|Year : 2018 | Volume
| Issue : 3 | Page : 191-196
A study of 200 skull fracture cases following vehicular accidents in the City of Guwahati: The gateway to North-East India
Nayan Kumar Das1, Raktim Pratim Tamuli2, Smritimala Sarmah3, Ravi Kumar Sharma2
1 Department of Forensic Medicine, Tezpur Medical College, Tezpur, Assam, India
2 Department of Forensic Medicine, Gauhati Medical College, Guwahati, Assam, India
3 Department of Physics, B. Borooah College, Guwahati, Assam, India
|Date of Web Publication||17-Jul-2018|
Raktim Pratim Tamuli
Department of Forensic Medicine, Gauhati Medical College, Guwahati - 781 032, Assam
Source of Support: None, Conflict of Interest: None
Introduction: Gradual increase in a number of vehicular accidents globally becomes a matter of concern, and adequate policies are required to reduce such incidents. This study was conducted in Guwahati city, the gateway to North-East India, to know the various factors related to such incidents associated with fractures of skull. Materials and Methods: A total of 200 cases were selected randomly over a period of 1 year. It was a cross-sectional study and data were collected from police, relatives of the deceased, and hospital records in an especially designed pro forma (questionnaire). Results obtained were tabulated and analyzed accordingly. Results: Results showed that almost 90% (89.5%) of the victims were male and 20–29 years was the most common age group involved. Fissured fracture was the most common skull fracture found in our study (56%), and temporal bone was involved in 56% of the cases. Occupants of two-wheelers were found more vulnerable to skull fracture. About 46% of the victims died before they could reach hospital, and in 71% of the cases, rural people were involved. Conclusion: Immediate and timely first-aid measure along with setting up of tertiary health-care centers in rural areas is absolutely necessary to prevent death due to vehicular accidents as the majority of the victims died before they could reach a well-equipped hospital. Public awareness about the use of protective gears, use of footpaths, and also safe usage of mobile phones while using roads would be of great help in reducing such incidents.
Keywords: Skull fracture, tertiary health-care center, vehicular accidents
|How to cite this article:|
Das NK, Tamuli RP, Sarmah S, Sharma RK. A study of 200 skull fracture cases following vehicular accidents in the City of Guwahati: The gateway to North-East India. CHRISMED J Health Res 2018;5:191-6
|How to cite this URL:|
Das NK, Tamuli RP, Sarmah S, Sharma RK. A study of 200 skull fracture cases following vehicular accidents in the City of Guwahati: The gateway to North-East India. CHRISMED J Health Res [serial online] 2018 [cited 2019 Oct 21];5:191-6. Available from: http://www.cjhr.org/text.asp?2018/5/3/191/236890
| Introduction|| |
The World Health Organization (WHO) defines accidents as “an unexpected, unplanned occurrence which may involve injury.” A WHO advisory group in 1956 defined accident as an “unpremeditated event resulting in recognizable damage.” According to another definition, an accident is “occurrence in a sequence of events which usually produces an unintended injury, death, or property damage.” According to a study conducted by the National Transportation Planning and Research Center, every 4 min, a person is killed or injured in road accidents in India. The spectrum of injuries depends on site, direction and force of impact, design of vehicle, ejection of victim, and supervening factors such as overturning or fire.
Death is the ultimate truth of life. Injuries and fatalities are killing around 1.2 million people each year and injuring 50 million people worldwide. These victims occupy 30%–70% of orthopedic beds in developing countries. The financial costs to the communities for road traffic accidents (RTA) are greater than required for the treatment of any other major diseases. These are the most common causes of death below the age 50 years in developed countries. With the continuation of present trends, road traffic injuries are predicted to be the third leading contributor to the global burden of disease, just behind clinical depression and heart disease by 2020. In developing countries, 90% of the disability-adjusted life years lost occurs because of road traffic injury.
World bank estimates that road traffic injuries cost 1%–2% of the gross national product of developing countries or twice the total amount of development aid received worldwide by developing countries.
Road traffic injuries account for 2.1% of global mortality. The developing countries bear a large share of burden and account for about 85% of the deaths as a result of road traffic crashes. India accounts for about 10% of road accident fatalities worldwide.
Developing countries are different from the industrialized countries with regard to the environment and the mix of vehicle in traffic stream. The following are the more important differences.
- A large number of pedestrians and animals share the roadway with fast-moving and slow-moving vehicles (e.g., bullocks and carts). There is almost no segregation of pedestrians from wheeled traffic
- A large number of old poorly maintained vehicles
- A large number of motorcycles, scooters, and mopeds
- Low driving standard
- A large number of buses often overloaded
- Widespread disregard to traffic rules
- Defective roads, poor street lighting, defective layout of crossroads, and speed breakers
- Unusual behavior of man and animals.
Accidents occur due to various factors. Since many factors influence RTAs, it is very difficult to sort out a single culprit lying behind it. According to few experts, these factors have been classified into six types which are in short known as TRAVEL.
