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REVIEW OF LITERATURE
Special Boards of
Inquiry investigated fatal traffic accidents. Within the main project 300-400
accidents were investigated annually. The main project was included those motor
vehicle accidents in which a person in the vehicle dies within three days of
accidents. The causes causing fatalities were Human factors accounted for 79.7%.
Condition of vehicle for 10.7% and traffic conditions for 9.6% of the cases1.
A study was
conducted with the object of studying various aspects of cranio-intracranial
injuries in road side vehicular accidents cases in Delhi. The analysed 1132
vehicular accidents pedestrians (50.7%) and motocyclists (18.28%) comprised most
common victims. Common age group involved was 21-40 years (46.01%). Head injury
was responsible for causing death in 71.99% of cases. Most of the victims died
on the spot (36.30%) incidence of cranio-intracranial injuries was highest in
cyclist (78.9%) and motor cyclist (72.46%) pedestrians (6.02), fracture skull
was observed in 79.87% of cases the most common bone involved was temporal bone
(58.67%). The commonest variety of intracranial haemorrhage was subarachnoid
haemorrhage (66.9%). Commonest complication observed in head injuries was
bronchopneumonia2.
A study was conducted to explain the Mechanism of Facial Injury. The
study illustrated the practical significance of biodynamics by looking at the
comparative frequencies and aetiologies of facial fractures. The mandibular
fractures are twenty times commoner than maxillary fractures. There is a 2:1
ratio of single to double mandibular fractures. Cyclist, motor cyclist and
ejected occupants of car often fracture their maxillae3.
An epidemiological study conducted on 556 autopsies of persons
having craniocerebral damage by blunt force impact observed that involvement of
males was five times than that of females and victims were mostly from 3rd and
4th decades. Vehicular accidents were involved in 4365 cases, while fall
from height in 18%. Commonest victims involved were pedestrians (36%) followed
by cyclist (9%). Survival of a victim after sustainance of injury varied from
spot-death to 56 days survival. Majority (53%) expired within first 24 hours of
sustaining the injuries. Paradoxically, 15% survived for over a week or more in
7th decade onwards, while only 10% survived for over one week in earlier age
group. In 104 cases cerebral decompression operations were carried in hospital.
In this group 24% died within first 24 hours after sustaining injuries, as
compared to the non operated group where 61% expired during first 24 hours. Thus
emphasizing the beneficial effect of operative decompression procedures in
such cases. Relatively the external injuries with the internal ones, about 19%
of the cases did not have any external injury, inspite of having significant
intracranial damage. 83% cases showed skull fractures and the rest 16.7% did not
show cranial damage. In 8 cases there was only fracture of skull without
intracranial damage and death was due to injuries in other parts of the body.
Majority (57.6%) showed fracture of both vault and base of skull. In 21 cases of
these, there was neither external visible injury on scalp/face nor
fracture in any part inspite of there being intra-cranial damage of certain
degree present4.
Analysis of 524 autopsies carried
out on the victims of road accidents in Srilanka. 51.4% of fatalities were among
pedestrian. The highest number of fatalities were in the age group 20-29 years.
Craniocerebral injury was the commonest cause of death in all groups of
victims5.
Analysing the intracranial injuries, Tyagi et al
found that in all but 8 cases primary intracranial lesions that had
contributed to the death of the individual, were seen. Extradural and cerebral
lesions were seen in 94.5% and 771.% respectively. This was as against secondary
cerebral damage, which were seen in 24.1% cases. Thus indicating that in one out
of four cases secondary brain damage played an important role in causing death.
Amongst all types of intracranial haemorrhage, subdural was commonest (69.3%)
followed by subarachnoid (55.1%). Extradural haemorrhage was seen in 18%
cases only, while intraventricular in 13.4% cases. In other cases, various
combinations of intracranial haemorrhage were seen, of which subdural and
subarachnoid was commonest (31.8% cases). Of the extradural haemorrhage,
unilaterality was seen in 86% cases and the rest had bilateral involvement.
The commonest region involved was temporo paritetal, followed by frontal;
occipital region was least involved. About one fourth cases of the persons with
extradural haemorrhage did not show any visible injury on scalp or face.
On the cases of subdural haemorrhage, in 43.4% it was all alone
while in 56.6% it was associated with other types of haemorrhages. Subarachnoid
haemorrhage was the commonest type, associated with it in 31.8% cases. In half
of the cases it was unilateral while in the rest it was bilateral. Fracture
skill, a common accompaniment, was not seen in 16.8% cases. In 16.8% cases there
was no visible external injury either on face or on scalp.
In his analysis of subarchnoid haemorrhage, Tyagi
et al found that it was present in 55.1% cases of intracranial haemorrhage. One
fourth of these were all alone and the rest 3/4th were associated with other
types, subdural association being the commonest (57.7%). 37.6% cases were
unilateral while 62.3% bilateral. Most of the unilateral haemorrhages were
localized. In several cases, it was patchy in nature. Associated fractures were
common but not seen in 10.9% cases. A significant finding was absence of
associated cerebral contusions in 28.1% cases, they concluded that the incidence
of subarachnoid haemorrhage in his study was less than that of subdural.
Intraventricular haemorrhage was seen in 13.4%
cases of intracranial haemorrhages. This was always seen in association with
other types of intracranial haemorrhages of which subarachnoid association was
commonest. A significant findings was that it was never present alone.
Cerebral contusions were the commonest finding in
cases of cranio-cerebral damage (95.2%) cases. It was present alone in 52.9%
cases while with lacerations in 42.3% cases. In 7 cases (1.7%) it was present
pall alone. Contusion of the brain was unilateral in 43% cases and the commonest
sites were frontal and temporal, bases and poles. Fracture skull and visible
injury on face and scalp were commonly associated but were not in 7.9% and
11.6% cases respectively.
