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The Geographic Incidence
and Treatment Variation of
Common Fractures of
Elderly Patients
Abstract
Fractures of the hip, wrist, proximal humerus, and ankle frequently
are observed among the elderly patient population in the United
States. The Medicare patient population has shown dramatic
geographic variation in the rates of these common fractures, with
an increased incidence observed throughout the Southeast.
Treatment (surgical versus nonsurgical) is also highly variable and
dependent on the geographic location but not necessarily on the
type of injury. Whereas regional variation in medical treatment
may be attributed to variations in practice patterns, the etiology
behind the dramatic variations in fractures is less well-defined and
is likely multifactorial, related to environmental, occupational,
genetic, or nutritional factors.
O
lder patients (>65 years) are
known to be at risk for fracture
because of their increased incidence
of osteoporotic bone, poor balance,
compromised vision, and delay-
ed reaction times.
1-4
Additionally,
many older patients have atrophic
soft tissues, such that forces may be
more easily transmitted to the un-
derlying bony structures.
4

As a re-
sult, this elderly group represents a
substantial proportion of the pa-
tients with fractures of the hip,
wrist, proximal humerus, and an-
kle.
5
Despite the well-known fre-
quency of fractures in older individ-
uals, little is known about the
geographic differences between frac-
ture rates and the geographic varia-
tion in treatment of these common
injuries.
Authors have shown varying
fracture patterns among elderly in-
dividuals throughout the United
States. In these limited patient pop-
ulations, patients residing in the
South were more likely than those
in the Northeast to sustain a hip
fracture.
6-10
However, researchers
know little about the underlying eti-
ology of this discrepancy and
whether the discrepancy persists
when patients change geographic lo-
cation.
11

Additionally, the regional
variation in treatment of these frac-
tures is not well understood.
Using Medicare data, Weinstein
in the Dartmouth Atlas of Muscu-
loskeletal Health Care (DAMHC)
showed large geographic variations
among the rates of the four most
common orthopaedic fractures in
the elderly (ie, hip, wrist, proximal
humerus, ankle) despite similar ac-
cess to medical care.
5
Additionally,
geographic residence among patients
sustaining these injuries strongly
correlates with the type of fracture
management (ie, surgical versus
nonsurgical).
12
Scott M. Sporer, MD, MS
James N. Weinstein, DO, MS
Kenneth J. Koval, MD
Dr. Sporer is Assistant Professor,
Department of Orthopaedic Surgery,
Rush Medical College, Winfield, IL. Dr.
Weinstein is Chairman and Professor,
Department of Orthopaedic Surgery,
Dartmouth-Hitchcock Medical Center,
Lebanon, NH, and Professor, Dartmouth

Medical School and the Center for the
Evaluative Clinical Sciences, Dartmouth
College, Hanover, NH. Dr. Koval is
Professor, Department of Orthopaedic
Surgery, Dartmouth-Hitchcock Medical
Center.
None of the following authors or the
departments with which they are
affiliated has received anything of value
from or owns stock in a commercial
company or institution related directly or
indirectly to the subject of this article:
Dr. Sporer, Dr. Weinstein, and Dr. Koval.
Supported in part by NIAMS #U01-
AR45444-01A1, the Robert Wood
Johnson Foundation, the American
Academy of Orthopaedic Surgeons, and
the American Hospital Association.
Reprint requests: Dr. Sporer, Rush
Medical College, 25 N Winfield Road,
Winfield, IL 60190.
J Am Acad Orthop Surg 2006;14:246-
255
Copyright 2006 by the American
Academy of Orthopaedic Surgeons.
246 Journal of the American Academy of Orthopaedic Surgeons
Variation in the Rates of
Fracture
The entire methodology of the
DAMHC may be found in its Appen-

dix on Methods. Briefly, Medicare
data from 1996 and 1997 were used
to evaluate regional variation in the
rates of fracture and surgical treat-
ment for fractures involving the hip,
wrist, proximal humerus, and ankle.
Databases provided through the
Health Care Financing Administra-
tion were analyzed to determine the
number of possible Medicare benefi-
ciaries in a designated region, as well
as demographic data for these indi-
viduals (age, sex, and race). The
Medicare Provider Analysis and Re-
view (MEDPAR) File (hospital
claims data) and Medicare Part B
data were analyzed to determine the
rates of utilization for fracture care
of the hip, wrist, proximal humerus,
and ankle. Hospital referral regions
were defined according to the 1996
to 1999 DAMHC guidelines.
12
These
hospital referral regions represent
tertiary care facilities in which there
is delivery of specific cardiovascular
and neurosurgical procedures.
The incidence of fracture of the
hip, wrist, proximal humerus, and

