Abstract
Summary
Osteoporotic hip fracture, mostly induced in falls among the elderly, is a major health burden over the world. The impact force applied to the hip is an important factor in determining the risk of hip fracture. However, biomechanical researches have yielded conflicting conclusions about whether the fall-induced impact force can be accurately predicted by the available models. It also has been debated whether or not the effect of impact force has been considered appropriately in hip fracture risk assessment tools. This study aimed to provide a state-of-the-art review of the available methods for predicting the impact force, investigate their strengths/limitations, and suggest further improvements in modeling of human body falling.
Methods
We divided the effective parameters on impact force to two categories: (1) the parameters that can be determined subject-specifically and (2) the parameters that may significantly vary from fall to fall for an individual and cannot be considered subject-specifically.
Results
The parameters in the first category can be investigated in human body fall experiments. Video capture of real-life falls was reported as a valuable method to investigate the parameters in the second category that significantly affect the impact force and cannot be determined in human body fall experiments.
Conclusions
The analysis of the gathered data revealed that there is a need to develop modified biomechanical models for more accurate prediction of the impact force and appropriately adopt them in hip fracture risk assessment tools in order to achieve a better precision in identifying high-risk patients.
Similar content being viewed by others
References
DeGoede KM, Ashton-Miller JA, Schultz AB (2003) Fall-related upper body injuries in the older adult: a review of the biomechanical issues. J Biomech 36:1043–1053
Rivara FP, Grossman DC, Cummings P (1997) Injury prevention. N Engl J Med 337:543–548
Green C, Molony D, Fitzpatrick C, ORourke K (2010) Age-specific incidence of hip fracture in the elderly: a healthy decline. Surgeon 8:310–313
Gullberg B, Johnell O, Kanis JA (1997) World-wide projections for hip fracture. Osteoporos Int 7:407–413
Kannus P, Leiponen P, Parkkari J, Palvanen M, Jarvinen M (2006) A sideways fall and hip fracture. Bone 39:383–384
Boonen S, Autier P, Barette M, Vanderschueren D, Lips P, Haentjens P (2004) Functional outcome and quality of life following hip fracture in elderly women: a prospective controlled study. Osteoporos Int 15:87–94
Phillips S, Fox N, Jacobs J, Wright WE (1988) The direct medical costs of osteoporosis for American women aged 45 and older. Bone 9:271–279
Huddleston JM, Whitford KJ (2001) Medical care of elderly patients with hip fractures. Mayo Clin Proc 76:295–298
Greenspan SL, Myers ER, Kiel DP, Parker RA, Hayes WC, Resnick NM (1998) Fall direction, bone mineral density, and function: risk factors for hip fracture in frail nursing home elderly. Am J Med 104:539–545
Hayes WC, Piazza SJ, Zysset PK (1991) Biomechanics of fracture risk prediction of the hip and spine by quantitative computed tomography. Radiol Clin N Am 29:1–18
Myers ER, Wilson SE (1997) Biomechanics of osteoporosis and vertebral fracture. Spine 22:25S–31S
Luo Y (2015) A biomechanical sorting of clinical risk factors affecting osteoporotic hip fracture. Osteoporosis International 1-17
Robinovitch SN, Hayes WC, McMahon TA (1991) Prediction of femoral impact forces in falls on the hip. ASME J Biomech Eng 113:366–374
Kroonenberg AJ, Hayes WC, McMahon TA (1995) Dynamic models for sideways falls from standing height. J Biomech Eng 117:309–318
Robinovitch SN, McMahon TA, Hayes WC (1995) Force attenuation in trochanteric soft tissues during impact from a fall. J Orthop Res 13:956–962
