© Borgis - New Medicine 1/2011, s. 3-7
Witold Pawłowski1, Paweł Krajewski2, *Marta Krasny3, Piotr Fiedor4
Correlation of trauma circumstances and mechanism with the type, localization and range of cranial and intracranial injuries in traffic accident casualties
1Department of Disaster Medicine, Warsaw Medical University, Poland
Head of Department: Witold Pawłowski
2Department of Forensic Medicine, Warsaw Medical University, Poland
Head of Department: Paweł Krajewski
3Department of Orthodontics, Warsaw Medical University, Poland
Head of Department: Barbara Siemińska-Piekarczyk
4Department of General and Transplantation Surgery, Transplantation Institute of Warsaw Medical University, Poland
Head of Department: Andrzej Chmura
A large number of traffic accident casualties are subjects to head traumas, causing difficulties in fast and correct diagnostics on site. It may lead to so called underdiagnosis and qualification of the case as ‘not urgent’.
Objective. The objective of the study was to obtain data, which would help to foresee the nature of intracranial injuries in traffic accident casualties based on circumstances of the trauma and visible injuries within head integument. We tried to capture possible relations between the mechanism of trauma, external injuries and serious intracranial pathologies, eventually causing the victim’s death.
Material and methods. Documentation of 219 traffic accident casualties kept by the Forensic Medicine Department, Medical University of Warsaw.
Results. Among casualties of traffic accidents leading to a fatal head trauma, males constituted the considerable majority (78.1%). The average age amounted to 29.9 in male casualties and 44.77 in female casualties. Victims exposed to angular acceleration or angular acceleration associated with direct impact suffered from injuries in the form of subarachnoid bleeding, intracerebral/intraventricular bleeding and/or tear of deep cerebral structures, whereas casualties with the injury mechanism qualified as linear acceleration significantly more often suffered from cortical contusion and epidural haematomas. Among injuries of deep cerebral structures, cases of brain stem contusion most frequently referred to casualties who experienced rotation as an additional damage mechanism.
Conclusions. Casualties of accidents suffering of trauma caused by rotation mechanism are exposed to considerably more severe injuries of cranial cavity structures than casualties of traumas caused by a different mechanism. Cerebral injuries induced by the mechanism of angular acceleration refer to the brain stem in particular. In cases where head protection has been used, they may occur without visible head injuries.
Growing numbers of traffic accidents and casualties create a serious medical and social issue. Along with expanding road traffic, mass casualty accidents and catastrophes become increasingly more common, which in view of paucity of medical professionals considering the needs, require the use of procedure algorithms. The problem in emergency medicine is that some subjects with serious injuries are underdiagnosed on the accident scene and due to being qualified as ‘not urgent cases’ they are referred to be managed or transported subsequently (1). Cases of underdiagnosis are mainly related to head traumas. It results from the fact, that external injuries of the head or cranial fractures are not always accompanied by intracranial injuries as well as serious intracranial injuries sometimes are not reflected by external injuries (2, 3).
Despite the significance of the issue consisting in predicting localization and severity of intracranial injuries based on local condition available for physical examination, studies regarding this problem are relatively scarce (2, 3, 4, 5, 6, 7, 8). Shortage of exploratory studies with autopsy material is apparent in particular, with a vast majority of publications covering only clinical material. In spite of progress in imaging diagnostics, only the autopsy may provide complete data in the scope of pathomorphologic lesions occurring in the cranial cavity.
AIM OF STUDY
The aim of the study was to obtain data allowing prediction of the intracranial injuries’ nature in traffic accidents casualties based on circumstances of the injury and visible head integument injuries. We tried to capture possible relations between the mechanism of trauma as well as external injuries and serious intracranial pathologies eventually leading to death of the patient.