ankle among Medicare enrollees was
determined from the Medicare Part
B file utilizing physician-generated
Current Procedural Terminology
(CPT) codes (Table 1). These codes
allowed all patients to be categorized
into surgical and nonsurgical treat-
ment groups. Procedures and diag-
nostic tests were adjusted for patient
age, race, and sex. The regional rates
of fracture for the wrist, proximal
humerus, hip, and ankle were then
calculated, and maps of the ratio be-
tween observed versus expected re-
sults were generated. The expected
number of fractures was calculated
by multiplying the average fracture
rate with the number of people in
each Health Services Administra-
tion population.
In 1996 and 1997, Medicare enroll-
ees sustained >450,000 fractures. The
hip, wrist, ankle, and proximal hu-
merus account for >400,000 of these
fractures and represent approxi-
mately 85% of all injuries observed
in this patient population
12
(Figure 1).
Fractures about the hip (intertro-

chanteric and femoral neck) ac-
counted for >213,000 injuries and
were the most commonly observed
types of fracture within the Medi-
care population for that period. The
incidence of hip fractures varied by a
factor of 2, from 4.9 (Honolulu, HI)
to 10.7 (Rome, GA) per 1,000 Medi-
care enrollees (Figure 2). Four hospi-
tal referral regions had rates of hip
fracture at least 30% greater than
the national average, whereas 6 re-
gions had rates at least 25% below
the national average.
12
Wrist fractures were the second
most common fracture observed in
the Medicare patient population, ac-
counting for >96,000 injuries, 85%
of them observed in women. The in-
cidence of wrist fractures varied by a
factor of 4, from 1.5 (Everett, WA) to
5.7 (Huntsville, AL) per 1,000 Medi-
care enrollees (Figure 3). Twenty-
nine referral regions had rates of
wrist fracture at least 30% greater
than the national average, whereas
61 regions had rates at least 25% be-
low the national average.
12

Ankle fractures accounted for
>46,000 injuries that occurred in the
Medicare patient population in 1996
and 1997. The incidence of ankle
fracture was far more varied
throughout the United States, with
certain regions of the country show-
ing a more than sixfold variation in
incidence, from 0.5 per 1,000 (Hono-
lulu, HI) to 3.1 per 1,000 (Danville,
PA) (Figure 4). Forty-six hospital re-
ferral regions had rates of ankle frac-
ture of at least 30% greater than the
national average, whereas 79 regions
had rates at least 25% below the na-
tional average.
Proximal humerus fractures ac-
counted for 43,500 injuries in the
Medicare patient population. Simi-
lar to ankle fractures, the incidence
of these injuries showed dramatic re-
gional variation, from 0.3 per 1,000
enrollees (Jackson, TN) to 3.4 per
1,000 enrollees (Covington, KY).
Fifty-six hospital referral regions had
rates of proximal humerus fracture
at least 30% greater than the nation-
al average, whereas 111 regions had
rates at least 25% below the nation-
al average.

12
Treatment Variation
Fractures can be treated either surgi-
cally or nonsurgically. The decision
to proceed with surgery is highly de-
pendent on a number of factors, in-
cluding the anatomic location, asso-
ciated soft-tissue injuries, and the
number of associated fractures. The
great majority of patients with frac-
tures of the hip undergo surgical in-
tervention. Conversely, the majority
of patients with fractures of the
proximal humerus undergo nonsur-
gical management. Other fractures,
such as those of the ankle and wrist,
often are treatable with either surgi-
cal stabilization or cast immobiliza-
tion, depending on the severity of in-
jury (Figure 5).
More than 98% of the Medicare
patients who sustained a hip fracture
in 1996 and 1997 were treated with
surgical stabilization. Mobilization is
difficult without surgery; therefore,
nonsurgical treatment is generally re-
served for patients with multiple co-
morbidities and for injuries that pose
a substantial surgical risk. W einstein
reported that the mortality rates for

patients undergoing surgery were 7%
at 30 days and 25% at 1 year.
5
In con-
trast, patients treated nonsurgically
had a 17% mortality rate at 30 days
and a 39% rate at 1 year.
Wrist fractures were most com-
monly managed with closed reduc-
tion and cast immobilization. De-
spite this trend, different regions of
the United States were far more
likely to incorporate surgical inter-
vention in their treatment with ei-
ther pins, screws, or external fixa-
tion. The proportion of wrist
fractures treated surgically varied by
Scott M. Sporer, MD, MS, et al
Volume 14, Number 4, April 2006 247
a factor of 10 from 5.1% (Greenville,
NC) to 50.7% (Olympia, WA). In gen-
eral, patients in the Northwest were
more likely than patients in the
Southeast to have surgical interven-
tion (Figure 6). In seven regions, 40%
of wrist fractures received surgical
treatment; in 30 regions, only 10% of
them received surgical treatment.
5
Similar to wrist fractures, most

