68 | 28.1/254.7 |
| Cervical spine | 11 179 | 16.5 | + 94% | 48/52 | 15.5/17.5 | 30/70 | 6.1/59.3 |
| Thoracic spine | 28 057 | 41.3 | + 32% | 64/36 | 51.4/30.8 | 35/65 | 18.1/137.4 |
| Sternum | 3134 | 4.6 | + 15% | 55/44 | 5.0/4.2 | 53/47 | 3.1/11.1 |
| Multiple ribs | 31 499 | 46.4 | + 40% | 43/57 | 38.7/54.5 | 39/61 | 22.2/146.4 |
| Rib | 7355 | 10.8 | + 5% | 46/54 | 9.6/12.1 | 42/58 | 5.7/32.1 |
| Femur and pelvis | |||||||
| Femur femoral neck | 81 570 | 120.2 | + 23% | 68/32 | 157.3/81.3 | 18/82 | 26.2/508.2 |
| Femur pertrochanteric | 73 785 | 108.7 | + 24% | 69/31 | 148.2/67.4 | 13/87 | 17.2/486.5 |
| Femur subtrochanteric | 13 817 | 20.4 | + 30% | 69/31 | 27.4/13.0 | 17/83 | 4.4/86.4 |
| Shaft of femur | 13 901 | 20.5 | + 38% | 66/34 | 26.6/14.1 | 27/73 | 6.9/76.5 |
| Distal femur | 9077 | 13.4 | + 30% | 77/23 | 20.1/6.3 | 31/69 | 5.2/47.3 |
| Acetabulum | 8142 | 12.0 | + 58% | 46/54 | 10.8/13.3 | 29/71 | 4.3/43.9 |
| Pelvis | 40 571 | 59.8 | + 39% | 81/19 | 94.4/23.5 | 17/83 | 12.5/255.2 |
| Lower leg and ankle | |||||||
| Patella | 9590 | 14.1 | 0% | 68/32 | 18.7/9.3 | 49/51 | 8.5/37.3 |
| Proximal tibia | 19 455 | 28.7 | + 9% | 63/37 | 35.0/22.0 | 71/29 | 25.3/42.5 |
| Shaft of tibia | 9077 | 13.4 | – 22% | 40/60 | 10.4/16.5 | 83/17 | 13.8/11.7 |
| Distal tibia | 9111 | 13.5 | – 20% | 49/51 | 12.9/14.0 | 77/23 | 12.8/15.9 |
| Fibula | 1741 | 2.6 | – 10% | 50/50 | 2.5/2.8 | 65/35 | 2.1/4.6 |
| Medial malleolus | 3235 | 4.8 | – 6% | 43/57 | 4.0/5.6 | 79/21 | 4.7/5.0 |
| Lateral malleolus | 33 226 | 49.0 | – 20% | 56/44 | 53.6/44.1 | 76/24 | 46.0/61.2 |
| Foot | |||||||
| Calcaneus | 6010 | 8.9 | – 16% | 30/70 | 5.2/12.7 | 84/16 | 9.3/7.1 |
| Talus | 1266 | 1.9 | + 3% | 34/66 | 1.2/2.5 | 92/8 | 2.1/0.7 |
| Tarsal bones | 1191 | 1.8 | + 28% | 43/57 | 1.5/2.1 | 87/13 | 1.9/1.2 |
| Metatarsal bones | 10 567 | 15.6 | + 11% | 56/44 | 17.0/14.0 | 81/19 | 15.6/15.5 |
eTable 3. Age- and sex-standardized incidence of fractures in 2019*.
