Introduction

Globally, advances in medical care and economic growth have led to longer and more active lives for people, including those in sub-Saharan Africa (SSA)1,2. While population ageing started in high-income countries (HICs), Africa's low- and middle-income countries are currently experiencing the fastest demographic shift towards older ages. Africa has seen a rise in the population of its inhabitants aged 60 and older from about 24 million in 1980 to 74 million in 2020, with a projection of 105 million by 2030 3. A consequence of this population ageing is the increasing proportion of older people among orthopaedic trauma victims4,5,6,7, suggesting an evolution of geriatric orthopaedic trauma (GOT) as a public health concern. Although there is no gold standard definition, some characteristics of a health condition portray it as a public health problem. These include: (i) a high burden vis-a-vis morbidity, mortality, quality of life, and costs, (ii) a disproportionate affectation of disadvantaged population groups, and (iii) availability (but lack of full implementation) of public health strategies to reduce the burden of the condition on the population and healthcare system8.

Based on several recent publications, GOT in SSA now possesses the characteristics mentioned above6,7,9,10,11. A burgeoning older population in SSA countries comes with an increase in the number of older people who move actively about on foot and by automobile. This increased mobility translates to higher chances of involvement in injury-causing falls and automobile crashes. In Malawi, two successive analyses of adult patients in the trauma registry at a central hospital revealed that the proportion of older patients was 2.9% in an earlier6 and 3% in a later analysis7. Fractures and dislocations were significantly more prevalent in older patients. A study at a trauma centre in Nigeria from 2017 to 2019 found that patients ≥ 60 years represented 4% of the trauma patient population seen, with a mortality of 6.1% 9. In Kenya, older patients formed 4.5% of all trauma admissions and the overall hospital mortality rate was 13.9% in a study between 2009 and 2010 at the national hospital in Nairobi10. A recent review at a major trauma centre in South Africa found that 4% of all trauma admissions were aged ≥ 60 years and the mortality rate was 6.5% 11.

Based on the percentages mentioned earlier, it may seem like the burden of GOT in SSA is insignificant. However, the problem becomes evident when the actual numbers are compared with the limited human and material resources available for treatment, the presence of multimorbidity, and the resulting higher morbidity and mortality compared to the younger population. For instance, in the Malawi study6, older age was associated with a significant increase in hospital admissions and mortality compared to the youngest age group (18–44 years). Further, 2.9% of the 42,816 adult patients were older people, which equals 1253 older patients over 5 years or 250 per year. According to a systematic review and meta-regression analysis by Williamson et al12, the estimated cost of in-patient care for hip fracture is $13,331. This cost seems very high for Malawi, considering its health sector budget for 2023/24 is about US$189 million, which translates to a per capita allocation of approximately US$14 13. The health sector budgets of most other SSA countries are similar.

Even though the absolute number of people aged 65 and above in SSA has increased from about 12 million to 35 million between 1980 and 2020, with a projection of reaching 100 million by 2050, the birth rate in most SSA populations is currently high, leading to a higher proportion of young people compared to the older3. However, this is expected to change in the future. According to the UN 2022 Revision of World Population Prospects3, the population aged 65 and above in SSA countries remained at approximately 3% of the total population between 1980 and 2020, but it is projected to increase to 5% by 2050. Over the same period, the proportion of people aged 15–64 increased from 52 to 55%, with a projection of reaching 62% by 2050. At the same time, the fertility rate decreased from 6.8 to 4.7 births per woman, and the proportion of people aged 0–14 decreased from 45 to 42%. The fertility rate and the proportion of people aged 0–14 are projected to further reduce to 3% and 33% respectively by 2050, indicating an inevitable shift towards an older population as the current 15–64 age group grows older.

The chances of GOT are further amplified by the fact that the physical environment resulting from rapid urbanisation in these countries is poorly adapted for an ageing population14. Floor tiling in homes without the use of slip-resistant footwear, and poorly constructed/maintained roads without adequate provision for pedestrians predispose the older persons to injuries15,16. Further, the population ageing in SSA is against the backdrop of pervasive poverty, unresolved development problems, HIV/AIDS scourge, and a decline in the traditional care and support of older adults aggravated recently by the mass emigration of the youths to HICs17,18. Additionally, many governments lack national ageing policies or safety net programmes for the older adults1,17,19. Older individuals who frequently use medical services face financial hardship when the government fails to pay or delays pension disbursements, as they primarily rely on out-of-pocket healthcare payments20.

