Epidemiology of proximal humeral fractures in Austria between 1989 and 2008

Summary

Incidence rates of proximal humeral fractures in Austria over a period of twenty years (1989–2008) were estimated. Age standardized incidence rates increased until 2008, primarily driven by an increase in incidence rates in women.

Introduction

The aim of the prevailing study was to estimate incidence rates of proximal humeral fractures and to assess changes in trend in the Austrian population aged 50 years and above, over a period of 20 years (1989–2008).

Methods

Number of proximal humeral fractures were obtained from the Austrian Hospital Discharge Register for the entire population >50 years of age. Adjustment factors were determined for multiple registrations of the same diagnosis, and for the fact that not all patients with proximal humeral fractures are treated in an inpatient setting. To analyze the overall change in this type of fracture for the period, average annual changes expressed as incidence rate ratios were calculated.

Results

The estimated age-standardized incidence (fractures per 100,000 individuals) of proximal humeral fractures among Austrians >50 years of age increased in men from 112 (95 % CI, 99–124) to 141 (129–153) and in women from 222 (202–241) to 383 (360–406). The increase appeared to be linear with no leveling off towards the end of the study period.

Conclusion

While some caution is necessary when interpreting the results given the use of adjustment factors, there appears to have been a rise in the incidence of proximal humeral fractures in Austria in both men and women, with no leveling off in recent years. The reasons for this are not clear, but in the light of previously reported leveling off in the increase in the incidence of hip fractures, a change in the patterns of falls cannot be ruled out.     

Epidemiology of distal forearm fractures in Danish children

We recorded all the distal forearm fractures in inhabitants under 20 years of age in Frederiksborg County, Denmark, throughout 1985. The population at risk was 97,791 persons, and fractures occurred in 269 boys and 205 girls. The peak incidence in girls occurred at ages 10-12 (105 per 10,000) and in boys at ages 12-14 (100 per 10,000). Fractures occurred more often in the autumn than in the spring.     

Epidemiology of distal forearm fractures in Danish children

We recorded all the distal forearm fractures in inhabitants under 20 years of age in Frederiksborg County, Denmark, throughout 1985. The population at risk was 97,791 persons, and fractures occurred in 269 boys and 205 girls. The peak incidence in girls occurred at ages 10-12 (105 per 10,000) and in boys at ages 12-14 (100 per 10,000). Fractures occurred more often in the autumn than in the spring.     

Epidemiology of distal forearm fractures in Oslo, Norway

Summary The population of Oslo has the highest incidence of hip fracture reported. The present study shows that the overall incidence of distal forearm fractures in Oslo is higher than in other countries and has not changed significantly when comparing the incidence of 1998/99 with 1979. Introduction The population of Oslo has the highest incidence of hip fracture reported. The present study reports the incidence of distal forearm fracture in Oslo and the fracture rates of immigrants. Methods Patients aged ≥20 years resident in Oslo sustaining a distal forearm fracture in a one-year period in 1998/99 were identified using electronic diagnosis registers, patient protocols, and/or X-ray registers of the clinics in Oslo. Medical records were obtained and the diagnosis verified. The age- and sex-specific incidence rates were calculated and compared with those for 1979. Data on immigrant category and country of origin of the patients were obtained. Results The age-adjusted fracture rates per 10,000 for the age group ≥50 years were 109.8 and 25.4 in 1998/99 compared with 108.3 and 23.5 in 1979 for women and men, respectively (n.s.). The relative risk of fracture in Asians was 0.72 (95% CI 0.53–1.00) compared with ethnic Norwegians. Conclusions The overall incidence of distal forearm fractures in Oslo is higher than in other countries and has not changed significantly when comparing the incidence of 1998/99 with 1979. Furthermore, the present data suggest that Asian immigrants in Oslo have a slightly lower fracture risk than ethnic Norwegians.     

Epidemiology of distal radius fractures

In the county of Frederiksborg, Denmark, all distal radius fractures in inhabitants over 20 years of age were recorded throughout 1981; the population at risk was a quarter million, and fractures occurred in 394 women and 99 men. The age-specific incidence confirmed the rise in osteoporotic fractures over the past 20 years demonstrated recently in Malm? and Oslo.     