ankle fractures sustained by the
Medicare population were treated
nonsurgically. Again, patients in cer-
tain regions of the country were
more likely than others to undergo
Table 1
CPT Codes for the Four Most Common Orthopaedic Fractures in the Elderly
Hip Fracture CPT Codes
27235 Percutaneous skeletal fixation, femoral fracture, proximal, neck
27236 Open treatment, femoral fracture, proximal, neck, internal fixation/prosthetic
27244 Open treatment, inter/per/subtrochanteric femoral fracture, with plate/screw type implant
27245 Open treatment, inter/per/subtrochanteric femoral fracture; with intramedullary implant
27230 Closed treatment, femoral fracture, proximal end, neck; without manipulation
27232 Closed treatment, femoral fracture, proximal end, neck; with manipulation
27238 Closed treatment, inter/per/subtrochanteric femoral fracture; without manipulation
27240 Closed treatment, inter/per/subtrochanteric femoral fracture; with manipulation
Ankle Fracture CPT Codes
27766 Open treatment, medial malleolus fracture, with/without internal/external fixation
27792 Open treatment, distal fibular fracture, with/without internal/external fixation
27814 Open treatment, bimalleolar ankle fracture, with/without internal/external fixation
27822 Open treatment, trimalleolar ankle fracture, medial/lateral malleolus; without fixation
27823 Open treatment, trimalleolar ankle fracture, medial/lateral malleolus with fixation
27826 Open treatment, fracture, weight bearing articular surface, distal tibia, with fixation; fibula
27827 Open treatment, fracture, weight bearing articular surface/portion, distal tibia, with fixation; tibia
27828 Open treatment, fracture, weight bearing articular surface, distal tibia, with fixation; fibula and tibia
27829 Open treatment, distal tibiofibular joint disruption, with/without internal/external fixation
27760 Closed treatment, medial malleolus fracture; without manipulation
27762 Closed treatment, medial malleolus fracture; with manipulation, with/without skin/skeletal traction
27786 Closed treatment, distal fibular fracture (lateral malleolus); with/without manipulation
27788 Closed treatment, distal fibular fracture (lateral malleolus); with manipulation

27808 Closed treatment, bimalleolar ankle fracture, without manipulation
27810 Closed treatment, bimalleolar ankle fracture, with manipulation
27816 Closed treatment, trimalleolar ankle fracture, without manipulation
27818 Closed treatment, trimalleolar ankle fracture, with manipulation
27824 Closed treatment, fracture, weight bearing articular portion, distal tibia without manipulation
27825 Closed treatment, fracture, weight bearing articular portion, distal tibia with skeletal traction
Proximal Humerus Fracture CPT Codes
23615 Open treatment, proximal humeral fracture, with/without internal/external fixation/tuberosity repair
23630 Open treatment, greater humeral tuberosity fracture with/without internal/external fixation
23670 Open treatment, shoulder dislocation w/fracture, greater tuberosity, with/without external rotation
23680 Open treatment, shoulder dislocation, w/surgical/anatomical neck fixator
23600 Closed treatment, proximal humeral fracture; without manipulation
23605 Closed treatment, proximal humeral fracture; with manipulation
23620 Closed treatment, greater humeral tuberosity fracture; without manipulation
23625 Closed treatment, greater humeral tuberosity fracture; with manipulation
23665 Closed treatment, shoulder dislocation with fracture, greater tuberosity, with manipulation
23675 Closed treatment, shoulder dislocation, with humoral neck fracture, with manipulation
Wrist Fracture CPT Codes
25611 Percutaneous skeletal fixation, distal radial fracture/epiphyseal separation, with manipulation
25620 Open treatment, distal radial fracture/epiphyseal separation
25600 Closed treatment, distal radial fracture; without manipulation
25605 Closed treatment, distal radial fracture; with manipulation
The Geographic Incidence and Treatment Variation of Common Fractures of Elderly Patients
248 Journal of the American Academy of Orthopaedic Surgeons
surgical fixation. The percentage of
ankle fractures treated surgically
varied by a factor of nearly 4 from
20.8% (Altoona, PA) to 77.1% (Chi-
co, CA). On average, patients in the
Northwest were more likely than

patients in the Southeast to receive
surgical intervention. In 32 regions,
at least 60% of ankle fractures were
surgically treated, whereas in 50 re-
gions, 30% of such fractures were
surgically treated.
5
Most proximal humerus fractures
represent low-energy injuries and
can be treated nonsurgically with a
sling and swath for immobilization.
Surgical intervention was initiated,
on average, 14.3% of the time in the
United States.
5
Large variations in
the percentages of surgical interven-
tion were observed, from 6.4%
(Takoma Park, MD) of all proximal
humerus fractures to 60.0% (Taco-
ma, WA) (Figure 7). In 8 regions, at
least 40% of proximal humerus frac-
tures were treated surgically; in 35
regions, less than 10% were treated
surgically.
5
Figure 1
Fractures among Medicare enrollees during 1996. Fractures of the hip, wrist, ankle,
and proximal humerus were the most common fractures observed. (Reproduced
with permission from Weinstein JN, Birkmeyer JD [eds]: The Dartmouth Atlas of