Van den Kroonenberg AJ, Hayes WC, McMahon TA (1996) Hip impact velocities and body configurations for voluntary falls from standing height. J Biomech 29:807–811
Hayes WC, Myers ER, Robinovitch SN, Van Den Kroonenberg A, Courtney AC, McMahon TA (1996) Etiology and prevention of age-related hip fractures. Bone 18:S77–S86
Robinovitch SN, Hayes WC, McMahon TA (1997) Distribution of contact force during impact to the hip. Ann Biomed Eng 25:499–508
Robinovitch SN, Hayes WC, McMahon TA (1997) Predicting the impact response of a nonlinear single-degree-of-freedom shock-absorbing system from the measured step response. J Biomech Eng 119:221–227
Sandler R, Robinovitch S (2001) An analysis of the effect of lower extremity strength on impact severity during a backward fall. J Biomech Eng 123:590–598
Robinovitch SN, Inkster L, Maurer J, Warnick B (2003) Strategies for avoiding hip impact during sideways falls. J Bone Miner Res 18:1267–1273
Robinovitch SN, Brumer R, Maurer J (2004) Effect of the squat protective response on impact velocity during backward falls. J Biomech 37:1329–1337
Feldman F, Robinovitch SN (2007) Reducing hip fracture risk during sideways falls: evidence in young adults of the protective effects of impact to the hands and stepping. J Biomech 40:2612–2618
Laing AC, Robinovitch SN (2010) Characterizing the effective stiffness of the pelvis during sideways falls on the hip. J Biomech 43:1898–1904
Levine IC, Bhan S, Laing AC (2013) The effects of body mass index and sex on impact force and effective pelvic stiffness during simulated lateral falls. Clin Biomech 28:1026–1033
Choi WJ, Cripton PA, Robinovitch SN (2015) Effects of hip abductor muscle forces and knee boundary conditions on femoral neck stresses during simulated falls. Osteoporos Int 26:291–301
Nasiri M, Luo Y (2016) Study of sex differences in the association between hip fracture risk and body parameters by DXA-based biomechanical modeling. Bone 90:90–98
Laing AC, Tootoonchi I, Hulme PA, Robinovitch SN (2006) Effect of compliant flooring on impact force during falls on the hip. J Orthop Res 24:1405–1411
Bateni H, Zecevic A, McIlroy W, Maki B (2004) Resolving conflicts in task demands during balance recovery: does holding an object inhibit compensatory grasping? Exp Brain Res 157:49–58
Smith LD (1953) Hip fractures: the role of muscle contraction or intrinsic forces in the causation of fractures of the femoral neck. J Bone Joint Surg 35:367–383
Phillips J, Williams J, Melick R (1975) Prediction of the strength of the neck of femur from its radiological appearance. Biomed Eng 10:367–372
Dalen N, Hellstrom L, Jacobson B (1976) Bone mineral content and mechanical strength of the femoral neck. Acta Orthop Scand 47:503–508
Leichter I, Margulies JY, Weinreb A, Mizrahi J, Robin GC, Conforty B, Makin M, Bloch B (1982) The relationship between bone density, mineral content, and mechanical strength in the femoral neck. Clin Orthop Relat Res 163:272–281
Mizrahi J, Margulies JY, Leichter I, Deutsch D (1984) Fracture of the human femoral neck: effect of density of the cancellous core. J Biomed Eng 6:56–62
Alho A, Husby T, Hoiseth A (1988) Bone mineral content and mechanical strength an ex vivo study on human femora at autopsy. Clin Orthop Relat Res 227:292–297
Esses S, Lotz J, Hayes W (1989) Biomechanical properties of the proximal femur determined in vitro by single-energy quantitative computed tomography. J Bone Miner Res 4:715–722
Lotz JC, Hayes WC (1990) The use of quantitative computed tomography to estimate risk of fracture of the hip from falls. J Bone Joint Surg 72:689–700
Courtney AC, Wachtel EF, Myers ER, Hayes WC (1994) Effects of loading rate on strength of the proximal femur. Calcif Tissue Int 55:53–58
Bouxsein ML, Courtney AC, Hayes WC (1995) Ultrasound and densitometry of the calcaneus correlate with the failure loads of cadaveric femurs. Calcif Tissue Int 56:99–103
