Skip to main content

Long-term mortality following fractures at different skeletal sites: a population-based cohort study



Adjusting for age, sex, and precipitating cause, the relative risk of death was increased following fractures at most skeletal sites.


This study aims to determine long-term survival following fractures due to any cause at each skeletal site.


In a historical cohort study, 2,901 Olmsted County, MN, USA, residents ≥35 years old who experienced any fracture in 1989–1991 were followed passively for up to 22 years for death from any cause. Standardized mortality ratios (SMRs) compared observed to expected deaths.


During 38,818 person-years of follow-up, 1,420 deaths were observed when 1,191 were expected (SMR, 1.2; 95 % CI, 1.1–1.3). The overall SMR was greatest soon after fracture, especially among the men, but remained elevated for over a decade thereafter. Adjusting for age and sex, relative death rates were greater for pathological fractures and less for severe trauma fractures compared to the fractures due to no more than moderate trauma. In the latter group, long-term mortality was increased following fractures at many skeletal sites. After further adjustment for precipitating cause, overall SMRs were elevated not only following fractures at the traditional major osteoporotic sites (i.e., distal forearm, proximal humerus, thoracic/lumbar vertebrae, and proximal femur) combined (SMR, 1.2; 95 % CI, 1.1–1.3) but also following all other fracture types combined (SMR 1.2; 95 % CI, 1.1–1.4), excluding the hand and foot fractures not associated with any increased mortality.


The persistence of increased mortality long after the occurrence of a fracture has generally been attributed to underlying comorbidity, but this needs to be defined in much greater detail if specific opportunities are to be identified for reducing the excess deaths observed.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3


  1. Cooper C, Atkinson EJ, Jacobsen SJ, O’Fallon WM, Melton LJ 3rd (1993) Population-based study of survival after osteoporotic fractures. Am J Epidemiol 137:1001–1005

    PubMed  CAS  Google Scholar 

  2. Haentjens P, Magaziner J, Colon-Emeric CS, Vanderschueren D, Milisen K, Velkeniers B, Boonen S (2010) Meta-analysis: excess mortality after hip fracture among older women and men. Ann Intern Med 152:380–390

    Article  PubMed  Google Scholar 

  3. Melton LJ 3rd, Therneau TM, Larson DR (1998) Long-term trends in hip fracture prevalence: the influence of hip fracture incidence and survival. Osteoporos Int 8:68–74

    Article  PubMed  Google Scholar 

  4. Cummings SR, Melton LJ 3rd (2002) Epidemiology and outcomes of osteoporotic fractures. Lancet 359:1761–1767

    Article  PubMed  Google Scholar 

  5. Cauley JA, Thompson DE, Ensrud KC, Scott JC, Black D (2000) Risk of mortality following clinical fractures. Osteoporos Int 11:556–561

    Article  PubMed  CAS  Google Scholar 

  6. Bliuc D, Nguyen ND, Milch VE, Nguyen TV, Eisman JA, Center JR (2009) Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women. JAMA 301:513–521

    Article  PubMed  CAS  Google Scholar 

  7. Melton LJ 3rd, Crowson CS, O’Fallon WM (1999) Fracture incidence in Olmsted County, Minnesota: comparison of urban with rural rates and changes in urban rates over time. Osteoporos Int 9:29–37

    Article  PubMed  Google Scholar 

  8. Melton LJ 3rd (1996) History of the Rochester Epidemiology Project. Mayo Clin Proc 71:266–274

    Article  PubMed  Google Scholar 

  9. ICD-9-CM (1978) International Classification of Diseases 9th revision, clinical modification, vol 1. Commission on Professional and Hospital Activities, Ann Arbor

  10. Melton LJ 3rd (1997) The threat to medical-records research. N Engl J Med 337:1466–1470

    Article  PubMed  Google Scholar 

  11. Teng GG, Curtis JR, Saag KG (2008) Mortality and osteoporotic fractures: is the link causal, and is it modifiable? Clin Exp Rheumatol 26:S125–S137