Musculoskeletal Health Care. Chicago, IL: American Hospital Publishing, 2000,
p 96.)
Figure 2
The geographic variation of hip fracture rates within the United States in 1996 and 1997, adjusting for age, race, and sex. No-
tice the increased prevalence of hip fractures throughout the southern states. (Reproduced with permission from Weinstein JN,
Birkmeyer JD [eds]: The Dartmouth Atlas of Musculoskeletal Health Care. Chicago, IL: American Hospital Publishing, 2000,
p 101.)
Scott M. Sporer, MD, MS, et al
Volume 14, Number 4, April 2006 249
Figure 3
The geographic variation of wrist fracture rates within the United States in 1996 and 1997, adjusting for age, race, and sex.
Notice the increased prevalence of fractures throughout the eastern states. (Reproduced with permission from Weinstein JN,
Birkmeyer JD [eds]: The Dartmouth Atlas of Musculoskeletal Health Care. Chicago, IL: American Hospital Publishing, 2000,
p 123.)
Figure 4
The geographic variation of ankle fracture rates within the United States between 1996 and 1997, adjusting for age, race and
sex. Notice the increased prevalence of fractures throughout the eastern states. (Reproduced with permission from Weinstein
JN, Birkmeyer JD [eds]: The Dartmouth Atlas of Musculoskeletal Health Care. Chicago, IL: American Hospital Publishing,
2000, p 109.)
The Geographic Incidence and Treatment Variation of Common Fractures of Elderly Patients
250 Journal of the American Academy of Orthopaedic Surgeons
Geographic Variation of
Fracture Rates
Hip
As the population ages, the prev-
alence of fracture in the United
States unquestionably will increase.
The population aged ≥80 years is the
fastest growing cohort in the United
States.

13
More than 450,000 fractures
of the hip, wrist, ankle, and proximal
humerus were identified in the
Medicare patient population aged
>65 years in 1996 and 1997.
5
Numer-
ous authors have demonstrated that
increased age, female gender, smok-
ing, and osteoporosis are risk factors
for sustaining these injuries.
14
Addi-
tionally, poor vision, decreased reac-
tion times, nutritional status, and a
smaller soft-tissue envelope pose
other risks for fracture.
2-4,15-17
Although studies have shown dra-
matic differences in regional variation
of certain surgical procedures, such as
radical prostatectomy and coronary
artery bypass, little information was
Figure 5
The proportion of fractures treated surgically among Medicare enrollees in 199 6
and 1997. Notice that nearly all hip fractures are treated surgically, whereas most
proximal humerus fractures are treated nonsurgically. Other fracture patterns
demonstrate marked regional variability in their preferred method of treatment.
(Reproduced with permission from Weinstein JN, Birkmeyer JD [eds]: The

Dartmouth Atlas of Musculoskeletal Health Care. Chicago, IL: American Hospital
Publishing, 2000, p 97.)
Figure 6
The proportion of wrist fractures treated surgically in 1996 and 1997. Note that most fractures are treated nonsurgically.
However, several areas treat
>40% of wrist fractures with surgery. (Reproduced with permission from Weinstein JN, Birkmeyer
JD [eds]: The Dartmouth Atlas of Musculoskeletal Health Care. Chicago, IL: American Hospital Publishing, 2000, p 125.)
Scott M. Sporer, MD, MS, et al
Volume 14, Number 4, April 2006 251
known about the regional variation
of common fractures in the Medicare
population.
12
Our results suggest that,
despite adjustment for age, sex, and
race, specific populations in various
regions of the country are at increased
risk of fracture.
5
Fractures of the prox-
imal humerus, ankle, wrist, and hip
showed a tenfold, sixfold, fourfold,
and twofold variation in fracture rate,
respectively.
5
The southeastern states, on aver-
age, had greater risk of fracture,
whereas northern states were rela-
tively protected. The underlying eti-
ology for these dramatic differences

has yet to be determined. It is un-
likely that the differences observed in
these multiple studies
5
are a result of
chance alone. Although there may be
a systemic sampling bias secondary
to variable physician coding, the ob-
served differences are too large to be
related to this variable alone. These
trends also have been observed over
very large geographic regions rather
than specific locations. Additionally ,
other authors have reached similar
conclusions with regard to the geo-
graphic variation of hip fractures.
9
One potential hypothesis is that peo-
ple living in the southern regions are
exposed to environmental factors
that place them at an increased risk
of fracture.
11
Potential environmental risk fac-
tors may be directly related to the re-
gion, such as air quality, degree of
sunlight, or the water quality. Alter-
natively, environmental risk factors
may be associated with specific ar-
eas of the country related to diet,

