Accrd. Anal. & Prcv. Vol. 16, No. 516. pp. 407416. 1984 Pnnted m he U.S.A.

mo)14575/&1 $3.00 + .oo Pcrgamon Press Ltd.

TWO-WHEELER INJURIES IN DELHI, INDIA: A STUDY OF CRASH VICTIMS HOSPITALIZED

IN A NEURO-SURGERY WARD7

B. K. MISHRA and A. K. BANERJI Department of Neurosurgery, All India Institute Medical Sciences, New Delhi, India

and

DINESH MOHAN Centre for Biomedical Engineering, Indian Institute of Technology, New Delhi, India

(Received 28 October 1983)

Abstract-The motorized two-wheeler population has increased in Delhi by more than 300% in the last decade. Bicyclists and motorcyclists accounted for 244 traffic accident deaths in Delhi in 1980. The present study was undertaken to determine the head injury patterns of two-wheeler riders admitted to a hospital in Delhi. A total of 87 crash victims were studied over a period of one year. The results indicate that collision patterns, age distribution, average injury severity and driving experience of patients admitted were different from those reported in studies conducted in industrialized countries. A vast majority of the injuries were in temporal, parietal and facial areas. Injury data indicate that helmets when used are effective in preventing or ameliorating head injury.

The motorized two-wheeler (MTW) population in Delhi has increased by more than 300% in the past decade. This is representative of the increase in production of these vehicles in India (Fig. 1) but out of proportion of the population growth rate of Delhi and the increase in the number of cars. Motorcycles and scooters constitute the largest group of motorized vehicles in Delhi but figures for the number of bicycles in the city are not available.

According to police records 663 persons were killed in road accidents in Delhi in 1980 [Report on Road Accidents and Enforcement, 19801. The distribution of these fatalities according to class of road user is given in Fig. 2. It is clear that two-wheeler fatalities constitute the largest group of road users. However, there are no detailed studies available on the injury patterns of two-wheeler crash victims. Some preliminary studies indicate that riding patterns and crash patterns in Delhi may not be similar to those in Europe and the U.S.A. [Mohan, 1982, 1983). A factor peculiar to Delhi is that only drivers of MTWs are required to wear helmets by law but not the passengers. Bicyclists are not required to use helmets and almost no one does.

The present study was undertaken to determine the head injury pattern of two-wheeler riders admitted to the All India Institute of Medical Sciences, New Delhi. Additional information was obtained on associated injuries, details of the crash, and effect of use of helmets.

METHODS

The data for this study are based on the records of all patients involved in two-wheeler crashes who were admitted to the Neurosurgery Department of All India Institute of Medical Sciences (AIIMS), New Delhi, for more than 24 hr and those who died within 24 hr between 1 August 1980 and 31 July, 1981. The study was a collaborative effort between the Neurosurgery Department of AIIMS and Centre for Biomedical Engineering, Indian Institute of Technology (IIT), New Delhi. AIIMS is both a general and referral hospital catering to all road traffic accidents from a part of South Delhi, as well as patients referred from all over the country.

tThis work was partly supported by the Motorcycle and Scooter Division, Escorts Limited, India.

407

408 B. K. MISHRA et al.

Fig.

ANNLIAL PROWCTION

REGISTERED IN DELHI

.,_ . . . /-

CARS REGISTERED IN DELHI

I 1 I 1 1 1970 1972 1974 1976 1979 1980

YEAR

1. Production and registration figures for cars and motorized two-wheelers

All patients with head injuries are directly managed by the Neurosurgery Department of AIIMS. Two-wheeler crash victims include drivers and passengers of motor-cycles, scooters, mopeds and bicycles. Pedestrians struck by MTWs were not included. All those who were discharged after first aid in Emergency and those who were admitted for less than 24 hr were not included in the study.

After admission to the Neurosurgery Ward the patient was clinically examined and interviewed if possible. The data were recorded on a form specifically designed for this study. The patient’s friends, relatives and witnesses were interviewed wherever possible. Injury details were recorded and graded according to the Abbreviated Injury Scale (AIS) [Baker and O’Neill, 19761 and Injury Severity Score (ISS) [Joint Committee on Injury Scaling, 19801. An attempt was made in the interviews to determine whether the victim was wearing a helmet at the time of the crash and also whether the victim was under the influence of alcohol or not.

