Pulmonary Embolism-Related Mortality in Femur Fracture Patients: A Recent Retrospective Epidemiological Analysis

Recent data from the Global Burden of Disease (GBD) study indicate that the age-standardized global incidence rate for all femur fractures was 187 per 100,000 individuals in 2019, reflecting a modest decline of 8.2% from 1990, when the incidence rate was approximately 204 per 100,000.[1] Despite this reduction, femur fracture remains a prevalent and severe injury associated with substantial disability and mortality. The widespread implementation of prophylactic anticoagulant therapy, including heparins and direct oral anticoagulants (DOACs), has significantly reduced the risk of venous thromboembolism in patients with femur fractures.[2] However, recent data indicate that pulmonary embolism (PE) is still diagnosed in up to 1.4% of these patients, with a substantial increase in their mortality risk.[3] Despite this, there remains a paucity of recent studies quantifying the burden of PE-associated deaths in this population.

To address this gap, we conducted a retrospective epidemiological analysis using data from the US National Center for Health Statistics (NCHS) WONDER (Wide-Ranging Online Data for Epidemiologic Research) Provisional Multiple Cause of Death online database.[4] This database contains information from death certificates of US residents, including demographic data and up to 20 multiple causes of death listed according to the 10th revision of the International Classification of Diseases (ICD-10). We extracted data from 2018 to 2024, focusing on cases with specific ICD-10 codes for femur fractures (S72.0-S72.9) with or without concurrent PE (I26.0, I26.9). The data were downloaded as total number of death episodes, categorized as either femur fracture alone or femur fracture with PE. The mortality rate (with 95% confidence interval [95% CI]) for deaths with both femur fracture and PE was then calculated relative to the total number of femur fracture deaths using MedCalc (MedCalc Software Ltd., Ostend, Belgium). Ethical committee approval was not required, as the NCHS WONDER database is publicly available, anonymized, and freely searchable.

A total of 136,727 deaths related to femur fractures were recorded between 2018 and 2024, of which 3,148 were associated with PE, yielding a mortality rate of 2.30% (95% CI: 2.22–2.38%). The temporal trend in mortality rates between 2018 and 2024 is illustrated in [Fig. 1], with rates ranging from a minimum of 2.15% in 2023 to a maximum of 2.47% in 2021. Data distribution was assessed using the Shapiro-Wilk normality test, which confirmed normality (p-values ≥0.16) for all years. One-way analysis of variance (ANOVA) did not reveal a statistically significant difference in mortality rates across the years (F-statistic: 1.137; p = 0.34).

Fig. 1 Temporal trend in mortality rates for femur fracture with associated pulmonary embolism between 2018 and 2024.

The findings of this study highlight that PE remains a notable contributor to mortality in femur fracture patients, despite advancements in thromboprophylaxis.[5] No statistically significant variation was observed in PE-associated mortality rates over the recent study period, which also included the coronavirus disease 2019 (COVID-19) pandemic. We acknowledge some limitations in this study. First, our analysis is based on death certificates, which may be subject to misclassification or underreporting of PE as contributing cause of death. The retrospective design also precludes the ability to infer causal relationships between the two pathologies. Finally, potential confounders such as comorbidities, anticoagulant use, and surgical interventions could not be accounted for due to the inherent limitations of the dataset. Further prospective studies, incorporating detailed clinical parameters, are hence warranted to confirm our data, showing the still important impact of PE as possible cause of death in femur fracture patients.

Publication History

Article published online:
15 May 2025

• References

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• 4 Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Provisional Mortality on CDC WONDER Online Database. Data are from the final Multiple Cause of Death Files, 2018–2023, and from provisional data for years 2024 and later, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed April 2, 2025 at: http://wonder.cdc.gov/mcd-icd10-provisional.html
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