Prevalence of Fractures in the Adult Population of Germany

An evaluation of inpatient and outpatient cases

Background: Fractures are a major public health problem, especially in older people. A better understanding of epidemiological trends and risk factors is essential for the development of prevention strategies.

Methods: We analyzed ICD-10 data provided by the German Federal Statistical Office and the Central Institute for Health Care (Zi) on inpatient and outpatient treatments for fracture in the year 2022. The frequency and distribution of fractures were examined according to anatomical site, sex, and age. The prevalence of inpatient cases was standardized to the German population and compared with figures from 2019.

Results: In 2022, there were 683 185 recorded fracture treatments in the inpatient setting, 1% fewer than in 2019. 63% of fractures were in women, and 71% in persons over age 65. The most common types were femoral neck fractures (129 per 100 000 population), pertrochanteric femur fractures (115/100 000), and distal radius fractures (106/100 000). Compared to 2019, there were more fractures of the femoral neck (+8%), femoral shaft (+7%), and distal humerus (+7%), and fewer fractures of the scaphoid bone (−31%), carpal and metacarpal bones (−30%), and ribs (−29%). 2 400 606 fractures were treated in the outpatient setting in 2022, corresponding to a prevalence of 2845.71/100 000. The most common types were distal radius fractures (210.76/100 000), finger fractures (186.1/100 000), and rib fractures (156.51/100 000 population).

Conclusion: Although the overall fracture prevalence declined slightly between 2019 and 2022, certain fracture types remained prevalent or even increased in frequency. This highlights the continued need for targeted preventive strategies, particularly for older adults.

Cite this as: Walter N, Szymski D, Bärtl S, Biehl C, Knapp G, Lang S, Alt V, Heiß C, Rupp M: Prevalence of fractures in the adult population of Germany: An evaluation of inpatient and outpatient cases. Dtsch Arztebl Int 2025; 122: 355–9. DOI: 10.3238/arztebl.m2025.0070

Fractures are a major public health problem and represent one of the most common causes of morbidity and mortality, especially in older population groups (1, 2). They are closely associated with a multitude of clinical and social factors, including demographic characteristics, lifestyle, bone health, and underlying diseases such as osteoporosis (3). These multifactorial influences make fractures a central topic in medical research and health care. In addition to individual consequences such as pain and functional limitations, fractures place a significant burden on the healthcare system—both through direct treatment costs and through long-term care and rehabilitation (4, 5).

In order to develop evidence-based prevention strategies and efficiently allocate health resources, a comprehensive understanding of fracture prevalence is crucial. The prevalence of fractures is significantly affected by demographic changes, in particular the aging of the population (6). An analysis of fracture prevalence in Germany from 2009 to 2019 showed that fracture risk is particularly high among older females. Moreover, a rise in the prevalence of certain fracture types, such as acetabular and clavicular fractures, has been seen (6).

This study updates the data from the previous analysis covering 2009–2019 and expands on it to include the period up to 2022. A further focus of this study was the analysis of outpatient presentations of patients with fractures in order to record conservatively treated fractures as well as those treated surgically and undergoing outpatient follow-up. The aim of this investigation was to identify current trends in the fracture burden in Germany with regard to age, sex, and fracture site. New data up to 2022 helped to map the temporal developments in fracture prevalence more precisely and analyze the influence of demographic change. Particular attention was paid to analyzing differences between sexes and the various age groups, as well as to providing reliable epidemiological data. These may reveal important implications not only for the development of prevention and interventional strategies but also for health planning and policy-making.

