Current and future burden of incident hip fractures in New South Wales, Australia

Incidence of fragility hip fracture across the Asia-pacific region: A systematic review

PURPOSE

This systematic review aimed to update fragility hip fracture incidences in the Asia Pacific, and compare rates between countries/regions.

METHOD

A systematic search was conducted in four electronic databases. Studies reporting data between 2010 and 2023 on the geographical incidences of hip fractures in individuals aged ≥50 were included. Exclusion criteria were studies reporting solely on high-trauma, atypical, or periprosthetic fractures. We calculated the crude incidence, age- and sex-standardised incidence, and the female-to-male ratio. The systematic review was registered with PROSPERO (CRD42020162518).

RESULTS

Thirty-eight studies were included across nine countries/regions (out of 41 countries/regions). The crude hip fracture incidence ranged from 89 to 341 per 100,000 people aged ≥50, with the highest observed in Australia, Taiwan, and Japan. Age- and sex-standardised rates ranged between 90 and 318 per 100,000 population and were highest in Korea and Japan. Temporal decreases in standardised rates were observed in Korea, China, and Japan. The female-to-male ratio was highest in Japan and lowest in China.

CONCLUSION

Fragility hip fracture incidence varied substantially within the Asia-Pacific region. This observation may reflect actual incidence differences or stem from varying research methods and healthcare recording systems. Future research should use consistent measurement approaches to enhance international comparisons and service planning.

Experiences of Boosting Inpatient Exercise After HipFracture Surgery Using An Alternative Workforce - A Qualitative Study

BACKGROUND

Thrice-daily physiotherapy immediately following surgical repair of hip fracture has been shown to be safe and to reduce total hospital length of stay. However, implementing this is challenging with respect to health service funding and staffing. A novel approach may be to utilize an alternative workforce (allied health staff and student physiotherapists) to deliver two of the three daily treatments. However, how patients and staff may view such an approach is unknown. Thus, the aim of this qualitative study was to explore the views of inpatients with surgical repair of a hip fracture, their carers, health care professionals, and physiotherapy students about the implementation and acceptability of thrice-daily physiotherapy, with two sessions delivered by the alternative workforce (the BOOST study).

METHODS

Semi-structured interviews and focus groups with patients, carers, health professionals and physiotherapy students. All interviews were digitally recorded and transcribed via verbatim. The transcripts were coded, and the data analysed via inductive thematic analysis.

RESULTS

A total of 37 interviews (32 one-to-one interviews and five focus group interviews) were analysed. Five main themes were identified: (1) individual perceptions of the intervention: inpatients/carer/staff/student, (2) implementation within the service and organisational context, (3) implementation strategies that were effective, (4) improvements to implementation strategies/barriers to implementation/unsuccessful strategies and (5) future directions of BOOST.

CONCLUSIONS

The qualitative data revealed that higher frequency physiotherapy was well-received by inpatients and that staff/students involved in providing care perceived it as a safe, acceptable and valuable practice. Implementation of higher daily frequency of physiotherapy using an alternative workforce may feasibly be adopted for inpatients following hip fracture surgery.

TRIAL REGISTRATION

This study was approved by the Human Research Ethics Committee (HREC) of the Western Sydney Local Health District (2020/ETH02718). Mutual recognition of approval was subsequently obtained from Northern Sydney Local Health District HREC.

The role of frailty risk for fracture-related hospital readmission and mortality after a hip fracture

BACKGROUND

Frailty risk estimated using hospital administrative data may provide a useful clinical tool to identify older hip fracture patients at-risk of fracture-related readmissions and mortality. This study examined hip fracture hospitalisation temporal trends and explore the role of frailty risk in fracture-related readmission and mortality.

METHODS

This retrospective cohort study was conducted using linked hospital admission and mortality data in New South Wales, Australia. Patients aged ≥65 years were admitted after a hip fracture between 2014 and 2021 for temporal trends and those admitted and discharged after a hip fracture in 2014-2018 for fracture-related readmission. The Hospital Frailty Risk Score was estimated, and patients were followed for at least 36 months after discharge. A semi-competing risk analysis was used to examine the associations of frailty with fracture-related readmission and/or mortality.

