INJURY PATTERN AMONG ROAD TRAFFIC ACCIDENT CASES : A STUDY FROM SOUTH INDIA Abstract: Nilambar Jha, D.K. Srinivasa, Gautam Roy, S. Jagdish* Deptt, of P.S.M. and Surgery*, Jawaharlal Institute of Post-Graduate Medical Education and Research, Pondicherry Research question: What are different types of injuries among the road traffic accident cases? Objective: To know the prevalence of injuries present among the road traffic accident cases. Study design: Descriptive. Setting: Study was performed in Jawaharlal Institute of Post Graduate Medical Education and Research Hospital, Pondicherry. Participants: 726 victims of road traffic accidents reported in one year (1994). Study variables: Demographic characteristics of the victims and injury pattern. Statistical analysis: Percentages, Critical ratio and Chi-square. Results: Among 726 road traffic accident victims, 603(83%) were males and 123(17%) females. The average age was 31.5 years and highest number of victims were in age group 20-29 years. Among the various injuries, the limbs and the face were the commonly affected areas to suffer external injuries. Head injuries were the commonest form of internal injuries seen in the victims (34.1%). These injuries were common among bicycle riders, pedestrians and riders of motorized two wheelers. The commonest sites for fracture was the lower limbs (43.4%). The severity of injuries suffered by the victims was graded according to the Trauma Index. Key Words: Road traffic accidents, Injury pattern, Accidents, Traffic accidents Introduction: Throughout the world, the growth of the transport system has been and continues to be a key element in economic development. An increase in gross national product is accompanied by a greater movement of people and goods and greater investment in both vehicles and transport infrastructure. In the developing world, current trends in population growth, industrialization and urbanization are putting heavy pressure on the transport network in general and on road system in particular. Some of the unwanted side-effects of this growth in traffic, such as congestion and noise are immediately obvious to the individual citizen. Others, such as the growing number of deaths and injuries from road traffic accidents (RTAs), are apparent only through aggregated statistics. These reveal a serious and growing problem, with absolute fatality and casualty figures rising rapidly in the majority of developing countries and with death rates considerably higher than in the developed world 1. Each year RTAs claim some 6,00,000 lives and thirty times this number, that is over fifteen million, are injured according To the World Health Organization. This represents more than one life lost every minute and an injury every two seconds. Two third of these victims are from the third world countries 2. Material and Methods: This study was conducted at Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) hospital Pondicherry from 1st January to 31st December 1994. The study group consisted of all the road traffic accident victims reporting to JIMPER casualty in the above one year period. For the purpose of the study, an RTA was defined as an accident which took place on the road between two or more objects, one of which must be any kind of moving vehicle. Any injury on the road without involvement of a vehicle (eg. a person slipping and falling on the road and sustaining injury) or injury involving a stationary vehicle (eg. persons getting injured while washing or loading a vehicle) or deaths due to RTA were excluded from the study. The victims of the accidents were interviewed to obtain the information about the circumstances leading to the accident. A pre-tested proforma specially designed for 85
Indian Journal of Community Medicine Vol. XXVIII, No.2, Apr-June, 2003 this purpose was used for interviewing the accident victims, either in the casualty or in the wards of JIPMER Hospital. Where the condition of the victims did not warrant the interview, the relatives or attendants were interviewed. The information collected consisted of personal identification data, protective gear worn and category of road users. In addition, the type and severity of injury suffered by the victims was graded using the "Trauma Index" 3. The treatment given and the outcome were also recorded for each case. The medicolegal records and case-sheets of the victims were referred for collecting additional information and where necessary for cross checking. Results: A total of 520 RTAs involving 726 victims, excluding 26 fatalities from 24 RTAs, reported at JIPMER hospital during the study period. Table I: Age and sex distribution of victims. There were 603(83%) male and 123(17%) female casualties. The average age of the victims was 31.5 years. The highest number (31.3%) of victims were between 20-29 years of age. About 71 % of the victims were under 40 years age group. There were 65 children (8.9%) below 12 years of age with an average age of 7.1 years. Table II: Type of vehicles involved in