Ethnic variation in epidemiology and rehabilitation of hip fracture

BMJ 1994; 309 doi: (Published 29 October 1994) Cite this as: BMJ 1994;309:1124
  1. S J Calder,
  2. G H Anderson,
  3. W M Harper,
  4. P J Gregg
  1. University Department of Orthopaedic Surgery, Glenfiled General Hospital, Leicester LE3 9QP
  1. Correspondence to: Mr Calder.
  • Accepted 6 June 1994

In Leicestershire 9.3% of the population of is Asian origin, most being from the Indian subcontinent. Only 4.3% of Asians in Leicesteshire are aged over 65 years compared with 16.3% of white people. The incidence of hip fracture in Leicestershire is predicated to increase over 10 years by 11.2%,1 and as a result of the skewed age distribution the vulnerable population (65 years and over) will increase disproportionately among Asians. Provision will have to be made for the increasing health care burden of this group of patients. We determined the epidemiology of hip fracture between the two groups to help define underlying causes and future allocation of resources.

Patients, methods, and results

We collected data over two years (1991-2) on all patients with hip fracture in Leicestershire,1 recording demographic data, type of fracture, treatment, length of stay in hospital, and destination of discharge. Ethnic origin was noted as white, Asian, or other. As hip fracture is predominantly a disease of elderly people, we used standardised age groups of 65 years and over and below 65.

The table shows the incidence of hip fracture according to age group, sex, and ethnic group. The average age at fracture was significantly lower in the Asian population (range 42-92 years, mean 76.0 (SD 11.9) years v 18-104 years, mean 80.2 (10.3) years; P<0.05 by Student's t test). The annual incidence in white people was 0.08% and the age-sex standardised rates for above and below 65 years old in Asians was 0.103% (SE 0.017) (95% confidence interval 0.0703 to 0.136). The ratio of standardised incidence in Asians to the annual incidence in white people was 1.30 (0.94 to 1.79). Neither of these standardised rates was significantly different from the values in white people at the 5% level.

Summary data on ethnic origin, age distribution, and incidence of hip fracture in patients in Leicestershire, 1991-2

View this table:

The risk of fracture in men over 65 was significantly higher in Asians (risk ratio 2.5; P<0.05 by a X2 test). There were no other significant sex differences (table). The incidence of subtrochanteric fractures was significantly higher in Asians (10% (4/41)) than white people (1.4% (17/1231)) (P<0.05 by Fisher's exact test). Asians stayed longer in hospital (median 21 days, mean 25.5 days, interquartile range 15-91 v 15 days, mean 17.6 days, 11-123; P<0.05 by the Kruskal-Wallis test). The percentage of patients returning directly to their place of residence before injury was lower among Asians (22% (9-41) v 27% (337/1231)) but not significantly so by X2 analysis.


Osteomalacia may not be a significant predisposing factor for hip fracture.2,3 Therefore, although the prevalence of osteomalacia in Asians is higher than that in white people,4,5 our findings of similar standardised incidences of hip fracture might be expected. As total numbers increase the difference may become significant.

In the Asian immigrant population vitamin D deficiency has gradually become less in children but not adults.4 Older citizens are more likely than subsequent generations to abide by their traditions, thereby perpetuating vitamin D deficiency among first generation Asian immigrants. Subtrochanteric fractures are more commonly associated with diseased bone than are other types of fracture. Asians had a much higher incidence of such fractures and elderly Asian men also have a higher incidence of fracture. These findings suggest that the cause of fracture may be different in Asians, at least in a proportion of patients, and could be vitamin D deficiency.

Postoperative mobilisation and nursing care are hindered by language barriers. Cultural differences in the way that families participate in aftercare may also play a part. The financial implications are considerable: in Leicester the extra bed days required for Asian patients cost about pounds sterling 32 000 annually.

These problems may be tackled by improved communication with and education of families and patients, perhaps with easier access to an interpreter on the wards. Pathophysiological differences probably caused by osteomalacia may become less influential over time. At present, however, proportionately more resources will be required to cater for the needs of the aging Asian population than for their white counterparts.

We thank Dr S J Iqbal for his advice.


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