Crash involved helmets were obtained from the patients by exchanging their helmets with brand new ones donated by a local manufacturer. The helmets collected during the study were examined for sites of impact, patterns of damage and for their role in preventing head injury.

RESULTS AND DISCUSSION

A total of 87 two-wheeler crash victims, 76 (87%) males and 11 (13%) females, were admitted for more than 24 hr to the Neurosurgery Ward of AIIMS, New Delhi in the one year

75

cl

2

BUS PEDESTRIANS CYCLlSTS MOTOR CYCLISTS OTHER OTHERS

COMMUTERS 6 SCOOTERISTS VEHICLE OCCUPANTS

Fig. 2. 1980 road crash fatalities in Delhi by class of road user (police data)

Study of crash victims hospitalized in a neuro-surgery ward 409

Table 1. Distribution of two-wheeler crash victims by type of vehicle

Vehicle Number of patients Number fatalities

scooter

Motorcycle

Bicycle

Moped

Total

53 (61") 10 11 (73%)

1B (21::) 2 (13%)

15 (17%) 1 ( 7%)

1 ( 1%) 1 ( 7') IO

87 (100"') a 15 (100%)

period of this study. They ranged in age from 5 to 70 yr with 67 drivers and 20 passengers. There were a total of 15 (17%) fatalities.

VEHICLE FACTORS

Type of Vehicle. A majority (83%) of the injured patients were MTW riders and the rest bicycle riders (Table 1). This is inspite of the fact that there are many more bicycle riders than MTW riders in Delhi and bicycle fatalities also out number MTW fatalities according to police records (Fig. 2). Scooters, motorcycles and mopeds had a ratio of 78 : 19: 2 respectively on the roads of Delhi at about the same time [Mohan, 19831. The patients in this study are represented in similar ratios. While Langwieder [1977] shows that the risk to moped and motorcycle riders is similar, others claim that the severity of injuries is higher among riders of more powerful vehicles [e.g. Kraus, er al., 19751 and also that they are more likely to be involved in crashes [Bragg et al., 19801. Since most scooters and mo- torcycles in Delhi fall within the capacity range of 125-250 cc it is not possible to differentiate

risk by capacity. The numbers of mopeds and large capacity motorcycles are too small and hence our sample does not show a disproportionate representation of any particular vehicle.

Type of Collision. In 40% of the cases impact site of the two-wheeler could not be determined (Table 2). Of the rest, only 4 (8%) reported to have been hit on the side. This is an extremely low figure compared to reports from Europe, Japan and the Americas [Hurt, 1979; Kawano, 1980; Newman, 1976; Otte et al., 19811 where side impacts generally account for 20-40x of the crashes. Almost 40% of the multiple vehicle crashes in this study were reported to be impacts to the rear of the two-wheeler compared to figures of less than 10% in the studies mentioned above.

It appears that collision patterns are very different in Delhi as compared to those in industrially advanced nations. This may be due to a different traffic mix and riding patterns in Delhi. The high proportion of rear impacts indicate that the rear of two-wheelers have to be made much more conspicuous for use in cities like Delhi.

Table 2. Impact site of two-wheeler

Impact sits Number of patients

Front 11

Rear 10

Right 2

Left 2

Single vehicle crash 29

Unknown 35

Total 87

410 B. K. MISHRA et al.

Table 3. Light conditions at time of crash

Light condition

Daylight

Dark

Dark but lighted

Sunset

Sunrise

Unknown

Number of patients

38 (44%)

16 (lL?:)

13 (15%)

7 ( 6%)

0 ( o?A)

13 (15%)

Total 87 (100%)

ENVIRONMENTAL FACTORS

Almost half of the crashes took place (where known) at sunset or at night (Table 3) when traffic density is lowest in Delhi. A vast majority of the crashes were reported to have occurred on straight roads (Table 4) and only 16 were recorded as collisions with cars, trucks and buses (Table 5). Here again the experience is different from that observed in Europe and Japan where intersection collisions and impacts with other vehicles seems to be much more common (Bragg er al., 1980; Hurt, 1979; Kawano, 1980; Kraus er al., 1975; Langwieder, 1977; Newman, 1976; One et al., 19811. This is probably due to the fact that the streets are not as well lit in Delhi and the small capacity MTWs and bicycles do not have bright lights

which could make them more conspicuous. Road hazards appear to be an important factor also. Eight of the victims claimed that they crashed while trying to save pedestrians on the road and another two crashed with an animal on the road. In another seven cases the crash was reported

due to obstacles or holes in the road.