poverty, or medical practice pat-
terns. Another hypothesis is that pa-
tients with different genetic suscep-
tibility to fractures live in the
southern regions.
14,18
Geographic variation in the rate of
hip fractures was initially described
by Bacon et al
19
during a review of
the 1979 to 1985 National Hospital
Discharge Survey.
20
The rates of hos-
pitalization for fracture of the hip
were 45% higher in the Northeast
compared with the South. This
study was limited in its ability to
provide only regional hospitalization
rates because of the sampling from
the National Hospital Discharge Sur-
vey. Additionally, this survey exam-
ined only procedures that were per-
formed within a specific region, and
it did not provide any patient demo-
graphic information. The authors hy-
pothesized that the increased risk of
hip fracture within the northern re-
gion may be secondary to a relatively

high proportion of residents of Scan-
dinavian ancestry in this area. Previ-
ous studies that evaluated national
hospital discharge data demonstrated
higher fracture rates throughout
northern European countries.
14,18
The increased risk for fracture is con-
sidered to be secondary to a higher
prevalence of osteoporosis through-
out this region.
Stroup et al
6
used data from the
1985 Medicare Provider Analysis
and Review file (MEDPAR) to deter-
mine the relative rate of hip fracture
within the United States. The inci-
dence of hip fractures was shown to
follow a north-to-south gradient,
Figure 7
The proportion of proximal humerus fractures treated surgically in 1996 and 1997. Note that most fractures are treated
nonsurgically. However, several areas treat
>40% of proximal humerus fractures with surgery. (Reproduced with permission
from Weinstein JN, Birkmeyer JD [eds]: The Dartmouth Atlas of Musculoskeletal Health Care. Chicago, IL: American Hospit al
Publishing, 2000, p 115.)
The Geographic Incidence and Treatment Variation of Common Fractures of Elderly Patients
252 Journal of the American Academy of Orthopaedic Surgeons
with higher fracture rates among the
southern states. The geographic vari-

ation in fracture rates was consistent
among both men and women and
among both “white” and “other
than white” age groups. The authors
did not think that the delivery of
health care or practice patterns
could account for these differences
because the trend was consistent
among both men and women.
Several authors have demonstrat-
ed an increased relative risk of frac-
ture among patients living in the
southeastern and Appalachian re-
gions. Hinton et al
7
reviewed Medi-
care date from 1984 to 1987 (687,850
hip fractures). They concluded that
rates of hip fracture were greater for
women than men and were higher in
the southern region of the United
States. There was an approximate
twofold variation throughout the
United States, from 0.88 (New Jer-
sey) to 1.25 (Mississippi) per 100,000
Medicare enrollees. This study also
examined the location of the hip
fracture as either cervical, trochan-
teric, or subtrochanteric. The rates
of both cervical and trochanteric

fractures remained higher in the
southern regions for white women
than in the northern regions. How-
ever, this variation was dispropor-
tionate because of the higher rates of
cervical fractures. The significance
of this finding is unclear, yet the au-
thors concluded that the cervical re-
gion of the hip may be more sensi-
tive to the effects of nutritional,
socioeconomic, or environmental
factors. This study also demonstrat-
ed that the risk of a hip fracture dou-
bles each successive 5 years and
that, among women, the relative
risk of cervical to trochanteric frac-
tures varies inversely by age.
21
Karagas et al
9
reviewed 39,599
Medicare hip fractures between 1986
and 1990 and found results similar
to those of Hinton et al.
7
The overall
rate of both femoral neck and tro-
chanteric fractures was highest
among white women, whereas the
ratio of trochanteric to femoral neck

fractures increased with advancing
age. However, these trends were not
observed among men or among
black patients. The authors hypoth-
esized that the observed hip fracture
rates could be related to localized
differences in bone density at specif-
ic sites of the proximal femur. Mel-
ton et al
21
had previously shown that
once a patient’s bone mineral densi-
ty drops below 0.60 g/cm
2
, that pa-
tient had an increased incidence of
trochanteric fracture.
Jacobsen et al
22
reported similar
north-to-south regional variation
among hip fractures using data from
the HCFA and the Department of
Veterans Affairs. Additionally, data
from the Bureau of Health Profes-
sions Area Resource File was used to
examine potential environmental
risk factors. A regression analysis
was performed that confirmed “a
positive association between hip

fracture incidence and the percent of
the 65-year and older population be-
low the poverty level and the per-
cent of land in farms.”
22
The authors
also found a weak association be-
tween soft and fluoridated water and
reduced sunlight exposure with an
increased risk of hip fracture.
The effect of fluoridated water
also has been evaluated by Karagas et
al.
8
Using a 5% sample of the Medi-
care population, a correlation be-
tween fluoridated drinking water and
the risk of hip or ankle fracture was
not observed. However, within the
study population, a north-to-south
geographic gradient for increased in-
cidence of hip fracture persisted.
The potential of reduced sunlight
as a risk factor for hip fracture was in-
directly examined by Jacobsen et al
10
when they reported on the seasonal
variation in the incidence of hip frac-
ture. Using HCFA data from 1984 to
1987, the seasonal variation among