Cerebral lacerations were seen in 45.1% cases having any
cerebral lesion. While taking into consideration all the intracranial lesions,
this lesion was not seen as a lone injury and was always associated with some
other intracranial lesion. Cerebral lacerations were unilateral in distribution
in 112 (58.6%) cases and bilateral in 79 (41.4%) cases. The common sites of
lacerations were again, frontal and temporal lobes of the brain. Fracture of the
skull was an accompaniment in all of these External injuries on face/scalp were
associated except for in 12 (6.2%) cases.
Deep brain substance haemorrhage was seen in 47
(11.1%) cases of those showing cerebral lesions.
Secondary alterations were seen in a significant
24.1% cases out of 548 cases showing intracranial lesions.
A study was conducted on road traffic deaths in
fifteen years of age and under from 1979 to 1985. 336 (26%) children aged 15
years and under died out of a total fatality of 1293. Among this number 83% were
pedestrians and 3% were pedal cyclist. The most common cause of death in this
age group was fracture of the skull with haemorrhage and laceration of the
brain6.
A study of motorcycle fatalities in period 1977-83
was studied. Among the operators killed one fifth were illegally operating the
motorcycle. The most severe lesion were located in the cranium-brain and thorax.
Ninety two percent had lesions located to the brain and skull, 75% had thoracic
lesions and 50% abdominal injuries7.
Review of 375 injured children and found that 83 suffered from
head injury, 70 boys and 13 girls. Ages ranged from 2 to 15 years with a mean of
10.4 years. Dirtbikes were implicated in 34 accidents, snow mobiles
in 28, 3-wheel ATV’s in 19 and 4 wheel ATV’s in 2. About 85% of the
accidents occurred in a rural setting. Loess of vehicle control was the
most common case of injury. Alcohol and drug abuse were not factors. Fifty
(60.2%) patients suffered loss of consciousness prolonged in 6 (7.2%). All head
injured children also suffered at least one associated injury, mainly involving
the musculoskeletal system. Associated spinal injury occurred in 18%. The
average hospital stay was 13 days. Three (3.6%) patients died as a result of
head injury8.
Analysis of 1116 pediatric trauma cases in an
urban setting in Sydney, Australia. The overall group and all deaths were
analysed as to their cause and possible preventability as well as salvageable
factors. Most of the children were not seriously injured, with the most common
injury being due to a fall (57%) and involving a single injury to the upper
limb. With the subgroup of 143 children (13% of the total who suffered
serious injuries the cranial cavity (90%) was the most common site of injury,
occurring most often in pedestrians (31% of the total injured). There were 16
deaths in the series, representing 1.4% of all pediatric trauma admissions and
11% of the admission who were seriously injured. All deaths were related to
motor vehicle accidents and associated with serious head injury9.
A retrospective study analysis for a 10 year period (1976-1985)
of road traffic accidents (RTA) fatalities was in port. Moresby, the capital of
Papua New Guinea. Highest fatality rates are in the age group between 15-44
years, followed by children below 14 and then adults above 45 years of age.
Males were far more prone to be involved in RTA fatalities than females. In
40.2% of all the fatalities the accidents occured between 6PM to 6AM, in 35.3%
between 6AM to 6PM. The monthly occurrence in the number of fatal road accidents
was seen to less between May-August for both five year periods of study.
Multiple injuries involving many organs appear to be more common in pedestrians
and passengers than among drivers. About two out of three victims died either at
the site of the accident or soon after arrival at the hospital casualty
department. Only one third of the victims survived long enough to receive some
form of treatment at the hospital and died later. Most fatal accidents occurred
during the weekend. Head injury was the dominant and possible cause of death in
all these categories of victims10.
A study was conducted in Coperrhagen Denmark to
known the role of fatigue in multiple car fatal accidents. 334 fatal multiple
car accidents were studied. Twenty one of these accidents happened between
midnight and 0600 hours and 11 drivers were found to intoxicated drivers in
night time accidents with that of control group, it is concluded that fatigue in
an overlooked but most obvious cause of otherwise unexplained accidents in night
time traffic11.
An experimental study was conducted using physical
models of the head and neck and ones of the skull. They found an impact incurred
by the movable head may bring about a change in intracranial pleasure and
this change may play an important part in the occurrence of cerebral contusion.
The model analysis revealed an unbending in the frontal and occipital regions of
the skull and on out bending in parietal and temporal regions immediately after
impact, followed by a reverse deformation12.
The autopsy material was analysed for the Traumatic Basal
subarachoid haemorrhages. Fourteen cases of traumatic basal subarachnoid
haemorrhage were examined in the year 1980-1988. Bleeding was connected with
fracture of transverse process of the atlas in eleven cases and with atlanto
occipital dislocation in three cases. The source of haemorrhage vertebral artery
rupture was determined only four times13.
A case was reported in Institute of Forensic
Medicine, Odense Denmark 20 year old alcohol intoxicated man was admitted to the
hospital after minor head injury. Intiially there was no neurological
disturbance or complaints, but after a few hours the become comatose and he died
four days later without regaining consciousness. No traumatic lesions could be
seen in upper cervical spine or the vertebral arteries, but the basilar artery
was occluded in its entire length. The detailed study showed the incomplete
arterial rupture with occluding luminar thrombosis superimposed and more well
known fatal complication to a minor head injury a subarachnoid haemorrhage14.
In March 1990 study of road traffic accidents
involving fatalities were studied. The number of person killed in road accidents
in March 1990 rose by 30.7% (to 217) compared to previous month (166). Of the
217 person killed in road accidents in March, 1990, drivers of motor vehicles
accounted for 81 (37.3%) passengers in motor vehicles (57(26.3%), drivers of
motor cycles 22 (10.1%) pedestrians 42 (19.4%) and pedal cyclist 12 (5.5%)15.
The study during the continuous period of one month round the
clock of 670 patients injured in road traffic accidents attending the
Govt. General Hospital, Madras revealed. 82.5% of the injured were males.