injuries to pedestrians. Motorized two wheelers = Motor cycle, Scooter and Moped, Four wheelers = Car, Jeep and Van Pedestrians and drivers were 22% and 35% of RTA victims respectively. The occupants of vehicles constituted the largest (43%) group of victims. Thirty-five pedestrians (21.9%) injured were involved in an RTA with a truck. Buses caused injuries to 20 pedestrians (12.5%). Motorised two wheelers and four wheelers were involved in RTAs in which 39(24.4%) and 34(21.3%) pedestrians were injured respectively. A total of 254 drivers were involved in RTAs. Among the drivers of different types of vehicles, there were 38.6% bicyclists and 16.9% bullock cart drivers. Motorized two wheeler drivers were victims in 31.1 % cases while bus and four wheeler drivers were victims in 5.1% and 3.5% cases respectively. Among motorized two wheelers 14(5.5%) were scooter drivers. Of the 254 drivers involved in RTAs, 187 could be interviewed. Among them 102 were bicyclists and bullock cart drivers who did not require a license. From the remaining 85 drivers of different motor vehicles, 71 mentioned that they had driving license, one had learner s driving license and 13(15.3%) had no valid license. All those who had no license were driving motorized two wheelers. None of the drivers or occupants of vehicles was using protective gear at the time of the accident. Out of 254 86
drivers, 38(14.9%) were found to have consumed alcohol. These included 19(50%) bicyclists who were the largest number, 17(44.7%) motorized two wheeler drivers and 2 (5.3%) bullock cart drivers. Of 312 occupants, bus occupants were the highest numbers (48%) of victims involved in RTAs followed by occupants of trucks (12.6%). Among the motorized two wheelers (11.3%), the pillion riders of scooters were least involved (2%), other occupants were from four wheelers like Jeep, Car, Van (9.9%), bullock cart (9.6%), bicycle (4.1%), three wheelers (2.9%) and tractor (1,6%). Table III: External injuries among the victims. Figures in parentheses represent percentages. The limbs and the face were the most commonly affected areas to suffer external injuries. The limbs (63.1%) and face (17.5%) were common sites for abrasion, while lacerations were common on the face (29.7%), head (28.2%) and the limbs (38.9%). Multiple superficial injuries were noted more commonly in the lower limbs (36.8%) and face (33.3%), while crush injuries were predominantly seen in the lower limbs (70.6%). Head injuries were the commonest form of internal injuries seen in victims (34.1%) followed by injuries to the lower limbs (13.7%) and face (10.7%). Injuries to the chest (8.5%), pelvis (8.2%) and upper limb (8.1%) were seen in roughly equal proportion of victims. Others sites were back (7.65%), spine (4.3%) and neck (0.9%). Table IV: Distribution of head injuries among the RTA victims. Head injuries were common among bicycle riders, pedestrians and riders of motorized two wheelers. Bicycle riders had the highest proportion (22.9%) of head injuries, followed by 22.6% among pedestrians and riders of 87
Indian Journal of Community Medicine Vol. XXVIII, No.2, Apr-June, 2003 motorized two wheelers. Compared to pedestrians, bicycle riders and riders of motorized two wheelers had a significantly higher proportion of head injuries (critical ratio=3.1 and 2.8 respectively). A total of 221 fractures were noted among the victims. The commonest site of fracture was he lower limb (43.4%), followed by upper limb (19.0%) and facial bones (10.9%). Other sites were ribs (7.7%), clavicle (6.8%), skull (5.4%), pelvis (3.6%), scapula (2.3%) and spine (0.9%). Table V: Severity of injuries according to "Trauma Index". *X 2 =l-5;df=l;p>0.05. The severity of injuries suffered by the victims was graded according to the "Trauma Index". According to this index injuries are classified as minor injuries (0-7), moderate injuries (8-18) and severe injuries (more than 18). A total of 372(51.2%) victims had mild injuries. Moderate injuries were seen in 349(48.1 %) victims and severe injuries in 5 victims. Males as compared to females had a higher number of mild and moderate injury scores but the difference was not significant. Most of the cases (99.5%) of RTA reporting to JIPMER hospital were managed within the hospital itself. While 23.6% of the victims did not need hospitalization and only 0.5% had to be sent to another hospital for further treatment. Discussion: In the present study the highest number of RTA victims (31%) were found between the age group of 20-29 years. Similar results were reported by others also 4,5. Whereas, some studies have found the age groups most commonly involved were 16-30 years and 15-35 years respectively 6 7. The people of the 3rd decade for age group were most commonly involved in RTAs 8. This study found that more than 53% of the victims were in the age group between 20-40 years. This shows that the people of the most active and productive age group are involved in RTAs, which adds a serious economic loss to the community. Similar