Cadmium exposure and distal forearm fractures.

The aim of this study was to analyze the relationship between low-level cadmium exposure and distal forearm fractures. Altogether, 1021 men and women exposed to cadmium in Sweden were included. The study indicates that cadmium exposure is associated with increased risk of forearm fractures in people over the age of 50. INTRODUCTION: Very few studies have been performed on environmental risk factors for fractures. Cadmium is known to cause damage to the kidneys and in high doses to the bone. The aim of this study was to analyze the relationship between low-level cadmium exposure and distal forearm fractures. MATERIALS AND METHODS: A total of 479 men and 542 women, 16-81 years of age, that were environmentally or occupationally exposed to cadmium were examined in 1997. Cadmium in urine was used to estimate dose, and information about previous fractures and risk factors for fractures was obtained from questionnaires. Fractures were validated using medical records. The association between cadmium dose and risk of forearm fracture was evaluated using Cox proportional hazard regression analysis. RESULTS AND CONCLUSION: The mean urinary cadmium in the study population was 0.74 nmol cadmium/mmol creatinine (10% and 90% percentiles are 0.19 and 1.42, respectively). For fractures occurring after the age of 50 years (n = 558, 32 forearm fractures), the fracture hazard ratio, adjusted for gender and other relevant co-variates, increased by 18% (95% CI, 1.0-38%) per unit urinary cadmium (nmol cadmium/mmol creatinine). When subjects were grouped in exposure categories, the hazard ratio reached 3.5 (90% CI, 1.1, 11) in the group of subjects with urinary cadmium between 2 and 4 nmol/mmol creatinine and 8.8 (90% CI, 2.6, 30) in the group of subjects with > or = 4 nmol/mmol creatinine. Associations between cadmium and fracture risk were absent before the age of 50. Cadmium exposure is associated with increased risk of forearm fractures in people over 50 years of age.     

Anatomical results after distal forearm fractures

A radiological evaluation of 207 fractures of the distal forearm was performed. 91.5% of the fractures were of Colles' type. Almost 60% of them were intra-articular. A practical classification of Colles' fractures according to intra-articular fracture lines was shown to be useful in assessing the severity of these fractures. It correlated well with the shortening of the radius and the amount of dorsal tilt of the fractured wrist. It also seemed to predict the tendency for worsening of the position during treatment. An impairment of the position was noticed in more than 60% of cases. The anatomical result was evaluated as good or excellent in 60% of cases. Women seemed to have slightly better results. In age groups 35-44 and 45-54 years, the outcome was somewhat worse.     

Epidemiology of distal radius fractures in Budapest: A retrospective study of 2,241 cases in 1989

Retrospective data concerning 2,223 patients with fracture of the distal radius were related to the age-and sex-profiles of the population. Compared with observations from other countries, we found a similar sex ratio with a steep rise in fracture incidence in women after age 30-40. Our data did not permit calculation of absolute fracture incidence rates.     

Remodeling of angulated distal forearm fractures in children

Seventy children treated for distal forearm fractures were clinically and roentgenologically reexamined with a median follow-up time of 3.5 years (range, 1.5-6.0 years). The angulation of the fractures and of the epiphyseal plates was measured at the time of healing and at the follow-up examination. The patients were divided into three age groups of 0-5 years, 6-10 years, and 11-15 years at the time of fracture. In children younger than 11 years of age with residual angulation after distal forearm fractures, the change of orientation of the epiphyseal plate toward normal seemed to account for nearly all the actual correction at the site of fracture, up to 28 degrees. In children older than 11 years of age the capacity of correction of the orientation of the epiphyseal plate was preserved, but its influence upon the correction of distal forearm fractures decreased. This did not prevent correction of possible residual angulation at the fracture site--up to 18 degrees. This may be because, in this age group, appositional bone formation and resorption are the most important remodeling factors. The importance of the orientation of the epiphyseal plate is related to the distance between the fracture site and the epiphyseal plate and by the age of the patient.     