Pinilla T, Boardman K, Bouxsein M, Myers E, Hayes W (1996) Impact direction from a fall influences the failure load of the proximal femur as much as age-related bone loss. Calcif Tissue Int 58:231–235
Cheng XG, Lowet G, Boonen S, Nicholson PHF, Brys P, Nijs J, Dequeker J (1997) Assessment of the strength of proximal femur in vitro: relationship to femoral bone mineral density and femoral geometry. Bone 20:213–218
Cheng XG, Lowet G, Boonen S, Nicholson PHF, Van Der Perre G, Dequeker J (1998) Prediction of vertebral and femoral strength in vitro by bone mineral density measured at different skeletal sites. J Bone Miner Res 13:1439–1443
Lang TF, Keyak JH, Heitz MW, Augat P, Lu Y, Mathur A, Genant HK (1997) Volumetric quantitative computed tomography of the proximal femur: precision and relation to bone strength. Bone 21:101–108
Keyak JH, Rossi SA, Jones KA, Skinner HB (1998) Prediction of femoral fracture load using automated finite element modeling. J Biomech 31:125–133
Bouxsein ML, Coan BS, Lee SC (1999) Prediction of the strength of the elderly proximal femur by bone mineral density and quantitative ultrasound measurements of the heel and tibia. Bone 25:49–54
Keyak JH (2000) Relationships between femoral fracture loads for two load configurations. J Biomech 33:499–502
Lochmuller EM, Groll O, Kuhn V, Eckstein F (2002) Mechanical strength of the proximal femur as predicted from geometric and densitometric bone properties at the lower limb versus the distal radius. Bone 30:207–216
Eckstein F, Wunderer C, Boehm H, Kuhn V, Priemel M, Link TM, Lochmüller E-M (2004) Reproducibility and side differences of mechanical tests for determining the structural strength of the proximal femur. J Bone Miner Res 19:379–385
Heini PF, Franz T, Fankhauser C, Gasser B, Ganz R (2004) Femoroplasty-augmentation of mechanical properties in the osteoporotic proximal femur: a biomechanical investigation of PMMA reinforcement in cadaver bones. Clin Biomech 19:506–512
Manske SL, Liu-Ambrose T, de Bakker PM, Liu D, Kontulainen S, Guy P, Oxland TR, McKay HA (2006) Femoral neck cortical geometry measured with magnetic resonance imaging is associated with proximal femur strength. Osteoporos Int 17:1539–1545
Pulkkinen P, Eckstein F, Lochmüller E-M, Kuhn V, Jämsä T (2006) Association of geometric factors and failure load level with the distribution of cervical vs. trochanteric hip fractures. J Bone Min Res 21:895–901
Pulkkinen P, Jämsä T, Lochmüller EM, Kuhn V, Nieminen MT, Eckstein F (2008) Experimental hip fracture load can be predicted from plain radiography by combined analysis of trabecular bone structure and bone geometry. Osteoporos Int 19:547–558
Langton CM, Pisharody S, Keyak JH (2009) Comparison of 3D finite element analysis derived stiffness and BMD to determine the failure load of the excised proximal femur. Med Eng Phys 31:668–672
de Bakker PM, Manske SL, Ebacher V, Oxland TR, Cripton PA, Guy P (2009) During sideways falls proximal femur fractures initiate in the superolateral cortex: evidence from high-speed video of simulated fractures. J Biomech 42:1917–1925
Dragomir D, Buijs J, McEligot S, Dai Y, Entwistle R, Salas C, Melton L, Bennet K, Khosla S, Amin S (2011) Robust QCT/FEA models of proximal femur stiffness and fracture load during a sideways fall on the hip. Ann Biomed Eng 39:742–755
Buijs J, Dragomir D (2011) Validated finite element models of the proximal femur using two-dimensional projected geometry and bone density. Comput Methods Prog Biomed 104:168–174
Koivumaki J, Thevenot J, Pulkkinen P, Kuhn V, Link TM, Eckstein F, Jamsa T (2012) CT-based finite element models can be used to estimate experimentally measured failure loads in the proximal femur. Bone 50:824–829
