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There have been changes in the incidence and epidemiology of pelvic ring fractures in recent decades?

Abstracts

The pelvic ring fractures comprise 2 -8% of all skeletal injuries. As the incidence rises to 25% in polytrauma and represents a negative prognostic factor with regard to morbidity and mortality of patients, we sought with this work to establish the profile of these, compared to an alteration in the profile of patients with pelvic ring fractures in recent decades. To this end, we evaluated the epidemiological profile, mechanism of injury and types of fractures. By reviewing the literature indexed in the databases related to the theme, 20 papers were selected that contained the requirements for the study. For the period between January 1987 and December 1999 (first decade), and another period in January 2000 and December 2010 (second decade), data were analyzed by Mann -Whitney test. The ratings Tile, Young and Burgess AO were adequate to permit their categorization. The research in each decade was homogeneous. At first the lesions were more prevalent in men with 62.5% with a tendency to reverse this pattern given the increase of women in the second decade (p = 0.286). The average age in the first decade was 39.3 years, an increase in the second (p = 0.068). The most prevalent mechanisms of trauma were related to traffic in both periods as well as fractures classified as type A (p = 0.203 and p = 0.457, respectively), having mortality rates decreased (p = 0.396). We conclude that there was a tendency to increase in the average age of patients (p = 0.068); however the increasing involvement of women (p = 0.286) and decreased mortality (p = 0.396) were not significant.

Pelvic bones ; Epidemiology; Hip fractures ; Meta-analysis


As fraturas do anel pélvico compõem de 2% a 8% de todas as lesões do esqueleto, incidência que sobe para 25% nos politraumatizados e representa fator prognóstico negativo no que diz respeito à morbidade e à mortalidade. Buscou-se com este trabalho estabelecer se houve mudança do perfil desses pacientes nas últimas décadas e por que ela ocorreu. Para tanto, avaliaram-se epidemiologia, mecanismo de trauma e tipos de fratura, por revisão bibliográfica nas bases de dados indexadas relacionadas ao tema, selecionados 20 trabalhos que continham os requisitos para o estudo. O período entre janeiro de 1987 e dezembro de 1999 (primeira década) e outro de janeiro de 2000 a dezembro de 2010 (segunda década) foram analisados e comparados estatisticamente pelo Teste de Mann-Whitney. As classificações de Tile, Young Burgess e AO foram adequadas para permitir sua categorização. As pesquisas em cada uma das décadas foram homogêneas. Na primeira, as lesões foram mais prevalentes em homens, com 62,5%, com tendência a inversão desse padrão, dado o aumento de mulheres acometidas na segunda década (p = 0,286). A média de idade na primeira década era de 39,3 anos e revelou um aumento na segunda (p = 0,068). Os mecanismos de trauma mais prevalentes foram aqueles relacionados ao tráfego nos períodos, assim como as fraturas classificadas como do tipo A (p = 0,203ep= 0,457, respectivamente). Os índices de mortalidade diminuíram (p = 0,396). Conclui-se que houve tendência ao aumento na média de idade dos pacientes (p = 0,068). Já o crescente acometimento das mulheres (p = 0,286) e a diminuição da mortalidade (p = 0,396) não foram significantes.

Ossos pélvicos ; Epidemiologia ; Fraturas do quadril ; Metanálise


Introduction

Trauma is a worldwide public health problem and it has been estimated that in traffic accidents alone, trauma is responsible for around 1.2 million deaths around the world.11. Abreu AM, de Lima JM, Matos LN, Pillon SC. Alcohol use and traffic accidents: a study of alcohol levels. Rev Lat Am Enfermagem. 2010;18. Spec No.: 513-20. It presents great morbidity that today affects more than 50 million people.22. Mello Jorge MH, Latorre MR. Traffic accidents in Brazil: data tendencies. Cad Saúde Publ Rio de Janeiro. 1994;10 Suppl.1:19 -44. This situation is worse in urban centers, especially in capitals and metropolitan regions, where the growing vehicle fleet and greater aggressiveness in traffic cause high-energy accidents and consequently increase the number of deaths.33. Marin L, Queiroz MS. Car accidents in the age of speed: an overview. Cad Saúde Publ Rio de Janeiro. 2000;16(1):7 -21. , 44. Rodrigues NB, Gimenes CM, Lopes CM, Rodrigues JM. Death, injuries an pattern of motorcycle accident victims in the city of Sorocaba, São Paulo, Brazil. Rev Fac Ciênc Méd Sorocaba. 2010;12(3):21 -5.

