Global burden of hand fracture from 1990 to 2021 and projected to 2050

Introduction

Hand fracture, involving carpal, metacarpal, or phalangeal bones, is one of the most common traumatic injuries requiring emergency medical care worldwide (1). It is mainly caused by accidental falls, sports injuries, and occupational accidents, with a high incidence in young and middle-aged males (2). Timely emergency disposal and standardized treatment are critical to avoid complications such as traumatic arthritis and joint stiffness, which can lead to long-term disability and increased public health costs (3). As a major component of non-fatal traumatic injuries, hand fracture imposes continuous pressure on emergency departments, rehabilitation services, and public health resource allocation globally (4).

Globally, hand fracture accounts for 16% to 28% of all adult fractures and nearly 8% of total fracture-related years lived with disability (YLDs), serving as a non-negligible component of the global musculoskeletal disease burden (5,6). Its full-cycle management also brings heavy economic pressure worldwide: the average direct medical cost per case ranges from $1,200 to $5,800 in high-income countries, while it brings catastrophic health expenditure to nearly 40% of affected families in low- and middle-income countries, with indirect economic losses 2 to 3 times higher than direct costs (7).

Existing research on hand fracture burden based on the Global Burden of Disease (GBD) database has clear core findings and unaddressed gaps, tied to GBD data update cycles. For GBD 2017, Crowe et al. (1) conducted the first global panoramic analysis, with core findings: hand fracture accounted for over 75% of hand trauma-related YLDs; its burden was significantly positively correlated with socio-demographic index (SDI), with the highest incidence in high SDI regions. For GBD 2019, no global panoramic study was published, only regional/national analyses: core findings include China had the largest absolute hand fracture cases globally, with age-standardized incidence rate (ASIR) rising 18.2% from 1990 to 2019 and higher burden in economically developed northern provinces, with similar national-level findings reported in Russia and Thailand (8,9). For the latest GBD 2021, no comprehensive global analysis of hand fracture burden has been published.

These existing studies have limitations: no full-cycle global analysis based on the complete GBD 2021 database; no systematic integration of driving factor decomposition, health inequality assessment, and long-term burden projection; limited research perspective from clinical treatment rather than public health emergency management; and no forward-looking burden projection up to 2050. This study aims to systematically analyze the spatiotemporal distribution characteristics, multi-dimensional health inequality status, long-term change trends, and core driving factors of the global incidence, prevalence, and disability burden of hand fracture from 1990 to 2021 based on the latest full GBD 2021 database, and project its burden change trend from 2021 to 2050. This study can fill the core gaps in the current global GBD research on hand fracture, and provide the latest evidence-based basis and decision-making reference for countries and regions with different SDI levels to formulate targeted trauma prevention and control strategies, optimize the allocation of emergency medical and rehabilitation resources, and reduce the disability burden and health inequality related to hand fracture. We present this article in accordance with the GATHER reporting checklist (available at https://jphe.amegroups.com/article/view/10.21037/jphe-2026-0022/rc).

Methods

Data source

Data were extracted from the 2021 GBD Study, which covers 204 countries and territories worldwide and provides comprehensive information on 459 health outcomes and associated risk factors (10). Hand fracture was defined based on the International Classification of Diseases and Injuries coding standards, including traumatic fractures of the carpal bones, metacarpals, and phalanges (11). Key burden indicators for hand fracture from 1990 to 2021 were extracted, including the number of incident cases, prevalence cases, YLDs, and their corresponding ASIR, age-standardized prevalence rate (ASPR), and age-standardized YLD rate (ASYR), each accompanied by 95% uncertainty intervals (UIs). YLDs were calculated as the product of the prevalence of fracture-related sequelae and their respective disability weights, reflecting the non-fatal burden and long-term rehabilitation needs of the injury (11).

Regions were stratified by the SDI [values ranging from 0 (lowest) to 1 (highest)] into five quintiles: low, low-middle, middle, high-middle, and high SDI; geographic stratification included seven GBD super regions and 21 GBD regions to analyze regional differences (10).