| Anatomical site | 20–29 years | 30–39 years | 40–49 years | 50–59 years | 60–69 years | 70–79 years | 80–89 years | ≥ 90 years |
| Percentage female/male Incidence female/male | ||||||||
| Total | 1.3/3.0 195.9/415.2 |
1.4/3.2 185.6/394.2 |
2.1/3.6 285.1/481.5 |
6.3/5.8 644.8/598.6 |
9.0/5.4 1146.7/731.4 |
14.2/6.0 2391.3/1203.3 |
21.4/7.3 4927.2/2646.2 |
7.9/1.9 10 284.5/4999.1 |
| Femur femoral neck | 0.1/0.1 1.1/2.4 |
0.1/0.3 2.1/4.8 |
0.4/0.8 6.5/12.6 |
2.8/2.4 33.5/29.1 |
6.2/4.3 95.1/68.7 |
15.6/8.2 310.4/192.7 |
29.9/12.9 816.6/554.9 |
11.9/4.0 1828.3/1224.4 |
| Femur pertrochanteric | 0/0.1 0.4/1.9 |
0.1/0.3 1.1/4.5 |
0.2/0.6 2.6/9.0 |
1.4/2.1 14.8/23.0 |
4.1/3.9 55.3/56.1 |
12.6/6.9 226.9/147.5 |
33.1/12.0 818.2/467.7 |
18.4/4.2 2549.9/1181.7 |
| Distal radius | 1.6/2.3 24.3/33.0 |
2.1/2.7 18.7/35.6 |
3.5/3.4 50.3/47.9 |
12.8/5.0 136.9/54.0 |
19.4/3.9 258.3/55.5 |
20.1/2.5 352.7/52.4 |
16.0/1.5 387.3/56.8 |
2.9/0.2 393.9/57.5 |
| Proximal humerus | 0.3/0.5 4.5/6.2 |
0.7/1.3 7.6/15.0 |
1.5/2.2 18.6/26.3 |
7.7/4.5 70.7/41.1 |
14.3/5.0 162.8/60.4 |
21.7/5.3 326.7/94.9 |
23.3/4.9 478.1/158.8 |
5.7/1.1 666.7/247.6 |
| Lumbar spine | 1.3/1.7 13.2/16.1 |
0.9/1.7 8.1/14.4 |
1.3/2.4 11.9/22.4 |
4.6/4.8 32.8/34.6 |
7.5/6.0 66.0/56.2 |
16.3/8.7 190.1/121.1 |
23.9/10.9 383.4/274.8 |
6.0/2.1 537.4/385.2 |
| Pelvic ring | 0.8/0.6 7.4/4.8 |
0.7/0.7 5.1/5.1 |
0.9/0.9 7.0/6.9 |
2.9/1.9 17.6/11.5 |
4.9/2.5 36.9/19.8 |
16.7/3.9 165.1/45.4 |
38.2/6.7 518.6/142.7 |
15.8/2.1 1203.4/316.8 |
| Lateral malleolus | 8.5/16.1 27.0/46.4 |
9.6/14.0 26.7/37.9 |
15.8/14.9 45.6/42.5 |
31.1/21.2 67.3/46.3 |
25.2/15.6 67.9/44.8 |
21.0/11.4 74.9/48.4 |
13.9/6.1 67.9/47.0 |
2.3/0.7 63.1/36.7 |
| Multiple ribs | 0.3/0.7 2.3/4.6 |
0.6/2.1 3.5/12.1 |
1.2/4.5 7.6/27.6 |
3.5/11.2 16.3/52.8 |
2.7/10.6 21.5/65.7 |
7.9/11.7 60.6/106.4 |
17.1/13.3 179.9/220.1 |
8.4/3.2 500.5/377.3 |
| Thoracic spine | 1.5/2.5 9.3/13.8 |
1.2/2.7 6.2/13.6 |
1.4/2.9 7.7/16.2 |
4.9/5.3 20.3/22.1 |
7.3/5.5 37.8/30.4 |
16.5/7.3 112.7/59.2 |
24.6/8.6 231.0/127.0 |
6.3/1.6 331.6/168.2 |
| Clavicle | 2.8/13.5 13.6/60.9 |
2.4/12.5 10.3/51.7 |
2.5/12.7 11.2/56.6 |
6.2/16.3 20.8/55.2 |
5.1/8.3 21.5/37.1 |
4.6/3.9 25.7/25.9 |
4.9/3.3 37.4/26.1 |
1.6/0.4 70.0/38.2 |
| Proximal tibia | 2.6/3.1 10.8/12.1 |
3.2/5.2 11.6/18.3 |
4.8/6.9 18.5/26.2 |
14.6/9.5 42.0/27.5 |
14.7/6.6 52.8/25.1 |
11.3/3.8 53.7/21.4 |
