Rev. bras. ortop. vol.48 número6

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w w w . r b o . o r g . b r

Review

Article

There

have

been

changes

in

the

incidence

and

epidemiology

of

pelvic

ring

fractures

in

recent

decades?

Cláudia

Diniz

Freitas

a,∗

,

José

Eduardo

Rosseto

Garotti

a

,

Juliana

Nieto

a

,

Rodrigo

Pereira

Guimarães

b

_,

_Nelson

_Keiske

_Ono

a,b

,

Emerson

Honda

a,b

,

Giancarlo

Cavalli

Polesello

a,b

a_Departamento_de_Ortopedia_e_{Traumatologia,}_Santa_Casa_de_{Misericórdia}_de_São_Paulo,_São_Paulo,_SP,_Brazil

b_Faculdade_de_Ciências_Médicas,_Santa_Casa_de_{Misericórdia}_de_São_Paulo,_São_Paulo,_SP,_Brazil

a

r

t

i

c

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o

Articlehistory:

Received30August2012 Accepted3October2012

Keywords:

Pelvicbones Epidemiology Hipfractures Meta-analysis

a

b

s

t

r

a

c

t

Thepelvicringfracturescomprise2–8%ofallskeletalinjuries.Astheincidencerisesto 25%inpolytraumaandrepresentsanegativeprognosticfactorwithregardtomorbidityand mortalityofpatients,wesoughtwiththisworktoestablishtheprofileofthese,compared toanalterationintheprofileofpatientswithpelvicringfracturesinrecentdecades.Tothis end,weevaluatedtheepidemiologicalprofile,mechanismofinjuryandtypesoffractures. Byreviewingtheliteratureindexedinthedatabasesrelatedtothetheme,20paperswere selectedthatcontainedtherequirementsforthestudy.FortheperiodbetweenJanuary1987 andDecember1999(firstdecade),andanotherperiodinJanuary2000andDecember2010 (seconddecade),datawereanalyzedbyMann–Whitneytest.TheratingsTile,Youngand BurgessAOwereadequatetopermittheircategorization.Theresearchineachdecadewas homogeneous.Atfirstthelesionsweremoreprevalentinmenwith62.5%withatendency toreversethispatterngiventheincreaseofwomenintheseconddecade(p=0.286).The averageageinthefirstdecadewas39.3years,anincreaseinthesecond(p=0.068).Themost prevalentmechanismsoftraumawererelatedtotrafficinbothperiodsaswellasfractures classifiedastypeA(p=0.203andp=0.457,respectively),havingmortalityratesdecreased (p=0.396).Weconcludethattherewasatendencytoincreaseintheaverageageofpatients (p=0.068);howevertheincreasinginvolvementofwomen(p=0.286)anddecreasedmortality (p=0.396)werenotsignificant.

Houve

mudanc¸as

na

incidência

e

na

epidemiologia

das

fraturas

do

anel

pélvico

nas

últimas

décadas?

Palavras-chave:

Ossospélvicos

r

e

s

u

m

o

Asfraturasdoanelpélvicocompõemde2%a8%detodasaslesõesdoesqueleto,incidência quesobepara25%nospolitraumatizadoserepresentafatorprognósticonegativonoque

∗ _{Corresponding}_author_.

E-mail:[email protected](C.D.Freitas).

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analisadosecomparadosestatisticamentepeloTestedeMann–Whitney.Asclassificações deTile,YoungBurgesseAOforamadequadasparapermitirsuacategorização.Aspesquisas emcadaumadasdécadasforamhomogêneas.Naprimeira,aslesõesforammais preva-lentesemhomens,com62,5%,comtendênciaainversãodessepadrão,dadooaumentode mulheresacometidasnasegundadécada(p=0,286).Amédiadeidadenaprimeiradécada erade39,3anoserevelouumaumentonasegunda(p=0,068).Osmecanismosdetrauma maisprevalentesforamaquelesrelacionadosaotráfegonosperíodos,assimcomoas frat-urasclassificadascomo dotipoA (p=0,203ep=0,457,respectivamente).Osíndices de mortalidadediminuíram(p=0,396).Conclui-sequehouvetendênciaaoaumentonamédia deidadedospacientes(p=0,068).Jáocrescenteacometimentodasmulheres(p=0,286)ea diminuiçãodamortalidade(p=0,396)nãoforamsignificantes.