Data were accessed publicly via the GBD Compare Data Visualization Tool. No custom inclusion or exclusion criteria were applied beyond standard GBD 2021 case definitions for hand fracture. Potential biases include underreporting in low SDI regions and variation in emergency care registration systems across countries. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Study population

This study included all age groups worldwide, with no age restrictions. Stratified analyses were conducted by age, gender (male, female), and geographic region (SDI quintiles, GBD super regions, GBD regions, and countries/territories) to identify high-risk populations and regions.

Statistical analyses

All statistical analyses and data visualization were performed using R software (version 4.2.0). The specific methods are described as follows:

Descriptive analysis

ASIR, ASPR, and ASYR were calculated using GBD standard population weights to eliminate the impact of population age structure differences (11). The 2021 burden of hand fracture was summarized at global, regional, and national levels to clarify the distribution of burden.

Health inequality analysis

To identify regions with insufficient emergency resources and guide targeted resource allocation, slope index (SI) and Pearson correlation analysis were used to evaluate the association between SDI and burden indicators (12).

Decomposition analysis

The change in absolute burden was decomposed into three factors: aging, population growth, and epidemiological change (10,13). The contribution of each factor was quantified to clarify the key drivers of increased burden.

Predictive analysis

Bayesian age-period-cohort (BAPC) model was used to project the global burden of hand fracture from 2022 to 2050 (14,15). The projected results provide a basis for long-term public health emergency planning and resource reserve.

Model selection was based on classical Joinpoint and BAPC approaches widely adopted in GBD-based burden studies; no multiple candidate models were compared. Model performance evaluation and sensitivity analysis were not performed separately, as analyses followed standardized GBD analytical protocols. Uncertainty was estimated using 95% UIs provided by the GBD 2021 study, covering sampling and modeling errors but not unmeasured biases from incomplete surveillance.

Results

Global, regional, and national burden of hand fracture in 2021

In 2021, the global burden of hand fracture was substantial, indicating significant emergency medical needs: the number of incident cases reached 19,778,953 (95% UI: 15,958,518–24,195,236) with an ASIR of 251.6 per 100,000 population; prevalent cases were 20,253,930 (95% UI: 18,663,870–22,064,823) with an ASPR of 241.4 per 100,000 population; YLDs were 256,119 (95% UI: 137,147–445,084) with an ASYR of 3.05 per 100,000 population (Table 1).

Regionally, high SDI regions had the highest ASIR (455.8/100,000) and ASPR (314.21/100,000), indicating high emergency medical demand. High-middle SDI regions had the highest ASYR (3.72/100,000), reflecting heavy long-term rehabilitation burdens. Low SDI regions had the lowest ASIR (170.69/100,000), but potential underreporting of emergency cases due to limited healthcare access (Table 1). Central Europe, Eastern Europe, and Central Asia had the highest ASIR (583.68/100,000), ASPR (472.77/100,000), and ASYR (5.98/100,000), requiring prioritized emergency resource allocation. Southeast Asia, East Asia, and Oceania had the largest absolute incident cases [3,746,461], indicating large-scale emergency response needs. Australasia had the highest ASIR (1,095.48/100,000) and ASYR (7.73/100,000). East Asia (including China, Japan, etc.) had the largest absolute incident cases [2,476,021], prevalent cases [3,750,985], and YLDs [48,098], being the core region for public health emergency intervention (Table 1).

Nationally, Australia had the highest ASIR (1,057.09/100,000); Afghanistan had the highest ASPR (631.31/100,000) and ASYR (7.6/100,000); Bangladesh had the lowest burden indicators. China had the largest global absolute burden (incident: 2,425,262; prevalent: 3,669,188; YLDs: 47,043) (Figure 1, Table S1).

Figure 1 Age-standardized rates of hand fracture in 204 countries and territories, 2021. (A) ASIR, per 100,000; (B) ASPR, per 100,000; (C) ASYR, per 100,000. ASIR, age-standardized incidence rate; ASPR, age-standardized prevalence rate; ASYR, age-standardized YLD rate; YLD, year lived with disability.

