A traumatic injury is defined as "an injury or wound to a living body caused by the application of external force or violence,"1 and includes injuries incurred in vehicular accidents, machinery, falls, sports, and other injuries caused by something outside a person’s body.
Index - Table of Contents
Falls and Traumatic Injuries
A traumatic injury is defined as "an injury or wound to a living body caused by the application of external force or violence,"1 and includes injuries incurred in vehicular accidents, machinery, falls, sports, and other injuries caused by something outside a person’s body.
Self-Reported Musculoskeletal Injuries
In 2012, 8.86 million persons reported seeking medical care for an injury during the prior three months. The number of self-reported injuries, even when extrapolated out to a full year, is much lower than the number of health care visits to physicians, emergency departments, outpatient clinics, and hospitals reported over the course of a year, suggesting that self-reported injuries are underreported. However, the proportion of these injuries that were musculoskeletal was similar to that reported by the national health care databases for injury-related health care visits, 72% and 77%, respectively. In addition, self-reported injuries reflected the distribution by demographic characteristics (i.e., sex, age, and race) in the same proportion as found in the general population and among health care visits in the national databases, confirming that musculoskeletal injuries occur to all people.
(Reference Table 6A.1.1.1 PDF CSV)
The type of self-reported injury reported varied somewhat by demographic group, particularly with respect to sex and age. Overall, the most common type of musculoskeletal injury for which medical attention was sought was a sprain or strain. This was particularly true for persons aged 65 to 74 years, and for females. People age 75 years and older were most likely to report a contusion, but this age group also reported higher proportions of fractures than other ages. Open wounds requiring medical attention were more likely to be reported by males and people 18 to 44 years than by other demographic groups. Sprains and strains as well as fractures were the most common musculoskeletal injury type reported for children ages 0 to 17 years; overall, children had a lower proportion of musculoskeletal injuries for which medical attention was sought than did other age groups. (Reference Table 6A.1.1.1 PDF CSV)
Injuries to the knee were the most common, accounting for 10% of all musculoskeletal injuries for which medical attention was sought. Knee injuries were slightly more likely to occur to young and middle age adults (18 to 64 years) than to children and older persons. Injuries to the back were the second most common injury for which medical attention was sought. People age 18 to 44 years were most likely to have a back injury, while children rarely reported injuries to the back. Children were most likely to have an ankle injury that required medical attention. About 40% of persons reported an injury in multiple anatomic sites that required medical attention. (Reference Table 6A.1.1.2 PDF CSV)
Cause and Source of Self-Reported Injuries
Although all are traumatic injuries, the NHIS separates falls from trauma caused by vehicular accidents, machinery, moving objects, and other types of traumatic injuries in self-reported data. Trauma was the most common cause of musculoskeletal injuries for which medical attention was sought, accounting for slightly more than half the injuries. This was particularly true for young adults age 18 to 44 years, when sports and activities can be the source of musculoskeletal injuries. However, for older persons, particularly those age 75 years and older, falls accounted for three in four injuries for which they sought medical attention. Males were also more likely to suffer an injury requiring medical attention as a result of trauma, while females reported falls and trauma about equally as the cause of the injury. (Reference Table 6A.1.2.1 PDF CSV)
It has long been known that most accidents occur in or around the home. In 2012, people reported more than one-half of the injuries for which they sought medical treatment occurred in the home (31%) or outside the home or farm (21%). Other common places of injury are recreation sites, public streets, and sidewalks. The proportion of injuries that are musculoskeletal is highest for injuries incurred at recreation sites, including fields, courts, parks, lakes, and rivers. More than three of four injuries for these sites were musculoskeletal. Injuries occurring inside the home had the lowest ratio of being musculoskeletal. (Reference Table 6A.1.2.2 PDF CSV)
The type of activity engaged in was not significantly different as a cause of musculoskeletal versus injuries to other body systems. More injuries occur when involved in non-sport leisure activities than any other activity. Sports and working in and around the home or other workplace are the cause of similar numbers of injuries for which medical care is sought. (Reference Table 6A.1.2.3 PDF CSV)
Self-Reported Musculoskeletal Injuries Limitations
The annual National Health Interview Survey asks participants if they are limited in activities of daily living, such as the ability to dress oneself, to get in or out of bed or a chair, or to work due to health issues. For all health concerns,1 more than 13 in 100 people in the United States reported they had limitations in a prior three-month period due to health issues. Fractures accounted for 8% of the primary causes of limitation, resulting in limitation in 1 in 100 people in the United States. Among older women, those age 75 years and older, fractures rose to 10.3% of the total causes of limitations, but was only 6.4% for men. Fractures were responsible for limitations in daily activities in 14% of men in the age range of 45 to 64 years who reported limitations. Overall, women reported being limited due to fractures more often than men until they reached the age of 75 years or older. (Reference Table 6A.1.3.1 PDF CSV)