- Traffic-related (T)
- Road related (R)
- Accident Victim Related (A)
- Vehicle related (V)
- Environment related (E)
- Legal related (L).
| Materials and Methods|| |
This study was conducted in Guwahati city, Assam, which is the gateway to North-East India. Guwahati has a cosmopolitan population of about 1 million; though the study was conducted in Guwahati, cases from other parts of the state as well as surrounding states are included in the study, as most of the advanced trauma care centers of North-East India are situated in Guwahati.
- 200 confirmed RTA cases have been selected in this study on the basis of Purposive Random Sampling Method (or Deliberate Random Sampling method)
- RTA cases showing fractures of skull are only included in the study
- Decomposed bodies have been exempted from the study
- Cases with no definitive history have also been excluded from the study
- Data about vehicular accidents were obtained regarding age and gender of the victims, time and place of accident, type of vehicle involved in the accident, the type of injuries sustained, type of road users (pedestrians, riders, or pillions), the outcome of the accident, etc., in a self-designed pro forma (questionnaire). Data collected for each parameter were tabulated and entered into the computer using the Microsoft Excel software for further analysis.
| Results|| |
Sex and age of the victims
Males comprised of 89.5% and females 10.5% of the total victims. The age groups of the victim were grouped into 10-year intervals with 7 groups ranging from 0 to + 60 years. The youngest victim was a male child aged 1.5 years and the oldest was a 76-year-old male. Age and sex distribution of the cases are shown in [Table 1].
From the table, it is evident that highest number of victims involved was from the age 20-29 years group (30.5%) and least in the 0-9 years age group (3.5%).
Place of incident
[Figure 1] represents the place of incident; it is seen from the figure that most of the incidents occurred in rural areas with a total of 84 number of cases (42%), which is followed by urban areas with 73 number of cases (36.5%). Semi-urban areas stood last in the list with 43 number of cases (21.5%).
Time of incident
[Table 2] represents the time of occurrence of the incidents; we have divided the 24 h time of a day into four periods of 6 h each, and the data analysis shows that most of the incidents (37%) occurred in the afternoon (12.01 pm to 6 pm) hours.
Period of survival
Of all the cases, 27.5% cases died on the spot and 46.5% of the cases died before they could reach a tertiary care center. Surgery was carried out in only 3% of the cases. Mean survival period was 1–6 h [Table 3] and [Table 4].
Type of victim and vehicle involved
[Figure 2] represents the type of victim involved in the incidents; it is seen that most common type of victim involved was pedestrian (32.5%) which is followed by rider of a two-wheeler (27%). Motorbike was the most common offending vehicle, which was involved in 54% of the cases, followed by truck with 32% involvement.
Use of helmet by two-wheeler occupants
Out of 77 two-wheeler occupants, 50 occupants (64.9%) did not wear helmet at the time of the incident.
Abrasion of the face (41.5%) was the most common external injury found in the craniocerebral region, which is followed by laceration of the scalp (30%). Fracture of the vault was seen in 113 number of cases, only base was fractured in 20 cases, and both vault and base were fractured in 49 cases. The whole skull was crushed in 18 cases. Fissured fracture was the most commonly observed fracture (56%), followed by comminuted fracture with 21.5% and the least common type seen was sutural fracture (4.5%). In the base, middle cranial fossa was mostly fractured (20%). Hinge or motorcyclist's fracture was noted in 21 cases. Temporal bone was the most common bone found fractured in the study (56.5%) and occipital bone was least involved in those vehicular accidents (25.5%).
Of all the intracranial hemorrhages, subdural hemorrhage (SDH) holds the number one slot (83%) and intracerebral hemorrhage came last (15%), in the study. Laceration was found to be the most common associated injury of the brain (20%) [Figure 3] and [Figure 4].
|Figure 4: Intracranial hemorrhages. EDH – Extra dural haemorrhage, SDH – Sub-dural haemorrhage, SAH – Sub-archnoid haemorrage, ICH – Intra-cerebral haemorrhage|
Click here to view
Abrasion of the limbs was the most common external-associated injury observed (78.5%), whereas fracture of the ribs was the commonest internal associated injury (25%) detected in this study.
| Discussion|| |
All RTA cases are treated as medicolegal cases in India and are investigated for prosecution concerns and compensation needs. Every year more than 1000 people die in RTA in our country.
In the present study, males are more commonly involved than the females with a male:female ratio being 8.5:1. This finding of our study is similar to studies conducted by Kumar et al. and Gupta et al. Study of Emejulu and Malamo  and Ahmad et al. also found more male cases in their studies, but ratio of male:female was very less with 3:1 and 1.89:1, respectively. Involvement of more male cases can be explained by the fact that, due to our social customs, female used to remain inside the house and males are traveling between home and workplace and more exposed to outdoors.
This study shows the highest number of victim involvement in the age group of 20–29 years and least number in the age group of below 10 years. This finding is consistent with various other studies conducted earlier, but on contrary to this, the studies conducted by Ahmad et al. and Khadim et al. depicted a different picture with more involvement of the 31–40-year age group. The reason behind the involvement of the younger age group is that they are the most ambulatory group of people earning for their family; moreover, people in these groups are also more in the society since mortality rates are higher in extremes of age. Again, persons in the extremes of the age usually remain indoors whereas children are confined to the outskirts of the residential premises only.