HUMAN FACTORS

Age and sex. Only 13% of the victims were females. This represents the low number of females using two-wheelers as transport in Delhi. Accurate statistics for exposure are

not available. The age distribution for 76 patients is given in Table 6. This shows that 36 (47%) patients were over 30 yr old and 10 were more than 50 yr old. Only 5 were in their late teens of which 3 were cyclists. This is very different from the age distribution presented by Kraus et al. [ 19751, Hurt [ 19791 and Bothwell [ 19621. In the present study the median age is 29 with 13% over 50 yr old, whereas in Hurt’s study (6) the median age was 24.8 years with only 5% over 50 yr old. In general, a much older group uses two-wheelers in Delhi as these vehicles are used mainly for commuting and not as sports vehicles and not many teenagers can afford to own them.

Experience. Only two victims reported driving experience of less than two years. This is in sharp contrast with Hurt’s (1979) study where 29% had less than 1 yr riding experience

Table 4. Crash location of two-wheeler on the road

Location

Road Junction

Straight road

Off road

Unknown

Number of patients

7

54

2

24

Total 87

Study of crash victims hospitalized in a neuro-surgery ward

Table 5. Details of the object two-wheelers collided with

411

Other object Nunber of CBSBS

Pedestrian 4

Animal 2

Car 7

Bus 3

Truck 6

Other two-wheeler 9

No collision 29

Unknown 27

Total 07

and Kraus’s [1975] study where 72% had less than 1 yr experience. Lack of riding experience has been considered to be a major factor in accident causation in studies conducted in Europe and U.S.A. but the results of this study show that in Delhi this does not seem to be very important.

Alcohol. 29% of the victims reported having consumed alcohol before the crash. Blood alcohol levels were not obtained. Since this figure is based on self-reporting, it may be an underestimate.

INJURY AND HELMET USE

Super$ciul injury. Out of a total of 87 patients 29 claimed that they had their helmets on but only 16 reported to have tied the straps. Since this study was done in a Neurosurgery Ward, all the patients had head/neck or facial injuries (Table 7). The face was the most frequently injured area followed by the scalp and hands. At least 11 (38%) of the patients who claimed helmet use suffered from abrasions and lacerations of the scalp which would not have normally occurred if the helmet was on the head during impact. Therefore, the helmet either flew off before the head impacted the ground or the recollections of these patients regarding helmet use are not accurate. None of the victims sustained soft tissue injuries on the crown of the head whether wearing a helmet or not. None of the injuries was found to be caused by a pointed object and no serious lacerations were judged to be due to sharp objects. Vallee et al. [1981] and Walz and Burkart [1982] also report that impacts to the top of the head are very rare but in their samples the fronto-facial area was most frequently injured. This difference is partly due to the higher rate of helmet use in their studies and so the parietal and temporal areas were better protected. Vallee er al. [ 198 l] also record that most of the objects struck were flat or corner type objects. The results of this study indicate that helmets should provide more protection

Table 6. Age distribution of two-wheelers crash victims

Age in years Vehicle type

o-4 5-14 15-20 21-30 31-40 41-50 >50 Total

Bicycle 1 3 2 5 - I12

Motorized two-wheeler - 2 2 30 14 7 9 64

Total 3 5 32 19 7 10 76

412 B. K. MISHFA ef al.

Table 7. Numbers and locations of superficial injuries of two-wheeler riders

Region Bicycle Motorized Two-wheeler

Claimed Helmet use No Helmet

AC L A C L A C L

Forehead 2

Face 7

Scalp 1

Neck 1

Shoulder 1

Arm 1

Forearm 1

Elbow 2

Hand

Trunk

Thigh

Leg 1

Foot

4

1 10

4 3

2

4

3

3

0 2

5

3

0 7

2

2

7 15

3 6

4

2

2

3

10

1 6

5

5

1

A - Abrasion C - Contusion L - Laceration

in the temporal and parietal areas of the head. The present Indian Helmet Standard (IS1 4151) does not specify any shock absorption test for the parietal-temporal area of the helmet and the standard would have to be ammended to make the helmets safer in side impacts. Since impacts by sharp and pointed objects seem to be rare even in the Indian conditions where road traffic has much more variety with hand carts and older vehicles, it would be worth while to re-examine the usefulness of the penetration test as specified in the standard.

