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

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

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

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

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

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

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

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

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,

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-

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

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

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

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

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-

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

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.
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