Introduction

Traumaisaworldwidepublichealthproblemandithasbeen estimatedthatintrafficaccidentsalone, traumais respon-sible for around 1.2 million deaths around the world.1 _It

presents great morbidity that today affects more than 50 millionpeople.2_This_situation_is_worse_in_urban_centers,

espe-ciallyincapitalsandmetropolitanregions,wherethegrowing vehiclefleetandgreateraggressivenessintrafficcause high-energyaccidentsand consequentlyincreasethenumber of deaths.3,4

In the young and economically active population, the maincauseofdeathisexternalagents.Incomparisonwith other age groups, this population is seen to have a more audaciousprofile,whichraisestheratesofmortalitydueto accidentsandurbanviolence.5–11_Within_this_scenario,

traf-ficaccidents are amongthe mainhealth hazards,and the risk factors for such accidents are young age group, male sexand lowsocial level.12 _The _severity_of _these _accidents

givesrisetolongperiodsofhospitalization,withademand forhigh-costresourcesandconsequentlygreaterexpenditure ofpublicandprivatefunds.12–16 _In_an_attempt_to_minimize

thecatastrophicrepercussionsoftrafficaccidentson Brazil-ianpublic health, medicaland governmental entities have beenincreasinglyadoptingpreventivemeasuresoverrecent years,withtheaimsofdiminishingtheabsolutenumberof accidents and minimizing their consequences. Installation ofmedicalrescueservices onhighways andalsoin Brazil-ian cities, from the 1980sonwards, is an example of this measures.17

Otherwell-knownadvanceswerethecreationofthe Brazil-ianNationalTrafficCodeof1998(Law9503ofSeptember23, 1997),18 _which_led_to_a_reduction_in_the _number _of_deaths,

and also legislation ofgreater rigor, suchas Law 11705 of June 19,2008,19 _popularly _known _as_the _“Dry _Law”, _which

showedaproportionaldecrease inthe riskofdeath.These measureshavebeenshowntobeeffective,althoughtheystill needimprovementandupdating,suchashigherenforcement

levelsanddeepeningoftheeducationalprocessamongthe Brazilianpopulation.20

In parallel with the implementation of these laws that werecreatedinanattempttodiminishthefrequencyofthese accidents,thevehiclefleethasbeenincreasingprogressively. AccordingtoDENATRAN,thenumberofmotorvehicleshas increased by around 300% over the last ten years. In the municipalityofSãoPaulo,themortalityrateamongvictims ofvehicleaccidentsincreasedfrom0.4/100,000inhabitantsto 1.4/100,000inhabitantsovertheperiodfrom1996to2005.21

Today,thereisstillalackofdetaileddataregardingtrauma severity,injuriesmostfrequentlyobserved,sequelaeand com-plicationsspecificallyrelatedtoaccidentsinvolvingvehicles around the world. Such information could help in imple-mentingpreventivemeasuresand providingattendancefor thesepatients,throughdirectingphysiciansintheir diagnos-ticinvestigationsandindeterminingpriorities.

Withthe aimofunderstanding the changesinbehavior within society over recent decades, withregard to trauma mechanismsandconsequentlythetypesofpelvicring frac-ture (Fig. 1A–D), the diagnosis,morbidity and mortalityof pelvicfractureshavebeenwidelydiscussedbyvarious med-icalsocieties,governmentsandthegeneralpopulation.17–19

Pelvicringfracturesaccountfor2–8%ofallskeletalinjuries, which increases to 25% among multiple trauma patients. Withinthiscontext,theyrepresentanegativeprognostic fac-torwithregard tomorbidityand mortalityamongmultiple traumapatients.Thus,thissituationstimulatedusto estab-lish the epidemiological profile of these fractures through reviewingtheliterature.22