Table 8. Numbers and locations of fractures (other than head) of two-wheeler riders

Location Number of fractures

Bicycle MTW

Maxilla 1

Mandible 1 2

Clavicle 1 4

Cervical Spine 3

SCapUla 1 2

Ribs 1 1

Humerus 1 1

Radius and Ulna 1 2

Femur 2

Tibia and Fibula 2 4

Total 8 22

Study of crash victims hospitalized in a neuro-surgery ward

Table 9. Location of skull fractures of two-wheel crash victims

Number of fractures+

413

Location of skull frsc- turs

Bicycle Motorized two-wheelers

Claimed No helmet Helmet use helmet use unknown

9 patients 11 patients 19 patients 4 patients

Frontal 3 2 5

Psrietal 6 4 12 1

Temporal 4 5 7 1

Occipital - 7

Base 1 5 3 2

* Single fractures of rmltiple bones srs listed under each bone e.g. a

fracture extending from the temporal to the psrietsl bone will be

listed under both psrietsl and temporal.

Fractures. The locations of skull fractures and distribution of other skeletal fractures are given in Table 8 and 9. There were only 3 cervical spine fractures and these only in the MTW group. Though bicycle riders constitute only 17% of the sample they account for 27% of the fractures. It is possible that this may be due to the small sample available for analysis.

Of the 87 cases 43 sustained skull fractures: 60% of the bicyclists and 47% of MTW riders. Here again we see that the larger fraction of bicyclists sustain skull-fractures than MTW riders. McDermott and Klug [ 19821 report from Australia that an analysis of police and coroner’s reports indicate that head injuries were significantly more frequent among bicyclists than mo- torcyclists. They attribute this mainly due to use of helmets by motorcyclists. However, in this study only 32% of the MTW riders claimed helmet use. Out of the cases where helmet use was claimed there were at least 11 (38%) with superficial scalp injuries which indicate that the helmet was not on the head during impact. Therefore, helmet use should not contribute to that great a difference between the incidence of severe injuries to bicyclists and MTW riders. This difference may be mainly due to self-selection or the sampling problems referred to earlier. In both class of riders the parietal and temporal region was most frequently fractured.

Zntracruniul lesions. Distribution of intracranial lesions is shown in Table 10. Intra- cranial lesions were sustained by 40% of the bicyclists and 35% of the MTW riders

Table 10. Intracranial lesions sustained by two-wheeler crash victims

Number of csses

Bicycle Motorized two-wheeler Type of lesion Total

Claimed No Helmet helmet use helmet use

unknown

Extrsdursl 0 2 2 hemstoms

hemstoms/contusion/3 Intrscerebrsl 6 13 2 24

laceration

Brain edema 3 1 1 5

Total 6 7 16 2 31

414 B. K. MISHRA et al.

admitted to the hospital. Intracerebral lesions (contusions and/or haematoma) were the most common types of lesions.

Head injury severity. Head injury scores of all the riders accordcing to outcome are shown in Table 11. Of the 87 admitted to the Neurosurgery Ward, 1 bicyclist (7%) out

of a total of 15 and 3 MTW riders (10%) out of a total of 29 claiming helmet use and 11 (25%) of the other MTW riders died of their injuries. This is a high fatality rate considering that for hospitalized patients Pedder et al. [1981] report 9% mortality in a Birmingham hospital and Feldkamp and Junghanns [1976] 8% mortality in Heidelberg. This is probably because only head injured patients are included in the present study, helmet use is higher in other studies, more serious injury patients are included in this study as all admissions of less that 24 hr have been excluded.