In the young and economically active population, the main cause of death is external agents. In comparison with other age groups, this population is seen to have a more audacious profile, which raises the rates of mortality due to accidents and urban violence.5 5. Carlini-Cotrim B, Gazal-Carvalho C, Gouveia N. Comportamentos de saúde entre jovens estudantes das redes pública e privada da área metropolitana do Estado de, São Paulo. Rev Saúde Públ. 2000;34(6):636 -45.

6. Laurenti R, Jorge MH, Gotlieb SL. Epidemiological profile of men: morbidity and mortality. Ciênc Saúde Coletiva Rio de Janeiro. 2005;10(1):35 -46.

7. Barros MD, Ximenes R, Lima ML. Child and adolescent mortality due to external causes: trends from 1979 to 1995. Rev Saúde Públ. 2001;35(2):142 -9.

8. Modelli MES, Pratesi R, Taui PL. Alcoolemia em vítimas fatais de acidentes de trânsito no Distrito Federal. Bras Rev Saúde Públ. 2008;42(2):350 -2.

9. Farias GM, Rocha KM, Freitas MCS, Cota KF, Dantas RA. Acidentes de trânsito decorrentes da influênca do uso do álcool. Inter Sci Place Rev Científica Int. 2009;2(9).

10. Abreu AM, Lima JM, Silva LM. Alcoholemy levels and mortality by traffic accidents in the city of Rio de Janeiro. Esc Anna Nery Enfermagem. 2007;11(4):575 -80.
- 1111. Gazal-Carvalho C, Carlini-Cotrim B, Silva OA, Sauaia N. Blood alcohol content prevalence among trauma patients seen at a level 1 trauma center. Rev Saúde Públ. 2002;36(1):47 -54. Within this scenario, traffic accidents are among the main health hazards, and the risk factors for such accidents are young age group, male sex and low social level.1212. Santos AM, Moura ME, Nunes BM, Leal CF, Teles JB. Profile of motorcycle accident victims treated at a public hospital emergency department. Cad Saúde Públ Rio de Janeiro. 2008;24(8):1027 -38. The severity of these accidents gives rise to long periods of hospitalization, with a demand for high-cost resources and consequently greater expenditure of public and private funds.12 12. Santos AM, Moura ME, Nunes BM, Leal CF, Teles JB. Profile of motorcycle accident victims treated at a public hospital emergency department. Cad Saúde Públ Rio de Janeiro. 2008;24(8):1027 -38.

13. Parreira JG, Coimbra R, Rasslan S, Ruiz DE. Politraumatizados com trauma craniencefálico grave: importância das lesões abdominais associadas. Rev Col Bras Cir. 2001;28(5):336 -41.

14. Parreira JG, Haddad L, Rasslan S. Lesões abdominais nos traumatizados com fraturas de bacia. Rev Col Bras Cir. 2002;29(3):153 -60.

15. Jorge MH, Koizumi MS. Gastos governamentais do SUS com internações hospitalares por causas externas: análise no Estado de São Paulo, 2000. Rev Bras Epidemiol. 2004;7(2):228 -38.
- 1616. Martins CB, Andrade SM. Causas externas entre menores de 15 anos em cidade do Sul do Brasil: atendimentos em pronto-socorro, internações e óbitos. Rev Bras Epidemiol. 2005;8(2):194 -204. In an attempt to minimize the catastrophic repercussions of traffic accidents on Brazilian public health, medical and governmental entities have been increasingly adopting preventive measures over recent years, with the aims of diminishing the absolute number of accidents and minimizing their consequences. Installation of medical rescue services on highways and also in Brazilian cities, from the 1980s onwards, is an example of this measures.1717. Malvestio MA, Sousa RM. Advanced life support: care provided to motor vehicle crash victims. Rev Saúde Públ. 2002;36(5):584 -9.