Objective

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Fig.1–Radiographsofpelvicringfracture.(A)PelvisfractureofTiletypeB,frontalradiograph.Imagefromthefilesofthe HipGroupofDOT-ISCMSP.(B)PelvisfractureofTiletypeB,inletradiograph.ImagefromthefilesoftheHipGroupof DOT-ISCMSP.(C)PelvisfractureofTiletypeB,outletradiograph.ImagefromthefilesoftheHipGroupofDOT-ISCMSP.(D) PelvisfractureofTiletypeB,postoperativeradiograph.ImagefromthefilesoftheHipGroupofDOT-ISCMSP.

Material

AfterobtainingapprovalfromtheResearchEthics Commit-teeofIrmandadedeMisericórdiadaSantaCasadeSãoPaulo (51/2012),abibliographicreviewwasconductedinthe Med-line,PubMed, Lilacsand Cochranedatabasesand literature relating to this topic over the last two decades, searching fordescriptionsoftheepidemiologyofpelvicringfractures. Thesearticleswouldneedtopresentsomeofthefollowing keywords in their content:fractures, pelvic ring; epidemi-ology; pelvic bones, injuries; fractures, bone/epidemiology; accidents,traffic;prospectivestudies;andretrospective stud-ies. The data were gathered between December 2011 and March2012.

Thearticleswereselectedaftercriticalassessmentofthe strength ofevidenceand were onlyacceptedif theimpact wasaminimumof2A.Articlesinwhich,despitetheir appear-anceinthesearchresults,themethodologydidnotinclude completeevaluationofdatabasedonage,sex,trauma mech-anism,mortalityandfracturetype(refinementcriteria)were discarded.

In evaluating the fracture types, we compared the Tile, Young-BurgessandAOclassifications.Weclassifiedfractures astypeAiftheywereTiletypeAandAOtypeA;typeBifthey wereTiletypeB,Young-BurgessgroupsAandBandAOtype B;andtypeCiftheywereTiletypeC,Young-BurgessgroupC andAOtypeC.23

Thesearchlocated152articles,ofwhich73metthe refine-mentcriteria. From these,textsthat appearedinduplicate (totalof52articles)were excluded.Afterreadingthetotals andabstracts,20studiesthatcontainedthedataneededfor thisstudywereselected(Tables1and2).

Method

These articleswere divided into twoperiods:between Jan-uary1987andDecember1999(namedthefirstdecade);and betweenJanuary2000and December2010(namedthe sec-onddecade).Thedatawere analyzedstatisticallyusingthe Mann–Whitneytest.

For thisstudy,the significancelevelwas definedas0.05 (5%), and confidence intervals were constructed over the lengthofthestudy,with95%statisticalconfidence(Table3).

Inthisstatisticalanalysis,thefollowingsoftwarewasused: SPSSV17,Minitab16andExcelOffice2010.

Results

Basically,wecansay (withtheexception ofthe numberof patients)thatstudygroupsineachdecadepresentedlow vari-abilityregardingtherefinementcriteria,sincethecoefficients ofvariancewerelowerthan50%anddemonstratedthatthe studiesineachofthedecadeswerehomogenous(Table3and

Fig.2).

Inthefirstdecade,pelvicringinjuriesweremore preva-lentamongmen(62.5%)thanamongwomen(37.5%).However, inthe seconddecade,agreater proportionofwomenwere affected(43.3%),althoughwithoutexpressingasignificant dif-ference(p=0.286).

Themeanageinthefirstdecade was39.3years,witha tendencytowardincreasedmeanage,ofuptosevenyears,in theseconddecade(p=0.068).

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5000

100 Mechanism–traffic%

Mortality % Fracture C %

Fracture A % Fracture B %

75

50

40

40 80 30 40 50

62

50

60

40

20 40

20

0

20

0 0

1990s 2000s

1990s 2000s 0

∗

Fig.2–Box-plotofthedecades,forallvariables.

vehicleaccidents,motorcycleaccidentsandbeingrunover. Thispredominance wasmaintainedthroughouttheperiod, with70.7%and62.7%,respectively(p=0.203),andwas there-forenotshowntobesignificantdata.

