We found that age played a significant role in defining fracture locations, and mechanisms of injury (P < .001) (Table 2). As expected, hip fractures were uncommon until ages 50 to 59 years old (15.0%), and they were the most frequent fracture in patients ≥60 years old (45.6%). Tibia/fibula fractures were the most frequent fractures in patients aged 18 to 59 years old accounting for 1 in 5 patients. The frequency of falls from standing increased with age, from 19.6% in patients aged 18 to 29 years old to the most common mechanism of injury (71.6%) in patients ≥60 years old. Motorcycle RTIs were the most common mechanism of injury in patients aged 18 to 29 years old (23.1%), decreasing with age.
This study reports descriptive results of the first large scale, clinical observational study describing the distribution of fractures in women in 17 LMICs.
We observed a previously identified role of aging in injuries among women across LMICs, adding additional quantification from prospective clinical data. Nearly two-third of patients were ≥50 years old. Falls from standing accounted for the most common mechanism of injury, and sharply increased with age, indicative of fragility fractures. Across 17 LMICs, hip fractures, commonly associated with osteoporosis and aging, were the most frequent, occurring within 3 in 10 patients. The frequency of hip fractures we observed was two- to fourfold higher than previous multiregional estimates of fragility fracture incidence.[19,20] Hip fractures carry a high risk of mortality, with a reported one-year postoperative mortality rate of 27%.[21,22] Consequently, compared to less serious fragility fractures, we suspect a higher proportion of hip fracture patients will seek care for their treatment, which may explain our higher measurements of frequency.
Among younger populations (18–49 years old), RTIs accounted for 4 in 10 fractures, while tibia/fibula were the most common fracture location. This is consistent with previous reports whereby tibia/fibula fractures are associated with RTIs. Within the subset of RTIs, being hit as a pedestrian, or, motorcycle related injuries were major sources of fractures, aligning with previous data, and demonstrating a need for improving road safety procedures.[24–27] Among female patients, we determined that 7.5% of fractures were open, with tibia/fibula fractures, and foot representing common locations. This is consistent with lower-extremity fractures accounting for the majority of treated open fractures.
To contrast the global trend of fragility fracture burden in women, patients in Africa sustained high frequencies of tibia/fibula, femur, and open fractures. Mechanistically, patients suffered the highest frequencies of pedestrian related RTIs, and RTIs resulting from nonmotorcycle motorized vehicles. We suspect this trend coincides with women in Africa being younger, and employed (e.g., business sector); thus, increasing their exposure to RTIs due to necessarily travelling outside the home.
Our results are comparable to a pilot surveillance study in South Africa, which found 77% of female patients were between the ages 20 to 59 years old, a similar distribution to our data. By contrast our data suggest a greater role for RTIs (∼40% of injury burden), among African women than a previous comprehensive report from Cape Town which reported 13.7%. Differences could result from our inclusion criteria, which consisted of patients who sustained orthopaedic fractures, instead of trauma more generally. Additionally, the inclusion of data from more African countries may contribute to differences. Nevertheless, the finding that more working age-women in Africa are sustaining RTI-related fractures has implications on indirect costs (e.g., from lost work), and poverty.
Across 17 LMICs, female patients within Other Asia sustained the highest levels of motorcycle related RTIs, and open fractures. Correspondingly, 1 in 5 female patients sustained a tibia/fibula fracture. Motorcycle accidents are particularly serious, resulting in a high mortality rate. We speculate this high frequency of motorcycle accidents reflects a noted rise in motorcycle taxi usage, and ownership within southeast Asia including in Thailand and Vietnam, which is included within Other Asia in our study. Our data shed preliminary insight into a need to address the burden of RTIs among women within this region, for example, through improved traffic regulations.
Patients in China, India, and Latin America mirrored the global trend, most commonly sustaining hip fractures, and fractures due to falls from standing. Regionally, spine fractures were high in China (18.9%), and virtually absent from other regions. Malleolus ankle fractures were common in Latin America (19.8%). As we did not sample all hospitals, these trends must be interpreted cautiously. Spine fractures may be clinically silent, resulting in patients not seeking treatment. Additionally, the treatment of spine fractures may require special trauma facilities outside of the hospitals included within our study. Patients sustaining ankle fractures likewise may not seek treatment. Interestingly, patients in India disproportionately sustained falls from height. This finding is consistent with a pilot study which suggests urban Indian households create numerous falling risks including the use of wooden ladders instead of staircases, and rooftop dwellings.