Although older patients have been noted to be the fastest-growing population in trauma centres of HICs and geriatric injuries have imparted a huge financial burden on their healthcare systems4,21,22,23, the inequality in resources implies that low-income settings will be more severely impacted by population ageing. Essentially, the current health systems of many SSA nations lack the resources to effectively manage the ageing-associated changes (such as impaired motor and cognitive function, decreases in vision, hearing, bone density, muscle strength and joint flexibility) or appropriately treat their consequences (such as orthopaedic injuries)22,24,25,26. Inequalities in terms of accessibility and affordability of trauma care services also exist within SSA societies27. Many older persons lack modern trauma care in their community. They also lack persons, money, and means to transport themselves to the big cities where the services are available28. Reducing inequality within and between countries is the United Nations (UN) Sustainable Development Goal (SDG) 10 and vital to achieving all SDGs including 1 and 3. A cornerstone of the 2030 Agenda for Sustainable Development is the commitment to “leave no one behind”29.

To improve the lives of older people, their families and communities through global collaboration, the UN declares 2021 – 2030 the Decade of Healthy Ageing1. Older people are not left out of the UN SDGs either30. For example, SDG 1 seeks to end poverty in all its forms everywhere, and older people are part of the vulnerable population in need of social protection (Target 1.3). SDG 3 wants to ensure healthy lives and promote well-being for all at all ages, including a target to halve the number of global deaths and injuries from road traffic crashes (Target 3.6). SSA cannot achieve these goals without addressing the emerging problem of orthopaedic injuries in its older population. SDG 10 may not be realised if the SSA older population are neglected. Ensuring access to a safe and affordable physical environment for older people will reduce orthopaedic injuries, and this is in line with the SDG targets 11.1, 11.2 and 11.3 9.

Earlier research works indicated that ground-level falls (GLFs) and traffic crashes are the predominant mechanisms of geriatric trauma. While studies in HICs found GLFs to be the most common mechanism4,22,23, road traffic crashes (RTC), including motor vehicle crashes (MVC) motorcycle crashes (MCC) and pedestrian vs automobile collisions (PAC) are the reported most common aetiology in developing countries10,31,32. Violent assault, elder abuse and suicide are other mechanisms that have been previously documented4,22,23,33. The injury pattern and severity vary, and just about any part of the body could be injured, isolated or multiple, closed or open10,22. Orthopaedic injuries recorded are fractures of the spine, lower and upper extremities, especially femur, proximal humerus, and wrist fractures22,34. In any case, the importance of GOT is in the fact that only one long-bone fracture tips the victim into the high-risk category, a fracture being a significant cardiovascular stressor22. Thus, for a given injury, there are greater risks and worse outcomes in the older population than the younger patients, even in HICs22,23.

Nigeria, a lower middle-income country, has the highest number of older people in Africa; people aged > 65 numbered about 2 million in 1980, 6 million in 2020, and are projected to be 16 million by 2050 3. Although the percentage of the total population that is aged 65 and above has been falling slightly35, this rapid growth in the actual numbers of older people is at a time of declining health financing, increasing economic hardship and insecurity that are forcing the emigration of the youth who could have mitigated the burden. Epidemiological studies are pertinent to underscore the magnitude of the emerging problem of GOT in SSA, aid health advocacy and improve healthcare planning. Hence, this retrospective study aimed to review the epidemiological characteristics of orthopaedic injuries in the older population (≥ 60 years, according to the United Nations definition36) treated at a Nigerian tertiary health facility to support previous similar studies and draw attention to the evolution of GOT as a public health concern in SSA. We hypothesised that, in Nigeria, like other SSA countries, there is an increasing incidence of geriatric orthopaedic injuries, and that age and gender influence the aetiology and nature of the injuries.