Other well-known advances were the creation of the Brazilian National Traffic Code of 1998 (Law 9503 of September 23, 1997),1818. Malta DC, Silva MM, Lima CM, Soares Filho AM, Montenegro MM, Mascarenhas MDM, et al. Impact of the legal alcohol restriction in the morbidity and mortality by transport-related injuries - Brazil, 2008. Epidemiol Serv Saúde. 2010;19(1):77 -8. which led to a reduction in the number of deaths, and also legislation of greater rigor, such as Law 11705 of June 19, 2008,1919. Malta DC, Soares Filho AM, Montenegro MM, Mascarenhas MD, Silva MMA, Lima CM, et al. Mortality analysis of traffic accidents before and after Brazil's dry law, from 2007 to 2009. Epidemiol Serv Saúde. 2010;19(4):317 -28. popularly known as the "Dry Law" , which showed a proportional decrease in the risk of death. These measures have been shown to be effective, although they still need improvement and updating, such as higher enforcement levels and deepening of the educational process among the Brazilian population.2020. Souza MF, Carvalho MD, Souza CG, Silva MM, Carvalho CG, Morais Neto OL. Descriptive and trend analyses of land transport accidents for public policies in Brazil. Epidemiol Serv Saúde. 2007;16(1):33 -44.

In parallel with the implementation of these laws that were created in an attempt to diminish the frequency of these accidents, the vehicle fleet has been increasing progressively. According to DENATRAN, the number of motor vehicles has increased by around 300% over the last ten years. In the municipality of São Paulo, the mortality rate among victims of vehicle accidents increased from 0.4/100,000 inhabitants to 1.4/100,000 inhabitants over the period from 1996 to 2005.2121. Denatran (Departamento Nacional de Trânsito). Frota antes de 2000 e frota 2011. Disponível em: http://www.denatran. gov.br/frota.htm/publicacoes/show public.asp?cod=
Disponível em: http://www.denatran. gov....

Today, there is still a lack of detailed data regarding trauma severity, injuries most frequently observed, sequelae and complications specifically related to accidents involving vehicles around the world. Such information could help in implementing preventive measures and providing attendance for these patients, through directing physicians in their diagnostic investigations and in determining priorities.

With the aim of understanding the changes in behavior within society over recent decades, with regard to trauma mechanisms and consequently the types of pelvic ring fracture (Fig. 1A -D), the diagnosis, morbidity and mortality of pelvic fractures have been widely discussed by various medical societies, governments and the general population.17 17. Malvestio MA, Sousa RM. Advanced life support: care provided to motor vehicle crash victims. Rev Saúde Públ. 2002;36(5):584 -9.

18. Malta DC, Silva MM, Lima CM, Soares Filho AM, Montenegro MM, Mascarenhas MDM, et al. Impact of the legal alcohol restriction in the morbidity and mortality by transport-related injuries - Brazil, 2008. Epidemiol Serv Saúde. 2010;19(1):77 -8.
- 1919. Malta DC, Soares Filho AM, Montenegro MM, Mascarenhas MD, Silva MMA, Lima CM, et al. Mortality analysis of traffic accidents before and after Brazil's dry law, from 2007 to 2009. Epidemiol Serv Saúde. 2010;19(4):317 -28. Pelvic ring fractures account for 2 -8% of all skeletal injuries, which increases to 25% among multiple trauma patients. Within this context, they represent a negative prognostic factor with regard to morbidity and mortality among multiple trauma patients. Thus, this situation stimulated us to establish the epidemiological profile of these fractures through reviewing the literature.2222. Bucholz RW, Court-Brown CM, Heckman JD, Tornetta P. Rockwood and Green's fractures in adults. 3rd. Philadelphia: Lippincott; 2010.

Fig.1
Radiographs of pelvic ring fracture. (A) Pelvis fracture of Tile type B, frontal radiograph. Image from the files of the Hip Group of DOT-ISCMSP. (B) Pelvis fracture of Tile type B, inlet radiograph. Image from the files of the Hip Group of DOT-ISCMSP. (C) Pelvis fracture of Tile type B, outlet radiograph. Image from the files of the Hip Group of DOT-ISCMSP. (D) Pelvis fracture of Tile type B, postoperative radiograph. Image from the files of the Hip Group of DOT-ISCMSP.

Objective

To compare whether there were any changes in the profile of patients with pelvic ring fractures between the 1990s and 2000s. For this, the epidemiological profile (age, sex and mortality), trauma mechanism and fracture types were evaluated.

