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1 Injury & Osteoporosis Research Center, UKK Institute for Health Promotion Research, Finland.
2 Medical School, University of Tampere, and Division of Orthopaedics and Traumatology, Department of Trauma, Musculoskeletal Surgery and Rehabilitation, Tampere University Hospital, Finland.
3 Tampere Research Center of Sports Medicine, UKK Institute for Health Promotion Research, Finland.
Address correspondence to Professor Pekka Kannus, MD, PhD, UKK Institute, P.O. Box 30, FIN-33501 Tampere, Finland. E-mail: pekka.kannus{at}uta.fi
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Methods. We assessed the current trend in the number and incidence (per 100,000 persons) of low-trauma fractures of the calcaneus and foot of older adults in Finland, a European Union country with a well-defined white population of 5.2 million, by taking into account all persons 50 years old or older who were admitted to Finnish hospitals for primary treatment of such injury in 1970–2005.
Results. The number and raw incidence of low-trauma fractures of the calcaneus and foot among Finns 50 years old or older rose considerably between the years 1970 and 2005, from 64 (number) and 5.6 (incidence) in 1970 to 294 and 15.2 in 2005. For the study period, the age-adjusted incidence of fracture was higher in men than women and showed a clear increase in both sexes in 1970–2005, from 7.3 to 17.4 in men (138% increase), and from 4.3 to 12.5 in women (191% increase). A similar finding was observed in the age-specific incidences. Assuming that the observed increase in the age-specific fracture incidence continues in the 50-year-old or older group and the size of this population increases as predicted, the annual number of low-trauma fractures of the calcaneus and foot in this population will be two times higher in the year 2030 (approximately 550 fractures annually) than it was during 2001–2005.
Conclusions. In Finnish persons aged 50 years or older, the number of low-trauma fractures of the calcaneus and foot has risen considerably in 1970–2005 with a rate that cannot be explained merely by demographic changes. Further studies are needed to explore the exact reasons for the rise and possibilities for fracture prevention.
Key Words: Calcaneus and foot • Elderly adults • Epidemiology • Falls • Low-trauma fractures • Secular trends
Epidemiologic information on these latter fractures, however, is limited, and the literature provides no study investigating the number, incidence, and long-term secular trends of low-trauma fractures of the calcaneus and foot among older adults. Therefore, we assessed the time trends in the absolute number and age-adjusted and age-specific incidence rates of low-trauma fractures of the calcaneus and foot in the 50-year-old or older population in Finland between 1970 (4.61 million inhabitants, of which 1.14 million or 25% were 50 years old or older) and 2005 (5.25 million inhabitants, of which 1.93 million or 37% were 50 years old or older).
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The Finnish NHDR contains data on age, sex, place of residence, hospital number and department, place and cause of injury, diagnosis, day of admission and discharge, and place of further treatment. Injury diagnoses at discharge of the patient are based on all the available clinical and radiological information obtained from the patient during the hospital visit. Concerning the low-trauma fractures of the calcaneus and foot, the final diagnosis is always based on both clinical and radiological information.
In accord with previous epidemiologic studies of low-trauma fractures (1–3,8), this epidemiologic study defined a low-trauma fracture of the calcaneus and foot as a fracture occurring in a person 50 years old or older as a consequence of low-energy trauma (a slip, trip, or fall from standing height or less with resulting ankle–foot contusion or distortion). Thus, all patients 50 years old or older who were admitted to hospitals in Finland for primary treatment of the first low-trauma fracture of the calcaneus or foot (toe fractures were not included) between 1970 and 2005 were selected from the NHDR. Fractures caused by vehicular crashes, falls from greater than standing height, or other high-energy traumas were excluded, as were cases with codes identifying sequalae of previous injuries or their orthopedic aftercare.
Fractures were recorded from the NHDR by evaluating both the primary and secondary diagnoses. The diagnoses were labeled with a 5-digit code according to the 8th, 9th, and 10th revisions of the International Classification of Diseases (ICD-8, ICD-9, ICD-10) that indicated the type of fracture. Between 1970 and 1986, the 8th revision of the ICD and its codes for calcaneus and foot fractures (82500, 82510, 82501, and 82511) were used. Between 1987 and 1995, the corresponding ICD-9 code classes were 8250A–8252F and 8253A–8253X, and between 1996 and 2005 the corresponding ICD-10 code classes were S92.0, S92.1, S92.2, and S92.3.
Database for the Population and Calculation of Fracture Incidence
Annual midyear populations were taken from the Official Statistics of Finland, the statutory, computer-based population register of the country (13). In this register, every Finn is registered by his or her personal identification number and the register is quality-controlled continuously and updated by Statistics Finland, the Central Statistical Office of Finland.
The gender-specific, age-adjusted fracture incidence (per 100,000 persons) was calculated with direct age standardization using the mean population of persons 50 years old or older between 1970 and 2005 as the standard population or reference point (a point for which each annual injury incidence was adjusted). In this way, the fracture rate estimates were amenable to comparison across study years and allowed estimation of the average annual individual risk for low-trauma fracture of the calcaneus and foot. The age-specific fracture incidences (per 100,000 persons) were calculated for three 10-year age groups (50–59, 60–69, and 
70 years).