RESULTS

Hip fracture hospitalisation rate was 472 per 100,000 and declined by 2.9 % (95 % confidence intervals (CI): -3.7 to -2.1) annually. Amongst 28,567 patients, 9.8 % were identified with low frailty risk, 39.4 %, intermediate frailty risk, and 50.6 % with high frailty risk. Patients with intermediate or high frailty risk had a higher chance of fracture-related readmission (Hazard ratios (HR): 1.33, 95 %CI: 1.21-1.47, HR: 1.65, 95 %CI: 1.49-1.83), death (HR: 1.50, 95 %CI: 1.38-1.63, HR: 1.80, 95 %CI: 1.65-1.96) and death post fracture-related readmission (HR: 1.32, 95 %CI: 1.12-1.56, HR: 1.56, 95 %CI: 1.32-1.84) than those with low frailty risk.

CONCLUSIONS

It appears that frailty risk estimated using hospital administrative data can contribute to identify patients who could benefit from targeted interventions to prevent further fractures.

HIP fracture Supplemental Therapy to Enhance Recovery (HIPSTER): a protocol for a randomised controlled trial

INTRODUCTION

Hip fractures result in substantial health impacts for patients and costs to health systems. Many patients require prolonged hospital stays and up to 60% do not regain their prefracture level of mobility within 1 year. Physical rehabilitation plays a key role in regaining physical function and independence; however, there are no recommendations regarding the optimal intensity. This study aims to compare the clinical efficacy and cost-effectiveness of early intensive in-hospital physiotherapy compared with usual care in patients who have had surgery following a hip fracture.

METHODS AND ANALYSIS

This two-arm randomised, controlled, assessor-blinded trial will recruit 620 participants who have had surgery following a hip fracture from eight hospitals. Participants will be randomised 1:1 to receive usual care (physiotherapy according to usual practice at the site) or intensive physiotherapy in the hospital over the first 7 days following surgery (two additional sessions per day, one delivered by a physiotherapist and the other by an allied health assistant). The primary outcome is the total hospital length of stay, measured from the date of hospital admission to the date of hospital discharge, including both acute and subacute hospital days. Secondary outcomes are functional mobility, health-related quality of life, concerns about falling, discharge destination, proportion of patients remaining in hospital at 30 days, return to preadmission mobility and residence at 120 days and adverse events. Twelve months of follow-up will capture data on healthcare utilisation. A cost-effectiveness evaluation will be undertaken, and a process evaluation will document barriers and facilitators to implementation.

ETHICS AND DISSEMINATION

The Alfred Hospital Ethics Committee has approved this protocol. The trial findings will be published in peer-reviewed journals, submitted for presentation at conferences and disseminated to patients and carers.

TRIAL REGISTRATION NUMBER

ACTRN12622001442796.

Measurement of Mobility and Physical Function in Patients Hospitalized With Hip Fracture: A Systematic Review of Instruments and Their Measurement Properties

OBJECTIVE

Hip fractures are common and significantly impact mobility and physical function. Measurement of patient progress post hip fracture in the acute hospital setting is important to monitor early recovery and outcomes. The objective of this systematic review was to assess the measurement properties (reliability, validity, responsiveness), interpretability, and clinical utility of instruments used to measure mobility and physical function in patients with hip fracture in the acute hospital setting.

METHODS

Three databases (MEDLINE, Embase, and CINAHL) were searched. Studies reporting direct clinician assessment instruments to measure mobility or physical function in patients with hip fracture were included. Data were extracted by 2 reviewers, and the quality of each study was determined using the COnsensus-based Standards for the selection of health Measurement INstruments risk of bias checklist.

RESULTS

Sixty-eight studies were included with 19 measurement instruments identified. The most frequently used instruments were the Timed "Up & Go" Test (TUG) (19 studies), Barthel Index (BI) (18 studies), Cumulated Ambulation Score (CAS) (18 studies), and Functional Independence Measure (FIM) (14 studies). All 4 of these instruments demonstrated good predictive validity (clinical outcomes and mortality) and responsiveness over time (effect sizes 0.63-2.79). The BI and CAS also had good reliability (intraclass correlation coefficient [ICC] >0.70). Floor effects were demonstrated for the TUG, CAS, and FIM (16%-60% of patients). The TUG, CAS, and BI all had good clinical utility.

CONCLUSION

Depending on the context (use by treating clinicians, research, benchmarking), 1 or a combination of the BI, CAS, and TUG provide robust measurement of mobility and physical function for patients with hip fracture in the acute hospital setting.

IMPACT

This study identified 3 instruments suitable for measuring mobility and physical function in hospitalized patients following hip fracture. This provides clinicians with tools to measure patient progress and benchmark across sites to improve patient outcomes.