Twenty of them were brought dead. 29.2% of the injured were cyclists and 28.1%
were pedestrians. 11.2% have received life threatening injuries, 10.5% seriously
disabling and 37.4% disabling injuries. Head and face were the most commonly
injured regions to the extent of 37.9%. Single vehicle accidents were the most
common cause of RTA injuries collision with heavy vehicles were the next common
cause of RTA injuries. Only 32.2% of the cases were reported to police records
from the hospital16.
The study conducted in Coimbatore city for a
period of 1985-1988. A total of 450 deaths from traffic accidents was reported
during these years constituting 18% of all unnatural deaths and 32% of
accidental deaths. 83% constituted males and 17% were females. Pedestrians
accounted for 32.7% of the victims and bicyclists for 27.2%. Commonest offender
involved heavy vehicles responsible for an average of 70% fatalities. Most of
the accidents occurred between 8 p.m. and 12 a.m. every day. Comparisons have
been made with data obtained in other parts of the country and abroad and
similarities and contrasts have been highlighted17.
Study presented as case review reported many
causes contribute to road accidents among which bad driving occupies a major
percentage including the care free behaviour of the driver, without taking
adequate care for the effect of weather, road conditions and breaking violently
at the last moment, risking a skid18.
In 203 fatal cases of head injuries due to vehicular accidents
brought to the All India Institute of Medical Sciences, New Delhi, Fimate found
that 139 (68.46%) had scalp injuries, 167 (82.26%) skull fractures, 178 (87.67%)
brain lesions, 197 (92.11%) intracranial haemorrhage, 34 (19.21%) brain stem
haemorrhage. Thus intracerebral haemorrhage constituted the highest incidence
(82.26%) among the cranio-intracranial lesions19.
Relating the survival time to period of survival,
they found that 172 of them had history of unconsciousness. None of the victims
who died within 6 hours were conscious. Eight victims who died within 3-14 days
and 4 victims who died in 31-53 days showed history of unconsciousness of
varying period. The survival time in altogether varied from spot death to up to
53 days. Most persons (142) who remained unconscious died within 72 hours of
sustaining the injury while most persons who had a history of consciousness (13)
after sustained head injury died between 3 and 7 days.
Analysing consciousness in relation to head injury
it was observed that unconsciousness is very high when intracranial haemorrhages
were associated with skull fracture (18.71%) whereas in case of brain lesions in
combination with intracranial haemorrhage the incidence of consciousness and
unconsciousness is the same (5 cases each).
They also observed that maximum number of victims 50.15% had the
combination of skull fracture, intracranial haemorrhage and brain lesions as the
degree of head injury (grade IV). This correlated well the survival time of less
than one day in these cases (82). Nineteen cases of grade IV injury survived for
3 to 7 days. Surprisingly, two cases of grade IV victims survived for more than
8 days and one case survived for 30 days. Thus concluding that the assumption
that survival time is shorter in cases of extensive cranio-intracranial lesion
than those with minimal lesion in the brain, does not hold true in all the
cases.
Two cases were reported of rupture of posterior
inferior cerebellar artery from blunt basal head trauma in Sweden. The authors
propose that the forensic term traumatic subarachnoid haemorrhage ought to be
abandoned and replaced by the nature and localization of the source of bleeding,
analogous to clinical practice at the spontaneous haemorrhage from rupture of
aneurysm20.
The study was conducted in Hartford Hospital in
Connecticut over a period of 5 years. The study included 83 motorcyclists,
helmeted and non helmeted, involved in crashes. The study showed that majority
of these patients were male and under age of 30 years. Sixty nine (69%) percent
who were non helmeted and statistically a significant number in this category
had a Glasgow Coma Scale (GCS) score of 8 or under. The study concluded that
helmets provide protection and certainly do not increase the incidence of
cervical spine injuries21.
Head trauma is the major source of morbidity and mortality
among injured motorcyclists. The effectiveness of helmets in reducing head
injuries has been well documented. Michael Johnson studied 331 injured
motorcyclists during a 4 year retrospective period to analyse the impact of
motorcycle helmet usage and associated factors on the type and incidence of
craniofacial injuries. These patients were admitted in a level I trauma center
at Ohio. Ohio does not have a helmet law, therefore, helmet use was
infrequent in these motorcyclists. Only 77 (23%) of those studied wore helmet,
whereas 254(77%) were not helmeted. They observed that nonhelmeted motocyclists
were three times more likely to suffer facial fractures than those wearing
helmets. There were no LeFort fractures wearing helmets while there were seven
Le Fort fractures in the nonhelmeted group. The orbit was the most commonly
fractured facial bone in this study. Skull fracture occurred in only one
helmeted patient, compared with 36 (12.3%) of nonhelmeted patients. Soft tissue
injuries of the head occurred in 15.6% helmeted patients, compared with 39.8%
non helmeted patients. The chin was the most common location of soft tissue
injury in the helmeted group, whereas the scalp was the most common location in
the nonhelmeted group. The majority of deaths, 21 of 24 (87.5%) in the non
helmeted group were secondary to head injuries. There were no deaths from head
injury in helmeted group. In nonhelmeted patients, 9.4% of patients
suffered basilar skull fractures while not a single cases of basilar skull
fracture was seen in helmeted patients22.
Head injury accounts for >60% of
bicycle-related deaths and about one third of emergency room treated bicycle
injuries. Many studies have demonstrated consistent evidence that use of helmets
can significantly reduce the risk of head injury among bicyclists and the
severity of head injury when a crash occurs.
Study of 2333 patients aged 0-14 years who were admitted
to trauma centers in the USA because of bicycle related injuries during 1989
through 1992, more than one half (54%) sustained head injury, predominantly
concussions and skull fractures. The most common head injury reported was
concussion (48%) followed by skull fracture (24%), intracranial haemorrhage (7%)
and cerebral laceration/contusion (5%). Among patients with skull fractures, 83%
also sustained intracranial injury. Of the patients with concussion, 68% lost
consciousness for a certain time period subsequent to injury. 7% had skull
fractures and 6% had intracranial injury. Among patients with head injury. 83%
also had other injuries, predominantly fractures to the limb and neck. Head
injury was the primary diagnosis for 44% of the study population. Other injuries
that frequently occurred were neck fracture (13% of patients), fracture of
humerus/radius/ulna 911%), fractures of face bones (10%), internal injury
(10%) and femur fracture (9%). Multiple injuries were common : 27% had two, 18%
had three and 25% had four or more injuries23.