More number of RTA deaths were found in the rural areas, whereas least number of cases occurred in the semi-urban localities. This finding correlates with the findings of a study conducted by Hoffman  and Cardoso and Pyper. Victims of RTA in rural areas are usually referred to tertiary care centers because of nonavailability of advance life care supports in those places, and this study was conducted at the place where most of the advanced tertiary care centers of North-East India are situated; again in this part of India, most of the people live in rural areas, which ultimately led to more cases from rural areas. Bad condition of roads and more disregards to traffic rules in rural areas might be other contributing factors.
Most accidents in our study occurred in the afternoon hours (12 pm–6 pm), which is followed by evening and night (6 pm–12 am). These findings are in concurrence with studies conducted by Menon and Nagesh, also with Jha et al. Whereas, findings of some studies show that accidents were more between 6 pm and 12 am, followed by 12 pm–6 pm., Traffic movement during these hours is usually at their peak and working people usually get strained physically and mentally by the end of the day. This results in the decreased reflex action of the person due to fatigue, which may lead to more accidents.
This study shows that most of the victims died within an hour of accident and before they could reach a tertiary health-care center. These findings are similar with various other studies. The 1st 4 h (golden hours) after any accident is the most crucial and survival increases if proper care and treatment are provided to victims on the spot and on the way to hospitals. Hence, the establishment of efficient emergency care facility is essential with trained care provider and well-equipped ambulance to improve the mortality and morbidity outcome in vehicular accident. The emergency medical care ambulances the Mrityunjoy (108 ambulance service) introduced by the Government of Assam is surely an appreciable step in this regard.
The data of this study have revealed that pedestrians were most commonly victimized in the RTA cases and in more than half of the cases, motorbike was the offending vehicle involved. These findings are correlated with the findings of Kumar et al. Common people are forced to walk on the main road, as footpaths and side of the roads are usually occupied by vendors and other commercial instillation. This ultimately leads to more involvement of pedestrians in the RTA cases, there is minimal space left for the common people to walk on and thus they met with such accidents commonly. Lack of Zebra crossings at places also plays an important role.
Here, in this study, we found that almost two-third of the victims of two-wheeler accidents did not wear helmet at the time of accident. Pruthi et al. and study of Shivakumar et al. found similar results in their studies. In contrast to that, Bahera et al. observed that, among 78.72% deceased, 54.05% individuals had worn helmet at the time of accident. Newlands discussed the advantages and disadvantages associated with helmet use and propagated that full face helmet reduces facial injuries.
Abrasion of the face is the most common craniocerebral injury we found associated with skull fracture. The presence of more number of facial abrasions can be explained by the fact that pedestrians and occupants of two-wheeler (most common victims found in our study) had fallen down on rough surface of the roads and skidded through, leading to abrasions. Moreover, nonusage of helmet by two-wheeler occupants can also be another contributing factor.
Findings of the study also tell that fracture of the vault was present in 56.5% of the cases, that of the base was present in only 10% cases, and facture of both vault and base was seen in rest 33.5% cases, including crushed skulls. These findings of our study are consistent with findings of studies conducted by Tirpude et al., Menon and Nagesh, and Tandle and Keoliya. However, findings of the study conducted by Yadav et al. (2008) and Shivakumar et al. found different results from our study where they found more number of combined fractures of vault and base.
Fissured fracture is the most common fracture we encountered in our study, which is followed by comminuted fracture. This finding is consistent with the findings of studies conducted by Menon and Nagesh, Menon et al. (2008), Ahmad et al., and Patel and Agnihotram.
Temporal bone was commonly fractured skull bone we found in our study. This finding of our study is in accordance with the findings of studies conducted by Kumar et al. (2008), Ahmad et al., Khadim et al., and Tandle and Keoliya.
One-fifth of the cases show laceration of the brain, which is consistent with the study of Chandra et al.
If we look at the various intracranial hemorrhages, SDH holds the number one spot. Studies conducted by Liko et al., Dhattarwal and Singh, and Menon and Nagesh  show similar results.
Abrasion of the limbs is the most common associated injury we found in our study. Therefore, it is not easy to predict the type and extent of injury, which would be compatible with life.
| Conclusion|| |
Before the RTA deaths hold the number one killer of human being, necessary steps must be taken to reduce the mortality. Education of young generation on road safety, strict implementation of traffic rules, ban on the use of mobile phones while on the road, construction of separate lanes for slow-moving vehicles, provision of sidewalks on both sides of the roads for pedestrian, exemplary punishment of the defaulters, mandatory use of proper protective gears by two-wheeler occupants, and periodic checkup of both driver and the vehicle are the various measures those can be suggested to reduce RTA. In a place like North-East India where communication is not at its best, another very important thing is to construct more number of tertiary care centers in rural areas so that the victims can get proper care at earliest near to the site of accident.
Financial support and sponsorship
This study was financially supported by DBT, through MD/MS thesis grant.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]