In 2021, the global burden of hand fractures varied substantially by age and sex. The number of incident cases and ASIRs peaked in adolescents and young adults. Across all age groups, males consistently had higher incidence rates than females. In contrast, both prevalence and YLDs increased progressively with age. The highest prevalence rate was found in males aged 95 years and older, at 1,753.62 per 100,000 (95% UI: 1,606.51–1,919.47), and in females of the same age group, at 1,736.67 per 100,000 (95% UI: 1,489.81–2,052.88). Similarly, YLDs rates peaked in the oldest age groups, with the highest rates observed in males aged 95 years and older at 20.38 per 100,000 (95% UI: 10.63–34.70) and in females aged 90–94 years at 17.57 per 100,000 (95% UI: 9.15–30.30). The burden of hand fractures thus exhibited a bimodal pattern by age, with incidence peaking in young adulthood and prevalence and YLDs accumulating in older age (Figure 2, Table S2).

Figure 2 Age-specific burden of hand fracture by sex, 2021. (A) Incidence cases/rate; (B) prevalence cases/rate; (C) YLD cases/rate, per 100,000. YLD, year lived with disability.

Health inequality of hand fracture

SI and Pearson correlation analysis confirmed significant positive correlations between SDI and hand fracture burden indicators at all geographic scales. At the 21 GBD regions level [1990–2021], R values for SDI vs. ASIR, ASPR, ASYR were 0.65, 0.62, 0.62 (all P<0.001). At the 204 countries level [2021], R values were 0.60 (ASIR), 0.47 (ASPR), 0.48 (ASYR) (all P<0.001) (Figures S1,S2, Table 2).

The SI for hand fracture burden showed a decline in health inequality from 1990 to 2021 across all measures. For incidence, the SI decreased from 468 in 1990 to 392 in 2021. For prevalence, the SI declined from 274 to 188 over the same period. For YLDs, the SI reduced from 3 to 2. All corresponding ncvTest P values were statistically significant (P<0.05) for both years across the three measures, indicating a decreasing trend in absolute inequality over time (Figure 3).

Figure 3 Socio-demographic inequality of hand fracture by SI across SDI quintiles, 2021. (A) SI of ASIR; (B) SI of ASPR; (C) SI of ASYR. *, multiplication sign. ASIR, age-standardized incidence rate; ASPR, age-standardized prevalence rate; ASYR, age-standardized YLD rate; SDI, socio-demographic index; SI, slope index; YLD, year lived with disability.

Decomposition of burden changes between 1990 and 2021

The global burden of hand fracture increased significantly from 1990 to 2021, with distinct driving factors for emergency and rehabilitation needs. For incidence, population growth was the primary contributor (8,235,671 cases), followed by aging (4,562,319 cases) and epidemiological change (1,980,963 cases). For prevalence, aging was the largest contributor (5,820,192 cases), followed by population growth (7,412,389 cases) and epidemiological change (851,449 cases). For YLDs, population growth contributed 41,089, aging contributed 32,105, and epidemiological change contributed 4,726. Regional decomposition showed that high SDI regions had the largest aging contribution, while low SDI regions had the highest population growth contribution (72.3% for incident cases), indicating different focuses of emergency resource planning across region (Figure 4).

Figure 4 Decomposition of hand fracture burden changes by SDI quintiles, 1990–2021. (A) Incident cases; (B) prevalent cases; (C) YLDs. Drivers: aging, population growth, epidemiological change. SDI, socio-demographic index; YLD, year lived with disability.

BAPC projection to 2050

From 2022 to 2050, the ASIR of hand fractures declined across all sexes, with males decreasing from 331.44 to 257.18 per 100,000 and females from 165.52 to 123.23 per 100,000. The ASPR decreased in males (308.97 to 285.06) but increased slightly in females (175.69 to 181.52). ASYR remained relatively stable. In contrast, the absolute number of cases increased substantially: incident cases rose from 13.36 to 16.33 million in males and from 6.54 million to 1.16 billion in females; prevalent cases increased from 12.75 to 19.29 million in males and from 7.82 to 15.12 million in females; total YLDs also increased across all groups. Prediction intervals widened considerably in later years, particularly for females (Figures 5,6).