The fracture data were drawn from the entire population of Finland, the study thus completely covering the intended study population (Finnish nation). Thus, the absolute numbers and incidences of low-trauma fracture of the calcaneus and foot are reported for the complete Finnish population (rather than cohort-based estimates that require statistical analyses with confidence intervals) (2,3).
Prediction of Fractures Until the Year 2030
Finally, the aforementioned age-specific incidence rates of low-trauma fracture of the calcaneus and foot in 1970–2005 were used to predict the age-specific incidence rates in the years 2010, 2020, and 2030 by a linear regression model. Then, within each age and sex group, the predicted absolute number of fractures was obtained by multiplying the aforementioned incidence by the estimated number of inhabitants based on Finnish Population Projections 2006–2030 (14).
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Age-Adjusted Incidence of Low-Trauma Fractures of the Calcaneus and Foot
Throughout the study period, the age-adjusted incidence of fracture was higher in men than women and showed a clear increase in both sexes from 1970 to 2005, from 7.3 to 17.4 in men (138% increase), and from 4.3 to 12.5 in women (191% increase).
Age-Specific Incidence of Low-Trauma Fractures of the Calcaneus and Foot
The age-specific incidence of low-trauma fractures of the calcaneus and foot also increased in all age groups of men and women during the study period (Figure 1). In men, the injury incidence rates in 1970 were 10.2, 5.3, and 4.7 in the age groups of 50–59, 60–69, and 70 years or older, respectively, versus 27.2, 9.9, and 8.2 in 2005. In women, these incidence rates were 5.6, 3.4, and 3.7 in 1970, versus 8.4, 9.4, and 21.7 in 2005.
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Low-Trauma Fractures of the Calcaneus and Foot in the Future
If trends in age-adjusted and age-specific fracture incidence continue at the same rate as were observed between 1970 and 2005, and the 50-year-old and older population increases as predicted (14), the number of low-trauma fractures of the calcaneus and foot in Finland will be twice as high by the year 2030 as was observed during 2001–2005.
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DISCUSSION |
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This nationwide epidemiologic study used the entire Finnish population 50 years old or older to describe the trends between 1970 and 2005 for the absolute number and incidence of low-trauma fractures of the calcaneus and foot. To our knowledge, no such study has been carried out previously, and thus our database and observations added entirely new information on the fracture epidemiology of elderly people. The study revealed that the incidence of low-trauma fractures of the calcaneus and foot was higher in men than women, and that overall number as well as age-adjusted and age-specific incidence of these fractures clearly rose from 1970 to 2005. Among men, the fracture incidence was highest and its secular rise steepest in the youngest age group (men 50–59 years old), whereas among women the same was true for the oldest age group (women 70 years old or older).
Our findings confirm previous observations from Finland and elsewhere that various fall-induced fractures and other injuries of older adults have been a rapidly growing problem in recent decades (2–7,15) and they suggest further that this undesirable trend has not stopped in the new millennium. It is also unfortunate that the further aging of the population is likely to increase the problem so that by the year 2030 Finland is likely to face more than 500 low-trauma fractures of the calcaneus and foot among persons 50 years old or older each year. Many other developed countries are likely to face similar problems, although detailed epidemiologic data from other countries are largely lacking. Although the homogeneity of our Finnish white population limits the direct generalizability of the results to different and more diverse populations, we feel that our findings provide important and useful public health information for many other countries as well.
The precise reasons for the rise in the age-adjusted incidence of various low-trauma injuries in elderly persons are unknown (2–5,7). An increase in the average risk of slipping, tripping, and falling—caused by impaired muscle strength, balance, and reaction time—may partly explain the phenomenon. The decrease in these domains of musculoskeletal performance have been explained by such factors as poorer physical condition, less-active lifestyle with increased average body weight, poorer nutritional status (vitamin D and calcium), increased consumption of cigarettes and alcohol, greater occurrence of coexisting medical problems, and the increased use of balance-affecting drugs (3,4,7,16).
In this study of low-trauma fractures of the calcaneus and foot, the age groups for highest risk of fracture were quite different between women and men, and this may suggest gender-related differences in fracture mechanisms and contributing factors. Among women, a highest and most steeply rising injury incidence was seen in the oldest age group (Figure 1). This is a characteristic feature for many types of frailty-associated falls and low-trauma injuries of elderly people and thus a very important public health issue (1,2,4,5,8). Men, however, showed two rather atypical injury characteristics: men's age-adjusted fracture incidence was higher than that in women, and the fracture incidence was highest in the youngest group of men (Figure 1). Because the general incidence of falling is higher in elderly women than elderly men (3,4,6,7), it can be hypothesized that the younger groups of elderly men have an increased risk for severe, uncontrolled slips, trips, and falls than do their female counterparts. Further studies are, however, needed to confirm these findings and examine the exact reasons for this gender difference. In this respect, the influence of gender difference in alcohol usage, risk-taking behavior, or any other indicator of hazardous lifestyle will be of interest.
Conclusion
In Finnish persons aged 50 years or older, the number of low-trauma fractures of the calcaneus and foot has risen sharply in 1970–2005 with a rate that cannot be explained merely by demographic changes. Further studies are needed to explore the exact reasons for the rise and possibilities for fracture prevention.
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Received October 26, 2006
Accepted August 27, 2007
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