Helmets have been shown to be effective in
preventing head injuries in motorcyclists, but some studies have suggested
that helmets may cause injury to parts of the head or neck because they
add mass to the head. This study examined patterns of fatal injuries in
helmeted and unhelmeted motorcyclists. Coroner reports, hospital records,
and police reports for motorcyclists fatally injured in crashes from July
1, 1988 through October 31, 1989 were examined. All injury diagnoses were
abstracted and coded to the 1990 version of The Abbreviated Injury Scale
and the International Classification of Diseases, 9th revision. Cerebral
injury, intracranial hemorrhage, face, skull vault, and cervical spine
injuries were more likely to be found in fatally injured unhelmeted
motorcyclists than in helmeted motorcyclists. These results expand earlier
reports showing that helmets provide protection for all types and
locations of head injuries, and show that they are not associated with
increased neck injury occurrence24.
A review of 481 deaths in an accident and emergency
department of a major general hospital in Singapore, over a 3 year period from
1992 to 1994 was undertaken. Full medico legal autopsies were conducted in 236
(55.1%) of the cases. There was a marked male preponderence in the age, race and
sex distribution. Seventy (29.7%) of these had died a traumatic death as
compared to the rest 166 (70.3%) due to natural causes. Out of these 70, closed
head injury was seen in 10 and open head injury in 4 of the victims. Thirty four
of these had multiple injuries. The other had various injuries on other parts of
the body25.
A study was undertaken to verify a possible connection
between the weight of the helmet worn and the occurrence of a ring fracture of
the base of the skull surrounding the foramen magnum. One hundred twenty two
fatally injured motorcyclists were studied retrospectively. In all cases, an
autopsy had been performed. The following data was observed. Ninety eight riders
were involved in collisions with motor vehicles. Sixty motorcyclists (49%) died
primarily as a result of their head injuries. The mean survival time was 0.5
hour. The overall prevalence of circular fractures of the base of the skull was
9.2%. Bleeding from the external auditory meatus were an obligatory finding.
Basal veins were lacerated in most cases of complete fractures. The lightest
helmet in the fracture group weighed 960 grams the heaviest 1950 grams (median
1255 grams). An increase in the prevalence of fractures correlated with a
helmet weight above 1500 grams. The weight of the helmet had no effect on the
incidence or severity of spinal cord injuries. It was concluded that the
accidents with axial load shift, helmets weighing more than 1500 grams increase
the risk of a basal skull fracture. Therefore high weight helmets should
be avoided. They suggested that a safe upper weight limit for helmets remains to
be defined26.
Statistics available with the Delhi traffic police
show in the first four months of 1996 maximum people were killed between
midnight and 6 AM on Delhi road. More than 50% of all road victims, and
about 90% of two wheelers riders, who are brought the hospital at night are
found to be drunk. In the first four months of 1996, 114 people were killed
between 8AM and 12 PM, 77 people lost their lives between 8PM and midnight. The
accidents fatalities show a steep rise between midnight and 6AM-136. It is a
custom observed by the elite and middle classes that they drunk in the evening
and return home late at night. This is the time when maximum hit and run cases
occur (30% of the total fatalities are hit and run cases), though curiously,
this is also the time when the density of traffic is at its lowest. The
guilty drivers get away easily since there is hardly anybody to given them a
chase. The traffic police call it a day by 10 PM in most areas. Most of the late
night accidents occur in the peripheral areas of Delhi such as Najafgarh Road,
Mathura Road, Ring Road and Rohtak road. Of the 136 people killed between
midnight and twilight, 64 were hit and run cases, mostly caused by HTVs.
Drinking and driving go together for most truck drivers. Many of their
unsuspecting victims are residents of villages that fall along the highways.
Head injuries are the commonest cause of death in the surgical
wards in Port Moresby and the commonest cause of death in road accidents. Three
prospective and retrospective studies performed over the last decade aimed to
determine the pathology and outcome in 274 head injuries admitted to Goroka in
1988-1991 (4 years) and Port Moresby in 1984-1985 and 1992-1993 (total 2.5
years). Head injuries were managed by general surgeons without CT scanning or
intracranial pressure monitoring. There were 196 adults and 78 (28%) children;
195 were male and 79 female. Assaults (32%), motor vehicle accidents (49%) and
falls (17%) were the commonest modes of injury. The case fatality rate was 21%
(57 of 274 cases). Six of the deaths were avoidable. The fatality rates for
admission Glasgow Coma Scores of 3-5, 6-8 and over 9 were 81%, 21% and 3%
respectively. Two patients died of infection complicating open depressed
fractures. The case fatality rate for extradural haematoma was 20% and subdural
haematoma 67%. Nine patients died of associated abdominal injuries. Most of the
deaths were unavoidable because of the severity of primary brain injury. The
speed of diagnosis and quality of care could have been improved but the most
important area is management of the airway. General surgeons properly trained in
trauma vcare (which includes emergency airway management) are well able to cope
with the majority of head-injured patients in Papua New Guinea27.
The study of total of 159 victims from bicycle accidents treated
as in patients at the Department of Neurosurgery, University of Bonn between
January 1987 and June 1995 with an aim to define the severity and features of
bicycle-related head injuries in a defined population. Results showed that 33%
of admitted bicycle victims sustained severe head injuries (Glasgow Coma Score
3-8). Neurosurgical operations were performed in 49% of patients and were mainly
related to the evacuation of an extracerebral hematoma. Of the 159 bicycle
victims, 112 (70%) made a good recovery, 11 (7%) remained moderately and 4 (3%)
severely disabled, and 26 (16%) had died at follow-up (mean 2 years). In
conclusion, data indicate that bicycle-related trauma accounts for
substantial proportion of all head injuries requiring neurosurgical treatment.