621,387 hip fractures demonstrated a
definite seasonal pattern among both
male and female patients, with a
peak in December and February and
a nadir between July and August.
This seasonal trend persisted among
all five latitude groups. The authors
hypothesized that, given that the for-
mation of vitamin D is dependent on
sunlight, and given that there are
fewer hours of sunlight during the
winter months, the degree of osteo-
malacia may increase in elderly pa-
tients during this time and can place
them at a higher risk for fracture.
Lauderdale et al
11
examined the
impact of former residence on the
rate of hip fracture in the Medicare
patient population. The authors con-
cluded that the risk for fracture was
dependent on region of residence
early in life rather than later in
life.
11
These results suggest that
strategies designed to improve peak
bone mass during early childhood
would be more effective than mini-

mizing risk factors later in life.
The etiology of the variable rates
of hip fracture throughout the Unit-
ed States is unknown. However, it is
unlikely that these large variations
are the result of chance alone. Rath-
er, the fracture variability probably
is multifactorial and includes exter-
nal factors related to environmental
exposure and internal factors related
to genetic predisposition.
Shoulder, Wrist, and Ankle
Fractures
Whereas the geographic variation
among hip fractures has been gener-
ally well-described, a paucity of in-
formation is available about the re-
gional variation among other
common fractures (ie, proximal hu-
merus, distal forearm, ankle) in the
elderly population. Karagas et al
8
were the first to describe geographic
trends among fractures of the proxi-
mal humerus, distal forearm, and
ankle. Using Medicare data, they
showed that fractures of the proxi-
mal humerus and distal forearm oc-
cur in a geographic pattern that is
distinct from that observed with hip

fractures. The risk of fracture in-
creased from west to east rather than
from north to south (a trend also ob-
served with hip fractures). The data
presented from the DAMHC sup-
Scott M. Sporer, MD, MS, et al
Volume 14, Number 4, April 2006 253
port the finding of an increased risk
of proximal humerus, distal forearm,
and ankle fractures among eastern
regions of the United States.
5
One
hypothesis for these observations is
that the risk factors for hip fractures
are different from the risk factors for
proximal humerus, distal forearm,
and wrist and ankle fractures.
The exact etiology of the geo-
graphic variation among fracture rates
within the United States remains un-
clear. It is likely multifactorial, a re-
sult of varying degrees of certain en-
vironmental, occupational, genetic,
and nutritional risk factors that exist
between regions of the country. One
of our hypotheses is that fractures of
the hip are related to relatively sed-
entary individuals, whereas fractures
of the ankle, distal forearm, or prox-

imal humerus are related to individ-
uals actively participating in the
workforce or in recreational activities.
A second hypothesis of ours is that
nutritional factors preferentially af-
fect the bone metabolism of the fem-
oral neck. We think that further ep-
idemiologic research should be
performed in this area to help reduce
the cost, societal burden, and loss of
independence related to these debil-
itating fractures within the elderly pa-
tient population.
Geographic Variation in
Treatment
There also are dramatic differences in
the treatment strategies used for the
most common fractures in Medicare
patients. Some fractures, such as
those of the hip, have been shown to
be treated best with surgical inter-
vention; thus they show little geo-
graphic variation in the proportion of
fractures treated surgically. This was
observed in the DAMHC data, with
more than 98% of patients receiving
surgical intervention for a hip frac-
ture.
5
Conversely, certain fractures

can be treated either surgically or
nonsurgically. In general, nondis-
placed fractures can be treated with
cast immobilization, whereas dis-
placed fractures require surgical re-
duction and fixation. We observed
large variations in the proportion of
wrist, ankle, proximal humerus, and
distal forearm fractures treated sur-
gically throughout the United
States.
5
In general, the northwestern
regions were more likely to initiate
surgical treatment despite their rel-
ative lower incidence of fracture.
There are several possible expla-
nations for the observed differences
in the proportion of patients receiv-
ing surgical treatment. It is possible
that the fractures encountered in the
Northwest are more displaced or
open or have associated injuries; the
severity of injury is unable to be de-
termined from the Medicare data.
However, to our knowledge, no data
support the concept that more se-
vere injuries are more likely to occur
in these regions.
Diagnostic intensity also has

