Ana Maria Calil1

Elias Aissar Sallum2

Cristiane de Alencar Domingues3

Lilia de Souza Nogueira3

Calil AM, Sallum EA, Domingues CA, Nogueira LS. Mapping injuries in traffic accident victims: a literature

review. Rev Latino-am Enfermagem 2009 janeiro-fevereiro; 17(1):120-125.

The objective of this study was to identify the body regions most affected in traffic accident victims and to map

the trauma and severity of the lesions. A systematic literature review using key words related to traffic accidents,

transportation accidents, wounds and injuries found a total of 248 articles. The electronic bases LILACS, MEDLINE,

and PAHO were surveyed between the years 1990 and December 2006. This review emphasized a series of

conclusive studies about the most frequent body regions involved and the major injuries occurring in these

situations. It also indicated information gaps in the Brazilian literature. We believe that these findings are

valuable for pre-hospital and intra-hospital teams and point the way to new investigations.

DESCRIPTORS: accidents, traffic; wounds and injuries; epidemiology


El objetivo del estudio fue identificar las regiones corpóreas más afectadas en víctimas de accidentes de

transporte e identificar la gravedad de las lesiones y del trauma. Fue realizada una revisión sistemática de la

literatura, utilizándose descriptores relacionados a los accidentes de tránsito, accidentes de transporte, heridas

y lesiones, totalizando 248 artículos. Las bases electrónicas investigadas fueron LILACS, MEDLINE y PAHO,

entre 1990 y diciembre de 2006. Esta revisión destacó una serie de estudios conclusivos sobre las regiones

corpóreas más frecuentes y aquellas de mayor gravedad afectadas en esos eventos y apuntó lagunas de

conocimiento en la literatura nacional. Pensamos que lo encontrado puede ser de gran importancia para los

equipos en los escenarios de prehospitalario e intrahospitalario y apuntan caminos en dirección de nuevas


DESCRIPTORES: accidentes de tránsito; heridas y lesiones; epidemiología


O objetivo do estudo foi identificar as regiões corpóreas mais atingidas em vítimas de acidentes de transporte

e mapear a gravidade das lesões e do trauma. Foi realizada revisão sistemática da literatura, utilizando-se

descritores relacionados aos acidentes de trânsito, acidentes de transporte, ferimentos e lesões, totalizando

248 artigos. As bases eletrônicas pesquisadas foram LILACS, MEDLINE e PAHO, entre 1990 e dezembro de

2006. Essa revisão destacou uma série de estudos conclusivos sobre as regiões corpóreas mais freqüentes e

aquelas de maior gravidade atingidas nesses eventos e apontou lacunas de conhecimento na literatura nacional.

Acredita-se que esses achados possam ser de grande valia para as equipes nos cenários de pré-hospitalar e

intra-hospitalar e apontem caminhos na direção de novas pesquisas.

DESCRITORES: acidentes de trânsito; ferimentos e lesões; epidemiologia

1RN, Ph.D. in Nursing, Collaborating Professor at Centro Universitário São Camilo, Brazil, e-mail: easallum.fnr@terra.com.br; 2Physician, Ph.D. in Medicine,
Assistant Physician at Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, e-mail: easallum.fnr@terra.com.br;
3RN, M.Sc. in Nursing, e-mail: crismingues@usp.br, lilianogueira@usp.br.

Artigo de Revisão
Rev Latino-am Enfermagem 2009 janeiro-fevereiro; 17(1):120-125


Disponible en castellano/Disponível em língua portuguesa
SciELO Brasil www.scielo.br/rlae



External causes are among the main causes
of morbidity and mortality in the world, and the

number of deaths as a result of traffic accidents in

2005 in Brazil was 35,763, which corresponds to an

average of 98 deaths per day(1).

As to the victims that were hospitalized, the

numbers are alarming. Almost 120,000

hospitalizations occurred in 2005, which represents a

rate of 64 hospitalizations for every 100,000

inhabitants(1) by the Sistema Único de Saúde (SUS) -

the Brazilian national public health system. The number

of accidents with victims in 2005 was 383,371, with a

total 513,510 victims, which translates to, on average,

1406 accidents/day and 1369 victims/day (1.30 victim

per accident)(1).