Figure 5 Projected age-standardized rates of hand fracture worldwide, 2022–2050. (A) ASIR; (B) ASPR; (C) ASYR, per 100,000. Observed/predicted, stratified by sex. ASIR, age-standardized incidence rate; ASPR, age-standardized prevalence rate; ASYR, age-standardized YLD rate; YLD, year lived with disability.

Figure 6 Projected absolute numbers of hand fracture burden worldwide, 2022–2050. (A) Incident cases; (B) prevalent cases; (C) YLDs. Stratified by sex. YLD, year lived with disability.

Discussion

This study analyzed the global burden of hand fracture from the perspective of public health emergency using GBD 2021 data and project its trends to 2050. The results confirm that hand fracture is a growing public health concern, with significant disparities in emergency medical needs across age, gender, and SDI levels, and population growth and aging are key drivers of increased burden.

A key finding of this study is the positive correlation between SDI and hand fracture burden, which contrasts with patterns observed for other non-fatal injuries (1,16). Several factors may explain this association. First, high SDI regions tend to have more comprehensive emergency medical systems and more accurate injury reporting, which may result in a higher recorded burden (17). Second, these regions often have greater participation in high-risk sports and occupational activities, potentially increasing the incidence of such injuries (18). Third, aging populations in high SDI regions are more susceptible to fall-related hand fractures, thereby contributing to increased demand for emergency care (19). In contrast, low SDI regions may underestimate the true burden due to limited access to emergency services and underreporting, although their actual unmet need for emergency care is likely substantial (20).

At the national level, marked heterogeneity in hand fracture burden is observed across countries. Australia’s high ASIR coincides with previously documented high levels of outdoor sports participation and stringent emergency reporting practices (21,22), although the present study does not directly quantify these factors. In Afghanistan, the elevated ASPR and ASYR may reflect limited emergency treatment capacity and higher risk of complications, as suggested by prior reports (23,24), but causal attribution cannot be established from GBD estimates alone. China exhibits the largest absolute burden, driven by its population size, while its moderate age-standardized rates suggest potential regional disparities in emergency resource distribution (25)—a pattern that warrants further investigation using disaggregated subnational data. Across all regions, consistent gender and age patterns reveal that males and older adults are disproportionately affected, reinforcing the importance of tailored prevention and emergency intervention strategies (26,27). Collectively, these national-level observations should be interpreted as descriptive findings that generate hypotheses rather than confirm causal pathways.

Decomposition analysis reveals distinct driving forces behind the growing global burden of hand fractures, with striking heterogeneity in burden drivers and care needs between service-based high SDI economies and low SDI developing regions that define the granularity of this global public health challenge. Incident cases—representing acute emergency demand—are driven primarily by population growth, whereas prevalent cases and YLDs—reflecting rehabilitation needs—are more strongly influenced by population aging (27,28). This divergence points to a fundamental dual challenge for health systems stratified by economic development type: regions experiencing rapid population growth (low SDI developing regions) require expanded emergency care capacity, while aging populations (service-based high SDI economies) demand strengthened post-fracture rehabilitation services, and both demographic contexts necessitate targeted population-level prevention strategies for hand fracture (the main causes being falls, crush injuries, and sports-related trauma) (5). In service-based high SDI economies, aging is the predominant contributor across all burden metrics, with a negative epidemiological change component that directly demonstrates the effectiveness of population-level prevention measures for hand fracture: workplace safety regulations have reduced crush-related hand fractures in occupational settings, and community-based fall prevention programs (e.g., environmental hazard modification, balance training) have mitigated fall-related hand fractures in older adults—these interventions have partially offset the demographic pressures of aging and population growth, providing concrete evidence that hand fractures are not inherently unpreventable at the population level (5,29). In contrast, low SDI developing regions exhibit a markedly different pattern: population growth accounts for the vast majority of the increase in incident cases, accompanied by a positive epidemiological change component indicating that underlying risk levels have risen over time, which is mainly attributed to the lack of standardized occupational safety measures and fall prevention interventions, as well as incomplete injury surveillance and underdeveloped emergency care systems (30). This combination is particularly concerning given the often-limited emergency infrastructure in these settings, and it further highlights the necessity of population-level prevention to curb the rising hand fracture burden in low-resource regions.