Material and MethodS
The analysis covered documentation of the Forensic Medicine Department, Medical University of Warsaw, collected between 1990 and 2004 concerning subjects deceased in result of traffic accidents. Cases included in the study were casualties managed on the scene, transported or hospitalised, who died due to injuries of the cranial cavity. Cases of casualties, who died instantly (dead on arrival or unsuccessful resuscitation) or in whom death was caused by other, concomitant injuries, were excluded from the study. The analysis included 219 reports. The local Bioethics Committee at the Medical University of Warsaw was informed on the objective of the study, material, and suggested methods and did not report any reservations.
The analysed parameters included circumstances of the injury, time and place of the event, anamnesis and physical examination, results of consultation and additional examinations, time and cause/causes of death.
The Student’s t-test was used to investigate differences between the mean values of constant variables (age, time of survival). Pearson’s chi-square test for quality variables or chi-square test with the Yates’ correction were used to analyse frequency differences in the scope of individual phenomena and to verify hypotheses, that phenomena observed in individual populations are independent. The Pearson’s C contingency coefficient or Cramer’s V association coefficient were used to assess the power of relation between individual variables, measurement of which are expressed in nominal scales.
Statistical analysis was performed with the use of STATISTICA 6.0 and IDAMS statistical packages. For statistical hypotheses testing the significance level of α=0.05 was assumed and two-sided critical region when the choice was left to the investigator’s discretion.
The group of 219 accident casualties included 171 (78.1%) males and 48 (21.9%) females. Age of the casualties ranged from 13 to 78 (mean victim’s age being 33.33). The mean age of males was 29.9 (SD = 14.91) and females – 44.77 (SD = 18.5). The median for males amounted to 24 and for females – to 50. Age of males was significantly lower (p < 0.001) both, in regard of all the accidents jointly as well as the traffic accidents as a separate group. Males took part in traffic accidents, mostly motorbike and bicycle accidents, more frequently in a statistically significant manner (p = 0.007). Only in case of railway accidents no significant differences between genders were found. Table 1 shows distribution of material according to the accident category.
Table 1. Categories of traffic event resulting in fatal cases among traffic participants identified in the examined material according to the gender.
|Type of accident||Number of casualties|
|Female casualties||Male casualties|
|Road traffic accidents jointly||44||155|
|Railway||Knocked down en-route||0||4|
|Event within a railway station||0||5|
|Railway accidents jointly||4||16|
|Total number of casualties according to gender||48||171|
|Total number of casualties knock down||219|
Reconstruction of the injury mechanism was based on autopsy findings and description of the injury course and circumstances. In the scope of data regarding the description of accidents with participation of pedestrians, cyclists and motorcyclists, the main focus was on whether the casualty was recoiled to the side or along the movement vector only, bringing into consideration the inertial rotational force in the first case. The crash helmet on a cyclist’s head and the fact of being recoiled to a soft shoulder (2 cases) caused far smaller range of external injuries comparing to other cases. One of these cases was qualified as a ‘clear’ linear acceleration type (straight line impact) in view of no cranial fractures. Also, if the description of a car accident included information about the vehicle hit by its side or/and somersaulting, rotation forces were examined. In situations, when a vehicle was equipped with pneumatic protection system (airbags, side airbags, curtain airbags), fact being confirmed by event description or model characteristics, usually no cranial fractures were observed and the events were qualified as the effect of ‘clear’ acceleration forces. In case of railway accidents with participation of the train passengers, the description of the event did not include information on what happened to the individual carriages during the accident. The results are compiled in table 2.
Table 2. Compilation of the number of intracranial pathologies found during autopsy in the examined material on a probable injury mechanism basis.
|Injury mechanism/injury type||Intracranial injury type|
|Epidural haematoma||Subdural haematoma||Sub-arachnoid haematoma||Intracerebral/intra-ventricular bleeding||Cortical contusion||Deep structure contusion||Disruption of cerebral tissue||Generalised oedema|
|Linear acceleration (N=10)||0||17||3||2||10||4||1||9|
|Direct contact/linear acceleration (N=141)||98||89||4||9||141||78||4||121|
|Angular acceleration (N=39)||2||19||17||31||11||29||26||32|
|Direct contact/angular acceleration (N=29)||13||15||15||22||29||22||17||22|
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