In our study, health insurance was highly stratified across LMICs, with 9 in 10 insured in China, and Latin America to 2 in 10 insured in Africa, and India. In LMICs, the high cost of care combined with an inability to work creates a fear of financial insecurity, and a barrier to receiving care. In Uganda, over half of adults who received care for trauma experienced financial catastrophe as a result of their treatment. A lack of insurance also impedes efficient emergency medical services, such as interhospital referrals.[34,40,41] As a result, within LMICs, a lack of insurance may prevent care, and exacerbate poverty in patients who recover.
Our data provide observational prospective clinical data continuously collected from 47 hospitals in 17 LMICs providing high-volume data over a 3-year period. The extensiveness of this dataset provides added demographic, and injury characteristics from LMICs. Our research approach was not designed to be epidemiological sampling of the fracture burden over the entire population within each region. Our estimates of catchment area rely on estimates of hospital beds per person as reported by the World Bank DataBank. This approach does not account for differences in population density, and relies on estimates from public data sources, which may not be current. Therefore, we emphasize our analysis cannot reliably generalize to patients who do not seek treatment for their injuries, and therefore does not purport to estimate fracture incidence within different regions. Instead, our cross-sectional analysis provides a description of the fracture burden of female patients who seek treatment at hospitals; thereby, reflects the clinical manifestations of fracture burden within these regions. Our conclusions may not be generalizable to women who do not seek treatment for their injuries or seek treatment from non-major hospitals (e.g., traditional healers).
Across all regions, a majority of female patients were over the age of 50 years old, coinciding with a high proportion of fragility fractures, and nearly one in three patients sustained a hip fracture. Patients in Africa, however, were primarily working age, sustained a higher proportion of tibia/fibula and femur fractures. Motorcycle RTIs and open fractures were especially common within Other Asia. Notable deficiencies in health care systems include a low frequency of ambulance use, and low health insurance coverage among women in Africa, India, and Other Asia. Our research provides preliminary insight into baseline fracture and demographic trends across marginalized women living in 17 LMICs, and we hope future research will build upon our analysis.
Appendix 1: List of INORMUS Investigators:
Steering Committee: Mohit Bhandari, MD, PhD, FRCSC (Chair, McMaster University); PJ Devereaux, MD, PhD, FRCSC (Co-Chair, McMaster University); Gordon Guyatt, MD, MSc, FRCP, Brad Petrisor, MD, FRCSC, and Lehana Thabane, MD, MS, FACS (McMaster University); Respicious Boniface, MD, M.Med (Muhimbili Orthopaedic Institute); Bruce Browner, MD, MS, FACS (University of Connecticut Health Center); Fernando de la Huerta, MD (Mexican Institute for Social Security); Rebecca Q Ivers, PhD (The George Institute for Global Health, University of New South Wales); Theodore Miclau III, MD (University of California); Paul Moroz, MD, FRCSC (Shriners Hospitals for Children, Honolulu); Andrew Pollak, MD, and Gerard Slobogean, MD, FRCSC (University of Maryland); Parag Sancheti, MBBS, MS, MCh, DNB, FRCS (Sancheti Institute for Orthopaedics and Rehabilitation); Emil Schemitsch, MD, FRCSC (University of Toronto); and Junlin Zhou, MD, PhD (Beijing Chaoyang Hospital, Capital Medical University).
McMaster University Global Method Center: Mohit Bhandari, MD, PhD, FRCSC (Principal Investigator); Sheila Sprague, PhD (Research Methodologist); Paula McKay, BSc, Chuan Silvia Li, BSc, Raman Mundi, MD, and Nathan O’Hara, MHA (Project Management); Diane Heels-Ansdell, MSc (Data Analysis); Lisa Buckingham, BSc (Data Management); and Nicole Simunovic, MSc (Grants Management).
