China's evolving fracture burden
Authors: Anna J Dare, Guoqing Hu
Journal: The Lancet Global Health (2017)

More than any other disease group, injuries chart the story of a country's development in real time. China has seen major changes in injury causes and risks over the past three decades1Wang SY Li YH Chi GB et al.Injury-related fatalities in China: an under-recognised public-health problem.Lancet. 2008; 372: 1765-1773Summary Full Text Full Text PDF PubMed Scopus (216) Google Scholar, 2Yang G Wang Y Zeng Y et al.Rapid health transition in China, 1990–2010: findings from the Global Burden of Disease Study 2010.Lancet. 2013; 381: 1987-2015Summary Full Text Full Text PDF PubMed Scopus (1510) Google Scholar attributable to rapid urbanisation, motorisation, and occupational shifts, as well as health reforms and demographic changes.2Yang G Wang Y Zeng Y et al.Rapid health transition in China, 1990–2010: findings from the Global Burden of Disease Study 2010.Lancet. 2013; 381: 1987-2015Summary Full Text Full Text PDF PubMed Scopus (1510) Google Scholar Life expectancy in China now approaches that of high-income countries, which is bringing new health challenges. Implementing context-appropriate injury control measures in China is crucial to maximising health and development gains. This requires a sound understanding of age-specific, sex-specific, and cause-specific injury patterns at the national and subnational levels. Fractures are a common sequelae of injuries and a major cause of morbidity and mortality, especially if left untreated.3Haagsma JA Graetz N Bolliger I et al.The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013.Inj Prev. 2016; 22: 3-18Crossref PubMed Scopus (746) Google Scholar Yet the burden and distribution of traumatic fracture is poorly characterised in low-income and middle-income countries (LMICs). In The Lancet Global Health, Wei Chen and colleagues4Chen W Lv H Liu S et al.National incidence of traumatic fractures in China: a retrospective survey of 512 187 individuals.Lancet Glob Health. 2017; (published online June 27.)http://dx.doi.org/10.1016/S2214-109X(17)30222-XSummary Full Text Full Text PDF PubMed Scopus (117) Google Scholar report on the findings of the China National Fracture Study, a nationally representative population-based study of more than half a million people that sought to estimate fracture incidence, distribution, and risk factors in 2014. Household surveys were used to collect data for self-reported fractures in the previous year by anatomical site and injury mechanism, which were confirmed by medical records and radiographic imaging. Fracture incidence at all ages was estimated to be 3·21 (95% CI 2·83–3·59) per 1000 people, with the highest incidence in women aged 55–64 years, at 7·04 (6·06–8·01) per 1000. Applying these rates to the population, the authors estimate that 4·39 million people experienced a traumatic fracture in China in 2014. Fragility fractures caused by low-energy trauma (slips, trips, and falls from standing height) comprised most of the fractures in the study (58%) and accounted for as many as 83% of all fractures in women older than 65 years. Road transport injuries were the second most common fracture cause (20%), and the leading cause among young and middle-aged men. Overall fracture incidence was highest among elderly women, especially those living in central and eastern China, with radius and ulna fractures predominating. Older age, a previous history of fracture, low socioeconomic status, alcohol consumption, and average sleep time less than 7 h were independent risk factors for traumatic fracture in adults. Among children (<15 years), boys, primary school children, and those who slept less than 7 h a day were at highest risk. These findings provide some insight into how China's economic and demographic transitions are changing the epidemiology of fractures in the country. In high-income countries (HICs), fracture incidence follows a bimodal age–sex distribution, peaking in young men due to major trauma (eg, high velocity road transport injuries) and in older women with bone fragility who sustain minor trauma.5Curtis EM van der Velde R Moon RJ et al.Epidemiology of fractures in the United Kingdom 1988–2012: variation with age, sex, geography, ethnicity and socioeconomic status.Bone. 2016; 87: 19-26Summary Full Text Full Text PDF PubMed Scopus (242) Google Scholar The incidence of fragility fractures in China and other LMICs is not well studied. Previous estimates suggest that it is very low, but projected to increase between 2010 and 2040 especially among women older than 50 years.6Oden A McCloskey EV Kanis JA Harvey NC Johansson H Burden of high fracture probability worldwide: secular increases 2010-2040.Osteoporos Int. 2015; 26: 2243-2248Crossref PubMed Scopus (291) Google Scholar Although the overall incidence of fracture reported in this study is still lower than in HICs,5Curtis EM van der Velde R Moon RJ et al.Epidemiology of fractures in the United Kingdom 1988–2012: variation with age, sex, geography, ethnicity and socioeconomic status.Bone. 2016; 87: 19-26Summary Full Text Full Text PDF PubMed Scopus (242) Google Scholar the age–sex distribution of fractures in China and their external causes followed a similar bimodal pattern. Notable is the second peak in burden attributed to fragility fractures in the elderly, especially women, which has occurred far sooner in China than previously