PATTERN OF THORACO ABDOMINAL INJURIES IN FATAL ROAD TRAFFIC ACCIDENTS IN PUNE (MAHARASHTRA) INDIA-AN AUTOPSY STUDY

Rashid Nehal Khan 1 , Ravi Rautji 2 and K V Radhakrishna 2 . 1. Assistant Professor, Department of Forensic Medicine & Toxicology, Armed Forces Medical College, Pune 411040 (Mahahrashtra)India. 2. Dept of Forensic Medicine &Toxicology Armed Forces Medical College, Pune (Mahahrashtra) India. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 20 October 2018 Final Accepted: 22 November 2018 Published: December 2018


Material AndMethods:-
Medico-legal cases of fatal Road Traffic Accident victims showing Thoraco-abdominal Injuries carried out at the mortuary of tertiary care hospital were selected for the study. A total of 120 medico-legal autopsies were studied and relevant data was collected. For the purpose of the study, a Road Traffic Accident (RTA) was defined as accident which took place on the road between two or more objects, one of which must be any kind of a moving vehicle Criteria For Selection Of Cases:-Inclusion Criteria:-All the medico legal autopsies showing thoracic and abdominal injuries who have definite history of road traffic accidents were included in the study. Autopsies showing multiple injuries along with thoracic and abdominal injuries due to road traffic accidents were also included in the study.
Exclusion Criteria:-Decomposed bodies in which organs had liquefied were excluded.

Collection Of Data:-
All the relevant findings observed during the autopsy were recorded in a proforma and data analysed Observations:-Thoracic injuries -Organs involved:-Amongst a total of 227 cases with thoracic injuries, rib fractures were noted in maximum number of cases (n= 83, 36.56 %). In 39 cases fracture of right ribs was seen, 12 cases showed fracture of left ribs and 32 cases had bilateral rib fractures. Lung injuries were second in number (n = 80, 35.24 %)). In 27 cases contusion of right lung was seen and 21 cases had contusion of left lung. Laceration of right lung was seen in 23 cases and laceration of left lung was seen in 9 cases. Amongst visceral injuries, lung contusion was most common (n = 48, 21.14%). Other injuries in thoracic cavity were rupture of diaphragm (8 cases), contusion / laceration of heart (7 cases), rupture of aorta (6 cases), fracture sternum (6 cases), rupture of great vessels (3 cases) and fracture clavicle (1 case)( Table 1 ) Abdominal injuries -Organs involved:-Amongst a total of 213 abdominal injuries, liver injuries was the most common and were found in 67 cases (28.63 %). Contusion was seen in 10 cases and laceration of liver was found in 57 cases. Second most common abdominal organ to be injured was kidney (n = 45, 19.23 %). Contusion of right kidney was seen in 18 cases and contusion of left kidney in 10 cases. Laceration of right kidney was seen in 13 cases and that of left kidney in 4 cases. Spleen was next most common organ to get injured (n = 24, 10.25 %). Contusion of spleen was seen in 5 cases and laceration in 19 cases. Other injuries to abdominal organs were rupture / contusion/ laceration of small intestine (9 cases), injury 1432 to large intestine (2 cases), contusion of mesentery (16 cases), rupture of bladder (11 cases) and rupture of ureter (1 case). 4 cases showed retro-peritoneal haematoma. Abrasions and contusions of abdominal wall were seen in 31 cases. Pelvic fracture was seen in 21 cases. (Table 2)   Age wise incidence:-Age wise distribution of cases was found to be different for the two sexes. It shows that male victims from age group 20 -29 years are maximum (n = 37, 36.63 %) as compared to the rest of age group among male population. The age group 30 -39 years ranks second with (n= 21, 20.79 %) followed by 10 -19 years group (n = 11, 10.89 %) and 40 -49 years group (n= 10 , 9.9% ) as third and fourth respectively. Rest of the age groups are 60-69 years ( n= 6, 5.94 % ), 70 years and above (n =4 ,3.96 % ), 50 -59 years group ( n =3 , 2.97 % )and 0-9 years group ( n = 2 , 1.98 % ) In comparison to male victims, the female victims show different age wise distribution with maximum fatalities in age group 30 -39 years group ( n= 6, 31.57%). The age group 40 -49 years group and 60 -69 years group are second (n = 4, 21.05 %). 10 -19 years group is third (n = 2, 10.52 %) The age group 20 -29 years and 0 -9 years are fourth (n = 1, 5.26 %).
The above observations establish that both sexes taken together, theage group of 20 -49 years is most vulnerable to fatalities in road traffic accidents. (n = 65, 54.16 %).

Sex wise distribution of cases:-
The observationsshow that in fatal road traffic accidents studied the number of male victims (n = 101, 84.17 %) was much more than females ( n = 19 , 15.83 % ), establishing that male population is at a much higher risk as compared to females.