Koivumaki JEM, Thevenot J, Pulkkinen P, Kuhn V, Link TM, Eckstein F, Jamsa T (2012) Cortical bone finite element models in the estimation of experimentally measured failure loads in the proximal femur. Bone 51:737–740
Nishiyama KK, Gilchrist S, Guy P, Cripton P, Boyd SK (2013) Proximal femur bone strength estimated by a computationally fast finite element analysis in a sideways fall configuration. J Biomech 46:1231–1236
Dall'Ara E, Luisier B, Schmidt R, Kainberger F, Zysset P, Pahr D (2013) A nonlinear QCT-based finite element model validation study for the human femur tested in two configurations in vitro. Bone 52:27–38
Mirzaei M, Keshavarzian M, Naeini V (2014) Analysis of strength and failure pattern of human proximal femur using quantitative computed tomography (QCT)-based finite element method. Bone 64:108–114
Gilchrist S, Nishiyama KK, de Bakker P, Guy P, Boyd SK, Oxland T, Cripton PA (2014) Proximal femur elastic behaviour is the same in impact and constant displacement rate fall simulation. J Biomech 47:3744–3749
Ariza O, Gilchrist S, Widmer RP, Guy P, Ferguson SJ, Cripton PA, Helgason B (2015) Comparison of explicit finite element and mechanical simulation of the proximal femur during dynamic drop-tower testing. J Biomech 48:224–232
Grassi L, Väänänen SP, Ristinmaa M, Jurvelin JS, Isaksson H (2016) How accurately can subject-specific finite element models predict strains and strength of human femora? Investigation using full-field measurements. J Biomech 49:802–806
Grassi L, Väänänen SP, Ristinmaa M, Jurvelin JS, Isaksson H (2016) Prediction of femoral strength using 3D finite element models reconstructed from DXA images: validation against experiments. Biomechanics and Modeling in Mechanobiology 1-12
Robinovitch SN, Evans SL, Minns J et al (2009) Hip protectors: recommendations for biomechanical testing-an international consensus statement (part I). Osteoporos Int 20:1977–1988
Haider IT, Speirs AD, Frei H (2013) Effect of boundary conditions, impact loading and hydraulic stiffening on femoral fracture strength. J Biomech 46:2115–2121
Weber T, Yang K, Woo R, Fitzgerald R (1992) Proximal femur strength: correlation of the rate of loading and bone mineral density. ASME Adv Bioeng BED 22:111–114
Beck TJ, Ruff CB, Warden KE, Scott WW Jr, Rao GU (1990) Predicting femoral neck strength from bone mineral data: a structural approach. Investig Radiol 25:6–18
Kanis J, McCloskey E, Johansson H, Oden A, Borgstrom F, Strom O (2010) Development and use of FRAX in osteoporosis. Osteoporos Int 21:407–413
Brekelmans WAM, Poorth HW, Slooff TJJH (1972) A new method to analyse the mechanical behaviour of skeletal parts. Acta orthop Scandinav 43:301–317
Nielson C, Bouxsein M, Freitas S, Ensrud K, Orwoll E (2009) Trochanteric soft tissue thickness and hip fracture in older men. J Clin Endocrinol Metab 94:491–496
Blaak E (2001) Gender differences in fat metabolism. Curr Opin Clin Nutr Metab Care 4:499–502
Robinovitch SN, Feldman F, Yang Y, Schonnop R, Leung PM, Sarraf T, Sims-Gould J, Loughin M (2013) Video capture of the circumstances of falls in elderly people residing in long-term care: an observational study. Lancet 381:47–54
Nasiri Sarvi M (2015) Assessment of hip fracture risk by a two-level subject-specific biomechanical model. Mechanical Engineering. Ph.D. thesis, University of Manitoba, Canada, p 164
Groen BE, Weerdesteyn V, Duysens J (2007) Martial arts fall techniques decrease the impact forces at the hip during sideways falling. J Biomech 40:458–462
Nasiri Sarvi M, Luo Y (2015) A two-level subject-specific biomechanical model for improving prediction of hip fracture risk. Clin Biomech 30:881–887
Nasiri Sarvi M, Luo Y, Sun P, Ouyang J (2014) Experimental validation of subject-specific dynamics model for predicting impact force in sideways fall. J Biomed Sci Eng 7:405–418