Reports by the World Health Organization

about the Mortality Database, referring to the period

from 1990 to 2003, revealed that external causes were

responsible for about 12% of the deaths in the world,

which corresponds to, approximately, 8 million deaths

per year, and traffic accidents were responsible for a

large proportion of these deaths (3.9 million)(2).

Early in this decade, some 20 to 50 million

people in the world became totally or partially

incapacitated due to injuries caused by traffic

accidents. Injured and trauma victims took 10% of

all hospital beds that year(3).

In Latin America, the approximate cost

associated with incapacities and death due to these

events was 18.9 billion dollars; in highly motorized

countries, it was 453.3 billion(3). In Brazil, in 2004,

traffic accidents caused a total of 117,155

hospitalizations. This means that 15.5% of

hospitalizations were due to injuries, which shows the

impact of these injuries(4).

A large number of patients remain for weeks,

months, or even years in rehabilitation programs and

physiotherapy, losing salaries and their jobs due to

these events. This points to the economic-social

dimension of the problem(5).

The inquietudes in view of this sad situation,

showing external causes as the third highest cause of

unclear deaths, as well as the urgency and necessity

of measures to help better understand the

consequences of trauma and implement assistance

programs to individuals involved in these occurrences,

led to the present inquiry about whether there are

similarities in the injuries of traffic accident victims.

To organize these possibilities and inquiries,

systematic reviews can be useful in their identification.

Within this context, the purpose of this study was to

identify the existence of specific and common

characteristic between the body regions and injuries

in traffic accident victims, considering their frequency

and severity.


This is a systematic review. Systematic

reviews aim to synthesize the knowledge in a certain

area by formulating a question and then identifying,

selecting, and evaluating studies, critically seeking a

consensus about some practice or concept in which

the available knowledge is insufficient or

controversial(6). The research question was: what body

regions are most frequently and most severely injured

in traffic accident victims? With this question, the task

was to identify similarities and differences in the

frequency and severity of traffic accident victim injuries.

The search for articles included a survey in

electronic databases, and a manual search of

statements in the initially identified publications. The

electronic databases included in the survey were

LILACS (Latin-American and Caribbean Health


Literature end Retrieval System on Line), and PAHO

(Pan American Health Organization Database). In

MEDLINE, only English keywords were used, while in

the others, the keywords used were in Portuguese,

Spanish, and English. The research period was

between 1990 and December 2006.

The article search was performed using

descriptors standardized by the Medical Subject

Heading (MESH) and Descritores em Ciências da Saúde

– Health Science Descriptors (DeCS), as follows: traffic

accidents, transportation accidents, wounds and

injuries, trauma severity indices, and epidemiology.

To refine the search, the terms classification,

prevention, control, and evaluation were added to

these combinations. In the end, there were 1236

combinations between the descriptors to obtain a

maximum possible number of references.

The titles and abstracts of each article

identified in the electronic search were reviewed.

Where possible, the studies that seemed to meet the

inclusion criteria were obtained in full. A list was made,

containing the articles to be included in the study.

Mapping injuries in traffic accident victims…
Calil AM, Sallum EA, domingues CA, Nogueira LS

Rev Latino-am Enfermagem 2009 janeiro-fevereiro; 17(1):120-125


The inclusion criteria were study articles

published in periodicals about traffic or transportation

accidents (pedestrians, motorcycle, or automobile),

containing data about the characterization of the

frequency, injury and/or trauma severity, or that

addressed the affected body regions. The period

considered in the survey was from 1990 to December

2006, and studies could be published in Portuguese,

Spanish, and English.

Studies were chosen if they identified the

injury severity using the Abbreviated Injury Scale

(AIS) index, of anatomical basis, presented as a

manual in which hundreds of injuries are listed

according to their type, location, and severity,

composing over 1300 injury descriptions. The

severity of each injury ranges from AIS1 to AIS6, of

which scores were defined by trauma specialists

according to life risk, i.e. score 1 indicates light injury

and 6 indicates maximum severity of injury(7).

Trauma severity was observed using the New

Injury Severity Score (NISS). The body regions,

according to the instructions in these severity

manuals, are divided into six categories: head/neck,

face, thorax, abdomen or pelvic contents, upper/

lower limbs, and external surface.