Methods

The available data comprise the annual ICD-10 diagnosis codes for 2022, which were collected by all German medical institutions in the inpatient and outpatient sectors. The datasets for patients treated in the inpatient setting were provided by the Federal Statistical Office (Destatis), which is responsible for the official collection and statistical analysis of health data in Germany (1). Destatis systematically collects and manages data from the entire healthcare system to enable a comprehensive analysis of the population’s health status. For the present analysis, all German hospitals provided Destatis with their annual reports on inpatient treatment cases, in line with mandatory reporting. These reports contain detailed information on diagnoses, treatment courses, and demographic characteristics of patients. In order to avoid duplicates, repeated inpatient admissions of the same person with the same diagnosis were grouped into a single case. Outpatient cases were identified using the dataset from Germany’s Central Institute for Health Care (Zentralinstitut für die kassenärztliche Versorgung, Zi). All outpatient presentations of patients with statutory health insurance (SHI-insured individuals) in Germany with a confirmed diagnosis coded according to the ICD-10 were included. The aim was to record all SHI-insured patients who had sustained a fracture—regardless of whether they were treated as inpatients or outpatients—through outpatient follow-up examinations. In order to avoid counting repeated presentations as multiple cases, all recordings of the same fracture were counted as a single case within a follow-up period of three quarters (up to Q3/2023).

To quantify the total number of fractures, ICD-10 codes S12.0–S92.3 were used (eTable). ICD-10 codes “S62.1,” “S62.2,” and “S62.3” were grouped under fractures of the carpal and metacarpal bones. Codes “S12.0,” “S12.1,” and “S12.2,” on the other hand, were considered as fractures of the cervical spine. To calculate the number of pelvic ring fractures, the diagnoses “S32.1,” “S32.2,” “S32.3,” “S32.5,” “S32.6,” and “S32.8” were grouped together. The analysis took into consideration the anatomical site of the fracture as well as patient sex and age, with age divided into 5-year categories. The study included only individuals aged 20 and older who were treated as inpatients, and people aged 18 and older who received outpatient treatment. Prevalence rates were calculated based on the German population aged 20 years and older for inpatient cases, and 18 years and older for outpatient cases. These were standardized by age and sex. To determine prevalence rates, the population figures per birth cohort for each of the 16 German federal states were used. The cut-off date for each year was 31st December.

eTable

ICD-10 codes used and their description

Results

Inpatient treatment

In 2022, a total of 683 185 fracture treatments were recorded in the inpatient setting. This corresponds to a slight decline of 1% compared to 688 185 fractures in 2019.

The prevalence of fractures in 2022 was 994 per 100 000 population. Women (63%) were significantly more frequently affected compared to men (37%). In total, 67% of all fractures occurred in patients aged over 65 years (Figure). The most common fracture type was femoral neck fractures: A total of 88 498 cases were registered, corresponding to a prevalence of 129/100 000 persons. The second highest prevalence was seen in pertrochanteric femoral fractures (115/100 000 population), followed by distal radius fractures (106/100 000 population), proximal humerus fractures (87/100 000 population), lumbar spine fractures (63/100 000 population), and pelvic ring fractures (59/100 000 population) (Table 1).

Figure

Fracture frequency among inpatient cases in 2022, standardized by age and sex

Table 1

Frequency of fractures in descending order

A comparison of fracture prevalence rates between 2019 and 2022 revealed that the greatest increases were seen in femoral neck fractures (+8%), femoral shaft fractures (+7%), and distal humerus fractures (+7%), followed by pertrochanteric femoral fractures (+7%) and cervical spine fractures (+6%). A decline in prevalence rates was seen for scaphoid bone fractures (−31%), carpal and metacarpal bone fractures (−30 %), rib fractures (−29 %), and metatarsal bones fractures (−23%).

The regional distribution of fractures shows clear differences between the federal states. The highest number of fractures was registered in the most populous states: North Rhine-Westphalia (178 921), Bavaria (128 789), and Baden-Württemberg (92 512).

Outpatient treatment

A total of 2 400 606 fractures in Germany in 2022 were identified as having been treated on an outpatient basis. This indicates a prevalence of 2846 fractures per 100 000 population, with women accounting for 57% of these. In terms of age, 40% of patients were aged over 65 years. The most common fractures were distal radius fractures (211/100 000), finger fractures (186/100 000, rib fractures (157/100 000), and fractures of the lumbar spine (128/100 000) (Table 2).

Table 2

Frequencies of fractures in outpatient follow-up care in Germany in 2022 in descending order

Discussion

The results of this study show that the fracture prevalence in Germany remains overall high, despite a slight decline in inpatient cases. The increase in certain fracture types is consistent with increasing life expectancy and the resulting rise in age-related health problems. A marked increase can be seen particularly in fractures of long bones such as the femur. This highlights the need for effective preventive measures to better protect older people and maintain their mobility and quality of life. These findings are in agreement with previous investigations that identified demographic change as the main driver of the rise in fracture rates (7, 8).