Pena E, Calvo B, Martinez MA, Doblare M (2007) An anisotropic visco-hyperelastic model for ligaments at finite strains. Formulation and computational aspects. Int J Solids Struct 44:760–778
Majumder S, Roychowdhury A, Pal S (2008) Effects of trochanteric soft tissue thickness and hip impact velocity on hip fracture in sideways fall through 3D finite element simulations. J Biomech 41:2834–2842
Natali AN, Carniel EL, Pavan PG (2008) Constitutive modelling of inelastic behaviour of cortical bone. Med Eng Phys 30:905–912
Malmivaara A, Heliovaara M, Knekt P, Reunanen A, Aromaa A (1993) Risk factors for injurious falls leading to hospitalization or death in a cohort of 19,500 adults. Am J Epidemiol 138:384–394
Greenspan SL, Myers ER, Maitland LA, Resnick NM, Hayes WC (1994) Fall severity and bone mineral density as risk factors for hip fracture in ambulatory elderly. JAMA 271:128–133
Laet C, Kanis JA, Oden A et al (2005) Body mass index as a predictor of fracture risk: a meta-analysis. Osteoporos Int 16:1330–1338
Bouxsein ML, Szulc P, Munoz F, Thrall E, Sornay-Rendu E, Delmas PD (2007) Contribution of trochanteric soft tissues to fall force estimates, the factor of risk, and prediction of hip fracture risk. J Bone Miner Res 22:825–831
Armstrong MEG, Spencer EA, Cairns BJ, Banks E, Pirie K, Green J, Wright FL, Reeves GK, Beral V, for the Million Women Study C (2011) Body mass index and physical activity in relation to the incidence of hip fracture in postmenopausal women. J Bone Miner Res 26:1330–1338
Johansson H, Kanis JA, Odén A et al (2013) A meta-analysis of the association of fracture risk and body mass index in women. J Bone Miner Res 29:223–233
Majumder S, Roychowdhury A, Pal S (2013) Hip fracture and anthropometric variations: dominance among trochanteric soft tissue thickness, body height and body weight during sideways fall. Clin Biomech 28:1034–1040
Bhan S, Levine IC, Laing AC (2014) Energy absorption during impact on the proximal femur is affected by body mass index and flooring surface. J Biomech 47:2391–2397
Choi WJ, Russell CM, Tsai CM, Arzanpour S, Robinovitch SN (2015) Age-related changes in dynamic compressive properties of trochanteric soft tissues over the hip. J Biomech 48:695–700
Derler S, Spierings AB, Schmitt KU (2005) Anatomical hip model for the mechanical testing of hip protectors. Med Eng Phys 27:475–485
Li N, Tsushima E, Tsushima H (2013) Comparison of impact force attenuation by various combinations of hip protector and flooring material using a simplified fall-impact simulation device. J Biomech 46:1140–1146
Laing AC, Robinovitch SN (2008) The force attenuation provided by hip protectors depends on impact velocity, pelvic size, and soft tissue stiffness. Journal of Biomechanical Engineering 130:
Laing AC, Robinovitch SN (2008) Effect of soft shell hip protectors on pressure distribution to the hip during sideways falls. Osteoporos Int 19:1067–1075
Choi WJ, Hoffer JA, Robinovitch SN (2010) Effect of hip protectors, falling angle and body mass index on pressure distribution over the hip during simulated falls. Clin Biomech 25:63–69
Luo Y, Nasiri Sarvi M, Sun P, Leslie WD, Ouyang J (2014) Prediction of impact force in sideways fall by image-based subject-specific dynamics model. International Biomechanics 1-14
Durkin JL, Dowling JJ, Andrews DM (2002) The measurement of body segment inertial parameters using dual energy X-ray absorptiometry. J Biomech 35:1575–1580
Luo Y, Nasiri Sarvi M (2015) A subject-specific inverse-dynamics approach for estimating joint stiffness in sideways fall. Int J Exp Comput Biomech 3:137–160
Lo J, Ashton-Miller JA (2008) Effect of pre-impact movement strategies on the impact forces resulting from a lateral fall. J Biomech 41:1969–1977
DeGoede KM, Ashton-Miller JA (2002) Fall arrest strategy affects peak hand impact force in a forward fall. J Biomech 35:843–848