Minimal trauma hip fracture hospitalisations among older Indigenous and non-Indigenous Australians: A retrospective population-based cohort study

OBJECTIVES

To compare minimal trauma hip fractures (MTHF) between older Indigenous and non-Indigenous Australians.

METHODS

Epidemiological study of retrospective New South Wales hospitalisation data (2005-2016) for MTHF among Indigenous and non-Indigenous Australians over 40 years of age.

RESULTS

Estimated age-standardised rates of MTHF were lower among Indigenous Australians than non-Indigenous Australians (142.2 vs. 161.7 per 100,000) with a direct standardised rate ratio of 0.887 (95%CI 0.78-0.99, p = 0.031). However, for both male and female Indigenous Australians, MTHF occur at a younger age than in non-Indigenous Australians (age 40-74: 52% vs. 19%, p < 0.001). Proportions of MTHF are higher among women and were almost double among rural Indigenous Australians compared with rural non-Indigenous Australians (59% vs. 31%, p < 0.001).

CONCLUSIONS

New South Wales Hospitalisation data showed that estimated age-standardised rates of MTHF appear lower among Indigenous Australians than in non-Indigenous Australians but also occur at a younger age for Indigenous people. MTHF are more common among rural Indigenous Australians and women.

Dedicated hip fracture services: A systematic review

BACKGROUND

Hip fractures (HFs) are common and pose a significant burden to both the individual and the community. Prompt operative management and aggressive rehabilitation have been shown to improve outcomes. However, there is often a delay in treatment due to lack of theatre availability and appropriate perioperative multi-disciplinary care. This study reviews the literature and reports on outcomes of HFs treated in dedicated units with allocated theatre time and pre-determined multi-disciplinary perioperative pathways. It also provides comparison against outcomes data from HF registries, both domestically and internationally.

METHODS

An electronic literature search was performed to identify original, English language studies reporting on patient outcomes from dedicated HF units (HFUs). Studies were graded using the Journal of Bone and Joint Surgery criteria. Data were extracted from the text, table and figures of the selected studies.

RESULTS

Five appropriate studies, with a total cohort of 6633 patients (4032 of whom were treated in a dedicated HFU), were identified. Patients treated in these units sustained a lower mortality rate (Risk Ratio  = 0.62, p = 0.01).

CONCLUSIONS

This review demonstrates that centres with dedicated HFUs result in improved 30-day mortality. Further research may demonstrate more sustained improvements in outcomes. The implementation of dedicated HFUs within health systems should be considered.

Hip fracture pain management in a regional Australian emergency department: A retrospective descriptive study

BACKGROUND

Hip fractures are a common and painful emergency presentation amongst elderly patients and are associated with significant morbidity and mortality. This study observed the frequency of documentation of pain scores and use of nerve blocks in hip fracture patients in a regional Australian ED and describes current practice in relation to national guidelines.

METHODS

This was a retrospective single-site observational study and included all patients with a recorded ED diagnosis of fracture neck of femur over the age of 18 presenting between 1 July 2017 and 31 December 2017 to a regional ED. Data collection included patient demographics, pain scores and analgesia administered.

RESULTS

Ninety-three patients were included in analysis. This population had a high proportion of patients who had a residential address remote to the base hospital. Thirty-eight patients (41%) had a documented pain score within 30min and the frequency of nerve blocks was 45%.

CONCLUSION

Management of pain for patients with hip fracture in this regional ED varied from Australian guidelines and practice in other Australian EDs, demonstrating potential areas for further research and quality improvement in assessing and treating pain in older adults. Geographic remoteness may be an important factor.

Evaluation of Nottingham Hip Fracture Score, Age-Adjusted Charlson Comorbidity Index and the Physiological and Operative Severity Score for the enumeration of Mortality and morbidity as predictors of mortality in elderly neck of femur fracture patients

Background:

This study evaluated the use of several risk prediction models in estimating short- and long-term mortality following hip fracture in an Australian population.

Methods:

Data from 195 patients were retrospectively analysed and applied to three models of interest: the Nottingham Hip Fracture Score, the Age-Adjusted Charlson Comorbidity Index and the Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity. The performance of these models was assessed with receiver operating characteristic curve as well as logistic regression modelling.