The 2050 projection indicates that global hand fracture burden will continue to rise, with East Asia and South Asia as core burden regions (28). This requires long-term public health emergency planning: high SDI regions should optimize emergency treatment processes and strengthen fall prevention for older adults; low SDI regions need to build emergency medical systems and improve injury reporting (31); international organizations should provide technical and resource support to low SDI regions to reduce health inequality (32).

The positive correlation between SDI and hand fracture burden, together with the contrasting patterns between high and low SDI regions, calls for a SDI-stratified population-level prevention framework for hand fracture (targeting falls, crush injuries, and sports injuries) combined with optimized emergency preparedness. In high-burden regions—particularly Central Europe, Eastern Europe, Central Asia, and East Asia—the greater demand for hand fracture care suggests a need to strengthen emergency department capacity, including trauma staffing and treatment protocols tailored to these injuries, and to simultaneously scale up population-level prevention interventions matched to local high-risk groups: for older adults (the main population of fall-related hand fractures), implement community-based fall prevention strategies (e.g., home safety modifications, group balance and muscle strength training, and medication review to reduce fall risk); for young and middle-aged males (the predominant population of crush and sports-related hand fractures), enforce mandatory occupational safety training and protective equipment use (e.g., anti-crush gloves for manual laborers) and popularize sports injury prevention education (e.g., proper warm-up, protective gear for high-risk sports such as rugby and rock climbing). In low SDI regions, where the recorded burden is likely an underestimate due to limited emergency infrastructure and underreporting, the priority should first shift toward establishing basic population-level prevention measures for hand fracture (e.g., basic occupational safety guidelines for manual labor, community fall risk education) while improving basic emergency access and establishing standardized hand fracture management to prevent long-term disability. These prevention measures are low-cost and highly feasible in low-resource settings, and they lay the foundation for reducing the underlying risk of hand fracture at the population level.

Limitations

This study has several limitations. First, GBD 2021 data relies on modeling for low-data regions, which may introduce bias (33). Second, cross-country differences in emergency reporting standards affect data comparability (34). Third, emergency-specific factors such as treatment delay and resource availability are not explored due to data constraints. Fourth, BAPC projections do not account for future policy interventions (34). Fifth, the GBD framework does not provide subnational stratification by urbanicity, city size, or economic structure, preventing analysis of urban-rural disparities and context-specific burden patterns. Sixth, hand fractures are reported as a single entity without differentiation by anatomical subtype, fracture complexity, or injury severity, which limits the clinical granularity and applicability of the proposed implications. These unexamined dimensions should be addressed in future studies using subnational surveillance, clinical registries, or more granular injury classification systems.

Conclusions

Hand fracture is a significant and growing public health emergency concern, with substantial disparities in emergency medical needs across age, gender, and SDI levels worldwide, and critical heterogeneity between service-based high SDI economies and low SDI developing regions is a defining feature of the global burden, shaping divergent driving factors, care demands, and intervention priorities. Population growth and aging are key drivers of the increasing burden (growth dominating in low SDI developing regions and aging in service-based high SDI economies), and the global burden will continue to rise by 2050, with East Asia remaining the core burden region. Targeted public health emergency interventions—centered on SDI-stratified population-level prevention strategies for hand fracture (targeting the main causes of falls, crush injuries, and sports injuries)—including SDI-differentiated emergency resource allocation, high-risk group-specific preventive risk reduction, emergency treatment standardization, and international emergency care and prevention capacity building, are essential to mitigate the global burden of hand fracture and reduce health inequality in emergency care access. The negative epidemiological change in high SDI regions has confirmed that population-level prevention is realistic and effective for hand fracture, and the stratified prevention framework for different SDI regions, age groups, and injury causes proposed in this study provides a clear and operable reference for global public health practice. This study provides a comprehensive overview of the current and future hand fracture burden from the public health emergency perspective, offering evidence-based support for global emergency medical planning and decision-making.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the GATHER reporting checklist. Available at https://jphe.amegroups.com/article/view/10.21037/jphe-2026-0022/rc

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-2026-0022/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-2026-0022/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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