Help required with routine needs was reported by 23% of people requiring help with activities of daily living; nearly one in three of those with a fracture reported needing help with routine needs. When broken down into specific types of help, help with personal care was identified more frequently than other types of care. Four of ten reported not being able to work at all due to health care issues, with half with a fracture unable to work. An additional one in four reported they were limited in the type of work that could be done. Walking without equipment was difficult for one-third of those with a medical problem, while one-half of those with a fracture required some sort of medical equipment to walk. (Reference Table 6A.1.3.2 PDF CSV)
- 1. Participants were asked, "What condition or health problem causes you to have difficulty with or need help with the following activities?" The list included conditions of vision, hearing, arthritis, back problems, injuries, heart and circulation conditions, diabetes, lung conditions, mental conditions, genitourinary system problems, tumors, alcohol or drug abuse, and old age," and responses included "yes" to at least one condition.
Incidence of Musculoskeletal Injuries
In order to compile a complete picture of the impact of musculoskeletal injuries, six major health care databases are used to estimate the number of visits to a health care provider in a specific year. Treatment episodes, for purposes of this study, have been defined as the accumulative total of cases for all diagnoses treated in physician offices, emergency departments, outpatient clinics, and hospital discharges. Diagnoses are based on variables within publicly available health care database that identify diagnoses or treatments based on ICD-9-CM codes submitted by health care providers. Databases used include from 3 to 25 diagnosis codes, or variables, per record. When analyzing the databases for a specific diagnosis or procedure, if any of the diagnosis variables in the database matches the code of interest, it is included in the total count. Hence, total numbers of injuries may exceed total records if more than one injury is sustained. In addition, health care visits, or episodes, are not the equivalent of patients, as there is some unknown probability that a person may have multiple visits over the year included in the database. While not an absolute, the numbers presented are a solid estimation of how a particular health care issue such as a musculoskeletal injury, compares to other health care issues.
Four of the databases included are produced by the National Center for Health Statistics (http://www.cdc.gov/nchs/index.htm ), a division of the Centers for Disease Control and Prevention, and include data on visits to physician offices (NAMCS), emergency departments (NHAMCS_ED), outpatient clinics (NHAMCS_OP), and hospital discharges (NHDS). These four databases include a representative sample that is weighted to reflect the U.S. population by demographic characteristics for the year from which the data is produced. The remaining two databases are produced by the Healthcare Cost and Utilization Project (HCUP: http://www.hcup-us.ahrq.gov/ ) under the U.S. Department of Health and Human Services Agency for Research and Healthcare Quality. These two databases focus on hospital discharges (NIS) and visits to emergency departments (NEDS), and include millions of data points submitted by participating hospitals and emergency departments. HCUP data is also weighted for representativeness of the U.S. population. All databases are structured to provide only autonomous data. When the two databases were analyzed for hospital discharges and emergency department visits, they yielded similar results, supporting the validity of the findings reported.
Health Care Treatment Visits for Musculoskeletal Injuries
Musculoskeletal injuries accounted for 4% of health care visits to physician offices, outpatient clinics, and hospital discharges. Visits to emergency departments for musculoskeletal injuries accounted for 15% of all emergency department visits. Overall, more than 65 million health care visits were made in 2010 for musculoskeletal injuries. By far, the largest share of these visits was to physician offices, accounting for nearly 80% of all visits and for 62% of visits for musculoskeletal injuries. Emergency departments and outpatient clinics see similar percentages of total patients (10% [NHAMCS_ED] and 8% [NHAMCS_OP]), but emergency departments are more likely to see patients with a musculoskeletal injury. Hospital discharges account for about 3% of patient visits for all health care reasons and for musculoskeletal injuries. (Reference Table 6A.2.2.1 PDF CSV)
Three of four (77%) health care visits associated with an injury diagnosis are related to a musculoskeletal injury. The largest share is found in injury treatments in a physician's office, where four of five (81%) injuries treated are musculoskeletal. The smallest share, 68%, is for hospital discharges. (Reference Table 6A.2.2.4 PDF CSV)
Females, in general, are more likely overall to have a health care visit than are males. With regard to musculoskeletal injury, however, this is true only for the category of health care visits related to hospital discharges, where females represent slightly more than their proportion in the general population. For other care sites, males represent a higher than expected proportion of visits for musculoskeletal injuries.