Material

After obtaining approval from the Research Ethics Committee of Irmandade de Misericórdia da Santa Casa de São Paulo (51/2012), a bibliographic review was conducted in the Medline, PubMed, Lilacs and Cochrane databases and literature relating to this topic over the last two decades, searching for descriptions of the epidemiology of pelvic ring fractures. These articles would need to present some of the following keywords in their content: fractures, pelvic ring; epidemiology; pelvic bones, injuries; fractures, bone/epidemiology; accidents, traffic; prospective studies; and retrospective studies. The data were gathered between December 2011 and March 2012.

The articles were selected after critical assessment of the strength of evidence and were only accepted if the impact was a minimum of 2A. Articles in which, despite their appearance in the search results, the methodology did not include complete evaluation of data based on age, sex, trauma mechanism, mortality and fracture type (refinement criteria) were discarded.

In evaluating the fracture types, we compared the Tile, Young-Burgess and AO classifications. We classified fractures as type A if they were Tile type A and AO type A; type B if they were Tile type B, Young-Burgess groups A and B and AO type B; and type C if they were Tile type C, Young-Burgess group C and AO type C.2323. Olson SA, Burgess A. Classification and initial management of patients with unstable pelvic ring injuries. Instr Course Lect. 2005;54:383 -93.

The search located 152 articles, of which 73 met the refinement criteria. From these, texts that appeared in duplicate (total of 52 articles) were excluded. After reading the totals and abstracts, 20 studies that contained the data needed for this study were selected (Tables 1 and 2).

Table 1
Studies analyzed in the first decade.

Table 2
Studies analyzed in the second decade.

Method

These articles were divided into two periods: between January 1987 and December 1999 (named the first decade); and between January 2000 and December 2010 (named the second decade). The data were analyzed statistically using the Mann -Whitney test.

For this study, the significance level was defined as 0.05 (5%), and confidence intervals were constructed over the length of the study, with 95% statistical confidence (Table 3).

Table 3
Comparison of the variables analyzed.

In this statistical analysis, the following software was used: SPSS V17, Minitab 16 and Excel Office 2010.

Results

Basically, we can say (with the exception of the number of patients) that study groups in each decade presented low variability regarding the refinement criteria, since the coefficients of variance were lower than 50% and demonstrated that the studies in each of the decades were homogenous (Table 3 and Fig. 2).

Fig. 2
Box-plot of the decades, for all variables.

In the first decade, pelvic ring injuries were more prevalent among men (62.5%) than among women (37.5%). However, in the second decade, a greater proportion of women were affected (43.3%), although without expressing a significant difference (p = 0.286).

The mean age in the first decade was 39.3 years, with a tendency toward increased mean age, of up to seven years, in the second decade (p = 0.068).

Regarding the trauma mechanisms for the pelvic ring fractures, the most prevalent types were those relating to traffic: vehicle accidents, motorcycle accidents and being run over. This predominance was maintained throughout the period, with 70.7% and 62.7%, respectively (p = 0.203), and was therefore not shown to be significant data.

We also found that most of the fractures were classified as type A (40.5%), followed by type B (26.7%) and type C (23.5%) in the first decade. There were slight increases in the types A and B injuries (48.6% and 28%) in the second decade, but these findings did not have statistical validity (p = 0.457 and p = 0.967, respectively).

The mortality rate was 15.1% in the first decade and this decreased to 13.6% in the second decade. This difference was not found to be significant, after analysis (p = 0.396).

Discussion

With regard to attendance for multiple trauma victims in this city, we have noted changes in the epidemiological pattern of pelvic ring fractures in patients treated at our service over recent years. This has given rise to the need for us to investigate whether such changes have also been noted in the specialized literature.

We studied 20 articles that covered the period from 1995 to 2012, respecting the criteria enumerated earlier. Through ATLS and public health measures that were implemented at the beginning of the 1980s, multiple trauma patients have become better understood, with care developed, implemented and systematized over the last 20 years. By focusing on this period, we sought to investigate the epidemiological profile of pelvic ring injuries.2222. Bucholz RW, Court-Brown CM, Heckman JD, Tornetta P. Rockwood and Green's fractures in adults. 3rd. Philadelphia: Lippincott; 2010.

A tendency toward inversion of the proportions regarding the gender most affected with pelvic ring fractures, given that the present review found that females became more affected in the last decade, although this increase was not significant (p = 0.286). This situation may be related to women's consolidation in the workplace and within social structures, which is increasingly active and economically participative, thus leading to greater exposure to traumatic events.