Active (e.g. traffic regulations, education of riders) and passive measures
(e.g. safety helmets) can be expected to reduce both incidence and severity of
head injuries among bicyclists28.
The first year of the mandatory bicycle helmet laws in Australia
saw increased helmet wearing from 31% to 75% of cyclists in Victoria and
from 31% of children and 26% of adults in New South Wales (NSW) to 76% and
85%. However, the two major surveys using matched before and after samples
in Melbourne (Finch et al. 1993; Report No. 45, Monash Univ. Accident
Research Centre) and throughout NSW (Smith and Milthorpe 1993; Roads and
Traffic Authority) observed reductions in numbers of child cyclists 15 and
2.2 times greater than the increase in numbers of children wearing
helmets. This suggests the greatest effect of the helmet law was not to
encourage cyclists to wear helmets, but to discourage cycling. In
contrast, despite increases to at least 75% helmet wearing, the proportion of
head injuries in cyclists admitted or treated at hospital declined by an average
of only 13%. The percentage of cyclists with head injuries after collisions with
motor vehicles in Victoria declined by more, but the proportion of head injured
pedestrians also declined; the two followed a very similar trend. These trends
may have been caused by major road safety initiatives introduced at the same
time as the helmet law and directed at both speeding and drunken-driving.
The initiatives seem to have been remarkably effective in
reducing road trauma for all road users, perhaps affecting the proportions
of victims suffering head injuries as well as total injuries. The benefits
of cycling, even without a helmet, have been estimated to outweigh the
hazards by a factor of 20 to 1 (Hillman 1993. Cycle helmets-the case for
and against. Policy Studies Institute, London). Consequently, a helmet
law, whose most notable effect was to reduce cycling, may have generated a
net loss of health benefits to the nation. Despite the risk of dying from
head injury per hour being similar for unhelmeted cyclists and motor
vehicle occupants, cyclists alone have been required to wear head
protection. Helmets for motor vehicle occupants are now being marketed and
a mandatory helmet law for these road users has the potential to save 17 times
as many people from death by head injury as a helmet law for cyclists without
the adverse effects of discouraging a healthy and pollution free mode of
transport29.
A prospective study was performed to analyze the particular
injuries of 76 cyclists who required in-patient treatment in our
department in 1994. There were 50 male and 26 female cyclists, with a
median age of 33 years (range: 4-87 years). The most frequent diagnosis,
in 50% (n = 38), was head injury. The series included 63 cyclist (83%) who
had not been wearing helmets, and 33 of these sustained a head injury; in
the helmet group head injury was found in only 38% (5 out of 13). It is
remarkable that more serious head injuries did not occur in the helmet
group. In 24 of these 33 head-injured patients (73%) without helmets
additional intra- and extracranial diagnoses were made: pathologic EEG in
18 patients (55%), skull fracture in 13 patients (39%), intracerebral
haemorrhagic contusion in 4 patients (12%) and an increase in intracerebral
pressure (edema) in 3 patients (9%). In contrast to these findings, only 2 of
the 5 head-injured patients (40%) in the helmet group showed slight changes in
the EEG. In our opinion the bicycle helmet can reduce the incidence and the
grade severity of head injuries significantly, particularly as we had 2 deaths
in the non-helmet group and none in the helmet group. The use of a bicycle
helmet is therefore strongly advocated30.
Bicycle-related head injuries are an important
cause of injury and death among bicycle riders. The use of bicycle helmets
could reduce the rate of serious head trauma among bicyclists involved in
accidents. A nationwide survey was conducted in Israel to determine the
usage of such helmets. This survey preceded a media campaign encouraging
the use of bicycle helmets. A second survey compared the rates of helmet
usage following the media campaign with those rates prior to the campaign.
A modest but significant increase in the use of bicycle helmets was
observed. In order to further increase this rate, additional educational
campaigns are needed and possibly the enactment of legislation31.
The report of three cases of ruptured traumatic aneurysms of the
peripheral anterior cerebral artery after closed head injury has been
described. These cases were all young men with closed head injury due to
traffic accidents. Consciousness level on admission was coma in all three
cases. Case 1 was a 19-year-old man with interhemispheric hematoma on
initial CT, then 7 days later his consciousness cleared. However, 14
dayslater he suddenly lapsed into a deep coma with a severe frontal hemorrhage.
Case 2 was a 13-year-old boy. Plain skull films demonstrated a frontal depressed
fracture, but CT scan showed no bleeding. Four days later his consciousness
cleared but 11 days after trauma, he lapsed into a deep coma with a frontal
hemorrhage. Case 3 was a 22-year-old man. Initial CT showed a slight ventricular
hemorrhage. Fourteen days later, his consciousness had almost cleared, but then
he lapsed into a deep coma with a large frontal hemorrhage 11 weeks after the
trauma. All these patients died within a few days after intracranial
bleeding. All patients underwent cerebral angiography but none of them
showed filling defect. Autopsy was performed and ruptured aneurysms were
found on the distal anterior cerebral artery that had no relation to the
branch of bifurcation. Histological examination demonstrated a lack of
elastic lamina and media in all of these three cases, so each of them was
a victim of so-called false aneurysm. Twenty reported cases of ruptured
traumatic aneurysms of the peripheral cerebral artery with delayed
hemorrhage after closed head injury were reviewed. Factors in the
traumatic aneurysm showed no relation to the duration of disturbed
consciousness. Within one month, delayed hemorrhage due to ruptured traumatic
aneurysm occurred. None of the delayed hemorrhages involved subarachnoid
hemorrhage. Subdural hematoma was seen in the distal middle cerebral artery and
frontal hemorrhage was found in the distal anterior cerebral artery. We consider
that frontal hemorrhage is a predictive finding for the type of delayed
hemorrhage due to traumatic aneurysm in the distal anterior cerebral artery32.
