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.
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