9.0/2.1 58.3/21.0 |
2.4/0.4 87.0/28.7 |
| Shaft of femur | 1.4/4.2 4.2/11.6 |
0.8/2.6 2.1/6.6 |
0.8/2.0 2.1/5.4 |
2.3/3.4 4.8/5.4 |
5.4/4.3 13.8/7.0 |
13.1/6.3 44.5/11.6 |
30.0/8.8 139.5/25.4 |
12.6/2.0 331.0/103.6 |
| Femur subtrochanteric | 0.1/0.5 0.4/1.4 |
0.1/0.7 0.3/1.7 |
0.4/1.0 1.0/2.8 |
2.0/2.5 4.0/5.2 |
5.3/4.6 13.5/12.6 |
14.1/7.4 47.4/29.8 |
31.4/11.0 145.3/79.7 |
15.5/3.4 402.2/178.8 |
| Shaft of humerus | 1.4/8.7 3.9/8.7 |
3.0/5.8 3.0/5.8 |
5.3/6.5 5.3/6.5 |
12.1/8.9 12.1/8.9 |
27.3/13.3 27.3/13.3 |
53.3/21.9 53.3/21.9 |
86.4/34.4 86.4/34.3 |
148.4/ 51.4 148.4/51.4 |
| Cervical spine | 0.9/2.4 2.2/5.2 |
0.9/2.5 1.8/5.1 |
0.9/3.0 2.1/6.6 |
2.4/5.9 4.0/9.8 |
3.8/7.1 7.9/15.6 |
10.0/11.0 27.4/35.8 |
20.2/16.3 75.5/96.2 |
8.9/3.6 188.3/153.1 |
| Metatarsal bones | 5.2/8.4 11.8/17.6 |
5.7/8.1 11.5/15.5 |
6.6/8.1 13.7/16.8 |
13.0/9.8 20.3/15.5 |
10.4/5.3 20.3/11.0 |
7.8/2.8 20.0/8.5 |
6.3/1.3 22.2/7.1 |
1.2/0.1 23.2/5.3 |
| Proximal ulna | 1.9/3.9 4.4/8.1 |
2.1/3.7 4.3/7.0 |
2.7/4.6 5.6/9.5 |
8.8/7.1 13.8/9.5 |
12.8/5.9 25.0/11.2 |
16.8/4.5 43.3/13.7 |
16.7/3.6 58.9/19.7 |
4.4/0.6 86.6/25.0 |
| Patella | 1.4/3.2 2.8/6.1 |
1.6/3.6 2.8/6.2 |
2.1/3.2 4.1/6.1 |
8.4/5.4 11.9/7.7 |
14.2/5.6 25.1/10.5 |
20.6/5.3 48.1/14.8 |
16.9/4.9 54.1/24.5 |
2.9/0.9 52.7/32.1 |
| Distal tibia | 3.2/6.4 6.4/11.5 |
3.8/9.1 6.5/15.0 |
5.6/9.3 10.1/16.5 |
10.3/12.2 13.8/16.6 |
9.2/8.0 15.5/14.3 |
7.3/3.7 16.2/9.8 |
7.3/2.1 22.3/10.0 |
2.4/0.3 40.7/10.6 |
| Distal femur | 0.9/2.1 1.8/3.9 |
0.7/1.8 1.3/3.0 |
1.3/2.0 2.4/3.6 |
5.1/3.9 6.9/5.3 |
9.2/3.8 15.4/6.8 |
16.3/4.1 36.2/10.7 |
28.2/4.1 85.6/19.4 |
15.3/1.1 261.2/ 36.3 |
| Shaft of tibia | 3.9/13.9 7.6/24.9 |
4.2/10.9 7.2/18.0 |
5.4/10.4 9.7/18.5 |
8.0/12.3 10.8/16.6 |
6.8/7.1 11.4/12.6 |
4.9/3.5 10.8/9.1 |
4.9/1.7 14.8/8.0 |
1.9/0.4 32.2/12.5 |
| Proximal radius | 3.5/7.0 6.4/11.7 |
5.2/10.1 8.3/15.4 |
6.9/9.3 11.5/15.3 |
16.6/9.4 20.8/11.8 |
14.5/4.1 22.5/6.8 |
7.7/1.5 15.9/3.6 |
3.3/0.5 9.2/2.1 |
0.5/0.1 7.2/3.0 |
| Carpal and metacarpal bones | 3.1/24.3 5.6/40.4 |
2.8/14.9 4.5/22.7 |
2.4/9.0 4.0/14.8 |
5.2/9.0 6.5/11.4 |
5.4/5.7 8.3/9.3 |
6.0/3.9 12.3/9.4 |
5.1/2.0 14.4/8.8 |
1.1/0.3 16.8/8.7 |
| Acetabulum | 0.6/1.8 1.0/2.9 |
0.6/2.0 0.9/3.0 |
0.7/2.4 1.1/3.8 |
2.2/6.8 2.7/8.2 |
3.6/7.9 5.4/12.7 |
9.6/11.9 19.1/28.2 |
19.7/15.6 53.6/67.0 |
9.0/5.5 137.8/169.0 |
| Rib | 1.0/1.8 1.5/2.6 |
1.1/3.6 1.5/4.7 |
2.0/5.6 3.0/8.0 |