When it comes to age, persons 75 years and older are far more likely to have a hospital discharge for a musculoskeletal injury than those younger in age. Children, defined as those under the age of 17, utilize outpatient clinics for injury treatment more than persons of other age groups. Young adults between the ages of 18 and 44 years visit emergency departments more frequently for injury care, while their slightly older peers, those aged 45 to 64 years, visit physician offices most often. People aged 65 to 74 years comprise about the same proportion of the general population as those 75 years and older, but they make fewer health care visits for musculoskeletal injury treatment.
Musculoskeletal Injuries by Type for Age and Sex
More than 18.3 million health care visits were for the treatment of fractures in 2010. A close second, sprains and strains accounted for 17 million health care visits. Contusions, open wounds, and dislocation visits numbered 9 million, 8 million, and 6.5 million, respectively. Other types of musculoskeletal injuries represented another 11 million visits. With the exception of contusions, musculoskeletal injuries are treated most frequently in a physician’s office. Nearly 5 million contusions were treated in emergency departments; this compares to 3.6 million treated in a physician's office. (Reference Table 6A.2.2.1 PDF CSV, Table 6A.2.2.4 PDF CSV, and Table 6A.2.2.5 PDF CSV)
Males have a slightly higher rate of musculoskeletal injury than females, with 22.0 injury visits to all provider sites per 100 males in 2010. This compares to 20.5 injury visits per 100 females. The proportion of all musculoskeletal injury visits for males versus females is the reverse of that found in the general population: 51% male to 49% female injury visits versus the 49% to 51% male to female ratio found in the general population. Males are more likely to suffer open wounds (62%) and dislocations (56%). Females have correspondingly lower rates for these injuries, and an expected share of other types of musculoskeletal injuries.
Males have a higher rate of injuries seen in a physician's office, while females are more likely to be discharged from a hospital or seen in an emergency department because of a musculoskeletal injury. Because injuries for which a patient is hospitalized are potentially more severe than those seen in a physician office, it might be surmised that females may incur more severe musculoskeletal injuries.
(Reference Table 6A.2.2.1 PDF CSV and Table 6A.2.2.5 PDF CSV)
Age is also a factor in the rate of musculoskeletal injury health care visits, with the rate per 100 persons increasing from 19.5 for children (ages 0 to 17 years) to 33.9 for people age 75 years and older. This rate increase is found across all provider sites. However, because elderly people comprise a smaller share of the general population, the actual number of injuries for which treatment is delivered is much larger in the younger age brackets. Those aged 45 to 64 years, with 22.3 million visits, had the largest number of musculoskeletal injuries treated in 2010. Older people aged 65 to 74 years had just over 5 million injury visits, while those age 75 years and older accounted for 6.3 million episodes.
Elderly people are particularly prone to fractures, accounting for 23% of fractures treated in 2010, while representing only 6% of the general population. Overall, the elderly accounted for 12% of all musculoskeletal injuries. Those between the ages of 18 and 44 years are disproportionately prone to dislocations and sprains and strains requiring medical attention. (Reference Table 6A.2.2.2 PDF CSV and Table 6A.2.2.5 PDF CSV)
In 2010, a substantial majority of the 5.8 million dislocations (76%) were treated in physician offices. Dislocation of the knee or leg joint represented 86% of these injuries, with the shoulder (8%) the only other anatomic site to account for more than a very small fraction of dislocations. This finding is likely an artifact of an ICD-9 coding anomaly. Isolated acute ligamentous injuries of the knee, (ie, anterior cruciate ligament [ACL], medial collateral ligament [MCL], posterior cruciate ligament [PCL], and lateral collateral ligament [LCL] disruptions) are coded as dislocations using ICD-9-CM methodology, whereas equivalent injuries in other joints are coded as sprains or strains rather than dislocations. True complete dislocations of the knee joint are actually very rare, and associated with marked morbidity.