    PubMed  CAS  Google Scholar 

  12. Poór G, Atkinson EJ, O’Fallon WM, Melton LJ, 3rd (1995) Determinants of reduced survival following hip fractures in men. Clin Orthop 319:260–265

    Google Scholar 

  13. Järvinen TLM, Sievänen H, Khan KM, Heinonen A, Kannus P (2008) Shifting the focus in fracture prevention from osteoporosis to falls. BMJ 336:124–126

    Article  PubMed  Google Scholar 

  14. Kanis JA, Oden A, Johnell O, De Laet C, Jonsson B, Oglesby AK (2003) The components of excess mortality after hip fracture. Bone 32:468–473

    Article  PubMed  CAS  Google Scholar 

  15. Tosteson AN, Gottlieb DJ, Radley DC, Fisher ES, Melton LJ 3rd (2007) Excess mortality following hip fracture: the role of underlying health status. Osteoporos Int 18:1463–1472

    Article  PubMed  CAS  Google Scholar 

  16. Ismail AA, O’Neill TW, Cooper C, Finn JD, Bhalla AK, Cannata JB, Delmas P, Falch JA, Felsch B, Hoszowski K, Johnell O, Diaz-Lopez JB, Lopez Vaz A, Marchand F, Raspe H, Reid DM, Todd C, Weber K, Woolf A, Reeve J, Silman AJ (1998) Mortality associated with vertebral deformity in men and women: results from the European Prospective Osteoporosis Study (EPOS). Osteoporos Int 8:291–297

    Article  PubMed  CAS  Google Scholar 

  17. Center JR, Nguyen TV, Schneider D, Sambrook PN, Eisman JA (1999) Mortality after all major types of osteoporotic fracture in men and women: an observational study. Lancet 353:878–882

    Article  PubMed  CAS  Google Scholar 

  18. Kado DM, Browner WS, Palermo L, Nevitt MC, Genant HK, Cummings SR (1999) Vertebral fractures and mortality in older women: a prospective study. Study of Osteoporotic Fractures Research Group. Arch Intern Med 159:1215–1220

    Article  PubMed  CAS  Google Scholar 

  19. Naves M, Diaz-Lopez JB, Gomez C, Rodriguez-Rebollar A, Rodriguez-Garcia M, Cannata-Andia JB (2003) The effect of vertebral fracture as a risk factor for osteoporotic fracture and mortality in a Spanish population. Osteoporos Int 14:520–524

    Article  PubMed  CAS  Google Scholar 

  20. Johnell O, Kanis JA, Oden A, Sernbo I, Redlund-Johnell I, Petterson C, De Laet C, Jonsson B (2004) Mortality after osteoporotic fractures. Osteoporos Int 15:38–42

    Article  PubMed  CAS  Google Scholar 

  21. Hasserius R, Karlsson MK, Jonsson B, Redlund-Johnell I, Johnell O (2005) Long-term morbidity and mortality after a clinically diagnosed vertebral fracture in the elderly—a 12- and 22-year follow-up of 257 patients. Calcif Tissue Int 76:235–242

    Article  PubMed  CAS  Google Scholar 

  22. Trone DW, Kritz-Silverstein D, von Muhlen DG, Wingard DL, Barrett-Connor E (2007) Is radiographic vertebral fracture a risk factor for mortality? Am J Epidemiol 166:1191–1197

    Article  PubMed  Google Scholar 

  23. Lau E, Ong K, Kurtz S, Schmier J, Edidin A (2008) Mortality following the diagnosis of a vertebral compression fracture in the Medicare population. J Bone Joint Surg Am 90:1479–1486

    Article  PubMed  Google Scholar 

  24. Morin S, Lix LM, Azimaee M, Metge C, Caetano P, Leslie WD (2011) Mortality rates after incident non-traumatic fractures in older men and women. Osteoporos Int 22:2439–2448