Studies using the Maximum Abbreviated

Injury Scale (MAIS), which refers to the major injury

identified by the AIS in a patient, were also included.

Reading was limited to articles that

addressed injury severity, trauma severity, and

analyzed the body regions or common aspects of

these variables.


In the MEDLINE database, considering the

period between 1990 and 2006, 2743 articles were

located and 178 were included. Of the total of 208

articles found in the LILACS database, 52 were

included, and only 18 of the 150 articles found in the

PAHO database were included. In total, 248 articles

met the inclusion criteria.

The main reasons for excluding articles were:

it was an update article, case study, or did not

describe the injuries in terms of their severity and

frequency or affected body region. The manual

search did not add any new articles. Some articles

were included in more than one database and, when

this occurred, the oldest article was included.

Of the 248 analyzed articles, 226 were cross-

sectional studies using a quantitative approach, 18

were cohort studies, and 4 were systematic reviews.

It is noted that, among the selected studies,

120 addressed injury severity, 55 also included trauma

severity, and only 73 addressed the most affected

body regions.

The survey found original studies from five

continents, highlighting North-American, Australian,

and Asian publications. Regarding Brazil, 34 studies

were located.

As to the patients’ characteristics, the studies

were unanimous in pointing out men aged 40 years

or less as the most common victims, especially those

aged 19 to 29 years. It was observed that children

and elderly individuals comprised the majority of those

involved in pedestrian-vs-auto accidents.

As to the type of victim, i.e., motorcycle user,

automobile user, and pedestrian (struck by vehicle),

there was a variation in the findings according to the

period the study was performed (before 1999) and

the country or location where the event took place.

In Asian countries, motorcycle and bicycle accidents

prevail in a uniform manner over the analyzed years,

due to the large number of these used as the main

mode of transportation.

In terms of auto and pedestrian accidents,

auto injury patients were found in greater numbers.

This finding was expected since there can be more

passengers in a vehicle, and also because of the great

number of cars in countries like the United States of

America (USA), Canada and Brazil.

Adopting preventive measures, such as

increasing the crossing time for pedestrians in streets

and avenues in European and North-American

countries, was identified as an effective measure to

reduce pedestrian-vs-auto accidents in some

countries. Nevertheless, the type of victim was found

with less homogeneity among the studies.

Specifically concerning Brazil, most studies

reported automobile users as the most frequent

victims until the year 2000, when motorcycle users

became the most frequent victims of injury. It should

be emphasized that accidents involving being struck

by an automobile are generally regarded as the most

lethal of accidents.

As to the most frequently injured body region,

upper and lower limbs are highlighted, followed by

the head region. The thorax region, external surface

and face alternated in the studies in terms of

Mapping injuries in traffic accident victims…
Calil AM, Sallum EA, domingues CA, Nogueira LS

Rev Latino-am Enfermagem 2009 janeiro-fevereiro; 17(1):120-125


frequency, and the thorax, abdomen, and limbs in

terms of severity.

As to severity, there is no doubt it can be

affirmed that injuries to the head region, referred to

as craniocerebral trauma (CCT), rank first in terms

of injury severity. It is important to emphasize that

numerous studies report the head region as the one

with most injuries IS≥4.
In terms of trauma severity, most studies state

that between 58% and 60% of people involved in

traffic accidents have trauma severity ≤16, considered
to be moderate to light, and around 35% to 40% have

serious or life-threatening trauma.


A great number of patients are transported

to the emergency ward due to traffic accident injuries.

These cases are a daily challenge for the teams

working in pre and intra-hospital settings, especially

due to the severity of the injuries and to the time it

takes to reach the hospital and forward patients to


The variety and possible severity of the clinical

conditions that occur in a trauma make it essential to

reach a fast and precise diagnosis of the nature of

the injuries. The differentiation between the injuries

and the severity potential that risk life (CCT, thoracic

and abdominal injuries) is critical in order to start

treatment immediately and discharge or admit patients

to hospital(8).