More than one-third (36%) of the 11.8 million sprain and strain injuries treated in physician offices in 2010 were to the back and sacroiliac joint. Shoulder (31%) and ankle and foot injuries (23%) represented the other two most common anatomic sites for sprains and strains treated in physician offices.
The total number of fractures of the upper and lower extremities treated in physician offices, emergency departments, and hospitals, while fluctuating from year to year, has varied between 12 million and 15 million from 1998 to 2010. Upper limb fractures, including those of the arm, forearm, wrist, hand, and fingers, have accounted for slightly more than one-half of all fractures, with a range of 52% to 59%. Fractures of the upper arm, or humerus, are the least common. In recent years, upper arm fractures have accounted for about 20% of total upper limb fractures. Fractures of the wrist, hand, and fingers occur slightly more often than fractures of the forearm.
Lower limb fractures, which include those of the hip and upper leg (femur), lower leg, ankle, foot, and toes, are reported in similar numbers to upper limb fractures, ranging from 11 million to 15 million. Between two-third and three-fourth of lower limb fractures occur in the ankle, foot, and toes. Breaks of the lower leg (tibia and fibula) are the least common overall.
The majority of fracture care episodes, 65% to 73%, occurred in a physician’s office. Fewer than one in ten fractures (8% or less) were treated with inpatient hospitalization in any given year. However, it is possible that initial care for a fracture was either at the ED or in a hospital admission, with follow-up visits associated with a physician’s office visit. It is, therefore, likely each individual fractures may have been associated with multiple episodes of care. (Reference Table 6A.2.3.1 PDF CSV and Table 6A.2.3.2 PDF CSV)
Unintentional injuries are tracked by the Centers for Disease Control and Prevention (CDC) through the Injury Center, and reported at WISQARS(TM).1 Injuries kill thousands every year, and many of those who survive have life-long impairment as a result of those injuries. Musculoskeletal injuries are the most common type of injury. While much of the focus has been on injury prevention, research to alleviate the impact of major trauma from vehicular accidents, falls, sports, and war injuries, among other causes, is necessary to reduce the burden.
Deaths Due to Unintentional Injuries
The number of unintentional deaths from injuries has remained fairly steady since the early 2000s, with 110,000 to 120,000 deaths occurring as a result of injuries each year.1 However, the proportion of these unintentional deaths that occur as a result of a fall has been steadily rising since 2000, increasing from 14% of deaths in 2000 to 24% in 2010. The age-adjusted rate2 per 100,000 persons has increased from 4.8 to 7.8 for the same time frame.
The primary cause of this increasing proportion is due to deaths from falls in the aging population. Among persons age 65 years and older, the proportion of unintentional injury deaths from falls has risen from 33% to 52% between 2000 and 2010. There has been a slight rate increase from 12% to 14% among persons age 55 to 64 years. The proportion has remained relatively steady for persons under the age of 54 years. Unintentional injuries are the top cause of death for all persons age 1 to 44 years; the third highest cause for those age 45 to 54 years; fourth highest for those age 55 to 64 years; and ninth for those age 65 years and older.3 (Reference Table 6A.3.1.1 PDF CSV)
In 2011, the death rate due to unintentional injury from falls remained at 22%. Females, however, experienced a higher death rate from falls than did males (29% versus 17%). Although the number of deaths from unintentional injury is similar across age groups, both sexes show a steep increase in deaths from falls with increasing age. Among children under age 18 years, the proportion of deaths from falls among all unintentional injury deaths is only 1.4%. Among persons age 85 years and older, it is 63%. (Reference Table 6A.3.1.2 PDF CSV)
- 1. Centers for Disease Control: Web-based Injury Statistics Query and Reporting System (WISQARS) (2011). National Center for Injury Prevention and Control. Available from URL: http://www.cdc.gov/injury/wisqars/ Accessed October 24, 2013.