A motorcycle safety survey conducted in Colorado.
Sixty five percent of respondent believed that motocycle riders of all age
should be required to wear helmets as motorcycle riders have a higher risk of
Traumatic Brain Injury disability and death33.
One hundred fatal cases who died due to
traumatic head injury were studied at the mortuary of Guru Teg Bahadur Hospital,
Shahdara, Delhi. Though all ages were affected, peak incidence was found in the
third decade (25%) followed by the 4th decade (22%). Individuals in the 2nd
decade were least effected.
The male : female ratio was 4.5:1 overall and
7.3:1 in the most commonly affected age-group (20-29 years). Females comprised
18% of the cases, the rest were males. Most of the cases occurred between 6PM
and 6AM (50%) with peak incidence between 6PM and 12 midnight (44%) and between
6PM 9PM (23%). The least incidence occurred between 12 midnight and 6AM (6%).
P.S. Seema Puri Recorded the maximum number of cases (26%) followed by
P.S.Seelam Pur (19%), P.S.Bhajan pura (13%) and P.S. Welcome (12%). Most were
Hindus (77%) while Muslims were only 23% of the cases.
Among those brought alive to the hospital 67%
of the cases reached within 30 minutes while 79.1% within 60 minutes of the
incident. Eight percent were brought dead to the hospital and 22% were cases of
spot death.
Seventy five percent victims survived for a variable period
after the incident. Among them, 26% survived utpo 1 to 6 hours and 19% up to 1
hour of the incident. Sixty victims died within 24 hours while 66 within 3
days of the incident. There were 5 cases operated (craniotomies for drainage of
EDH). Among these, three lived between 3-20 days and the other two died within
24 hours.
Accidents were responsible for 89% deaths,
homicides for 8% and suicides for 1% only. Sixteen percent women were victim of
accidents and 2% of homicides. The rest 80% were male. In 2% cases, manner of
death was not known.
RTAs were responsible for maximum (65%) deaths
(73% of the accidents), followed by fall from a height (14%), blunt trauma
(homicidal) (7%) train accidents (6%), collapse of a wall (3%), firearm (2%) and
machinery accident (1%), Scalp injuries were present in 77% of the cases,
crushing injury in 12% and none in 1% of the cases. Bruises were commonest (68%)
followed by lacerations (46%) and abrasions (29%). The commonest region of scalp
involved was frontal, followed by temporal, parietal and occipital. Puncture
wounds of skull were seen in 10 cases.
Skull fractures were observed in 80% of the
cases with both, skull base and vault fractures in 42%, skull base alone in 34%
and vault alone in 4% cases. All the fractures were commonest in the age group
20-29 years, followed by 30-39 years, followed by 30-39 years (25% and 22%
respectively).
Linear fractures of the skull vault were the commonest type
(29%) followed by comminuted (18%) and the depressed (13%) type, most frequently
present in the parietal followed by temporal and frontal regions.
Base of the skull fractures were most frequent
in the age group 20-39 years (50.8% of skull base fractures) and linear
fractures were more common than comminuted (65.2% vs 50.8%). There were 2 cases
with ring fractures. Middle cranial fossa was the commonest fossa involved (44.9
% fractures), followed by posterior (35.6%) and anterior (19.5%) cranial fossa.
Intracranial injuries were present in 87%
cases. Out of these SAH was the commonest (86.2%), followed by SDH (63.2%), ICH
(51.7%), contusion 923%), EDH (10.3%) and IVH (4.6%). Age wise SAH, ICH, SDH
were common in the group 20-29 years while contusions in 0-9 years group.
All intracranial lesions were most frequent in
temporal region, followed by parietal occipital and frontal. The combination of
SDH and SAH was the most common, present alone in 21% cases.
There were 71% victims of vehicular accidents.
Among them, most were pedestrians (66.2%), followed by scooterists (15.5%).
Among offending vehicles, most were trucks (22.7%), followed by buses (12.7%)
and tempos (11.3%). Vehicle was unidentified in 32.4% cases.
There were 47% pedestrians as victims of
vehicular accidents. Out of these, most were hit by a vehicle/train while
crossing the road (48.9%) or railway track (12.8%), About 17% were hit while
walking by the side of the road and 6.4% while standing by the side of
road, waiting for a bus. In 14.9% pedestrian cases, circumstances were unknown.
External facial injuries were present in 38% cases and
crush injury in 12%. Face was uninvolved in 50% victims. Abrasions were
the commonest of facial injuries (external 94.7%) followed by lacerations
(86.8%) and bruises (15.8%). Most of these were present on cheek, nose, chin and
ear.
Associated injuries on the body (other than
the head) were present in 83% of the cases. Abrasions were commonest (92.8% of
these cases), followed by lacerations (28.9%) fracture ribs (26.5%) fracture of
limb bones (24.0%) and bruises (9.6%). Most of these injuries were present on
chest, followed by shoulder, legs, forearms, abdomen and knees, elbows and arms.
None of these were responsible in causing death of the victim.
Out of the 77% victims with scalp injuries,
89.6% had cranial injuries (fracture vault or base of skull) and 97.4% had
intracranial injuries. Out of 80% cases of cranial injuries, 86.3% had
extracranial injuries (of the scalp) and 87.5% had intracranial injuries. Also
out of 87% cases of intracranial injuries, 86.2% had associated extracranial and
80.4% cranial injuries34.