Methods

Study centre

The study centre was established in 1907 by an American missionary as a secondary mission health facility in Ogbomoso, an ancient semi-urban city in southwestern Nigeria. It was upgraded to a tertiary mission hospital in 2009 when it was converted to a mission teaching hospital. The hospital served as a referral centre for the health facilities in towns and cities nearby and far away. Orthopaedic care in the hospital was coordinated by the senior author, an older orthopaedic surgeon, supported mostly by non-orthopaedic medical practitioners. Anaesthesia was provided occasionally by the visiting anaesthesiologists but mostly by nurse anaesthetists. There were no intensive care specialists or ventilators. A physiotherapy department helped rehabilitate but its efficiency is affected by a high turnover rate due to frequent staff exits to greener pastures. The patients who had co-morbid conditions were co-managed with the medical team which has specialist cardiologists, nephrologists, neurologists and endocrinologists. The population served by the hospital included artisans, taxi drivers, motorcyclists, government workers, small-scale farmers, and traders. Health insurance was unavailable, except for a few civil servants with limited coverage for some surgical conditions. The majority of patients pay for healthcare out-of-pocket.

Study design

This 5-year retrospective study was from July 2018 to June 2023. The Institutional Research Ethics Committee approved the study protocols. The inclusion criteria for this study were patients aged 60 years and older who were admitted for treatment of orthopaedic injuries. (For this study, an orthopaedic injury was defined as pelvic and extremity injury of the musculoskeletal system, including fractures, dislocations, tendon lacerations and extremity crush injuries). The exclusion criteria were non-orthopaedic trauma such as burns and isolated head, chest, or abdominal trauma without a concomitant orthopaedic injury. The GOT victims who were treated as outpatients were also excluded. A comprehensive list of GOT patients was ensured by comparing the admission and discharge records on the surgical wards with the operating room records. These records contain a list of all adult orthopaedic trauma admissions and surgeries. The case files were subsequently retrieved from the Medical Records department. All retrieved files had the needed information for the study.

Data management and statistical analysis

Data extracted included patients’ age, gender, the distance of their residence to our hospital, mechanism, nature and duration of injury, and co-morbidities. The data were analysed with SPSS version 23 (IBM Corp, New York, USA) and presented in tables and figures. The injuries were classified as fresh if they were presented to our hospital within 3 weeks of occurrence and as old if presented later than 3 weeks. The location of the femur fractures was defined according to the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) guideline as proximal end segment (AO/OTA 31), diaphyseal segment (AO/OTA 32), and distal end segment (AO/OTA 33)37. The normality of the data was assessed visually with histograms to determine the appropriateness of parametric tests. Univariate analyses were performed to determine significant associations using the independent sample t-test for numerical variables and Pearson’s chi-square (χ2) test for categorical variables. All p values were two-tailed, and the level of significance was set at p < 0.05.

Ethics declarations

Approval was obtained from the Bowen University Teaching Hospital (BUTH) Research Ethics Committee (Ethics approval number: BUTH/REC – 1014). The procedures used in this study adhere to the tenets of the Declaration of Helsinki. Informed consent was obtained from all individual participants. (Obtaining consent from a parent and/or legal guardian was not relevant to this study as there were no participants less than 18 years old). All study procedures were conducted per ethical standards.

Results

Incidence of geriatric orthopaedic admission, mortality and trend

Over the study period, patients aged ≥ 60 years who received in-patient care for orthopaedic injuries were 241 out of 1135 adult orthopaedic trauma admissions, constituting 21.2%. Nine patients died while on admission, giving a mortality rate of 3.7%. The percentage of all adult orthopaedic trauma admissions contributed by older patients increased steadily over the 5-year study period (Fig. 1). The rise in Year 3 coincided with the COVID-19 lockdown period.

Figure 1
figure 1

Percentage of all adult orthopaedic trauma admissions contributed by older patients (N = 241), Year 1 July 2018–June 2019, Year 2 July 2019–June 2020, Year 3 July 2020–June 2021, Year 4 July 2021–June 2022, Year 5 July 2022–June 2023.

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Patient's characteristics, mechanism and nature of injury

From Table 1, their mean age was 72.5 years (range, 60–105 years), 108 (44.8%) were older than 70 years and 51% were males. The mean distance of the patient’s place of residence from our hospital was 35.8 km (range, 1–349 km) with about one-half (50.6%) living farther than 10 km. About one-half (50.6%) of injuries were caused by GLFs and nearly all the rest (48.1%) by RTC, including MCC, PAC and MVC. The majority (91.7%) of the injuries were fractures. Only one bone was fractured in 209 (86.7%) patients while 27 (11.2%) had multiple bone fractures. The femur, with 161 fractures, was the most commonly injured bone (15 in patients with multiple bone fractures and 146 isolated fractures (Fig. 2)). The femur fractures were located at the proximal end segment (109, 67.7%), diaphyseal segment (42, 26.1%) and distal end segment (10, 6.2%). The 109 proximal end segment fractures consisted of 67 at the femoral neck and 42 at the trochanteric area. There were very few patients with radius/ulna fractures (2 isolated and 7 as part of the ‘multiple bone’ in Fig. 2) because radius/ulna fractures were mostly treated conservatively on an outpatient basis. More than one-quarter (27.4%) were old (> 3 weeks) injuries. Almost one-half of the patients had comorbid conditions, systemic hypertension being the most common (26.6%) followed by multiple comorbidities (12.9%) and type 2 Diabetes (5.8%) (Table 1).