- 2. Age-adjusted to the 2010 US Census Population. Age-adjusting rates is a way to make fairer comparisons between groups with different age distributions. For example, a county having a higher percentage of elderly people may have a higher rate of death or hospitalization than a county with a younger population, merely because the elderly are more likely to die or be hospitalized. A standard population distribution is used to adjust death and hospitalization rates. The age-adjusted rates are rates that would have existed if the population under study had the same age distribution as the standard population. You cannot compare adjusted rates that use different standard populations, for example, a different Census year.
- 3. Centers for Disease Control: Web-based Injury Statistics Query and Reporting System (WISQARS) (2011). National Center for Injury Prevention and Control. "20 Leading Causes of Death, United States 2010, All Races, Both Sexes". Available at: http://www.cdc.gov/injury/wisqars/ Accessed October 24, 2013.
Cause of Nonfatal Unintentional Injuries
The CDC reported that 30 million unintentional injuries were treated in hospital emergency departments in 2011. Of these 30 million, 90%, or 27.2 million patients, were treated and released. The remaining 10% were hospitalized. These numbers are very similar to those reported in the national health care databases (29.1 million, 91% treated in the ED, 9% hospitalized). (Reference Table 6A.3.2.1 PDF CSV)
Falls are the most common cause of nonfatal unintentional injuries, and are responsible for slightly more than 3 in 10 injuries overall. For injuries in which the person is hospitalized, falls account for nearly one in two. Other forms of trauma are described as the cause in the majority of injury visits to an emergency department in the national health care databases, accounting for 54% of all the injury visits. Among persons hospitalized, trauma other than falls was the cause in 27% of the discharges. The CDC breaks down the cause of unintentional injuries into more categories. (Reference Table 6A.3.2.4 PDF CSV)
In 2011, the overall rate of visits to an emergency department for treatment of unintentional injuries was 87.2 per 1,000 persons. When visits for which the patient was hospitalized are included, the rate increases to 96.4 per 1,000, or roughly 1 in 100 persons who are treated for an injury in an emergency department in a given year. The rate per injury by cause varies significantly by age of the patient. For example, while falls have an overall rate of 29.7 per 1,000 persons, among persons age 74 to 85 years the rate increases to 64.9. For persons age 85 years and older, it jumps to 141.6 per 1,000. (Reference Table 6A.3.2.2 PDF CSV)
Hospital Stays, Cost, and Disposition Due to Musculoskeletal Injuries
The Nationwide Inpatient Sample1(NIS) and Nationwide Emergency Department Sample2 (NEDS) produced by HCUP include data on hospital stays and disposition of patients from hospital and ED visits. This information is used to provide an estimate of the cost related to hospitalization, and the need for additional care by some patients.
- 1. HCUP Nationwide Inpatient Sample (NIS): Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality, Rockville, MD. 2011. Available at: www.hcup-us.ahrq.gov/nisoverview.jsp Accessed December 26, 2014.
- 2. HCUP Nationwide Emergency Department Sample (NEDS): Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality, Rockville, MD. 2010. Available at: www.hcup-us.ahrq.gov/nedsoverview.jsp Accessed on December 26, 2014/
The average length of stay for hospital discharges with any injury diagnosis was approximately 6 days in 2011. Injuries other than musculoskeletal had a slightly longer length of stay of just over 6 days, while musculoskeletal injury patients had an average of slightly more than 5 days. Increasing age was associated with a longer stay, with the longest average stays reported by persons in the 45- to 74-year range. The type of injury also had an impact on length of stay, with open wounds resulting in the longest hospital stay among musculoskeletal injuries. The range for all types of injuries varied between 4 and 7 days. (Reference Table 6A.4.1.1 PDF CSV)
Average hospital charges1 were also slightly higher for patients with non-musculoskeletal injuries, which include brain and spinal injuries, with the exception of average charges for fracture injury patients. However, because of the much higher number of musculoskeletal injury patient stays, the overall total hospital charges for treatment of musculoskeletal injuries were almost twice those of non-musculoskeletal injuries in 2010.
Average total hospital charges for musculoskeletal injuries were $48,700, while they were $52,900 for non-musculoskeletal injuries. The highest average hospital charges were $73,300 for those aged 18 to 44 hears being treated for dislocations.