Results:

The median age of participants was 83 years and 69% were women. Ten percent of patients were deceased by 30 days, 25% at 6 months and 31% at 12 months post-operatively. While there was no statistically significant difference between the models, the Age-Adjusted Charlson Comorbidity Index had the largest area under the receiver operating characteristic curve for within 30 day and 12 month mortality, while the Nottingham Hip Fracture Score was largest for 6-month mortality. There was no evidence to suggest that the models were selecting a specific subgroup of our population, therefore, no indication was present to suggest that using multiple models would improve mortality prediction.

Conclusions:

While there was no statistically significant difference in mortality prediction, the Nottingham Hip Fracture Score is perhaps the best suited clinically, due to its ease of implementation. Larger prospective data collection across a variety of sites and its role in guiding clinical management remains an area of interest.

The Positive Predictive Value of Hip Fracture Diagnoses and Surgical Procedure Codes in the Danish Multidisciplinary Hip Fracture Registry and the Danish National Patient Registry

Aim

The health-care databases may be a valuable source for epidemiological research in hip fracture surgery, if the diagnoses are valid. We examined the validity of hip fracture diagnoses and surgical procedure codes in the Danish Multidisciplinary Hip Fracture Registry (DMHFR) and the Danish National Patient Registry (DNPR) by calculating the positive predictive value (PPV).

Methods

We identified a random sample of 750 hip fracture patients registered in the DMHFR between 2014 and 2017. Diagnoses have been coded by the 10^th revision of the International Classification of Diseases, while procedures have been coded by the Nordic Medico-Statistical Committee classification in the DNPR and directly transferred to the DMHFR. Using the surgical procedure description from the medical record as gold standard, we estimated the PPV of the hip fracture diagnoses and surgical procedure codes in the DMHFR and the DNPR with 95% confidence interval (CIs).

Results

The PPV was 90% (95% CI: 86%-93%) for fracture of the neck of femur, 92% (95% CI: 87%-95%) for trochanteric fracture, and 83% (95% CI: 78%-88%) for subtrochanteric fracture. Joining trochanteric and subtrochanteric fracture resulted in a PPV of 97% (95% CI: 95%-98%). Procedure codes had a PPV of 100% for primary prosthetic replacement and internal fixation with intramedullary nail, 96% (95% CI: 85%-99%) for internal fixation using screws alone, 91% (95% CI: 84%-96%) for internal fixation using plates and screws, and 89% (95% CI: 83%-94%) for internal fixation with other or combined methods. Stratifying by age group, gender, hospital type and calendar year of surgery showed similar results as the overall PPV estimates.

Conclusion

Our findings indicate a high quality of the hip fracture diagnoses and corresponding procedure codes in the DMHFR and the DNPR, with a majority of PPVs above 90%. Thus, the DMHFR and the DNPR are a valuable data source on hip fracture for epidemiological research.

Swallowing disorders in an older fractured hip population

OBJECTIVE

Dysphagia is prevalent in the older population and might lead to complications, such as pneumonia, malnutrition and dehydration. This study examines an older population post hip-fracture surgery to examine the factors correlated with dysphagia, severity of dysphagia and the incidence of dysphagia in a regional setting.

DESIGN

This prospective cohort study replicates Love et al's (2013, Age Ageing, 42:782) and compares the studies' results. Participants were assessed for dysphagia within 72 hours post hip-fracture surgery. Descriptive statistics were used to calculate the incidence and severity of dysphagia, and collate pre-operative and post-operative characteristics. Univariate and multivariate logistic regression analyses were used to describe relationships between dysphagia and explanatory variables, and to predict the presence of post-operative oropharyngeal dysphagia.

SETTING

General orthopaedic ward at a North Queensland regional hospital.

PARTICIPANTS

One-hundred-three participants: 78 women and 25 men, aged 65-94 years.

MAIN OUTCOME MEASURE(S)

The presence and severity of dysphagia were identified based on the clinical judgement of speech pathologists with at least 2 years' experience in managing patients with acute dysphagia.

RESULT

Fifty-four per cent of the participants were diagnosed with dysphagia of varying severity. Female sex, post-operative confusion and living in a residential aged-care facility prior to admission, significantly predicted dysphagia post-surgery. Post-operative confusion and living in a residential aged-care facility prior to admission, were also significantly correlated with severity of dysphagia post-operatively.

CONCLUSION

Dysphagia was present in a higher proportion of this cohort than that reported by Love et al. This highlights the necessity of timely assessment and management of dysphagia in an older population post-surgery for a fractured hip.