observations were also made by others 9 10. The present study shows that below and above the age of 20 and 49 years, the proportion of accidents was low. The reason may be that children were taken care of by elders and less use of vehicles in the adolescent age group. Lower proportion of RTAs in those aged 60 and above could he due to the generally less mobility of the people. The accident rates were 4.9 times higher in males than in females according to this study. This was also observed in Delhi, whereas, another study from Delhi has reported very high male and female ratio (9:1) 4 8. It was observed that 80% of the victims involved in RTAs were males 6,11. Males are much more exposed to RTAs than females. In this study, pedestrians constituted 22% of the road users involved in RTA, followed by bicyclists (15.3%) and two wheeler drivers (10.9%}. Similar results were also observed in Delhi, Haryana, Aligarh and Madras 4,6-8,11. However, in same Delhi study it was observed that animal driven vehicle users were only 3.4% compared to 6% in the present study. This could be explained by the fact that the present study was from a semi urban area and bullock carts ply frequently on the roads, whereas, another study was from the cosmopolitan city of Delhi 4. Among the motorized two wheelers, moped drivers were more commonly involved in RTAs. This could be due to the higher speed, which can be achieved over short distances and less stability of the vehicle. One of the most common mode of transportation used by people is the bus and this is reflected by the fact that bus occupants constituted the highest number (48%) of RTA victims. 88
This study found 15.3% drivers of different vehicles were without driving license, which is much higher compared to 7.4% found in Delhi 4. The reason may be the easy accessibility of the vehicles and the casual attitude of drivers towards obtaining license. When they were interviewed they mentioned that they would be applying for and obtaining the license in future. No protective gear was used by any of the two wheeler victims in this study, because there is no such law in Pondicherry or in the adjacent state of Tamil Nadu regarding helmet use. In the present study, 15% of the drivers involved in RTA had consumed alcohol. This is a higher proportion than 4.6% and 8%, reported by others from Delhi 4 12. The role of alcohol in impairing driving ability is well documented. Also the impairment increases as the blood alcohol level rises. In addition, the risk of accidents are higher in youngsters and elderly people for similar blood alcohol levels 1. Abrasions and lacerations were the commonest types of injuries among the external injuries noted in this study. Similar results were also observed by others 4 13. Head injury was the highest among the internal injuries noted in this study, a feature also reported by other studies 4,6,14. Other common sites were the lower limbs and face. Similar observation were made by others 4 6. Bicyclists and pedestrians suffered the highest number of head injuries, followed by motorized two wheeler riders. The pedestrians and bicyclists in most of the instances were knocked down by another vehicles leading to head injury. Helmet was not used by any motorized two wheeler user. This could be the possible reason for head injury among them. Among fractures, present study found that lower limbs were the commonest site for fracture, followed by fracture of upper limbs and facial bones. But in another study it was reported that the highest number of fractures were in upper limbs followed by lower limbs and facial bones 13 However, their study was confined to only two wheeler accidents, whereas, the present study takes into account all types of road accidents. It was possible to objectively score the injuries by using the Trauma Index. It was observed that about one half of all injuries caused by RTAs were of minor nature and all of them were treated as out patients and sent home. Another 48% had sustained moderately severe injuries and were managed in the JIPMER hospital. Only 5 victims (0.7%) had sustained severe injuries and four of them had to be refereed to other hospitals for neurosurgery. Conclusion and Recommendations: As this study shows head injuries were common among motorized two wheelers (22.6%) and none used helmet. The use of properly designed helmet should be made compulsory specially among the riders of motorized two wheelers. This might be effective in reducing head injuries. Prompt and adequate ambulance service should be provided to the victims with the help of government and other voluntary agencies. Computerization and use of International Classification of Diseases code in the hospitals would help in preparation of a good database for future studies and other uses. References: 1. WHO. Road traffic accidents in developing countries. Technical Report Series No. 73, World Health Organization, Genera 1984. 2. Downing A, et al. International overview of road safety In: International workshop on Prevention and control of traffic accidents and injuries (24 Nov-3 Dec. 1992). New Delhi, India. p4-12. 3. Kirkpatric JR, Youmans RL. Trauma Index. J of Trauma 1971; 11 (8): 711-4. 4. Mehta SP. An epidemiological study of road traffic accident cases admitted in Safdarjang Hospital, New Delhi, Indian J of Medical Research 1968; 56(4): 456-66. 5. Jha N. Road traffic accident cases at BPKIHS, Dharan, Nepal: one year in retrospect. J of Nepal Medical Association 1997; 35: 241-4. 6. Sathiyasekaran BWC. Study of the injured and the pattern in road traffic accidents. Indian J of Forensic Sciences 1991; 5: 63-8. 89