George Institute for Global Health UNSW Methods Center: Rebecca Q Ivers, PhD (Lead Investigator); Jagnoor Jagnoor, PhD, Robyn Norton, PhD, Jing Zhang, MSc, Maoyi Tian, PhD, and Soumyadeep Bhaumik, MBBS, MSc (Project Management).
Institute for Global Orthopaedics and Traumatology (IGOT), University of California, San Francisco Method Center: Theodore Miclau III, MD (Lead Investigator) and Saam Morshed, MD, PhD, and Madeline C. MacKechnie, MA (Project Management).
Participating Clinical Sites: China: Junlin Zhou, MD, PhD, Qiushi Wang, MSc, Junfei Li, MSc, and Haoran Zhang, MSc (Beijing Chaoyang Hospital, Capital Medical University); Zhentao Zhang, MSc, Wei Zhang, MSc, Shiwen Tian, MSc, Guang Chen, MSc, Zichao Jia, MD, and Tao Guo, MSc (Langfang People's Hospital); Yinghua Ma, MD (Langfang Aidebao General Hospital); Xinlong Ma, MD, Jianxiong Ma, PhD, Haobo Jia, PhD, Shuangshuang Cui, MSc, Zhihu Zhao, MSc, Lin Fu, MSc, Hongqiang Jiang, MSc, and Jianwei Lv, MSc (Tianjin Hospital); Sanbao Hu, PhD, Yongwei Wang, MSc, and Mingyao Sun, PhD (Beijing Anzhen Hospital, Capital Medical University); Yanguo Qin, PhD, Jincheng Wang, PhD, and Dan Luo, MSc (The Second Hospital of Jilin University); Shuqing Zhou, MSc, Baochang Qi, MSc, and Ming Gao, MSc (The Second Affiliated Hospital of Harbin Medical University); Bo Wu, MSc, Chunsheng Zhi, PhD, and Ben Xing, MSc (Shenyang Orthopedic Hospital); Jun Yang, MD, Wenjie Dai, MD, and Duo Lu, MD (Hanzhong People's Hospital); Shisheng He, PhD, Xinyu Cai, MD, and Gejun Liu, PhD (Shanghai 10th People's Hospital); Gang Rui, PhD, Baoshan Hu, PhD, and Pingfang Shi, MD (The First Affiliated Hospital of Xiamen University); and Hua Chen, MD, Te Wang, MSc, Qingqing Wang, PhD, Linzhen Xie, MSc, and Huanguang Xie (The Second Affiliated Hospital of Wenzhou Medical University); India: Parag Sancheti, MCh, Ashok Shyam, MS, Madhav Borate, MS, Nalini Gawande, MSc, and Nutan Jadhav, B.Pharm (Sancheti Institute for Orthopaedics and Rehabilitation, Pune); Sampat Dumbre Patil, DNB, Sachin Karkamakar, MS, Shailesh Patil, D.Ortho, Abhijeet Ranaware, DNB, Shadab Tamboli, BHMS, Manish Gandhalikar, D.Ortho, Rohini Tupe, MA, Vishal Choudhary, DNB, and Avanti Joshi, BHMS (Noble Hospital, Pune); Sandeep Shrivastava, PhD, Pradeep K Singh, PhD, Sanjay Deshpande, MS, and Sumit Baheti, MBBS (Datta Meghe Institute of Medical Sciences); Mandeep S. Dhillon, MS, and Sarvdeep S. Dhatt, MS (Post Graduate Institute of Medical Education & Research, Chandigarh); Vijay Shetty, MS (Dr L H Hiranandani Hospital); Sanjay Patil, MS, Tejas Gandhi, MS, Chintamani Latkar, MS, and Gopal Pundkare, DNB (Bharati Vidyapeeth University Medical College, Pune); Ravi Mittal, MS, and Vijay Sharma, MS (All India Institute of Medical Sciences, Delhi); Anupam Mahajan, MS, Ritesh Pandey, Bobby John, and Jeewan S. Prakash (Christian Medical College, Ludhiana); Vinoo Mathew Cherian, MS, Thilak Samuel Jepegnanam, MS, Vijay T. K. Titus, MS, Manasseh Nithyananth, MS, Palapattu R. J. V. C. Boopalan, MS, Viju Daniel Varghese, MS, Justin Arockiaraj, MS, and Vinu Mathew George, MS (Christian Medical