they include the establishment of an injury surveillance system with more accurate identification of specific injuries and their causes.

Nevertheless, it is clear that fractures are quite common and that osteoporosis is responsible for a substantial portion of them, a figure currently estimated at more than 1.3 million fractures annually.35 The significance of these numbers is better grasped by noting that the lifetime risk of a hip fracture, 15 percent in white women and 5 percent in men,5 is equivalent to the combined lifetime risk of developing breast, uterine, or ovarian cancer in women and about the same as the lifetime risk of prostate cancer in men. These fractures increase dramatically in incidence with aging, and, at any age, rates are greater for women than for men (Figure 6-1). Based on the few data available, the same general pattern applies to nonwhite populations, but rates for these groups are lower.27

Mortality

The fractures associated with osteoporosis may, in turn, lead to substantial disability and, in the case of hip fractures, even death. Hip fractures lead to an overall 5 to 20 percent reduction in expected survival.5 The excess mortality may be seen for up to six months following the fracture and varies with age and sex (there appear to be no detailed data concerning the influence of race). For example, about 90 percent of hip fracture victims under 75 years of age are still alive one year later (92 percent of those expected to be alive), compared with only 73 percent (83 percent of expected) of those aged 75 years and older at the time of their fracture.27 Despite their greater average age when fractures occur, survival is better among women, 83 percent of whom are still alive one year after the fracture, compared with only 63 percent of men. Survival is mediated primarily by coexisting serious illnesses24 but, after the first six months, is about as expected for persons of comparable age and sex in the general population. Still, hip fractures are associated with many deaths and are partly responsible for the fact that falls are the leading cause of accidental death among men and women aged 75 years or older in the United States and the second leading cause among those aged 45 to 74 years. In contrast, wrist fractures and osteoporotic spine fractures cause no increase in mortality.27

Disability

A substantial minority of hip fracture patients are nonambulatory or dependent even before the fracture. However, the devastating



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