4.2/9.9 4.6/10.9 |
3.9/9.1 5.3/13.1 |
8.1/10.1 14.5/21.6 |
17.1/11.7 42.0/45.1 |
8.2/2.6 113.2/73.0 |
| Distal humerus | 2.3/3.1 3.5/4.4 |
3.2/2.9 3.1/3.8 |
2.4/2.5 3.4/3.5 |
6.3/4.7 6.7/5.0 |
11.4/4.5 15.1/6.4 |
15.7/4.7 27.6/9.8 |
23.4/5.1 56.3/19.2 |
7.6/1.2 103.4/31.8 |
| Calcaneus | 1.3/5.9 1.7/7.1 |
2.3/13.1 2.7/14.2 |
3.2/14.6 3.8/17.1 |
6.1/19.5 5.4/17.5 |
7.2/11.1 8.0/13.1 |
5.9/4.2 8.7/7.3 |
3.3/1.3 6.6/4.2 |
0.8/0.1 9.6/2.6 |
| Scapula | 1.0/5.9 0.7/3.9 |
1.2/8.5 0.8/5.2 |
1.7/8.7 1.1/5.7 |
5.0/1 4.72.5/7.4 |
6.6/1 0.64.1/7.0 |
8.5/6.7 7.0/6.6 |
11.0/5.2 12.4/9.3 |
3.3/1.2 20.9/15.1 |
| Medial malleolus | 6.2/11.2 4.3/7.2 |
4.1/10.1 2.5/5.9 |
3.4/10.2 2.2/6.4 |
7.2/11.4 3.4/5.5 |
7.2/8.2 4.3/5.3 |
7.2/3.9 5.9/3.7 |
5.8/1.7 6.3/2.9 |
1.5/0.3 9.2/3.4 |
| Sternum | 3.3/2.8 2.2/1.7 |
2.4/3.3 1.4/1.9 |
3.7/4.4 2.3/2.7 |
8.0/8.2 3.7/3.8 |
8.9/8.3 5.2/5.1 |
11.9/7.7 9.1/7.0 |
13.2/8.9 13.9/14.6 |
3.9/1.2 23.0/14.7 |
| Shaft of radius | 1.9/11.0 1.2/6.3 |
2.7/8.2 1.5/4.3 |
3.8/5.9 2.2/3.3 |
8.3/7.6 3.5/3.3 |
11.6/3.9 6.2/2.2 |
12.1/3.2 8.5/2.6 |
13.2/2.2 12.8/3.4 |
4.2/0.2 22.6/2.6 |
| Shaft of ulna | 3.0/7.5 1.8/4.1 |
3.5/6.9 1.8/3.5 |
4.0/7.5 2.2/4.1 |
8.4/9.9 3.5/4.1 |
12.5/7.3 6.5/4.0 |
11.8/3.9 8.1/3.2 |
8.8/2.7 8.2/4.0 |
1.9/0.4 10.2/4.2 |
| Tarsal bones | 6.0/12.9 1.6/3.0 |
5.5/13.0 1.3/2.8 |
7.8/10.6 1.8/2.5 |
8.3/11.7 1.5/2.1 |
5.5/5.5 1.2/1.3 |
5.0/2.9 1.5/1.0 |
4.1/0.7 1.6/0.4 |
0.4/0.0 0.9/0.0 |
| Fibula | 2.0/8.4 0.8/2.9 |
2.9/7.1 1.0/2.2 |
4.0/7.5 1.4/2.6 |
9.1/10.5 2.4/2.6 |
7.2/6.1 2.3/2.7 |
10.2/6.7 4.3/2.1 |
11.3/3.8 6.6/3.5 |
3.2/0.0 10.4/3.5 |
| Scaphoid | 3.4/35.8 1.1/11.0 |
2.8/15.6 0.8/4.4 |
2.2/8.4 0.7/2.5 |
6.3/7.6 1.4/1.8 |
5.4/4.8 1.5/1.5 |
3.2/1.9 1.2/0.9 |
2.0/0.8 1.0/0.6 |
0.0/0.0 0.0/0.0 |
| Talus | 10.9/19.1 3.0/4.8 |
6.3/17.5 1.5/4.0 |
3.7/11.4 0.9/2.8 |
4.6/10.7 0.9/2.0 |
3.1/4.8 0.7/1.2 |
3.2/1.8 1.0/0.7 |
1.6/0.6 0.7/0.4 |
0.6/0.0 1.3/0.0 |
* The incidence values of the male and female population per 100 000 inhabitants are presented for the age groups in 10-year increments as well as in percentage proportion of the total number of fractures at the respective anatomical site
Acknowledgments
Translated from the original German by Dr. Grahame Larkin, MD
Footnotes
Conflict of interest statement
The authors confirm that they have no conflicts of interest.
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