Wealsofoundthatmostofthefractureswereclassifiedas typeA(40.5%),followedbytypeB(26.7%)andtypeC(23.5%) inthefirstdecade.TherewereslightincreasesinthetypesA andBinjuries(48.6%and28%)intheseconddecade,butthese findingsdidnothavestatisticalvalidity(p=0.457andp=0.967, respectively).

Themortalityratewas15.1%inthefirstdecadeandthis decreasedto13.6%intheseconddecade.Thisdifferencewas notfoundtobesignificant,afteranalysis(p=0.396).

Discussion

Withregardtoattendanceformultipletraumavictimsinthis city,wehavenotedchanges intheepidemiologicalpattern ofpelvicringfracturesinpatientstreatedatourserviceover recentyears.Thishasgivenrisetotheneedforusto inves-tigate whether such changes have also been noted in the specializedliterature.

Westudied20articlesthatcoveredtheperiodfrom1995 to2012,respectingthecriteriaenumeratedearlier.Through ATLSandpublichealthmeasuresthatwereimplementedat the beginning ofthe 1980s, multipletrauma patients have becomebetterunderstood,withcaredeveloped,implemented andsystematizedoverthelast20years.Byfocusingonthis period,wesoughttoinvestigatetheepidemiologicalprofileof pelvicringinjuries.22

Atendencytowardinversionoftheproportionsregarding thegendermostaffectedwithpelvicringfractures,giventhat thepresentreviewfoundthatfemalesbecamemoreaffected inthelastdecade,althoughthisincreasewasnotsignificant (p=0.286).Thissituationmayberelatedtowomen’s consoli-dationintheworkplaceandwithinsocialstructures,whichis increasinglyactiveandeconomicallyparticipative,thus lead-ingtogreaterexposuretotraumaticevents.

The aging of the population, with increasing life expectancy worldwide, is leading to a need for effective participationinday-to-dayactivitiesamongindividualsover the ageof60 years,who nowadaysseemtobemore inde-pendent and self-sufficient.Theimproved abilitytoaccess appropriate healthcare services, which formerly did not provideadequateortimelycareforsurvivalwithinthisage group, andoptimizationofattendanceformultipletrauma victims, corroborate the findings of increased mean age for pelvicring injuries, comparingthe two periods),which expressedastatisticaltendencyafteranalysis(p=0.068).

Inthe studiesevaluatedhere, thetraumawas predomi-nantlyduetovehicletraffic-relatedaccidents,inbothperiods, eventhoughthisfindingdidnothavevalidation(p=0.203).On theotherhand,therewasnostratificationamongthe differ-entpossibilitiesforthistypeofevent,suchas:beingrunover, motorcycleaccidentsorcaraccidents.Thisgivesrisetoa cer-tainamountoffrustration,giventhatinmakingananalysis onthedata,itwasnotpossibletomakeinferencesregarding whichvectorsweremoreprevalent.

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Table1–Studiesanalyzedinthefirstdecade. Reference

(1) BrennemanFD,KatyalD,BoulangerBR,TileM, RedelmeierDA.Long-termoutcomesinopenpelvic fractures.SourceDepartmentofSurgery,

SunnybrookHealthScienceCenter,Universityof Toronto,Ontario,Canada.JTrauma.1997 May;42(5):773–7.

(2) LindseyM,KohlRW3rd.Pelvicfractureamong polytraumadecedents:trauma-basedmortalitywith pelvicfracture–acaseseriesof74patients.TheBen TaubGeneralHospital,BaylorCollegeofMedicine, Houston,Texas,USA.ArchOrthopTraumaSurg. 2001;121(1–2):43–9.

(3) GrotzMRW,AllamiMK,HarwoodP,PapeHC,Krettek C,GiannoudisPV.Openpelvicfractures:

epidemiology,currentconceptsofmanagementand outcome.Injury.2005;36(1):1–13.