Epidemiology and chrono-epidemiology of distal radius fractures

The frequency of distal radius fractures of patients treated in the outpatient clinic of the Herz-Jesu-Krankenhaus between Jan. 1997 and Dec. 1999 were evaluated retrospectively. Records of 366 patients (m: 132, f: 234) were assessed. The frequency of distal radius fractures was fitted to a cosine model using non-linear regression in order to detect a circadian or circannual rhythm. The goodness of fit was assessed by means of the F statistics and the coefficient of determination r2. Moreover, spectral analysis was performed. In 1997 135, in 1998 119, and in 1999 112 distal radius fractures were treated. The mean age of the patients was 40.3 ys. (women: 48.8; men: 25.3). The extended wrist was the most common position during Trauma, Accidents at home (41%), during spare time activities (23.8%), and during physical activities (21.6%) were more frequent than accidents during working hours (12.5%) or traffic accidents (1.1%). The latency for definite surgical treatment in our clinic was 8.5 hours (minimum: 15 min; maximum: 7 days and 14 hours). A significant cosine model could be fitted for a period of 24 hours (r2 = 0.82) with a maximum at 15.00 hours. Spectral analysis revealed an ultradian rhythm of approximately 12 hours in addition to the circadian periodicity. No significant circannual model could be fitted (r2 = 0.2), although a slight increase of frequency was found during May and June. In conclusion, the frequency of distal radius fractures shows a clear circadian but no circannual periodicity.     

Weight loss and distal forearm fractures in postmenopausal women

Summary  

Weight loss is a risk factor for hip fractures, but few studies have evaluated the effect of weight loss on distal forearm fracture risk. In this longitudinal study including 7,871 postmenopausal women, weight loss of 5% or more was associated with an increased risk of distal forearm fractures.     

Aftercare following distal forearm fractures and carpal trauma

Rehabilitation following operative or conservative treatment of fractures of the distal forearm and carpal trauma takes effect through adequate immobilization and ought to be maximized by a differentiated application of every means of physiotherapy, ergotherapy, and physical medicine available. Rehabilitation of the fractured distal forearm and carpal trauma are presented based on the therapeutic guidelines as applied by the Department of Hand Surgery, Plastic and Microsurgery of the Berufsgenossenschaftliches Unfallkrankenhaus Hamburg.     

Long-term results following pediatric distal forearm fractures

Introduction The purpose of this retrospective study was to investigate the frequency and extent of clinical and radiological late sequelae and to identify predicting factors.Materials and methods A total of 220 patients of growing age with 232 closed, conservatively treated fractures were re-examined clinically and radiologically at a median follow-up time of 10 years (range 5–16 years). Clinical and radiological findings were summarised as an overall result.Results Of the total of patients, 19% reported pain in the injured wrist, and wrist mobility was limited in 5% of patients. Forearm rotation was decreased in 16%, primarily in epiphyseal separation of the ulna (p=0.0033). Radial inclination was different in 6% of patients, palmar tilt in 2%, and ulnar variance in 37%, compared with the contralateral side. Ulnocarpal impaction syndrome was present in 75% of the patients with positive ulnar variance. Overall outcome was excellent in 72%, good in 19%, moderate in 6%, and poor in 3% of patients. The younger the children were at the time of injury, the more favourable the results were (p=0.009). Children who were older than 10 years when they suffered a severe fracture dislocation had the poorest results (p=0.008). Further factors having a negative influence on outcome were repeated reduction maneuvers and an additional fracture of the ulna.Conclusion Our follow-up examinations showed that the majority of patients achieved good results, especially in children under 10 years old. Large dislocations at the time of fracture healing do not influence long-term results in this age group and thus can be tolerated. Patients over 10 years old, whose fractures healed with an angular deformity of more than 20° and/or fragment dislocation over half the breadth of the shaft showed the poorest results. Thus, such dislocations should not be tolerated, and reduction should be attempted in this age group by only one reduction maneuver.     

Urban-rural differences in distal forearm fractures: Cohort Norway

Summary

The prevalence of forearm fractures increased with increasing degree of urbanization for both genders in the population-based study “Cohort Norway” with more than 180,000 participants. The differences were not explained by available risk factors. Prospective studies with information on bone mineral density and falls are warranted.