College, Vellore); Rajagopalan N., MS, and Naveen Nair, MS (Indira Gandhi Medical College and Research Institute, Pondicherry); Rajkumar S. Amaravathi, FRCS, Srinivasalu Santhanagopa, DNB, Anoop Pilar, MS, and Keith Behram Tamboowala, MS (St. John's Medical College, Bengaluru); Harvinder Singh Chhabra, MS, Ritabh Mittal, MS, Pushkar Chawla, MS, Rajesh Sharawat, MPT, and Rashmi Yadav, BSc (Indian Spinal Injuries Centre); Asolie Chase, MS (Baptist Christian Hospital, Tezpur); and Neel M. Bhavsar, MS, Darshan Shah, MBBS, and Ramiz Musa, MS (Smt. NHL Municipal Medical College, Ahmedabad); Iran: Soheil Saadat, MD, PhD, Mohammadreza Zafarghandi, MD, Mohammadreza Golbakhsh, MD, and Mashyaneh Haddadi, MD (Sina Trauma and Surgery Research Center (STSRC) and Tehran University of Medical Sciences [TUMS]); Nepal: Subin Byanjankar, MD, Ruban Raj Joshi, MD, Rajeev Dwivedi, MD, and Jay Raj Sharma, MD (Lumbini Medical College); Pakistan: Raja Irfan Qadir, MBBS, FCPS, Syed Imran Bukhari, MBBS, FCPS, and Khushnood Ali Baz, MD, PhD (Northwest General Hospital & Research Centre, Peshawar); Philippine: Irewin Tabu, MD, Paula Veronica Reyes, Iardinne Caiquep, Jenna Gonzalez, and Joni Mitchell (University of the Philippines Manila,Philippine General Hospital); Thailand: Wanjak Ponggsamakthai, MD, FRCOST (Khon Kaen Hospital) and Paphon Sa-ngasoongsong, MD (Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University); Vietnam: La Ngoc Quang, MD, PhD (Hanoi University of Public Health); Nguyen Duc Chinh, MD, PhD (Viet Duc Hospital); and Vu Bao Hong, MPH (National Lung Hospital); Botswana: Panchu Subramanian, FRCS, and Olivia L Mosweu, PRN (Princess Marina Hospital); Cameroon: Henry Tanyi Ndasi, FCS (ortho); Tagakou Jules Mbula, M.Med (ortho); Nietiayurk Aminake Ghislain, MS (ortho); and Mala Irine Shey and Ikose John Nanje; Ethiopia: Samuel Hailu, MD, Geletaw Tessema, MD, Bahiru Bezabih, MD, Birhanu Ayana, MD, Hiwot Hailu, MD, Samrawit Esayas, MD, Samuel Tesfaye, MD, Betelhem Zewdneh, MPH, and Hana Tesfaye, BSc (Black Lion Hospital); Ghana: Vincent Ativor, MBChB, FGCS, FWACS, FICS, Dominic Konadu-Yeboah, MBChB, MPH, FGCS, FWACS, Peter Konadu, MBChB, FA, FGCS, Raphael Kumah-Ametepey, MD, FA, FGCS, Dominic Awariyah, MD, FACHIR, FA, FGCS, FWACS, Raphael Quartey, MD, PhD, Osman Saani, MD, Robert Ekow Quansah, MD, PHD, FWACS, FGCS, Peter Trafton, MD, David Anyitey-Korkor, MBChB, MGCS, MWACS, Michael Leat, MBChB, MGCS, Jonny Sobotie, MBChB, MSC, MGCPS, Godwin Opuni, MBChB, MGCS, Kusi Kwasi, MBChB, MGCS, Twumasi-Baah Jnr, MBChB, MWACS, Felicia Agbenorwu, Phyllis Osei-Donkor, Paul Okyere, Bernice Mensah, Doris Akuoko Sarpong, and Priscilla Opoku (Komfo Anokye Teaching Hospital); Michael Segbefia, MD, FWACS, and Paa Kwesi Baidoo, MBChB, FGCS, FWACS (Korle-Bu Teaching Hospital); Nigeria: Gerald Chukwuemeka Oguzie, MD, FWACS, FMCOrtho, Emmanuel Chino Iyidobi, MSc, FWACS, FAOSI, Cajetan Uwatoronye Nwadinigwe, FWACS, Sharon Amarachi Uloma Oguzie, MSc, and Emina Bami Kesiena, MWACS, MMCS (National Orthopaedic Hospital Enugu); Olufemi Olukemi Temiloluwa, MD, FWACS (Ortho), FMCOrtho; Adeyeye Adeolu