Yoshikawa T, Turner CH, Peacock M, Slemenda CW, Weaver CM, Teegarden D, Markwardt P, Burr DB (1994) Geometric structure of the femoral neck measured using dual-energy X-ray absorptiometry. J Bone Miner Res 9:1053–1064
Hayes W, Myers E, Morris J, Gerhart T, Yett H, Lipsitz L (1993) Impact near the hip dominates fracture risk in elderly nursing home residents who fall. Calcif Tissue Int 52:192–198
Cc S, Hayes WC, McMahon TA (2001) Disturbance type and gait speed affect fall direction and impact location. J Biomech 34:309–317
Nag PK, Vyas H, Nag A, Pal S (2008) Applying stabilometry in characterizing floor sitting modes of women. Int J Ind Ergon 38:984–991
Nag PK, Chintharia S, Saiyed S, Nag A (1986) EMG analysis of sitting work postures in women. Appl Ergon 17:195–197
Hsiao ET, Robinovitch SN (1998) Common protective movements govern unexpected falls from standing height. J Biomech 31:1–9
Sabick MB, Hay JG, Goel VK, Banks SA (1999) Active responses decrease impact forces at the hip and shoulder in falls to the side. J Biomech 32:993–998
DeGoede KM, Ashton-Miller JA (2003) Biomechanical simulations of forward fall arrests: effects of upper extremity arrest strategy, gender and aging-related declines in muscle strength. J Biomech 36:413–420
Lo J, Ashton-Miller JA (2008) Effect of upper and lower extremity control strategies on predicted injury risk during simulated forward falls: a study in healthy young adults. J Biomech Eng 130:410–415
Nevitt MC, Cummings SR, Hudes ES (1991) Risk factors for injurious falls: a prospective study. J Gerontol 46:M164–M170
Robinovitch SN, Chiu J, Sandler R, Liu Q (2000) Impact severity in self-initiated sits and falls associates with center-of-gravity excursion during descent. J Biomech 33:863–870
Weerdesteyn V, Rijken H, Geurts ACH, Smits-Engelsman BCM, Mulder T, Duysens J (2006) A five-week exercise program can reduce falls and improve obstacle avoidance in the elderly. Gerontology 52:131–141
Weerdesteyn V, Groen BE, van Swigchem R, Duysens J (2008) Martial arts fall techniques reduce hip impact forces in naive subjects after a brief period of training. J Electromyogr Kinesiol 18:235–242
Groen BE, Smulders E, de Kam D, Duysens J, Weerdesteyn V (2010) Martial arts fall training to prevent hip fractures in the elderly. Osteoporos Int 21:215–221
Van der Zijden AM, Groen BE, Tanck E, Nienhuis B, Verdonschot N, Weerdesteyn V (2012) Can martial arts techniques reduce fall severity? An in vivo study of femoral loading configurations in sideways falls. J Biomech 45:1650–1655
Choi WJ, Wakeling JM, Robinovitch SN (2015) Kinematic analysis of video-captured falls experienced by older adults in long-term care. J Biomech 48:911–920
O'Neill TW, Varlow J, Silman AJ, Reeve J, Reid DM, Todd C, Woolf AD (1994) Age and sex influences on fall characteristics. Ann Rheum Dis 53:773–775
Iyo T, Maki Y, Sasaki N, Nakata M (2004) Anisotropic viscoelastic properties of cortical bone. J Biomech 37:1433–1437
Wu Z, Ovaert TC, Niebur GL (2012) Viscoelastic properties of human cortical bone tissue depend on gender and elastic modulus. J Orthop Res 30:693–699
Bembey AK, Oyen ML, Bushby AJ, Boyde A (2006) Viscoelastic properties of bone as a function of hydration state determined by nanoindentation. Philos Mag 86:5691–5703
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflicts of interest
None.
Electronic supplementary material
Supplementary Fig. 1
(PDF 120 kb)
Supplementary Fig. 2
(PDF 119 kb)
Supplementary Fig. 3
(PDF 112 kb)
Supplementary Fig. 4
(PDF 121 kb)
Rights and permissions
About this article
Cite this article
Nasiri Sarvi, M., Luo, Y. Sideways fall-induced impact force and its effect on hip fracture risk: a review. Osteoporos Int 28, 2759–2780 (2017). https://doi.org/10.1007/s00198-017-4138-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00198-017-4138-5