The epidemiology and economic burden of hip fractures in Israel

Background

Hip fractures increase the risks of mortality and major morbidity in the elderly. Hip fractures are associated with chronic pain, reduced mobility, disability and increasing dependence. We evaluated the direct costs incurred to the Israeli healthcare system in 2013 as a result of hip fracture injuries in elderly patients.

Methods

Hip fractures costs evaluation consisted of first-year and long-term direct costs. Data on the incidence of hip fractures resulting in hospitalizations were retrieved from the Israeli Ministry of Health’s (MOH) Central Database of Hospital Admissions. Hospitalization, rehabilitation and nursing utilization rates and costs were estimated based on the professional literature and according to the MOH’s price list.

Results

During 2013, 6285 elderly patients were hospitalized in Israel due to hip fractures. Direct costs of hip fracture, comprising hospitalization, rehabilitation and nursing costs incurred during the first year after the injury, were estimated at 454 million New Israeli Shekels (NIS; 83,841 NIS per person). Long-term nursing care costs in 2013 were 265 million NIS, with an average cost of approximately 49,000 NIS for 1600 elderly persons receiving long-term nursing care as a result of a hip fracture. Overall, the total direct costs of hip fracture in the elderly population in Israel in 2013 were 719 million NIS.

Conclusions

The direct costs of hip fractures in Israel among the elderly are approximately 719 million NIS per year. The majority of costs are associated with the first year following the injury. To reduce healthcare costs in Israel, changes in the country’s healthcare policy on hip fractures are required. For example, there is a need for a program for detecting high- risk populations, and for early intervention following the injury.

Electronic supplementary material

The online version of this article (10.1186/s13584-018-0235-y) contains supplementary material, which is available to authorized users.

The burden of inpatient care for diabetic and non-diabetic patients with osteoporotic hip fractures-does it differ? An analysis of patients recruited into a fracture liaison service in Southeast Asia

Hospital care and mortality of diabetic and non-diabetic osteoporotic Asian patients undergoing hip fracture surgery were explored with no difference in length of hospitalization, incidence of post-operative complications, or mortality between diabetics and non-diabetics seen. Time to operation correlated with post-operative complications occurrence and therefore surgery should be expeditiously done.

INTRODUCTION

Whether burden of inpatient care, problems after admission, and mortality rates differ between diabetics and non-diabetics undergoing surgery for osteoporotic hip fractures has not been explored in Asian populations.

METHOD

Three hundred eighty-nine multi-ethnic diabetic and non-diabetic patients recruited into a FLS at a large Asian hospital with new osteoporotic hip fractures requiring operative repair were analyzed.

RESULTS

87.9% were Chinese, 6.4% Malay, and 3.6% Indians. BMI and age did not significantly differ between diabetics and non-diabetics. Median (IQR) length of hospitalization (LOHS) in days was 12 (9, 17) in diabetics and 11 (8, 14) in non-diabetics (p = 0.011). Median time from admission to operation (TTO) was 3 (2, 5) in diabetics versus 2 (1, 4.5) in the non-diabetics (p = 0.003). Occurrence of aggregate post-operative complications did not differ between diabetics and non-diabetics. No in-hospital mortalities occurred in either group. Thirty-day and 1-year mortality rates did not differ between the two groups. One-year mortality was 2.8% in the entire cohort. On multivariate regression analysis adjusted for age and race, only TTO (β; 1.8, 95% CI 1.5-2.0, p < 0.001) and occurrence of post-operative complications (β; 6.3, 95% CI 3.7-7.9, p < 0.001) correlated with LOHS. TTO and age-adjusted Charlson's Comorbidity Index (CCI) correlated significantly with the development of post-operative complications.

CONCLUSIONS

Diabetes was not independently associated with LOHS in patients undergoing hip fracture surgery. Aggregate post-operative complications did not differ between diabetics and non-diabetics. TTO and occurrence of post-operative complications significantly affected LOHS. TTO correlated with post-complications development. Surgery should be expeditiously done in both diabetics and non-diabetics to avoid the development of post-operative complications and to prevent prolonged hospital stay.

Mortality risk among older Australians hospitalised with hip fracture: a population-based matched cohort study

With an ageing population, the burden of hip fractures is expected to increase in the coming decades. Older individuals with hip fracture are more than 3.5 times more likely to die within 12 months compared to non-injured individuals. The main priority for reducing mortality should be prevention of hip fracture.

PURPOSE

The aim of this study is to quantify and describe the 12-month mortality of older persons presenting to hospitals in Australia with a hip fracture.