Introduction

The purpose was to investigate urban-rural gradients in self-reported forearm fractures and assess the contribution of possible explanatory factors.

Methods

“Cohort Norway” comprises ten population-based surveys inviting 309,742 individuals age 20 years and older. All 181,891 participants underwent a standardized examination and answered 50 common questions, including one concerning former forearm fractures. Based on the home-addresses, participants were divided into three population density groups: cities, densely populated areas and sparsely populated areas. Analyses were limited to 149,725 participants 30 years or over with valid information on exposure and outcome. Of these, 21,627 reported having suffered a forearm fracture.

Results

The prevalence of forearm fractures increased with increasing degree of urbanization for both genders. After adjustment for age and explanatory factors, the odds ratio of having sustained a forearm fracture in men living in densely populated areas and in cities were 1.12 (95% CI, 1.04–1.21) and 1.38 (95% CI, 1.30–1.46), respectively, compared to rural areas. Similar odds ratios were observed among women.

Conclusions

Prospective studies are needed to verify whether lower bone mineral density, different lifestyle and/or more falls may explain the higher proportion of self-reported forearm fractures found in urban compared to rural areas.     

Epidemiology of distal radius fractures in Iceland in 1985

Between March 1985 and March 1986, 249 fractures of the distal radius in patients over 15 years of age were treated in the Reykjavik area, which had a total at risk population of 100,154. The incidence pattern was similar to what has been reported in recent Nordic studies except that the fracture risk of women was lower than in Oslo in 1979 and Malm? in 1980-81, and for men higher than in Fredriksborg in 1981. Fifty-seven percent of the patients had employment at the time of accident. The majority of accidents happened outdoors, especially on sidewalks and in streets, and were more common during the winter months.     

Think twice before re-manipulating distal metaphyseal forearm fractures in children

Background

Treatment of displaced paediatric distal forearm fractures is not always successful. Re-occurrence of angular deformity is a frequent complication. No consensus exists when to perform secondary manipulations. The purpose of this study was to analyse the long-term outcome of re-angulated paediatric forearm fractures to determine if re-manipulations can be avoided.

Methods

Children who underwent closed reduction for distal forearm fractures and presented with re-angulation at follow-up were included in this retrospective cohort study. We compared those that were re-manipulated to those managed conservatively. Re-angulation was defined as ≥15° of angulation on either the AP or lateral view. Children were reviewed after 1–8 years post injury. Outcome measures were residual angulation on radiographs, active range of motion, grip strength, Visual Analogue Scales (satisfaction, cosmetics and pain) and the ABILHANDS-kids questionnaire.

Results

Sixty-six children (mean age of 9.6 years) were included. Twenty-four fractures were re-manipulated and 42 fractures had been left to heal in angulated position. At time of re-angulation, children <12 years in the conservative group had similar angulations to those re-manipulated. Children ≥12 years in the re-manipulation group had significantly greater angulations than children in the conservative group. At final follow-up, after a mean of 4.0 years, near anatomical alignment was seen on radiographs in all patients. Functional outcome was predominantly excellent. There was no significant difference in functional, subjective or radiological outcomes between treatment groups.

Conclusion

Re-manipulation of distal forearm fractures in children <12 years did not improve outcomes, deeming re-manipulations unnecessary. Children ≥12 years in the conservative group achieved satisfactory outcomes despite re-angulations exceeding current guidelines. Based on observed remodelling, we now accept up to 30° angulation in children <9 years; 25° angulation in children aged 9–<12; 20° angulation in children ≥12 years, when re-angulation occurs. We conclude that clinicians should be more reluctant to perform re-manipulations.     