Although the clinical presentation of patients

with traffic accident injuries can vary immensely,

especially because of the organic responses from shock

and changes in hemodynamic and respiratory

parameters, about 50% of patients present limb injuries

and about 40% present more than one injury(3,9).

A national study analyzed the distribution of

injuries per body region in traffic accident victims, and

found that motorcycle users had a significantly higher

number of injuries to the upper limbs, lower limbs,

and pelvis compared to other victims, while there were

more head/neck and face injuries in run-over and

automobile accidents(10).

Another study verified the injuries in 3594

hospital admissions in 28 North American trauma

centers and identified that the most affected body

regions were the upper limbs, lower limbs, and pelvis

in 51% of cases(11).

The analysis regarding the location of injuries

in 6099 victims of this event in the South of Brazil

identified that the most affected body regions were

the lower and upper limbs (69.7%), the head (49.6%),

and the thorax (19.9%)(12).

The distribution found in the analyzed studies

often shows the upper/lower limbs and pelvis, and

head/neck regions as the two most affected body

regions in traffic accidents, with variations for the other

affected regions.

Isolated upper or lower limb injuries are rarely

fatal, but often require reparative and corrective

surgeries and amputations, which have a direct

influence on the quality of life of patients and their


Only one national study evaluated the most

common injuries in automobile users, motorcycle

users and pedestrians, using the proposed severity

indices, and found that the most common injuries for

the limb region were: wrist contusion, torsion of the

clavicle, elbow contusion, finger fracture (AIS=1),

lower and upper limb bone fracture, elbow luxation,

tendon laceration, hand laceration (AIS=2), multi-

fragmentary pelvis fracture, femur fracture, knee joint

rupture, femoral and axillary artery laceration

(AIS=3), and traumatic amputation above the knee

(AIS=4). Injuries with greater severity, like AIS=5

and AIS=6, were not identified.

As to the most severely affected body region,

the head/neck had a percentage a lot higher than the

other regions; these injuries scored AISe”4 in most

studies. This finding is extremely important, due to

the high prognostic value determined by injuries in

this body segment(13).

CCT in traffic accident victims is the most

common isolated injury in severe and fatal cases,

and it causes the highest number of sequelae,

incapacities and deficiencies. The overall analysis of

the studies highlights pedestrians as the victim in cases

that are most likely to evolve to death when this body

segment is injured(5,10).

The most common head injuries, according

to the severity classification, were: post-CCE

amnesia, post-trauma headache, and cervical spine

torsion (AIS=1), simple skull fracture, cervical spine

luxation (AIS=2), cerebral contusion (AIS=3),

intracranial hematoma, depressed skull base fracture

(AIS=4). Injuries of greater severity (AIS=5 and

AIS=6) were not identified(10).

Mapping injuries in traffic accident victims…
Calil AM, Sallum EA, domingues CA, Nogueira LS

Rev Latino-am Enfermagem 2009 janeiro-fevereiro; 17(1):120-125


The thoracic region appears as the second

most severely injured region in most studies. Recent

studies about trauma report it is a body segment

with high risk to patients, since it contains organs

like the heart and lungs(10). The injuries most

frequently found in this body segment were: rib

fracture (AIS=2), lung, hemo or pneumothorax

contusion (AIS=3), and bilateral hemopneumothorax,

hemopneumomediastinum (AIS=4). One pedestrian

had an injury of severity = 5 (bronchi rupture) and

another pedestrian had a maximum severity injury

=6 (total aorta dissection)(10).

As to the abdomen, the main injuries found

were: stomach laceration, liver contusion, spleen

contusion (AIS=2), retroperitoneum hematoma,

important contusion involving liver/spleen veins

(AIS=3), important liver laceration (AIS=4). There

was one automobile user with an injury AIS=5

(complex liver rupture)(10).

As to the face region, commonly injured in all

kinds of traffic accidents, the following injuries are

highlighted: nose and tooth fracture (AIS=1),

cheekbone or mandible fracture, cornea laceration

(AIS=2), and optic nerve laceration and Lefort II

fracture (AIS=3). On the external surface, there are

mostly contusions, abrasions, and superficial lacerations

that do not have a severity index above AIS=2.