projected.6Oden A McCloskey EV Kanis JA Harvey NC Johansson H Burden of high fracture probability worldwide: secular increases 2010-2040.Osteoporos Int. 2015; 26: 2243-2248Crossref PubMed Scopus (291) Google Scholar The first peak among young and middle-aged men due to transport injuries and falls is also seen, but the injury mechanisms reported are not sufficiently detailed to determine whether transport-related fractures occurred primarily due to motorised vehicles as in HICs, or among vulnerable road users (eg, pedestrians, cyclists), a pattern seen more commonly in LMICs.7Norton R Kobusingye O Injuries.New Engl J Med. 2013; 368: 1723-1730Crossref PubMed Scopus (242) Google Scholar The major limitations of this retrospective study are that it includes only fractures that occurred in living household members at the time the survey was conducted, and does not present detailed external causes of fractures using the standard ICD-10 classification. Those individuals who sustained a fracture during the study period of interest but who died—either as a result of their injuries or from other causes—were not included. This omission is likely to undercount individuals with fractures from high-velocity transport-related mechanisms, which are associated with polytrauma, increased injury severity, and increased case fatality rates, and are a leading cause of death among young adults in China.1Wang SY Li YH Chi GB et al.Injury-related fatalities in China: an under-recognised public-health problem.Lancet. 2008; 372: 1765-1773Summary Full Text Full Text PDF PubMed Scopus (216) Google Scholar It also risks undercounting those who sustained fragility fractures at anatomical sites associated with increased rates of mortality—eg, hip fractures in the elderly population. This might explain the lower proportion of hip fractures seen at older ages in this study compared with in other estimates.8Cheng SY Levy AR Lefaivre KA Guy P Kuramoto L Sobolev B Geographic trends in incidence of hip fractures: a comprehensive literature review.Ost Int. 2011; 22: 2575-2586Crossref Scopus (158) Google Scholar However, this does mean that the overall fracture incidences presented are conservative, and that the true population burden of traumatic fracture is undoubtedly larger than estimated. The absence of complete details on external cause or place of injury somewhat restricts the use of the data to inform targeted preventative measures, particularly for transport injuries. Injuries have recently been recognised in China's long-term development agenda "Healthy China 2030".9Ning P Schwebel DC Hu G Healthy China 2030: a missed opportunity for injury control.Inj Prev. 2017; (published online Feb 23.)https://doi.org/10.1136/injuryprev-2017-042314Crossref PubMed Scopus (14) Google Scholar Underpinning the development of sound injury policy in China is high-quality, context-specific research. The study by Chen and colleagues shows the country's capacity to conduct large-scale, representative, population-based studies on injury epidemiology, and adds to the information already collected by China's national mortality surveillance systems, national health service surveys, and hospital discharge records.1Wang SY Li YH Chi GB et al.Injury-related fatalities in China: an under-recognised public-health problem.Lancet. 2008; 372: 1765-1773Summary Full Text Full Text PDF PubMed Scopus (216) Google Scholar, 10Duan L Deng X Wang Y et al.The National Injury Surveillance System in China: a six-year review.Injury. 2015; 46: 572-579Summary Full Text Full Text PDF PubMed Scopus (35) Google Scholar Carefully formulated research questions, data quality, and completeness, and better integration across data sources would further strengthen China's injury surveillance efforts, and ensure that research outputs can be readily used to inform injury control policies and interventions.11Hu G Baker TD Baker SP Injury control in China: priorities and actions.Lancet. 2009; 373: 214Summary Full Text Full Text PDF PubMed Scopus (17) Google Scholar In emerging economies, transport injuries have occupied centre place in research and policy efforts directed towards unintentional injuries. By contrast, fragility fractures from minor trauma have been completely absent from injury prevention dialogue. This study shows that fragility fractures are an important contributor to injury burden in China, and will continue to be as the population ages. Primary and secondary prevention of osteoporosis and fragility fracture using proven lifestyle, medication, and environmental measures targeted to at-risk groups must be included within China's injury control strategies, and should be considered by other middle-income countries facing similar health and demographic changes. We declare no competing interests. National incidence of traumatic fractures in China: a retrospective survey of 512 187 individualsOur results provide detailed information about fracture incidence, distribution, and risk factors, which can now be used as an up-to-date clinical evidence base for national health-care planning and preventive efforts in China and elsewhere. Specific public health policies that focus on decreasing alcohol consumption, prohibiting drunk driving, promoting smoking cessation, and encouraging individuals to obtain sufficient sleep and maintain a healthy bodyweight should be urgently implemented to help reduce the risk of traumatic fractures. Full-Text PDF Open Access