The aging of the population, with increasing life expectancy worldwide, is leading to a need for effective participation in day-to-day activities among individuals over the age of 60 years, who nowadays seem to be more independent and self-sufficient. The improved ability to access appropriate healthcare services, which formerly did not provide adequate or timely care for survival within this age group, and optimization of attendance for multiple trauma victims, corroborate the findings of increased mean age for pelvic ring injuries, comparing the two periods), which expressed a statistical tendency after analysis (p = 0.068).

In the studies evaluated here, the trauma was predominantly due to vehicle traffic-related accidents, in both periods, even though this finding did not have validation (p = 0.203). On the other hand, there was no stratification among the different possibilities for this type of event, such as: being run over, motorcycle accidents or car accidents. This gives rise to a certain amount of frustration, given that in making an analysis on the data, it was not possible to make inferences regarding which vectors were more prevalent.

Thus, we draw attention to the need to carry out trials that might define the trauma mechanism implicated in pelvic ring fractures, with the envisaged aim of not only conducting clinical studies on this topic but also making correlations between the mechanisms and the fracture classification, severity, evolution, complications and prognosis. The relevance of these data lies in their ability to help implement preventive public health measures, particularly with regard to traffic education and the need for referral and specialization centers for treating injuries of this type.

Type A fractures were the most prevalent type during both of the periods analyzed, which may be explained by accepting that this type of injury does not progress to death, thus making it possible for all cases with this diagnosis to be included in the databases (p = 0.457). There was an increase in the numbers of fractures classified as B (p = 0.967), comparing the decades analyzed. This result was expected because of the improvement of pre-hospital care, which ensured these patients' survival by improving their arrival at the emergency service. With attendance at the hospital that was more appropriate and increased admission of these patients, the number of patients treated increased. However, these results were not statistically significant over the period analyzed.

Despite the slight decrease in the mortality rate over the last decade (p = 0.396), it can be inferred that even without statistical significance, and despite policies for accident prevention, attendance logistics and initial management of multiple trauma patients, and with structural improvements to vehicles and public highways, humans continue to seek to surmount limits, thus often insisting on risking their own lives, and the lives of others. This results in severe and often fatal accidents.

There are some limitations to the present study. The lack of standardization regarding trauma mechanisms and fracture classification in the studies evaluated gave rise to some difficulties, in addition to the lack of statistical significance of the data found, despite the n used, which was translated by the homogeneity of the sample. Use of studies written in English, Portuguese and Spanish may have affected the final result obtained. Future studies similar to this should take this into consideration.

Conclusion

We observed that the epidemiological profile of the pelvic ring fractures in the two decades did not present any significant changes. The growing trend for women to be more affected, the increase in the mean age, and the decrease in mortality over the period analyzed were the findings observed in our study, but without statistical significance.

Acknowledgements

We thank Prof Dr. Walter Riccioli Junior, Dr. Daniel Daniachi and Dr. Marcelo Queiroz, attending physicians in the Hip Surgery Group of IMSCSP, for performing the operations correlated with this topic that instigated the present line of research.