Table 1 Patients’ sociodemographic characteristics, injury details and comorbid conditions.
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Figure 2
figure 2

Fractured bones (N = 241).

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Univariate analyses to test for significant association among variables

Comparison using independent sample t-test showed a statistically significant difference between the mean ages of the male (mean = 70.8 years, SD = 9.08) and female (mean = 74.3 years, SD = 10.26) patients (t = -2.780, p = 0.006). Cross tabulation and Pearson’s chi-square (χ2) test revealed that a significantly higher proportion (64.6%) of patients who presented with old injuries lived farther than 10 km from the hospital (p = 0.008) (Fig. 3). Table 2 shows that significantly more patients aged ≤ 70 years were injured in RTC/assault while those aged > 70 years were injured in GLFs (p < 0.001). The presence of comorbid conditions among patients aged > 70 years was statistically significant compared to the younger ones (p = 0.009). The duration of injury bore no significant relationship with age. A significantly higher proportion of proximal end segment femur fractures occurred in patients older than 70 years while diaphyseal and distal end segment fractures involved more patients ≤ 70 years (p < 0.001) (Table 2). Moreover, end-segment femur fractures resulted significantly more from GLFs while diaphyseal fractures resulted more from RTC or assault (p = 0.001) (Fig. 4). Similarly, Table 3 shows that significantly more males got injured in RTC and by assault, while females were injured in GLFs (p < 0.001). None of the other variables had a statistically significant association with gender.

Figure 3
figure 3

Relationship between patients’ distance from the hospital and duration of injury (N = 241), χ2 = 6.972, df = 1, p = 0.008.

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Table 2 Association between patients' age and other variables. Significant values are in bold.
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Figure 4
figure 4

Relationship between the cause of injury and femur fracture location (n = 161)), χ2 = 13.358, df = 2, p = 0.001.

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Table 3 Association between patients' gender and other variables. Significant values are in bold.
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Discussion

Our study found that the 241 patients aged ≥ 60 years made up 21.2% of all adult orthopaedic trauma admissions over the study period and that the yearly percentage increased steadily with a spike during the COVID-19 lockdown year (Fig. 1). The COVID-19 lockdown in Nigeria lasted only about 6 months, all within 2020. However, not all the 36 states of the nation were locked down. There was no lockdown in Oyo state where our hospital is located. Although social distancing and wearing face masks were mandated, and large social and religious gatherings were suspended, citizens of the state were allowed to move around and work. This could explain the spike in Year 3, as patronage by injured people from nearby locked-down states increased during this time.

The increasing representation of the older persons among the orthopaedic trauma population supports the findings of previous studies in Africa10,31,38. However, 21.2% contributed by the older people in this study is much higher than what previous studies reported because those studies included other injuries besides orthopaedic ones6,7,9,10,11. Moreover, many (44.8%) of the patients were older than 70 years (mean, 72.5 years; range, 60–105 years), with almost one-half having comorbid conditions, and more than one-half (50.6%) living farther than 10 km from the hospital offering care for their injuries (Table 1). The significance of these findings becomes apparent when placed against the backdrop of poverty, lack of comprehensive health insurance, grossly inadequate Emergency Medical Services, poor road network, disintegration of the erstwhile supportive traditional family system, and lack of operational geriatric care policy and safety nets by the governments17,18. The presence of comorbid conditions in the older individuals complicates the care process. For the same severity of an injury, the resource consumption is higher and outcomes are worse for the older than the younger population22,23,24,25. Living far away from the hospital can lead to delayed presentation due to poor transportation, lack of ambulance services, and patients' unfamiliarity with the big cities where the hospitals are located28. Early presentation and intervention can reduce mortality4,22, so it is logical to assume that delayed presentation will increase mortality.