Total cost for inpatient hospital care for injuries in 2011 was more than $123 million, with musculoskeletal injuries accounting for two-thirds of this total. Fractures, with more than $59.5 million in total hospital charges in 2011, accounted for 72% of musculoskeletal injury charges and nearly one-half (48%) of all injury charges. Increasing age was associated with a steady increase in the proportion of charges for musculoskeletal injury to all injury hospital discharges and in the share of total charges.
- 1. Generally, total charges in the HCUP databases do not include professional fees and non-covered charges. If the source provides total charges with professional fees, then the professional fees are removed from the charge during HCUP processing. In a small number of HCUP databases, professional fees cannot be removed from total charges because the data source cannot provide the information. Emergency department charges incurred prior to admission to the hospital may be included in total charges. Medicare requires a bundled bill for Medicare patients admitted to the hospital through the ED. Other payers may or may not have similar requirements.
Hospital charges are only part of the cost burden associated with musculoskeletal injuries. Nearly one-half of people discharged from a hospital following an injury are discharged to another type of care facility, such as a short-term, skilled nursing, or intermediate care facility. Still another 13% receive home health care following discharge. These ratios are substantially higher than for all hospital discharges, where 70% of patients are discharged to home without additional care.
Age is clearly a factor in the type of hospital discharge received. By the age of 85 years and older, only 10% of hospital discharges for musculoskeletal injuries are to home without additional home health care, with 76% being discharged to another type of care facility and 10% receiving home health care. With the exception of those under the age of 18 years, fracture injuries are the most likely to result in discharge to additional care. After the age of 45 years, fractures to the lower limb are most likely to result in discharge to additional care, while for those younger than 45 years, a torso fracture is the most likely diagnosis to require additional care. (Reference Table 6A.4.2.1 PDF CSV, Table 6A.4.2.3 PDF CSV, and Table 6A.4.2.5 PDF CSV)
Among those seen in an ED for injury treatment overall, 8% to 9% are admitted to a hospital for further care. About 1% will be sent to a skilled nursing or intermediate care facility. Again, as the age of the patient increases, so does the likelihood of being admitted to the hospital from the ED or being sent to a skilled or intermediate care facility. Very few patients are referred to home health care from the ED. Type of injury follows the same pattern as hospital discharges, with fractures the most likely type of injury to require additional health care outside the ED. Fractures to the torso result in more hospital admissions than upper or lower limb fractures overall, but lower limb fractures for persons age 65 years and older account for more hospital admissions. (Reference Table 6A.4.2.2 PDF CSV, Table 6A.4.2.4 PDF CSV, and Table 6A.4.2.6 PDF CSV)
Bed and Lost Work Days Due to Musculoskeletal Injuries
Every year, musculoskeletal injuries result in hundreds of millions of days spent in bed1 or missed work2 for the millions of persons suffering the injuries. In 2012, 57.5 million adults aged 18 years and older reported spending an average of more than 9 days in bed, for a total of 528 million bed days, due to a musculoskeletal injury. Musculoskeletal injuries accounted for 70% of self-reported bed days for all medical conditions in 2012. The most common musculoskeletal conditions for which persons reported days in bed were back or neck pain (average of 12.3 days in bed) and arthritis/rheumatism (average of 10.3 bed days). Together, these conditions accounted for nearly 3 in 4 days spent in bed because of a musculoskeletal condition. With respect to bed days, age is not a factor in increasing numbers, as persons aged 65 years and older report fewer bed days for all musculoskeletal conditions, and for all medical conditions, than those younger than 65 years. (Reference Table 6A.5.1 PDF CSV and Table 6A.5.3 PDF CSV)
Work days lost due to medical conditions were reported at more than 216 million days, based on average lost. As with bed days, musculoskeletal conditions accounted for 70% of the work days reported lost. Back and neck pain was reported as the cause of one-third of the lost work days, with arthritis and rheumatism accounting for another quarter of days. Not unexpectedly, persons age 65 years and older reported fewer lost work days than did younger persons, in part because many are out of the work force already. Although males reported one day longer, on average, of time away from work due to a medical cause, the lower number of males reporting lost work days resulted in females having a slightly higher share of total days lost. This was also true for musculoskeletal conditions, with fewer males reporting work days lost than females, but with a higher average of days lost per person. (Reference Table 6A.5.2 PDF CSV and Table 6A.5.3 PDF CSV)