Ikechukwu, MD, FMCOrtho; Ige Oluwole Olugbenga, MD, FMCS (Ortho); and Ojodu Ishaq Bamidele, MD, FWACS, and Oladimeji Oladipupo Akanbi, MD, FWACS (Ondo State Trauma and Surgical Centre; University of Medical Sciences, Ondo City, Ondo State); South Africa: Gregory Firth, MBBCh, FCS, M Med, Anna Grisillo Biscardi, Ananias Poopedi Machuene, Johan Moolman, Brenda Milner, and Matimba Maluleke (Chris Hani Baragwanath Acadamic Hospital; University of the Witwatersrand, Orthopaedic Division); Mmampapatla Thomas Ramokgopa and Susan van Deventer, FC ORTH (SA); Timothy Pikor (Charlotte Maxeke Johannesburg Academic Hospital; University of the Witwatersrand, Orthopaedic Division); and Ravi Bhaga (Helen Joseph Hospital; University of the Witwatersrand, Orthopaedic Division); Tanzania: Paul Marealle, MD, Athman Wanini, Marwa Elisha, Damas Zumbulu, and Respicious L. Boniface, MD, M.Med (Muhimbili Orthopaedic Institute) and Rogers Temu, MD (Kilimanjaro Christian Medical Centre); Uganda: Tonny Mutanda, Juliet Ntuulo, Flavia Lubega, Gayita Teddy Tracy, and Kayondo Zaitun (Mulago Hospital) and Pariyo Bonane Godfrey, MBchB (Fort Portal Regional Referral Hospital); Argentina: Carlos Amanquez, MD (Hospital General de Agudos Juan A. Fernandez); Bolivia: Sergio Iriarte Vincenti, Alfredo Pozzo Bobarin, and Dalton Salinas Sanchez (Clinica Del Sur); Brazil: Nelson Elias, MD, PhD (Escola de Medicina da Santa Casa de Misericordia de Vitória); José Eduardo Grandi Ribeiro (Vila Velha Hospital); William Dias Belangero, José Ricardo Lenzi Mariolani, Bruno Livani, André Lugnani, Felipe Rossi, and Angela Katayama (State University of Campinas, UNICAMP); Fabricio Fogagnolo, MD (University of São Paulo, Ribeirão Preto); Fernando Baldy and Vinícius Ynoe de Moraes (Federal University of São Paulo); and Kodi Edson Kojima, Jorge dos Santos Silva, Marco Kawamura Demange, Fernando Brandão de Andrade e Silva, and Adriana Carvalho Gomes da Silva (Institute of Orthopedics and Traumatology, University of Sao Paulo); Colombia: Jose Eduardo Quintero, MD (Hospital Universitario San Jorge); Costa Rica: Fernando Contreras (Hosptal San Juan de Dios); Ecuador: Gavino Merchan (Hospital de la Policia Guayaquil); Haiti: Georges Beauvoir (Faculté de Médecine de Pharmacie et de Biologie Médicale, Université d’Etat d’Haïti, Port-au-Prince); Mexico: Edgar Efren Mercado Salcedo, MD (Instituto Mexicano del Seguro Social, Guadalajara); Fryda Medina (Instituto Mexicano del Seguro Social, Mexico City); Gerardo Aguilar (Instituto Mexicano del Seguro Social, Monterrey); Jorge Rubio-Avila, MD (OPD Servicios de Salud del Municipio de Zapopan); Hernando Cuevas Ochoa, Hernando Cuevas Cano, Dra. Adriana Vaca González, and Nubia Itzel Gonzalez Gutierrez (Servicios Medicos Municipales De Zapopan Cruz Verde Sur Las Aguilas); Clotilde Fuentes Orozco (Mexican Institute of Social Security); José de Jesús Martínez Ruíz, MD; Paola Alejandra Alvarez Lopez, MD; Adan Cervantes Gomez, MD; Fatima Nohemi Franco Bravo, MD; Eugenia de los Angeles Reyes Arias, MD; Jose Guadalupe Alfaro Garcia, MD; and Gustavo Cedric Enciso Dumuin, MD (Hospital