The implication of the foregoing is that the available caregivers would often take an injured older patient first to a proximal, easily accessible and affordable healthcare provider in their community39,40. Hence, it was unsurprising that patients’ distance from the hospital had a significant negative association with injury duration (Fig. 3). More than one-quarter of the injuries were older than 3 weeks at presentation (Table 1), having initially sought care from traditional bone setters and charlatans nearer to their homes39. This often translates to psychological distress, social and economic costs in terms of loss of work days (for the caregivers) and eventual higher cost of effective treatment, aggravating the existing poverty41,42,43. It also leads to increased morbidity and worse outcomes for the patients. Previous studies have found that early intensive monitoring, aggressive resuscitation, and a short time to surgical intervention reduce mortality4.

Similar to some previous studies38, the majority of the injuries encountered were fractures, mostly of the proximal femur, caused by GLFs and RTCs. However, contrary to many past African studies, GLFs alone caused more injuries (50.6%) than all forms of RTCs combined (48.1%)10,31,32. This insinuates a trend similar to that of HICs where fragility fractures of the proximal femur caused by GLFs are more prevalent in the older population than injuries from traffic crashes22,23. This is alarming because most SSA countries lack the resources to cater to the enormous needs of older patients with fragility fractures12,22,23,24,44. Besides, the substantial contribution of RTCs to these injuries implies a double tragedy for SSA: while nations are still grappling with RTCs, injuries from falls are increasing. It is also a pointer to the geriatric unfriendliness of both the physical environment originating from rapid urbanisation and the precarious transport systems of many countries in the continent14.

As we hypothesised, age and gender significantly influenced the aetiology and nature of the injuries. The mean age of females was significantly higher than that of males (74.3 vs. 70.8 years, p = 0.006). Likewise, the number of females injured by GLFs was significantly greater (p < 0.001) while RTCs/assault injured more males (Table 3), as previously found by a study in Ghana31. Our study found statistically significant proportions of older patients (> 70 years) among those who suffered from GLFs (p < 0.001), had comorbidities (p = 0.009), and proximal end-segment femur fractures (p < 0.001). Earlier studies reported similar findings10,38. Conversely, younger patients (≤ 70 years) got injured more by RTCs/assault, had fewer comorbid conditions, and had more diaphyseal and distal end-segment femur fractures (Table 2).

Even though it is not unusual for older females to be more than males in any country, these findings in the SSA context suggest that the number of older females suffering from fragility fractures will, reasonably, rise in the coming years. The World Health Organization has expressed concern over the rising number of households headed by women over the age of 60. These households consist solely of older individuals and their grandchildren, as younger family members have either migrated for economic reasons, succumbed to infectious diseases such as HIV/AIDS or are unable or unwilling to care for their ageing relatives45. Therefore, countries and communities in this context must take proactive measures to either prevent the trend or effectively treat the inevitable injuries. Practical measures aimed at reducing injuries resulting from RTCs, particularly MCC and PAC, must be implemented and maintained by governments across the continent. As the population ages and comorbidity increases, African health systems must invest in specialised geriatric trauma centres and improve multidisciplinary management of injuries in the older people. This has been shown to produce superior outcomes in HICs4,22,23.

However, this study has limitations that require caution in generalising our findings. First, its single-centre retrospective design and relatively short study period may have unintentionally omitted important information from the data. Second, the study covers the COVID-19 lockdown period, which impacted patient flow, making it difficult to see the true trend of GOT without the pandemic. Further, with 65 out of 241 patients presenting after 3 weeks of injury, some may have died in the community, meaning that the number of patients admitted and included in this study may not accurately represent the true burden of GOT.

Despite these limitations, the present epidemiological review in Nigeria corroborates previous analogous studies to show that GOT is evolving as a public health problem in SSA, propelled by poverty, development problems, poorly planned rapid urbanisation, economic hardship forcing emigration of youths to HICs, deterioration of the traditional family system, and lack of vibrant ageing policies or safety net programmes for the older people. The UN 2030 Sustainable Development agenda is therefore apt to stem the trend of GOT. Concerted efforts must be mobilised for SSA to reduce inequalities, eradicate poverty, ensure decent work and economic growth, build sustainable cities and communities, and promote peaceful and inclusive societies to achieve good health and well-being for its older population.