The fatality rate of the helmeted (claimed) riders is much less than the unhelmeted riders even though 38% of the former probably did not have their helmets on at the time of head impact. An examination of the type of injuries sustained by MTW riders who were judged to have had their helmets on during impact indicates that the helmets played a significant role in preventing more serious injury. An AIS score of 5 for head injury was observed in 33% of the bicyclists, 24% of the helmeted (claimed) MTW riders and 56% of the unhelmeted MTW riders. Of these 35% died and 47% suffered permanent neurological deficit. Fewer helmeted riders suffered a neurological deficit than non- helmeted riders. A study based on road observations by Mohan [1983] reports a much higher helmet use statistic (58%) than observed in this study. This shows that a larger percentage of unhelmeted riders sustain serious head injuries and get admitted to AIIMS.

Table 11 shows that 43% of all cases had head AIS of 5, 23% had an AIS of 4, and 82% had an AIS of 3 or more. These are very high proportions for serious injuries compared to the studies in Europe and the U.S. referenced above. This again indicates that more seriously injured patients gain admission to the neurosurgery ward at the hospital being used for this study.

Overall injury. Table 12 shows the ISS of the crash victims and their status vis-a-vis permanent disability and death. Only 24 (28%) of the patients had scores less than 16. The data show that probability of death or permanent disability rises dramatically with scores of more than 25.

Hospital stay. The above discussion shows that the two-wheeler victims had serious injuries but only 8% stayed in the hospital for more than 4 weeks. 68% were either discharged or died within the first week, 18% in the second week and 6% in the third week. This is not significantly different from the treatment periods of other patients in the same ward. This may be because factors like pressure on bed space and ability of patients to stay in the hospital may have influence on the length of hospital stay. Therefore the average values for different groups may end up being nearly the same. A more detailed study would be necessary to determine factors influencing hospital stay and whether these statistics can be compared with those from other countries.

Table Il. Head injury severity of riders classified according to out comes

AIS Bicyclists Claimed No helmet Helmet use Total score helmet "se unknown

N D E N D E ND E N D E

1. _-_ 2 - - 2__ -__ 4(5X)

2. 5 - - 3 - - 4__ _-- 12(14%)

3. 2 - - 6 - - 6__ -__ 14(16?;)

4. 3 - - 9 2 - 221 -l- 20(23%)

5. 13 1 2 2 3 3118 -12 37(43%)

Total 11 3 1 22 4 3 17 13 9 - 2 2 87(101%)

N-No Neurological deficit O-Neurological deficit E-Expired

Study of crash victims hospitalized in a neuro-surgery ward

Table 12. Injury severity score and permanent physical disability of two-wheeler crash victims

415

15s scars Number of CBSES

No disability Permanent Expired Total disability

o-5 7 (100%) 7 (100%)

6-10 13 (100%) 13 (100%)

11-15 4 (100%) 4 (100%)

16-20 12 (75%) 3(19%) l( 6%) 16 (100%)

21-25 9 ( 56%) 4c?5%) 3 (19%) 16 (100%)

26-30 3 (15%) 9(45%) 8 (40%) 20 (100%)

> 30 2 (18%) 6(55%) 3 (27%) 11 (100%)

Total 50 (57%) 22(25X) 15 (17%) 87 (99%)

CONCLUSIONS

(1) Two-wheeler collision patterns are very different in Delhi compared to those in more industrialized nations. In particular, rear impacts and collisions on straight roads seem to be more frequent in Delhi. Bicyclists appear to be under represented in this hospital based study.

(2) Two-wheeler crash victims in Delhi appear to be much older and have more driving experience than in Europe and the Americas. Driving experience does not appear to be a critical factor in crash causation.

(3) The average injury severity of those admitted to our hospital appears to be greater than reported in studies from industrialized nations.

(4) Helmeted riders of MTWs appear to sustain less serious head injuries than unhelmeted riders.

(5) It appears that at least 38% of those who claimed helmet use did not have their helmets on during head impact. More comfortable chin-straps with better retention capabilities would help alleviate this problem.

(6) There were no injuries on top of the head and or due to pointed objects. Most of the impacts were on the sides of the head. Helmet designs and standards need to be modified to provide greater protection to the sides and re-examine the utility of the penetration test.