This increase in fracture prevalence rates, particularly in the older population, has significant health and social policy implications (2, 3, 9). Preventive measures on multiple levels are required in order to manage the growing burden on the healthcare system. In addition to individual prevention programs, population-wide strategies could be implemented, such as state-sponsored awareness campaigns on fall prevention or programs to promote physical activity (10, 11). Particularly the ongoing rise in fracture rates among older women points to the importance of and need for osteoporosis diagnosis and treatment. There is an urgent need for action to implement standardized screening programs, similar to those that have been established for decades in cancer prevention. At the systemic level, the expansion of geriatric trauma centers could play a key role in ensuring specialized care and further improving treatment outcomes (12). In this context, the development of interdisciplinary treatment approaches that integrate orthopedics, geriatrics, and physiotherapy—and which have been established as a Fracture Liaison Service (FLS) in some cases—appears to be particularly promising (9, 13).

One positive finding of our study is the decline in the frequency of certain fracture types. This decline may be due to advances in prevention, for example, in the form of improved fall prevention measures, or to an increased awareness among the population of potential risk factors (14, 15). It could also be related to the fact that nowadays, these patients are increasingly treated in the outpatient setting rather than on an inpatient basis. Further investigations are needed to determine the extent to which these declines are due to targeted measures, changes in lifestyle, or structural adjustments in healthcare provision.

The limitations of this study need to be carefully considered. Firstly, the study is based on administrative data, which is subject to coding errors. These errors may be random or systematic, thereby distorting the results. The quality of coding depends heavily on the individual skills and diligence of the respective hospital staff. This can lead to inconsistencies. Furthermore, a retrospective analysis of administrative data always harbors the risk that relevant clinical details that may be important for a deeper interpretation of fracture causes are lacking (16).

In addition, the data provided by the Central Institute for Health Care (Zi) covered both outpatient- and inpatient-treated patients. The inpatient data from the German Federal Statistical Office (Destatis), on the other hand, cover all cases admitted for inpatient care. To avoid uncontrolled double counting of cases, these datasets were analyzed separately. Since the Zi data include only individuals covered by statutory health insurance, a direct comparison of the two datasets is methodologically unhelpful. Merging the datasets would carry the risk of overestimating the case numbers, since individuals treated on an inpatient basis may be recorded again in outpatient follow-up. To counteract this problem, the Zi data were processed in such a way as to rule out multiple registrations of the same case. Nevertheless, the inability to differentiate between primary outpatient fractures and follow-up visits represents a methodological limitation that hampers more precise case classification.

The period from 2020 to 2021 was intentionally excluded from the analysis in order to avoid a distortion of the data by the pandemic. The changes in health behavior and healthcare utilization shown to result from the COVID-19 pandemic may impair the comparability of the data (17). This approach was chosen in order to avoid conclusions that would be of only limited relevance for long-term epidemiological trends and future years.

Another aspect that must be borne in mind is the lack of differentiation between osteoporotic fractures in our analysis. The ICD-10 diagnostic code “M80. Osteoporosis with current pathological fracture” makes a distinction between different etiologies of osteoporosis (for example, postmenopausal, drug-induced, idiopathic); however, this coding key also covers many different fracture types that are grouped together under nonspecific categories such as “other fractures.” This leads to high heterogeneity of the data (18). Due to the non-uniformity of the data and the resulting lack of robustness, we decided not to include the M80 dataset in our analysis, thereby avoiding unnecessary complexity and potential distortions (19).

Summary

In summary, this study demonstrates that, despite a slight decline in certain areas, fracture prevalence remains a significant public health problem, especially in view of the aging population. In order to effectively address the growing challenges in the area of fracture care, there is an ongoing need to continually expand epidemiological surveys and gain a better understanding of the specific causes and risk factors.

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript submitted on 6 January 2025, revised version accepted on 7 April 2025.

Translated from the original German by Christine Rye.

Corresponding author
Prof. Dr. med. Markus Rupp

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