    Article  PubMed  CAS  Google Scholar 

  25. Cooper C, Atkinson EJ, O’Fallon WM, Melton LJ 3rd (1992) Incidence of clinically diagnosed vertebral fractures: a population-based study in Rochester, Minnesota, 1985–1989. J Bone Miner Res 7:221–227

    Article  PubMed  CAS  Google Scholar 

  26. Lowe H, Shane E (2008) Osteoporosis associated with illnesses and medications, Chapter 52. In: Marcus R, Feldman D, Nelson DA, Rosen CJ (eds) Osteoporosis, 3rd edn. Elsevier, Amsterdam, pp 1283–1305

    Chapter  Google Scholar 

  27. Mussolino ME, Gillum RF (2008) Low bone mineral density and mortality in men and women: the Third National Health and Nutrition Examination Survey linked mortality file. Ann Epidemiol 18:847–850

    Article  PubMed  Google Scholar 

  28. Ensrud KE, Thompson DE, Cauley JA, Nevitt MC, Kado DM, Hochberg MC, Santora AC 2nd, Black DM (2000) Prevalent vertebral deformities predict mortality and hospitalization in older women with low bone mass. Fracture Intervention Trial Research Group. J Am Geriatr Soc 48:241–249

    PubMed  CAS  Google Scholar 

  29. Browner WS, Pressman AR, Nevitt MC, Cummings SR (1996) Mortality following fractures in older women. The Study of Osteoporotic Fractures. Arch Intern Med 156:1521–1525

    Article  PubMed  CAS  Google Scholar 

  30. Shortt NL, Robinson CM (2005) Mortality after low-energy fractures in patients aged at least 45 years old. J Orthop Trauma 19:396–400

    Article  PubMed  Google Scholar 

  31. Rozental TD, Branas CC, Bozentka DJ, Beredjiklian PK (2002) Survival among elderly patients after fractures of the distal radius. J Hand Surg Am 27:948–952

    Article  PubMed  Google Scholar 

  32. Piirtola M, Vahlberg T, Lopponen M, Raiha I, Isoaho R, Kivela SL (2008) Fractures as predictors of excess mortality in the aged-a population-based study with a 12-year follow-up. Eur J Epidemiol 23:747–755

    Article  PubMed  Google Scholar 

  33. Barrett JA, Baron JA, Beach ML (2003) Mortality and pulmonary embolism after fracture in the elderly. Osteoporos Int 14:889–894

    Article  PubMed  Google Scholar 

  34. Hill RM, Robinson CM, Keating JF (2001) Fractures of the pubic rami. Epidemiology and five-year survival. J Bone Joint Surg Br 83:1141–1144

    Article  PubMed  CAS  Google Scholar 

  35. Melton LJ 3rd, Kearns AE, Atkinson EJ, Bolander ME, Achenbach SJ, Huddleston JM, Therneau TM, Leibson CL (2009) Secular trends in hip fracture incidence and recurrence. Osteoporos Int 20:687–694

    Article  PubMed  Google Scholar 

Download references


This work was supported by research grant P01 AG04875 and made possible by the Rochester Epidemiology Project (R01 AG034676) from the National Institute on Aging, US Public Health Service. The authors wish to thank Mrs. Judy Bruen and Mrs. Leona Bellrichard for data collection and Mrs. Mary Roberts for assistance in preparing the manuscript.

Conflict of interest


Author information

Authors and Affiliations


Corresponding author

Correspondence to L. J. Melton III.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Melton, L.J., Achenbach, S.J., Atkinson, E.J. et al. Long-term mortality following fractures at different skeletal sites: a population-based cohort study. Osteoporos Int 24, 1689–1696 (2013).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Cohort study
  • Epidemiology
  • Fractures
  • Population-based
  • Survival