(4) ChongKH,DeCosterT,OslerT,RobinsonB.Pelvic fracturesandmortality.IowaOrthopJ.1997;17:110–4. (5) GurevitzS,BenderB,TytiunY,VelkesS,SalaiM,

SteinM.Theroleofpelvicfracturesinthecourseof treatmentandoutcomeoftraumapatients.IsrMed AssocJ.2005;7(10):623–6.

6) BarzilayY,LiebergallM,SafranO,KhouryA, MosheiffR.PelvicfracturesinalevelItrauma center:atestcasefortheefficacyoftheevolving traumasysteminIsrael.IsrMedAssocJ.2005 Oct;7(10):619–22.

(7) GiannoudisPV,GrotzMR,TzioupisC,DinopoulosH, WellsGE,BouamraO,LeckyFJ.Prevalenceofpelvic fractures,associatedinjuries,andmortality:the UnitedKingdomperspective.Trauma.

2007;63(4):875–83.

(8) GänsslenA,PohlemannT,PaulC,LobenhofferP, TscherneH.Epidemiologyofpelvicringinjuries. Injury.1996;27Suppl.1:S-A13-20.

(9) SchmalH,MarkmillerM,MehlhornAT,SudkampNP. Epidemiologyandoutcomeofcomplexpelvicinjury. ActaOrthopBelg.2005;71(1):41–7.

(10) PohlemannT,TscherneH,BaumgärtelF,EgbersHJ, EulerE,MaurerF,FellM,MayrE,QuiriniWW, SchlickeweiW,WeinbergA.Unfallchirurg.Pelvic fractures:epidemiology,therapyandlong-term outcome.Overviewofthemulticenterstudyofthe PelvisStudyGroup.1996;99(3):160–7[German] (11) ParreiraJG,HaddadL,RasslanS.Abdominalinjuries

inpatientssustainingpelvicfractures.RevColBras Cir.2002;29(3):mai/jun.

conducting clinical studies on this topic but also making correlations between the mechanisms and the fracture classification, severity, evolution, complications and prog-nosis. The relevance of these data lies in their ability to help implement preventive public health measures, par-ticularlywith regard to traffic education and the need for referralandspecializationcentersfortreatinginjuriesofthis type.

TypeAfractureswerethemostprevalenttypeduringboth oftheperiodsanalyzed,whichmaybeexplainedbyaccepting thatthistypeofinjurydoesnotprogresstodeath,thusmaking itpossibleforallcaseswiththisdiagnosistobeincludedinthe databases(p=0.457).Therewasanincreaseinthenumbers offracturesclassifiedasB(p=0.967),comparingthedecades

Table2–Studiesanalyzedintheseconddecade. Reference

(1) HolsteinJH,CulemannU,PohlemannT.Whatare predictorsofmortalityinpatientswithpelvic fractures?Symposium:DisruptionsofthePelvic Ring:AnUpdate.ClinOrthopRelatRes. 2012;470:2090–20977(8).

(2) OoiCK,GohHK,TaySY.Patientswithpelvic fracture:whatfactorsareassociatedwithmortality? IntJEmergMed.2010;3(4):299–304.

(3) TosounidisG,HolsteinJH,CulemannU,

HolmenschlagerF,StubyF,PohlemannT.Changesin epidemiologyandtreatmentofpelvicringfractures inGermany:ananalysisondataofGermanPelvic MulticenterStudyGroupsIandIII(DGU/AO).Acta ChirOrthopTraumatolCech.2010;77(6):450–6. (4) SharmaOP,OswanskiMF,RabbiJ,GeorgiadisGM,

LauerSK,StombaughHA.Pelvicfracturerisk assessmentonadmission.AmSurg. 2008;74(8):761–6.

(5) ChienLC,ChengHM,TsaiMC.Pelvicfractureand riskfactorsformortalityApopulationbased.EurJ TraumaEmergSurg;2010;2:131–138.

(6) Je ˇzekM,D ˇzupaV.Theinfluenceofpatientageand mechanismofinjuryonthetypeofpelvicfracture: epidemiologicalstudy.ActaChirOrthopTraumatol Cech.2012;79(1):65–8.