Civil de Guadalajara); Nicaragua: Dino Aguilar Martinez, MD, MBA (Hospital Vivian Pellas); Panama: Mario Garuz (Hospital Santo Tomás); Paraguay: Julio Segoiva Altieri, MD (Instituto de Previsión Social); Peru: Iván J. Salce Cutipa (Hospital Central FAP/Clinica San Borja, Lima), and Christian Lozano Lurita, David Torres Manrique, and Jorge Hurtado Fernandez (Clinica Anglo Americana); Uruguay: Antonio Barquet, Daniel Rienzi (Asociación Española Primera de Socorros Mutuos); Venezuela: Igor A. Escalante Elguezabal, MD, Ennio Antonio Rizzo, Jean Michel Hovsepian, and Victor Rodriguez (Hospital Universitario de Caracas). Table A1 and Figure A1.
1. Vos T, Abajobir AA, Abate KH, et al Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390:1211–1259.
2. Hofman K, Primack A, Keusch G, et al Addressing the growing burden of trauma
and injury in low- and middle-income countries
. Am J Public Health. 2005;95:13–17.
4. Wegman F. The future of road safety: a worldwide perspective. IATSS Res. 2017;40:66–71.
5. Mock C, Joshipura M, Arreola-Risa C, et al An estimate of the number of lives that could be saved through improvements in trauma
care globally. World J Surg. 2012;36:959–963.
6. Stewart Williams J, Kowal P, Hestekin H, et al Prevalence, risk factors and disability associated with fall-related injury in older adults in low- and middle-incomecountries: results from the WHO Study on global AGEing and adult health (SAGE). BMC Med. 2015;13:147.
7. Beard JR, Biggs S, Bloom DE, et al Global Population Ageing: Peril or Promise. Geneva: World Economic Forum; 2011.
8. Cooper C. The epidemiology of fragility fractures: is there a role for bone quality? Calcif Tissue Int. 1993;53:S23–S26.
10. Agarwal-Harding KJ, von Keudell A, Zirkle LG, et al Understanding and addressing the global need for orthopaedic trauma
care. J Bone Jt Surg. 2016;98:1844–1853.
11. Alkire BC, Shrime MG, Dare AJ, et al Global economic consequences of selected surgical diseases: a modelling study. Lancet Glob Heal. 2015;3:S21–S27.
12. Shawar YR, Shiffman J, Spiegel DA. Generation of political priority for global surgery: a qualitative policy analysis. Lancet Glob Heal. 2015;3:e487–e495.
13. Osamor PE, Grady C. Women's autonomy in health care decision-making in developing countries: a synthesis of the literature. Int J Womens Health. 2016;8:191–202.
14. Geere J-A, Bartram J, Bates L, et al Carrying water may be a major contributor to disability from musculoskeletal disorders in low income countries: a cross-sectional survey in South Africa. Ghana Vietnam J Glob Health. 2018;8:010406.
15. Sprague S, McKay P, Li CS, et al International orthopaedic multicenter study in fracture care. J Orthop Trauma
16. INORMUS InvestigatorsINternational ORthopaedic MUlticentre Study (INORMUS) in fracture care. J Orthop Trauma
17. Aleem IS, DeMarco D, Drew B, et al The burden of spine fractures in India: a prospective multicenter study. Glob Spine J. 2017;7:325–333.
18. Haagsma JA, Graetz N, Bolliger I, et al The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the global burden of disease study 2013. Inj Prev. 2016;22:3–18.
19. Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int. 2006;17:1726–1733.
20. Pfeilschifter J, Cooper C, Watts NB, et al Regional and age-related variations in the proportions of hip fractures and major fractures among postmenopausal women: the Global Longitudinal Study of Osteoporosis in Women. Osteoporos Int. 2012;23:2179–2188.
21. Panula J, Pihlajamäki H, Mattila VM, et al Mortality and cause of death in hip fracture patients aged 65 or older: a population-based study. BMC Musculoskelet Disord. 2011;12:105.
22. Bliuc D, Nguyen ND, Milch VE, et al Mortality risk associated with low-trauma
osteoporotic fracture and subsequent fracture in men and women. JAMA. 2009;301:513.
23. Mock C, Cherian MN. The global burden of musculoskeletal injuries: challenges and solutions. Clin Orthop Relat Res. 2008;466:2306–2316.
24. McGreevy J, Stevens KA, Ekeke Monono M, et al Road traffic injuries in Yaoundé, Cameroon: a hospital-based pilot surveillance study. Injury. 2014;45:1687–1692.
25. Hsiao M, Malhotra A, Thakur JS, et al Road traffic injury mortality and its mechanisms in India: nationally representative mortality survey of 1.1 million homes. BMJ Open. 2013;3:e002621.
26. Chalya PL, Mabula JB, Dass RM, et al Injury characteristics and outcome of road traffic crash victims at Bugando Medical Centre in Northwestern Tanzania. J Trauma
Manag Outcomes. 2012;6:1.
27. Curry P, Ramaiah R, Vavilala MS. Current trends and update on injury prevention. Int J Crit Illn Inj Sci. 2011;1:57–65.
28. Srour M, Inaba K, Okoye O, et al Prospective evaluation of treatment of open fractures. JAMA Surg. 2015;150:332.
29. Schuurman N, Cinnamon J, Matzopoulos R, et al Collecting injury surveillance data in low- and middle-income countries
: The Cape Town Trauma
Registry pilot. Glob Public Health. 2011;6:874–889.
30. Nicol A, Knowlton LM, Schuurman N, et al Trauma
surveillance in Cape Town, South Africa. JAMA Surg. 2014;149:549.
31. Yamano T, Jayne T. Measuring the impacts of working-age adult mortality on small-scale farm households in Kenya. World Dev. 2004;32:91–119.
32. Gulati D, Aggarwal AN, Kumar S, et al Skeletal injuries following unintentional fall from height. Ulus Travma Acil Cerrahi Derg. 2012;18:141–146. http://www.ncbi.nlm.nih.gov/pubmed/22792820
. Accessed October 6, 2018.
33. Hanche-Olsen TP, Alemu L, Viste A, et al Trauma
care in Africa: a status report from Botswana, Guided by the World Health Organization's “Guidelines for Essential Trauma
Care”. World J Surg. 2012;36:2371–2383.
34. Meara JG, Leather AJM, Hagander L, et al Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386:569–624.
35. Kumar V, Khajanchi M, Raykar NP, et al Waiting at the hospital door: a prospective, multicentre assessment of third delay in four tertiary hospitals in India. Lancet. 2015;385:S24.
36. Zia N, Shahzad H, Baqir SM, et al Ambulance use in Pakistan: an analysis of surveillance data from emergency departments in Pakistan. BMC Emerg Med. 2015;15:S9.
37. Fehlings MG, Voccaro A, Wilson JR, et al Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PLoS One. 2012;7:e32037.
38. Grimes CE, Bowman KG, Dodgion CM, et al Systematic review of barriers to surgical care in low-income and middle-income countries. World J Surg. 2011;35:941–950.
39. MacKinnon N, St-Louis E, Yousef Y, et al Out-of-pocket and catastrophic expenses incurred by seeking pediatric and adult surgical care at a public, tertiary care centre in Uganda. World J Surg. 2018;42:3520–3527.
40. Kuzma K, Lim AG, Kepha B, et al The Tanzanian trauma
patients’ prehospital experience: a qualitative interview-based study. BMJ Open. 2015;5:e006921.