been shown to influence the rates of
surgical intervention. Regions with
more aggressive diagnostic imaging
tend to have higher surgical rates for
specific conditions.
23
However, pa-
tients who sustain fractures of the
hip, wrist, ankle, and proximal hu-
merus are in significant discomfor t,
and plain radiographs are sufficient
to make a diagnosis. Therefore, in-
creased diagnostic testing is unlike-
ly a plausible explanation.
The varying incidence of surgical
intervention also may be related to
the population density of practicing
orthopaedic surgeons in a particular
area of the country. Keller at el
24
de-
scribed regional variation in the pro-
cedural rate among several major or-
thopaedic conditions, a variation
that may be partially attributed to
the number of practicing ortho-
paedic surgeons in an area. However,
other authors have failed to show a
similar relationship between the uti-
lization of certain orthopaedic proce-

dures and the population density of
orthopaedic surgeons in an area.
25,26
It has been shown that surgeons
possess varying thresholds to recom-
mend and initiate surgical interven-
tion, referred to as the local aggres-
siveness phenomena.
12
As a result,
regions throughout the country tend
to have so-called surgical signa-
tures, reflecting the practices regard-
ing surgical treatment of the ortho-
paedic surgeons in that area. A
region’s surgical signature may be a
result of variability in orthopaedic
training in different parts of the
country or a result of a paucity of
data regarding the optimal treatment
of a particular fracture. Weinstein
27
has shown that the rate of surgical
intervention depends on the vari-
ability in clinical decision making as
well as patient-perceived risks and
benefits. For low variability proce-
dures, such as hip fractures, the sur-
gical rate is relatively constant
throughout the United States. In

contrast, disk herniations have nu-
merous treatment options, less sci-
entific uniformity, and greater po-
tential risks. Consequently, regional
variability is far greater than that
seen with hip fractures.
Patient expectations also may
contribute to the geographic vari-
ability among surgical rates. It is
possible that the perceived benefit of
surgery is regionally dependent, and
that patients in the northwestern
portion of the United States think
that the likelihood of returning to
their preinjury status is greater with
surgery. Consequently, patients and
surgeons may be more likely to ini-
tiate surgical intervention for a par-
ticular fracture.
Patients are the ones ultimately
affected by the decision to proceed
with surgical intervention. Thus, pa-
tients need to be actively involved in
the decision-making process in order
to make an informed choice.
7
When
patients are properly educated about
surgical alternatives, they make
choices that are most appropriate for

their specific situations.
Summary
The United States’ population is ag-
ing. As a result, orthopaedic sur-
The Geographic Incidence and Treatment Variation of Common Fractures of Elderly Patients
254 Journal of the American Academy of Orthopaedic Surgeons
geons are likely to experience a
greater number of fractures in the
elderly population. Throughout the
country, the variability in the inci-
dence of the most common fractures
is marked. The underlying etiology
is unclear but likely is multifactori-
al, including social, environmental,
nutritional, and genetic characteris-
tics. There also is a wide range of hy-
potheses; one possibility is that the
risk factors for fractures in different
locations vary, another that certain
fractures are related to the activity
level of the individual, and another
that nutrient factors preferentially
affects bone metabolism in different
regions. There also is marked vari-
ability in treatment among these
common fractures. This surgical
variability likely represents the sur-
geon’s preference and his or her
threshold for initiating surgical
treatment. Hypothetically , this vari-

ability also may exist because some
fractures encountered in one region
are different from those in another or
it may be a result of the population
density of orthopaedic surgeons
practicing in a region. Additional
studies are needed to elucidate un-
derlying patient preferences and
whether the decision to proceed
with surgery is driven by the physi-
cian, the patient, or both jointly.
References
Citation numbers printed in bold
type indicate references published
within the past 5 years.
1. Baron JA, Barrett JA, Karagas MR: The
epidemiology of peripheral fractures.
Bone 1996;18(suppl 3):209S-213S.
2. Felson DT, Anderson JJ, Hannan MT,
Milton RC, Wilson PW, Kiel DP: Im-
paired vision and hip fracture: The
Framingham Study. J Am Geriatr Soc
1989;37:495-500.
3. Kelsey JL, Browner WS, Seeley DG,
Nevitt MC, Cummings SR: Risk fac-
tors for fractures of the distal forearm
and proximal humerus: The Study of
Osteoporotic Fractures Research
Group. Am J Epidemiol 1992;135:
477-489.