(7) CordtsRMF,ParreiraJG,Perlingero,JAG,SoldáSC,de CamposT,AssefJC.Pelvicfracturesasamarkerof injuryseverityintraumapatients.RevColBrasCir 2011;38(5):310–315.

(8) SiegmethA,MüllnerT,KuklaC,VécseiV.Associated injuriesinseverepelvictrauma.Unfallchirurg. 2000;103(7):572–81.

(9) ChueireIAG,FilhoGC,dosSantosAFI,PockelIKP. Fraturasdoanelpélvico:estudoepidemiológico. ActaOrtop.Bras.2004;12(1),SãoPaulo,Jan./Mar.

analyzed.Thisresultwasexpectedbecauseofthe improve-ment of pre-hospital care, which ensured these patients’ survivalbyimprovingtheirarrivalattheemergencyservice. Withattendanceatthehospitalthatwasmoreappropriate and increasedadmission ofthese patients, the number of patientstreatedincreased.However,theseresultswerenot statisticallysignificantovertheperiodanalyzed.

Despitetheslightdecreaseinthemortalityrateoverthe last decade (p=0.396), it can be inferred that even with-out statisticalsignificance,anddespitepoliciesforaccident prevention,attendance logisticsandinitialmanagementof multipletraumapatients,andwithstructuralimprovements tovehiclesand public highways,humans continueto seek tosurmountlimits,thusofteninsistingonriskingtheirown lives,andthelivesofothers.Thisresultsinsevereandoften fatalaccidents.

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Meanage 1990s 39.3 40.0 7.8 20% 35.0 41.2 29.0 58.0 11 4.6 0.068

2000s 46.8 45.6 8.2 18% 39.8 52.8 37.0 58.0 8 5.7

Men% 1990s 62.5 60.1 6.6 11% 57.5 66.2 55.0 75.0 12 3.7 0.286

2000s 55.7 59.0 11.1 20% 45.0 64.0 42.0 72.1 9 7.3

Mechanism–traffic% 1990s 70.7 73.0 13.6 19% 63.8 76.2 44.0 95.5 10 8.5 0.203

2000s 62.7 58.0 11.6 18% 53.9 71.4 50.0 80.0 7 8.6

FractureA% 1990s 40.5 40.6 19.9 49% 30.4 55.9 5.0 68.0 11 11.8 0.457

2000s 48.6 46.4 17.1 35% 38.7 56.3 25.7 81.0 8 11.9

FractureB% 1990s 26.7 25.0 10.9 41% 20.0 28.5 11.6 49.0 11 6.4 0.967

2000s 28.0 26.7 17.1 61% 17.6 34.4 8.7 62.3 8 11.8

FractureC% 1990s 23.5 16.0 15.0 64% 13.3 30.7 9.0 55.0 11 8.8 0.433

2000s 16.2 17.5 7.3 45% 11.4 22.3 3.8 24.0 8 5.1

Mortality% 1990s 15.1 13.5 8.6 57% 9.7 22.8 4.3 30.0 12 4.8 0.396

2000s 13.6 6.5 12.7 94% 4.8 20.5 3.8 37.0 8 8.8

CV,coefficientofvariance;Q1,1stquartiledistributionofupto25%ofthesample;Q3,3rdquartile,distributionofupto75%ofthesample;CI, confidenceinterval;p-value,resultfromeachcomparison.

Conclusion

Weobservedthattheepidemiologicalprofileofthepelvicring fracturesinthetwodecadesdidnotpresentanysignificant changes.Thegrowingtrendforwomentobemoreaffected, theincreaseinthemeanage,andthedecreaseinmortality overtheperiodanalyzedwere thefindingsobservedinour study,butwithoutstatisticalsignificance.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgements

We thank Prof Dr. Walter Riccioli Junior, Dr. Daniel Dani-achi and Dr. Marcelo Queiroz, attending physiciansin the HipSurgeryGroupofIMSCSP,forperformingtheoperations correlatedwiththistopicthatinstigatedthepresentlineof research.

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