It should be emphasized that victims with

injuries equal to or above 5 died and, of the total

studied patients (220), 45 died, of which 30 (66.6%)

were pedestrians. This type of victim had more CCE

(48.5%) than the others(10). These findings are in

agreement with the literature(3, 8-9).

Approximately 40% of the injuries are

multiple and occur in the following body regions: head/

neck, face, abdomen/pelvic content, and more than

50% occur on upper limbs, lower limbs and pelvis.

Traffic accident victims are often characterized as

polytrauma patients or as having multiple injuries in

the same body segment. This situation worsens the

prognosis and, therefore, requires emergency

evaluation from the surgery teams(14).

It is observed that, in most traffic accidents,

the severity rates equal to or below 15 correspond to

around 58%-60% of all events, but an important

percentage of traffic accident victims present trauma

severity ISS ≥16(15-17).
Studies involving trauma severity highlight

pedestrians as the most frequent fatal victims. This

situation is easy to understand because it is a case of

hundreds of kilos of steel against a far smaller number

of kilos of weight, and it is the most mortal type of

traffic accident in the world(10,15).

There is a difference in Brazil in terms of the

type of accidents, with collisions prevailing in

approximately 50% of cases. The proportion of events

varies considerably; for instance, pedestrian-vs-

automobile accidents in Roraima were responsible for

7.1% of all accidents, while they account for 39.5%

and 43.3% in Rio de Janeiro and Amazonas,


This distinct panorama found in the country

should serve as a guide for preventive and educational

measures in each region.

It is important to emphasize that the mortality

rate for motorcycle users showed the highest increase

from 1996 to 2005: 540%, rising from 0.5 to 3.2 per

100,000 inhabitants. This rapid climb can be

understood due to the increase in the current fleet

(65.3% between 2001 and 2005), whereas the

automobile fleet increased from 142.5 to 165.5 (a

16.1% increase)(1,13).

After this broad review, points of agreement

and disagreement were found regarding the universe

of traffic accident victims. It was found that the national

literature presents a solid body of knowledge about

the epidemiology of external causes in terms of traffic

accidents. Nevertheless, there is a scarcity of studies

that describe the injuries affecting these victims with

greater detail.

The knowledge of this traffic accident reality,

and facts regarding the most frequently affected body

regions, as well as their severity, could contribute to

implement, set up and develop assistance programs

for individuals involved in these accidents, in addition

to providing an analysis of the situation and appoint

the need to perform other studies that would serve

as a reference for the teams working in pre- and intra-

hospital environment, to establish conducts, assign

priority of care, develop protocols, direct human/

material resources, and plan care.


The analysis of the studies showed that the

most commonly affected body regions in traffic

accident victims are upper/lower limbs, followed by

the head/neck region. In terms of severity, the head/

neck region is highlighted in studies related to severity

Mapping injuries in traffic accident victims…
Calil AM, Sallum EA, domingues CA, Nogueira LS

Rev Latino-am Enfermagem 2009 janeiro-fevereiro; 17(1):120-125


and mortality. It is important to emphasize that

numerous studies report the head region as the area

most affected by injuries with AIS equal to or above 4.

Regarding the third most affected body region, studies

differ in identifying the face, thorax, and external

surface regions; in terms of severity, the thoracic

region is highlighted as second. Several studies

emphasize that health teams should double their

attention in accidents in which the thorax and

abdomen regions have been injured or, due to the

trauma mechanism, present potential for injuries in

these body segments, because of their relation to

serious cases of hemorrhage and respiratory arrest.

As to the type of victim, there was no homogeneity

among the studies, varying in terms of the location of

the accident (country) and the analyzed period.

In Brazil, accidents and mortality involving

motorcyclists increased significantly as of 1999,

although the literature reports pedestrians as the most

vulnerable victims. Studies that analyze traffic

accident injury frequency, type and particularities are

scarce in our environment or extremely circumscribed

to a location/municipality, and most choose to focus

on only one type of victim, which makes comparisons

difficult. Further broader (multicentric) studies should

be encouraged.


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Recebido em: 12.10.2007
Aprovado em: 27.10.2008

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Calil AM, Sallum EA, domingues CA, Nogueira LS

Rev Latino-am Enfermagem 2009 janeiro-fevereiro; 17(1):120-125