A study was conducted to study the pattern of Cranio-cerebral
injuries in road traffic accidents. In the study 80 victims of road traffic
accidents brought for autopsy over a period of 5 years were studied. Out
of them 54 (67.5%) were having cranio cerebral injuries; pedestrian was
commonest victim group accounting for 42.59% of all cases, male out numbering
females. Most of the victims were young adults in the age group of 21 to 30
years. Commonest injuries were found to be fracture of the vault (62.96%),
injury to brain (70.62%) and extradural haemorrhage (20.37%). Study pointed lack
of road safety measures and awareness on the part of public poor road
conditions35 In another study on fatal head injury victims in road traffic
accidents in North East Delhi during November 91-October 92, about 31% of those
autopsied (405 cases) had died of head injury alone and 116 (29%) were the
victims of road traffic accidents. A male preponderance (86%) and 31-40 years of
age as the most susceptible group was found. It was found that 22.2% cases of
head injury had not external injury on the scalp although intracranially 62.%
such cases had fracture skull, 12.5% had brain injury and intracranial
haemorrhage was present in 87.5% cases. Victims of head injury with external
scalp injury (77.7% cases) had fracture skull in 50% cases, injury to the brain
in 27.7% cases and intracranial haemorrhage was found in 58.3% of such cases.
Head injury victims were mostly pedestrians (47.3%) and the offending vehicles
were mostly heavy vehicles (47.3%). Cyclist (44.4%) were the most common victims
amongst the occupants in vehicle to vehicle accidents with 75% being hit by
heavy transport vehicles. Spot death was seen in 55.5% cases. Out of the
surviving head injury victims, 56.6% died within first 6 hours of the accidents
and only 12.5% persons survived for more than one day. The combination of
subdural and subarachnoid haemorrahge was the commonest of all the intracranial
haemorrhages. It was also observed that cerebral oedema took about 6 hours
after the accident to develop as none of the victims who survived for less than
6 hours had developed cerebral oedema35.
A study was conducted with a query of “Does Traumatic
subarachnoid haemorrhage caused by diffuse brain injury cause delayed ischemic
brain damage? Comparison with subarachnoid haemorrhage caused by ruptured
intracranial aneurysms. 99 patients with diffuse brain injury with traumatic
cause and 114 patients with aneurysms were subjected to CT and cerebral blood
flow studies. The traumatic subarachnoid haemorrhage is not confined to Circle
of Willis only but extended to supratentorial regions and interhemispheric
cisterns. The cerebral blood flow decreased maximal on 0 day in traumatic
causing maximal neurological deterioration with no peaks. The finding suggest
that incidence of vasospasm is low in association with traumatic cases and there
is no evidence that in the traumatic cases diffuse brain injury leads to delayed
ischemic brain damage and secondary deterioration of outcome.37.
A study was conducted for traumatic intracranial
carotid tree aneurysms. Twelve cases of traumatic aneurysms intracranial carotid
tree were analysed in this study. Neurological examination results, CT and pre
and post embolization of cerebral angiogram were included. In 11 of 12 cases,
traumatic aneurysms were of cranial base origin, in 1 case the aneurysm was
located in the distal anterior cerebral artery. Study suggested that patients
with head trauma who presents with sphenoid sinus fracture and massive epistaxis
should be evaluated for development of traumatic aneurysms38.
The prospective study was to quantify the anatomic severity of
head and cervical spine injuries in hospital admitted victims of
motorcycle and moped accidents in relation to helmet use and controlled
for non-head injuries (i.e. kinetic impact). Two hundred and twenty-three
patients entered the study group, of which 152 were motorcyclists and 71
were moped riders. Our results reveal that helmets do prevent head injury
in motorcycle and moped accidents, especially in those crashes involving
relatively low kinetic energy transfers. Helmet use does not lead to an
increase of the incidence or severity of cervical spine injury. As a
result compulsory helmet laws should not be limited to motorcyclists but
also focus on all moped riders and probably also bicyclists. This study
illustrates that emergency departments can provide important
epidemiological information for injury control purposes. However, the
epidemiological use of emergency department data and hospital data in general
requires cautiousness. Confounding is a common problem which should be dealt
with during analysis39.
A case of 34-year-old man struck over the
left mastoid region by a hockey puck, who suffered a fatal rupture of a
left vertebral artery berry aneurysm is reported. He became apneic within
seconds of the injury and had no brainstem reflex within minutes. The
postmortem examination showed massive subarachnoid hemorrhage in the
posterior fossa and the remnants of a berry aneurysm near the intradural
origin of the left vertebral artery, 11 mm proximal to the posterior
inferior cerebellar artery. Rupture of a saccular aneurysm as a result of
head trauma is rare. This is the first reported case of a posterior
circulation aneurysm rupture as a result of head trauma40.
The review of the findings from 86 motorcycle accidents during a
1-year period at the Trauma Center "Bergmannsheil" in Bochum,
Germany is described. A study of the case histories supplemented by
telephone conversations yielded the following results: 90.7% of the
patients were men, and the average age was 28.8 years; most of the
accidents occurred in the 25- to 30-year-old age group (27.9%). Motorcycle
accidents happened mostly during recreational rides on weekends in the
summertime. Although there was a high rate of helmet use (98.8%), the head
region was affected in 12 victims. Two patients died because of their severe
head injuries (2.3%). Lower extremity injuries (46%), especially open tibia
fractures (19.7%), were among the most common injuries sustained. Fractures of
the distal radius constituted the largest portion of upper extremity injuries
(18.8%). The average stay in our hospital was 35.4 days; 23.4% of the patients
had to change jobs after the accident. Fifty percent of the crashes happened
with motorcycles between 500 and 750 cc stroke volume. Although 34.5% possessed
their driver's licenses for more than 8 years, they had not had much experience
handling a motorbike. These results underline the fact that motorcycle accidents
are sustained by young men in their working prime; as a result, these accidents
pose a tremendous burden to individuals and society and every attempt should be
made to offer highly qualified surgical and trauma care to minimize the damage
to the motorbiker. A plea is made for more preventive measures like driver
education, better road conditions, or legislative changes to prevent motorcycle
crashes. The wearing of a helmet is strongly advocated41.
The neuropathology of trauma is reviewed based on the mechanism
of injury. Pathology is divided into primary and secondary injury, based
on the relationship to the time of injury. It is further divided by
mechanism, with primary impact injury including skull fracture, epidural
hematoma, brain contusion and laceration, and intracerebral hemorrhage;
primary inertial injury including subdural hematoma, diffuse axonal
injury, and diffuse vascular injury; and secondary injury including
hypoxia/ischemia, brain swelling, infection, and increased intracranial
pressure42.