METHODS

Population-based matched cohort study using linked hospital and mortality data from four Australian states (New South Wales, Queensland, South Australia, and Tasmania). Individuals aged 65 years and older who had a hospital admission with a primary diagnosis of hip fracture in 2009 (n = 9748) and a matched comparison cohort of non-injured individual were selected from the electoral roll (n = 9748). The comparison group was matched 1:1 on age, sex, and postcode of residence. Adjusted mortality rate ratios (MRR) and attributable risk percent were calculated. Cox proportional hazard regression was used to examine the effect of risk factors on survival.

RESULTS

The hip fracture cohort experienced significantly worse survival at the 12-month post-fracture hospitalisation (P < 0.0001). Individuals with hip fracture were more than 3.5 times more likely to die within 12 months compared to their non-injured counterparts (MRR 3.62 [95%CI 3.23-4.05]). Hip fracture was likely to be a contributory factor in 72% of mortality within 12 months after the index hospital admission. Excess mortality risk at 12 months was higher in males than that in females and in the 65-74-year age group.

CONCLUSIONS

With an ageing population in Australia, the burden of hip fractures is expected to increase in the coming decades. Because incident hip fracture is the main predictor of subsequent mortality, the main priority for reducing excess mortality after hip fracture is primary and secondary prevention of hip fracture.

Validity of routinely collected data in identifying hip fractures at a major tertiary hospital in Australia

OBJECTIVES

To examine the validity of routinely collected data in identifying hip fractures (HFs) and to identify factors associated with incorrect coding.

METHOD

In a prospective cohort study between January 2014 and June 2016, HFs were identified using physician diagnosis and diagnostic imaging and were recorded in a Registry. Records of HFs in the health information exchange (HIE) were identified using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification/Australian Classification of Health Interventions/Australian Coding Standards codes. New HFs were estimated by episode of care, hospital admission and with an algorithm. Data from the HIE and the Registry were compared.

RESULTS

The number of HFs as the principal diagnosis (PD) recorded by episode (864) was higher than by admission (743), by algorithm (711) and in the Registry (638). The sensitivity was high for all methods (90-93%) but the positive predictive value was lower for episode (68%) than for admission (80%) or algorithm (81%). The number of HFs with surgery recorded in the PD by episode (639), algorithm (630) and in the Registry (623) was similar but higher than by admission (589). The episode and algorithm methods also had higher sensitivity (91-92%) than the admission method (84%) for HFs with surgery. Factors associated with coding errors included subsequent HF, long hospital stay, intracapsular fracture, younger age, male, HF without surgery and death in hospital.

CONCLUSIONS

When it is not practical to use the algorithm for regular monitoring of HFs, using PD by admission to estimate total HFs and PD by episode in combination with a procedure code to estimate HFs with surgery can produce robust estimations.

The Epidemiology of Incident Fracture from Cradle to Senescence

To reduce the burden of fracture, not only does bone fragility need to be addressed, but also injury prevention. Thus, fracture epidemiology irrespective of degree of trauma is informative. We aimed to determine age-and-sex-specific fracture incidence rates for the Barwon Statistical Division, Australia, 2006-2007. Using radiology reports, incident fractures were identified for 5342 males and 4512 females, with incidence of 210.4 (95 % CI 204.8, 216.2) and 160.0 (155.3, 164.7)/10,000/year, respectively. In females, spine (clinical vertebral), hip (proximal femoral) and distal forearm fractures demonstrated a pattern of stable incidence through early adult life, with an exponential increase beginning in postmenopausal years for fractures of the forearm followed by spine and hip. A similar pattern was observed for the pelvis, humerus, femur and patella. Distal forearm, humerus, other forearm and ankle fractures showed incidence peaks during childhood and adolescence. For males, age-related changes mimicked the female pattern for fractures of the spine, hip, ribs, pelvis and humerus. Incidence at these sites was generally lower for males, particularly among the elderly. A similar childhood-adolescent peak was seen for the distal forearm and humerus. For ankle fractures, there was an increase during childhood and adolescence but this extended into early adult life; in contrast to females, there were no further age-related increases. An adolescent-young adult peak incidence was observed for fractures of the face, clavicle, carpal bones, hand, fingers, foot and toe, without further age-related increases. Examining patterns of fracture provides the evidence base for monitoring temporal changes in fracture burden, and for identifying high-incidence groups to which fracture prevention strategies could be directed.