7. Dhingra N, Khan MY, Zaheer M, Sinha SNS, Khan A, Dhingra M. Road Traffic Management - A national strategy 1991. Proceedings of the International Conference on Traffic Safety 27-30 January 1991, New Delhi, India. 8. Ghosh PK. Epidemiological study of the victims of vehicular accidents in Delhi. J of Indian Medical Association 1992; 90(12): 309-12. 9. Chunlin C, Huichun W, Xiaohong S. The investigation and analysis of 1000 cases of traffic injury emergency treatment in five cities in China 1991, Proceedings of the International Conference on Traffic Safety 27-30 January 1991, New Delhi, India. 10. Balogun JA, Abereoje OK. Pattern of road traffic accident cases in a Nigerian University Teaching Hospital between 1987 and 1990. J of Tropical Medicine and Hygiene 1992; 95: 23-9. 11. Varghese and Mohan D. Transportation injuries in rural Haryana, North India 1991. Proceedings of the International Conference on Traffic Safety 27-30 January 1991, New Delhi. 12. Sood S. Survey of factors influencing injury among riders involved in motorized two wheelers accidents in India: A Prospective study of 302 cases. J of Trauma 1988; 28(4): 530-4. 13. Clark DW, Morton JH. The motorcycle accident - A growing problem. J of Trauma 1971; 11(3): 230-7 14. Sathiyasekarn BWC. Accident trauma - A descriptive hospital study. J of the Royal Society of Health 1991: 10-1. Instructions for Contributors (Contd. from page 73) Abbreviations: As there are no universally accepted abbreviations, authors should use familiar ones and should define them first. Acknowledgements: These should be placed as the last element of the text before references. References: In citing other work only references consulted in the original should be included. If it is against citation by others this should be so stated. Signed permission is required for use of data from persons cited under personal communications. The Journal follows the Vancouver system of references. References should be numbered and listed consecutively in the order in which they are first cited in the text and should be identified in the text, tables and legends by superior Arabic numerals. The full list of references at the end of the paper should include; names and initials of all authors unto six (more than 6, only the first 6 are given followed by el. al); the title of the paper; the journal title abbreviated according to the style of Index Medicus; year of publication: volume number; first and last page numbers. References of books should give the book title, place of publication, publisher and year; those of multiple authorship should also include the chapter title, first and last page numbers and names and initials of editors. 1. Mehta MN, Mehta NJ. Serum lipids and ABO blood group in cord blood of neonates. Indian J Pediatr 1984; 51: 39-43. 2. Smith GDL. Chronic ear disease. Edinburgh: Churchill Livingstone, 1980; 78-81. Malhotra KC. Medicogenetic problems of Indian tribes. In: Veena 1C, ed, Medical Genetics in India, Vol. 2. Pondicherry; Auroma enterprises, 1978: 51-5. Papers accepted but not yet published should be included in the references followed by in press. Those in preparation, personal communications and unpublished observation should be referred to as such in the text only. For more detailed information about the Vancouver system, authors should consult: Uniform requirements for manuscripts submitted to biomedical journals. (New England Journal of Medicine 1997; 336: 309-15). Legends: A descriptive legend must accompany each illustration and must define all abbreviations used therein. They should not duplicate material in the text. Illustrations: These should be of the highest quality, submit glossy black and white photographs. Graphs should be drawn by the artist. Number all illustrations with Arabic numerals (1,2,3...) Tables: These must be self explanatory and must not duplicate information in the text. Each table must have a title and should be numbered with Roman numerals (I, II etc.) Manuscripts and all editorial correspondence should be sent to the Chief Editor, Indian Journal of Community Medicine, Deptt of S.P.M., Pt. B.D. Sharma PGIMS, Rohtak-124001, Haryana, India. Important: Review of the sent articles takes any time between one to six months. Authors are requested to quote the reference number of the article (sent in the acknowledgment letters) in all correspondence with the office of the ICJM. 90