4. Kreiger N, Kelsey JL, Holford TR,
O’Connor T: An epidemiologic study
of hip fracture in postmenopausal
women. Am J Epidemiol 1982;116:
141-148.
5. Weinstein JN, BirkmeyerJD(eds): The
Dartmouth Atlas of Musculoskeletal
Health Care. Chicago, IL: American
Hospital Publishing, 2000.
6. Stroup NE, Freni-Titulaer LW,
Schwartz JJ: Unexpected geographic
variation in rates of hospitalization
for patients who have fracture of the
hip: Medicare enrollees in the United
States. J Bone Joint Surg Am 1990;72:
1294-1298.
7. Hinton RY, Lennox DW, Ebert FR, Ja-
cobsen SJ, Smith GS: Relative rates of
fracture of the hip in the United
States: Geographic, sex, and age vari-
ations. J Bone Joint Surg Am 1995;77:
695-702.
8. Karagas MR, Baron JA, Barrett JA, Ja-
cobsen SJ: Patterns of fracture among
the United States elderly: Geographic
and fluoride effects. Ann Epidemiol
1996;6:209-216.
9. Karagas MR, Lu-Yao GL, Barrett JA,
Beach ML, Baron JA: Heterogeneity of
hip fracture: Age, race, sex, and geo-

graphic patterns of femoral neck and
trochanteric fractures among the US
elderly. Am J Epidemiol 1996;143:
677-682.
10. Jacobsen SJ, Goldberg J, Miles TP, Bro-
dy JA, Stiers W, Rimm AA: Seasonal
variation in the incidence of hip frac-
ture among white persons aged 65
years and older in the United States,
1984-1987. Am J Epidemiol 1991;
133:996-1004.
11. Lauderdale DS, Thisted RA, Goldberg
J: Is geographic variation in hip frac-
ture rates related to current or former
region of residence? Epidemiology
1998;9:574-577.
12. Wennberg JC, Cooper MM: The Dar t-
mouth Atlas of Health Care. Chicago,
IL: American Hospital Publishing,
1997.
13. Trends in aging United States and
worldwide. MMWR Morb Mortal
Wkly Rep 2003;52:101-106.
14. Lips P: Epidemiology and predictorsof
fractures associated with osteoporo-
sis. Am J Med 1997;103:3S-8S.
15. Cummings SR, Kelsey JL, Nevitt MC,
O’Dowd KJ: Epidemiology of os-
teoporosis and osteoporotic fractures.
Epidemiol Rev 1985;7:178-208.

16. Lewinnek GE, Kelsey J, White AA III,
Kreiger NJ: The significance and a
comparative analysis of the epidemi-
ology of hip fractures. Clin Orthop
Relat Res 1980;152:35-43.
17. Felson DT, Kiel DP, Anderson JJ, Kan-
nel WB: Alcohol consumption and hip
fractures: The Framingham Study.
Am J Epidemiol 1988;128:1102-1110.
18. Bacon WE, Maggi S,Looker A, etal: In-
ternational comparison of hip frac-
ture rates in 1988-89. Osteoporos Int
1996;6:69-75.
19. Bacon WE, Smith GS, Baker SP: Geo-
graphic variation in the occurrence of
hip fractures among the elderly white
US population. Am J Public Health
1989;79:1556-1558.
20. US Department of Health and Human
Services: Utilization of short-stay
hospitals: Annual summary, in Statis-
tics NCFH. US Department of Health
and Human Services Publication
(PHS)87-1752, series 2, no 39. Wash-
ington, DC: Government Printing Of-
fice, 1987.
21. Melton LJ III, Wahner HW, Richelson
LS, O’Fallon WM, Riggs BL: Os-
teoporosis and the risk of hip fracture.
Am J Epidemiol 1986;124:254-261.

22. Jacobsen SJ, Goldberg J, Miles TP, Bro-
dy JA, Stiers W, Rimm AA: Regional
variation in the incidence of hip frac-
ture: US white women aged 65 years
and older. JAMA 1990;264:500-502.
23. Birkmeyer JD, Sharp SM, Finlayson
SR, Fisher ES, Wennberg JE: Variation
profiles of common surgical proce-
dures. Surgery 1998;124:917-923.
24. Keller RB, Soule DN, Wennberg JE,
Hanley DF: Dealing with geographic
variations in the use of hospitals: The
experience of the Maine Medical As-
sessment Foundation Orthopaedic
Study Group. J Bone Joint Surg Am
1990;72:1286-1293.
25. Vitale MG, Krant JJ, Gelijns AC, et al:
Geographic variations in the rates of
operative procedures involving the
shoulder, including total shoulder re-
placement, humeral head replace-
ment, and rotator cuff repair. J Bone
Joint Surg Am 1999;81:763-772.
26. Peterson MG, Hollenberg JP, Sza-
trowski TP, Johanson NA, Mancuso
CA, Charlson ME: Geographic varia-
tions in the rates of elective total hip
and knee arthroplasties among Medi-
care beneficiaries in the United
States. J Bone Joint Surg Am 1992;74:

1530-1539.
27. Weinstein JN: The missing piece: Em-
bracing shared decision making to re-
form health care. Spine 2000;25:1-4.
Scott M. Sporer, MD, MS, et al
Volume 14, Number 4, April 2006 255