The regional pediatric trauma center in Buffalo, NY, has been
active in pediatric injury prevention programs, including community
education and distribution of bicycle helmets, since 1990. Since June 1,
1994, the use of bicycle safety helmets for children under 14 years of age
has been mandated by a state law in New York. The authors undertook this
study to assess the impact of this legislation on the frequency of helmet
use in children involved in bicycle crashes presenting to the regional
pediatric trauma center, and to assess the impact of helmet use on the
number and severity of head injuries. Bicycle crash victims (n = 208) admitted
to a regional pediatric trauma center from 1993 to 1995 were studied
retrospectively. Head injuries were classified as concussion alone, skull
fractures, intracranial hemorrhages (ie, epidural, subdural, and
subarachnoid), cerebral contusions, or diffuse cerebral edema alone
(without any other intracranial injury). Helmeted children (HC) were
compared with nonhelmeted children (NHC) using chi2 and Fisher's Exact test. P
value less than .05 was considered significant. Only 31 children (15%)
wore helmets at the time of the crash. Helmet use increased from 2%, during the
period of education alone, to 26% after the legislation went into effect (P <
.00001). The proportion of children suffering head injuries was similar in both
groups (HC, 68%; NHC, 61%; P = NS). However, the type of head injury was
different. HC were more likely to sustain concussion alone (HC, 65%; NHC, 44%; P
< .03). HC were less likely to have skull fractures (HC, 0%; NHC, 13%; P <
.02), and exhibited a trend toward less intracranial hemorrhages (HC, 0%;
NHC, 9%; P = NS), cerebral contusions (HC, 3%; NHC, 5%; P = NS), and
cerebral edema (HC, 0%; NHC, 0.6%; P = NS). Excluding the isolated
concussions, head injuries were noted in only one HC, compared with 30 NHC
(P < .04). None of the three children who died wore helmets at the time
of the crash, and all died of multiple head injuries. The bicycle helmet
safety law resulted in a 13-fold increase in the use of bicycle helmets
among the children admitted to a regional pediatric trauma center after
bicycle crashes, but the helmet use remains inadequate. Helmet use reduced
the severity of head injuries, and might have prevented deaths caused by
head injuries43.
Car surfing is an infrequent cause of traumatic
injuries treated by emergency physicians. This very dangerous activity can
result in serious injury or death. We report 5 cases of injuries caused by
car surfing seen at our hospital during 1996 and 1997. All involved head
injuries after a fall from a moving motor vehicle. There were 3 male and 2
female patients, and 3 cases were fatal. Health care providers should be
aware of this type of injury and support efforts to prevent it43.
Study conducted upon pedestrian reported children and the
elderly were found to be at high risk as pedestrians. Lack of knowledge by
children about the safe crossing behaviour and the inability of the
elderly to sustain and or easily recovery from injury. Pedestrian safety
measures in Jordan should be designed to overcome the limitations of children
and elderly pedestrians as a prime target45 Study conducted in Argentina in a
population of approx. 33 million and almost 6 million vehicles, it has one of
the highest rates of fatalities in traffic accidents a total of 7714 in 1996
that is 22 fatalities a day more than 100,000 injured people in a year and huge
material losses caused by chaotic traffic and accidents estimated in $10,000
million a year in Argentia. In 1996, 1270 died in traffic accidents here46
A study examined the effect of helmet wearing and the New Zealand helmet
wearing law on serious head injury of cyclists involved in on road motor vehicle
and non motor vehicle crashes. The study population consisted of three age
groups of cyclists (primary school children (ages 5-12 yrs) secondary
school children (ages 13-18 years) and adults (19+ years) admitted to public
hospitals between 1988 and 1996. Data were disaggregated by diagnosis and
analysed using negative binomial regression models. Results indicated that there
was a positive effect of helmet wearing upon head injury and this effect was
relatively consistent across age groups and head injury (diagnosis) types.
They concluded that the helmet law has been an effective road safety
intervention that has lead to a 19% (90% CI :14,23) reduction inhead injury to
cyclists over its first 3 years47.
The study of two cases of traumatic rupture of the basilar
artery are reported. In the first case, severe basal subarachnoid hemorrhage (SAH)
due to a complete transverse tear of the basilar artery was observed in a 53
year old restrained male driver who was involved in a head on collision while
intoxicated and drowsy. He lost consciousness shortly after the accident and was
admitted to hospital in cardiopulmonary arrest. Intensive resuscitative
therapies produced cardiac response, but he died 50 minutes after the accident.
The ethanol concentration in his blood and urine was 0.35 and 0.55 mg/ml
respectively. In the second case, SAH due to a similar tear of the basilar
artery was observed in a 47 year old man who received several fist blows to the
face while intoxicated. He suddenly lost consciousness after the final blow and
was admitted to hospital in cardiopulmonary arrest. Intensive resuscitative
therapies produced cardiac response, but he died 4 hours after the event.
In these cases, the mechanism of the traumatic rupture of the basilar artery is
thought to be overstretching due to hyperextension of the head, and
intoxication, drowsiness, or both may have interfered with the decedents ability
to protect themselves, thus the hyperextension of the head may have been rather
forceful48
In a rear end crash if an occupants head is unsupported it lags behind as the
torso is accelerated forward. This causes the neck to change shape, first taking
an S-shape and then bending backward in whiplash motion. This sudden
differential movement of the head and torso can cause whiplash injuries to the
neck. This paper reviews methods to minimize the differential head/torso
movement and reduce the resulting injuries focusing on the necessary first step
for prevention, which is a head restraint that is behind and close to the back
of an occupants head during the crash. The history of head restrains since the
1950s is reviewed with particular attention to advanced restraint designs that
are proving effective in reducing whiplash injury risk in dynamic tests using a
new crash test dummy neck and a new neck injury criterion49.