Time interval between injury and hospitalization:-
Majority of injured victims availed medical treatment within 0-1 hrs (n = 60, 50 %) while 29 (16 %) availed treatment within 1 -12 hrs post injury. The incidence of spot deaths were (n = 23, 19.16 %). The data regarding time interval of hospitalization of two cases was unknown.
In the present study (Table 2) among the total of 213 abdominal injuries, blunt injuries to liver were the most common and were found in 67 cases (28.63 %). Contusion of liver was seen in 10 cases and laceration of the organ in 57 cases. Second most common abdominal organ to be injured was kidney (n = 45, 19.23 %). Spleen was the next most common organ to get injured (n = 24, 10.25 %). Among injury to other abdominal organs, rupture / contusion/ laceration of small intestine were seen in 9 cases, injury to large intestine in 2 cases, contusion of mesentery in16 cases, rupture of bladder in 11 cases and rupture of ureter in1 case. 4 cases showed retro peritoneal haematoma.
According to Bowley D and Boffard K 4 thoracic injury directly accounts for 20-25% of deaths due to trauma; thoracic injury or its complications are a contributing factor in a further 25% of trauma deaths. Aortic injuries contribute to 15% of RTA fatalities. The reported incidence of diaphragmatic rupture is between 0.8% and 1.6% in patients admitted to hospital with blunt trauma. The most commonly injured intra abdominal organ following blunt trauma is the spleen. In their study, the reported incidence of bowel and mesenteric injuries after blunt abdominal trauma was approximately 1.3%. A study byKumar A et al 5 says that most commonly injured abdominal organ is liver (n= 532, 21.52%). Singh H and Dhattarwal 6,7 report chest injuries in 44% cases which included fracture of ribs in 36.9% cases, contusions and lacerations of lungs in 29.8% cases and rupture of diaphragm in 2% cases. Abdominal injuries were seen in 31.8% cases and included lacerations of liver (26.9%), spleen (12.7%), gut (4.7%), kidneys (3.8%) and bladder (2.9%).Newman R et al 8 report that in frontal impacts in unrestrained occupants, rib fracture was the most common injury followed by lung injury.Sevit S 9 reports fracture multiple ribs was most common (49.8%) of chest injuries while laceration of liver was the most common abdominal organ injured (62.1 % of abdominal injuries.) Findings of the present study in this respect tally with those of the above mentioned studies, except for the study by Bowley D and Boffard K 4 which reports spleen as the most commonly injured abdominal organ.

Age wise incidence:-
The present study shows that male victims from age group 20 -29 years are maximum in number (n = 37, 36.63 %) as compared to other age groups amongst males. In comparison to male victims, the female victims show a different trend with maximum fatalities in age group 30 -39 years group ( n= 6 , 31.57 % ). The above observation clearly shows that both sexes taken together, age group 20 -49 years is most vulnerable to fatalities in road traffic accidents. (n = 65, 54.16 %) and extremes of life the least (5.88 %).
NCRB data of 2007, 3 also has recorded the age group maximally involved as 25-35 yr (18.3%). Kaul A et al 10 report that the principal age group involved in fatal RTA was 25-44 years, (33.68%) and least involved were extremes of ages i.e. below 10 years, 5.38%, and above 65 years. Meera T and Nabachandra H 11 report the commonest age group of the victims as 21-30 years (20.80%). Jha N and Agarwal C S 12 report that 58% of the injuries occurred in the 15-44 year group. Kumar A et al 5 report that the commonest age group affected was between 21-40 years involving 1341 (54.24%) cases. Thus the findings of the present study, regarding the most common age of victims involved in fatal road traffic accidents are consistent with the above studies.

Sex wise distribution of cases:-
In the present study it is seen that majority of deceased were males (84.16 %) and females were (15.84 %) The Male: Female ratio was 5.65: 1. Similar results have been reported by Jha N et al 1 who reported that there were 83% male and 17% female accident victims. Singh Y N et al 13 state that a total of 1628 male and 244 females were killed in road traffic accidents giving a male : female ratio of 7:1. Singh H and Dhattarwal S K 6 report that males outnumbered females in a ratio of9:1. Meera T and Nabachandra H 11 have stated that males outnumbered females in a ratio of 3.8:1. Present study is consistent with above studies. The reason attributed is that it is the male who commonly goes out to work and thus is more vulnerable to road traffic accidents.

Time interval between injury and hospitalization:-
In the present study it was seen that majority of injured victims availed medical treatment within 0-1 hrs (n = 60, 50 %) while (n = 35, 29.16 %) availed treatment within 1 -12 hrs post injury.

Mode of transfer of casualties:-
In the present stud it is observed that most common mode of transfer of casualties was Taxis (n = 55, 45. 83 %) and Ambulances evacuated only 19 (16. 67 %) casualties. Thus highlighting the lack of proper facilities for evacuation of trauma victims. Ambulances can start emergency resuscitation in transit and thus can save many lives. Similar findings are reported from Indian Council of Medical Research in its annual report 2007-2008 17 , whichstates that most of the injured were taken to the hospital in private vehicles and taxis and ambulance was used in only 19% cases. Thus the findings of the present study are consistent with the ICMR annual report.

Conclusions:-
Urgent attention needs to be paid to the prevention and control of road accidents. Until recently, it was believed, that a vast majority of accidents, are the result of, "human error." Professionals however have now opined that it is not so easy to pinpoint these "errors" to an individual or an organization. We have to do away with the tradition of fixing blame and educate the society about road safety..