Urban Bengnér

Increasing age-adjusted risk of fragility fractures: a sign of increasing osteoporosis in successive generations?

The age-adjusted incidence of fragility fractures is increasing. This is the outcome of almost all epidemiologic studies that have been done throughout the world during the last 40 years. However, a few studies that have shown an unchanged incidence of hip fractures are as often cited in recent literature, which motivates a discussion of the issue. There are signs that favor the fact that the increasing incidence of fractures in the elderly is evidence of a deterioration of the skeleton in successive generations. Its possible reasons are discussed. The epidemiology of fractures has been studied more thoroughly in Malmr, Sweden than in any other place. The favorable conditions for such investigations in our city have been used in many studies since the beginning of this century [1, 2], up to the present, where all the fractures from those occurring at birth [3] to the fractures sustained by already hospitalized elderly [4] have been investigated. These investigations together with all other studies on fracture epidemiology (to our knowledge) are reviewed in the first part of this article. In the second, possible reasons for the increasing ageadjusted incidence of fragility fractures are discussed.

Increasing incidence of forearm fractures A comparison of epidemiologic patterns 25 years apart

During 1980 and 1981, 1914 fractures of the distal forearm occurred in Malmö, Sweden. The age-specific incidence peaked in childhood and there was a large increase in women after the age of 50; in men there was a smaller increase after the age of 70. In comparison with the Alffram & Bauer (1962) study of the same population in 1953-57, the age-specific incidence in elderly women and men has almost doubled. There was almost the same incidence of shaft fracture of the ulna or radius as 25 years ago.

Changes in the incidence of fracture of the upper end of the humerus during a 30-year period. A study of 2125 fractures

The incidence of fracture of the upper end of the humerus by age group and sex was studied for a 32-year period from 1950 to 1982. The following numbers of humeral fractures occurred: 1950-1954, 411 fractures; 1961-1964, 552 fractures; 1971-1973, 639 fractures; and 1981-1982, 523 fractures. There was a progressive increase in the age-related incidence in older persons, especially in women. There was a higher incidence of fractures classified as severe in the 1980s compared with the 1950s.

Changes in incidence and prevalence of vertebral fractures during 30 years

SummaryThe age and sex-specific incidence and prevalence of vertebral compression fractures were compared between the 1950s and 1980s in an urban population. In women over 80 years of age the incidence of symptomatic vertebral fractures has increased approximately four times; in elderly men even more. Mainly, low-energy trauma has caused these fractures. Thus, one clinical manifestation of osteoporosis-vertebral fracture-has increased in number, incidence, and prevalence over the last 30 years.

Fractures of the distal end of the radius in young adults: a 30-year follow-up

76 patients were examined clinically and radiologically 27 to 36 years after a fracture of the distal radius. The average age was 31 years at the time of injury and 63 years at follow-up. In 81% of the patients there was no difference between the fractured and the non-fractured side. No patient had to change his or her occupation or leisure activities because of the fracture. There were more degenerative changes in the fractured wrist than in the non-injured side. A statistically significant correlation was found between axial compression and the presence of degenerative changes in the radio-carpal and distal radio-ulnar joints. Treatment of the fracture of the distal end of the radius in the young adult should aim to conserve the length of the radius. However, after 30 years, complaints are few and correlate with degenerative changes in the radio-carpal joint only. 47 patients with articular fractures of the distal end of the radius were examined in the same way. The average age at the time of injury was 32 years and 58% of the patients were men. In 87% of the patients there was no difference between the fractured and the non-fractured side. However 37% had minor complaints. A higher proportion of patients with articular fractures developed degenerative changes than those with non-articular fractures. The existence of radiographic signs of osteoarthritis is directly related to axial compression and the persistant incongruity, after reposition, in either the radio-carpal or the distal radio-ulnar joints.

Epidemiology of ankle fracture 1950 and 1980: increasing incidence in elderly women

During 1980-82, 739 ankle fractures occurred in Malmö. These were compared with 383 ankle fractures occurring in 1950-52. In men there was an increase in the age-specific incidence up to the age of 60, especially in fractures of the lateral malleolus. In women there was an increase in the age-specific incidence above the age of 50, both in lateral malleolar fractures and, even more pronounced, in bi- and tri- malleolar fractures.

Supination-eversion fractures of the ankle joint: changes in incidence over 30 years

The sex- and age-specific incidence has been calculated for ankle fractures from the first part of the 1950s and compared with the 1980s, a 30-year interval. The fractures were also classified according to Lauge-Hansen. Altogether 1784 fractures were found. During that time interval ankle fractures had become more common, particularly those with extensive skeletal involvement, such as the stage IV supination-eversion fractures, which today have an incidence pattern more typical of a fragility fracture in elderly women.

Forearm fractures in Malmo, Sweden. Changes in the incidence occurring during the 1950s, 1980s and 1990s

Between the 1950s and the 1980s, the incidence of forearm fractures increased in the city of Malmö. We have now collected data on all forearm fractures during 1991 and 1992 and compared them with previously published data from 1953-1957 and 1980-1981. During the 1990s, 1314 individuals with wrist fractures and 125 with shaft fractures were recorded. In men, we found a twofold increase in the standardized morbidity ratio (SMR) in the 1990s, compared with the 1950s. The 1990s, compared with the 1980s, showed a reduction in SMR to 0.85. In women, a comparison between the 1990s and the 1950s revealed a slight reduction in SMR, 0.9 during the 1990s. Comparison of the 1990s with the 1980s revealed a reduction in SMR to 0.7 after the age of 70 years. In individuals 60 years and older, we found a fivefold increase in the incidence of fractures of the shaft of the forearm, when comparing the 1990s with the 1980s. In women, the increase in incidence of wrist fractures appears to have been interrupted, when comparing the years 1991-1992 and 1980-1981. Among men, the incidence of wrist fractures appears to be increasing, even after the 1980s. The reduction in incidence among women may partly be explained by warmer winters during 1991-1992.

Incidence of femoral and tibial shaft fractures. Epidemiology 1950-1983 in Malmö, Sweden.

We studied 362 fractures of the femur that had occurred during the years 1950-57 and 1973-83, and 849 fractures of the tibia that occurred during the the years 1950-55 and 1980-83. There was an increase in age-specific incidence over aged 60 years. The risk of low-energy femoral shaft fractures also had increased in elderly women. Both fracture types shifted their age- and sex-specific incidence in the direction of a fragility pattern. There was no increase in the incidence of tibial shaft fractures. Fracture type, site, and degree of displacement of the tibial fractures remained unchanged during the 30 years, i.e, they were predominantly distal, longitudinal fractures with moderate displacement.

Increasing incidence of tibia condyle and patella fractures

The age and sex specific incidence of tibial condyle fractures and patellar fractures were compared between 1950-55 and 1980-83 in the urban population of Malmö. In elderly women there was an increased incidence over these 30 years for both fracture types.