(7) Most of the two-wheeler victims admitted to the neurosurgery ward had severe head injuries of which 17% died and 25% suffered permanent disability.

REFERENCES - Baker S. P. and O’Neill, B., The injury severity score: an update. J. Trauma, 16(11), 882-885, 1976. Bothwell P. W., The problem of motorcycle accidents. Practioner. 188, 874488, 1962. Bragg B. W. E., Dawson N. E. and Jonah B. A., Profile of the Accident Involved Motorcyclist in Canada.

Proc. Inr. Motorcycle .Safq Conf. III: 1131-l 151, Linthicum, Maryland, Motorcycle Safety Foundation, 1980.

Feldkamp G. and Junghanns K. The typical Traffic Accidents in Adolescents: The Motorcycle Accident-Some Epidemiological Features and the Effectiveness of Safety Helmets and Clothing. Proc. Meeting on Biomechanics of Injury to Pedestrians, Cyclists and Motorcyclists. 75-80, IRCOBI, Bron, France, 1976.

Haddad J. P. et al., Motorcycle accidents: A review of 77 patients treated in a three month period: J. Trauma, 16(7), 550-557, 1976.

Hurt H. H., Status Report of Accident Investigation Data, Motorcycle Accident Cause Factors and Identification of Countermeasures. DOT-HSS-01160, Springfield, Virginia, National Technical Information Service, 1979.

Joint Committee on Injury Scaling, The Abbreviated Injury Scale (AIS), 1980 Revision, Arlington Heights Illinois, American Association for Automotive Medicine, 1980.

Kawano S., Actual status and preventive measures for motorcycle accidents in Japan. Proc. Int. Mororcycle Co& III: 1223-1256, Linthicum, Maryland, Motorcycle Safety Foundation, 1980.

416 B. K. MJSHRA et al.

Kraus J. F., Riggins R. S. and Franti C. E., Some epidemidogical features of motorcycle collision injuries-I. Introduction, methods and factors associated with incidence. Am. J. Epidemiol. 102(l), 74-98, 1975.

Langwieder K., Collision characteristics and injuries to motorcyclists and moped drivers. Proc. 21sr Srapp for conf, P-73, 261-301, Warrendale, Pennsylvania, Society of Automotive Engineers. 1977.

McDermott E T. and Klug G. L., Differences in head injuries of pedal cyclist and motorcyclist casualities in Victoria. Med. J. Aust, 2, 30-32, 1982.

Mohan D., Discard the helmet and die. Science Today, XVI(2), 45-51, 1982. Mohan D., A study of helmet and motorized two-wheeler use patterns in Delhi, Indian Highways, 115, 8-16, 1983. Newman J. A., Characteristics of Motorcycle Accidents Proceedings of the Meeting on Biomechanics of Injury to

Pedestrians, Cycbsts and Motorcyclists. 250-259 Bran, France, International Research Committee on the Biokinetics of Impacts, 1976.

Otte D., Kalbe P. and Suren E. G., Typical Injuries to the Soft Body Parts and Fractures of the Motorized Two-wheelers. Proc. 6th Int. IRCOBI Conf. Biomechanics of Impacts. 148-165 Bron, France, International Research Committee on the Biokinetics of Impacts. 1981.

Pedder J. B. et al., A study of Two-wheeled Vehicle Casualties Treated at a City Hospital. Proc. 6th Int. IRCOBI Co@ Biomechanics of Impacts. 111-127, Bron, France, International Research Committee on the Biokinetics of Impacts, 1981.

Report on Road Accidents and Encorcement 1980. Delhi Traffic Police, New Delhi, 1981. Mimeo. Specifications for Protective Helmets for Scooter and Motorcycle Riders, IS: 4151, New Delhi, Indian Standards

Institution. Vallee H. et al., Characteristics of Objects Struck by the Head of Moped Riders or Motorcyclists. Proc. 6rh Int.

IRCOBI Conf. the Biomechanics of Impacts. Bron, France, International Research Committee on the Biokinetics of Impacts, 1981.

Walz F. and Burkart F., Fahrradunfalle: Kopfanprallstelle and Implikationen fur die schutzhelmentwicklung. Gerichtlich Medizinisches Instut, Universitat Zurich, 1982.