The incidence of distal forearm fractures in Zaragoza (Spain)

We present the results of a retrospective study of the epidemiology of distal forearm fractures in patients over 15 years of age in Zaragoza (Spain) during 1998-1999. We analysed a total of 2506 fractures of the distal forearm. Fractures were classified according to age, sex, Frykman classification and mechanism of injury. Fractures were Frykman type III in 23.5% of cases, Frykman II in 17.9%, Frykman IV in 14.5% and Frykman I in 12.8%. The rest of fractures were distributed homogeneously between the remaining fracture types. The mechanisms of injury was low energy in 78.2% of cases and high in 21.8%. Analysis of the age distribution showed an increase in the incidence of this type of fracture over 50 years of age, with a peak between 60 and 69 years as a result of accidental falls. We found an increased incidence in males below 49 years of age, as a result of traffic accidents, and a predominance of females over 50 years of age due to osteoporosis and an increased number of falls.     

Different risk profiles for hip fractures and distal forearm fractures: A prospective study

In a prospective cohort of elderly persons, aged 70 years and over, we examined risk indicators for which data could be easily obtained, to construct risk profiles for hip fractures and distal forearm fractures. Participants lived independently, in apartment houses for the elderly or in homes for the elderly. At baseline, information was obtained in 2578 subjects on age, gender, residence, mobility and the frequency of going outdoors. Mobility was measured using a walking score ranging from 1 (not able to walk independently) to 3 (able to walk independently for a fair distance). During the study period (median duration 3.5 years, maximum 4 years) 106 participants sustained a hip fracture and 60 participants suffered a distal forearm fracture. Women compared with men, adjusted for age, had a higher risk of hip fracture (adjusted relative risk (RR)=2.4, 95% confidence interval (CI) 1.3–4.3) and distal forearm fracture (RR=3.7, 95% CI 1.5–9.2). Age, adjusted for gender, was related to hip fractures only: the relative risk of fracture for those in the highest age category (>85 years) was 9.5 (95% CI 4.3–21.2) compared with those in the lowest age category (70–75 years). Moderately impaired walking ability compared with normal walking ability, adjusted for age and gender, was associated with a higher risk of hip fracture (RR=1.8, 95% CI 1.2–2.7) but with a lower risk of distal forearm fracture (RR=0.4, 95% CI 0.2–0.8). The outdoor score, adjusted for age and gender, was associated with distal forearm fractures only: going outdoors less than once a week, compared with three times or more, was associated with a lower risk of fractures (RR=0.3, 95% CI 0.1–0.9). In those living in homes for the elderly the risk of hip fracture was higher compared with those living independently (RR=2.4, 95% CI 1.4–4.2), adjusted for age and gender. Risk profiles were constructed using stepwise Cox's proportional-hazards regression. The risk profile predicted probabilites of sustaining a hip fracture in a 4-year period ranging from 0.4% to 25.9%, and of distal forearm fractures ranging from 0.2% to 4.5%, depending on the subject's characteristics as defined by the risk indicators. We conclude that easily obtainable risk indicators can be used in the prediction of fractures and can discriminate among fracture types.     

Secondary osteoporosis and the risk of distal forearm fractures in men and women

Secondary osteoporosis plays an important role in the pathogenesis of hip and spine fractures, but relatively little is known about the potential impact of secondary osteoporosis and fall-related disorders on the risk of distal forearm fractures. To address this issue, we conducted a population-based, nested case-control study comparing 496 Rochester, Minnesota, residents with an initial distal forearm fracture to an equal number of age- and gender-matched controls. Potential risk factors were assessed by review of each subject's complete (inpatient and outpatient) medical records in the community (median duration >30 years) and analyzed using multiple logistic regression. Although history of diabetes mellitus in women (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.15-0.75) and long-term anticonvulsant use in both genders (OR 3.58, 95% CI 1.26-10) were independently associated with fracture risk in a multivariate analysis, the conditions linked with secondary osteoporosis had, in aggregate, no statistically significant association with distal forearm fractures. Fall-related conditions altogether were associated with a borderline increase in risk (OR 1.36, 95% CI 0.98-1.91) and might have accounted for 19% of forearm fracture occurrence in the community. Among women (OR 2.72, 95% CI 1.20-6.19), but not men, a history of prior osteoporotic fracture was also associated with an increase in distal forearm fractures. These factors do not appear to account for the discrepancy in forearm fracture incidence in women when compared with men.