REFERENCES

  • 1
    Abreu AM, de Lima JM, Matos LN, Pillon SC. Alcohol use and traffic accidents: a study of alcohol levels. Rev Lat Am Enfermagem. 2010;18. Spec No.: 513-20.
  • 2
    Mello Jorge MH, Latorre MR. Traffic accidents in Brazil: data tendencies. Cad Saúde Publ Rio de Janeiro. 1994;10 Suppl.1:19 -44.
  • 3
    Marin L, Queiroz MS. Car accidents in the age of speed: an overview. Cad Saúde Publ Rio de Janeiro. 2000;16(1):7 -21.
  • 4
    Rodrigues NB, Gimenes CM, Lopes CM, Rodrigues JM. Death, injuries an pattern of motorcycle accident victims in the city of Sorocaba, São Paulo, Brazil. Rev Fac Ciênc Méd Sorocaba. 2010;12(3):21 -5.
  • 5
    Carlini-Cotrim B, Gazal-Carvalho C, Gouveia N. Comportamentos de saúde entre jovens estudantes das redes pública e privada da área metropolitana do Estado de, São Paulo. Rev Saúde Públ. 2000;34(6):636 -45.
  • 6
    Laurenti R, Jorge MH, Gotlieb SL. Epidemiological profile of men: morbidity and mortality. Ciênc Saúde Coletiva Rio de Janeiro. 2005;10(1):35 -46.
  • 7
    Barros MD, Ximenes R, Lima ML. Child and adolescent mortality due to external causes: trends from 1979 to 1995. Rev Saúde Públ. 2001;35(2):142 -9.
  • 8
    Modelli MES, Pratesi R, Taui PL. Alcoolemia em vítimas fatais de acidentes de trânsito no Distrito Federal. Bras Rev Saúde Públ. 2008;42(2):350 -2.
  • 9
    Farias GM, Rocha KM, Freitas MCS, Cota KF, Dantas RA. Acidentes de trânsito decorrentes da influênca do uso do álcool. Inter Sci Place Rev Científica Int. 2009;2(9).
  • 10
    Abreu AM, Lima JM, Silva LM. Alcoholemy levels and mortality by traffic accidents in the city of Rio de Janeiro. Esc Anna Nery Enfermagem. 2007;11(4):575 -80.
  • 11
    Gazal-Carvalho C, Carlini-Cotrim B, Silva OA, Sauaia N. Blood alcohol content prevalence among trauma patients seen at a level 1 trauma center. Rev Saúde Públ. 2002;36(1):47 -54.
  • 12
    Santos AM, Moura ME, Nunes BM, Leal CF, Teles JB. Profile of motorcycle accident victims treated at a public hospital emergency department. Cad Saúde Públ Rio de Janeiro. 2008;24(8):1027 -38.
  • 13
    Parreira JG, Coimbra R, Rasslan S, Ruiz DE. Politraumatizados com trauma craniencefálico grave: importância das lesões abdominais associadas. Rev Col Bras Cir. 2001;28(5):336 -41.
  • 14
    Parreira JG, Haddad L, Rasslan S. Lesões abdominais nos traumatizados com fraturas de bacia. Rev Col Bras Cir. 2002;29(3):153 -60.
  • 15
    Jorge MH, Koizumi MS. Gastos governamentais do SUS com internações hospitalares por causas externas: análise no Estado de São Paulo, 2000. Rev Bras Epidemiol. 2004;7(2):228 -38.
  • 16
    Martins CB, Andrade SM. Causas externas entre menores de 15 anos em cidade do Sul do Brasil: atendimentos em pronto-socorro, internações e óbitos. Rev Bras Epidemiol. 2005;8(2):194 -204.
  • 17
    Malvestio MA, Sousa RM. Advanced life support: care provided to motor vehicle crash victims. Rev Saúde Públ. 2002;36(5):584 -9.
  • 18
    Malta DC, Silva MM, Lima CM, Soares Filho AM, Montenegro MM, Mascarenhas MDM, et al. Impact of the legal alcohol restriction in the morbidity and mortality by transport-related injuries - Brazil, 2008. Epidemiol Serv Saúde. 2010;19(1):77 -8.
  • 19
    Malta DC, Soares Filho AM, Montenegro MM, Mascarenhas MD, Silva MMA, Lima CM, et al. Mortality analysis of traffic accidents before and after Brazil's dry law, from 2007 to 2009. Epidemiol Serv Saúde. 2010;19(4):317 -28.
  • 20
    Souza MF, Carvalho MD, Souza CG, Silva MM, Carvalho CG, Morais Neto OL. Descriptive and trend analyses of land transport accidents for public policies in Brazil. Epidemiol Serv Saúde. 2007;16(1):33 -44.
  • 21
    Denatran (Departamento Nacional de Trânsito). Frota antes de 2000 e frota 2011. Disponível em: http://www.denatran. gov.br/frota.htm/publicacoes/show public.asp?cod=
    » Disponível em: http://www.denatran. gov.br/frota.htm/publicacoes/show public.asp?cod=
  • 22
    Bucholz RW, Court-Brown CM, Heckman JD, Tornetta P. Rockwood and Green's fractures in adults. 3rd. Philadelphia: Lippincott; 2010.
  • 23
    Olson SA, Burgess A. Classification and initial management of patients with unstable pelvic ring injuries. Instr Course Lect. 2005;54:383 -93.

Publication Dates

  • Publication in this collection
    Nov-Dec 2013

History

  • Received
    30 Aug 2012
  • Accepted
    03 Oct 2012
Sociedade Brasileira de Ortopedia e Traumatologia Al. Lorena, 427 14º andar, 01424-000 São Paulo - SP - Brasil, Tel.: 55 11 2137-5400 - São Paulo - SP - Brazil
E-mail: rbo@sbot.org.br