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Pelvis and hip joint injuries as a reconstructive factors in car-to-pedestrian accidents
Forensic Science International 124 (2001) 68±73
Pelvis and hip joint injuries as a reconstructive factors in car-to-pedestrian accidents Grzegorz TeresinÂski*, Roman MaÎdro Department of Forensic Medicine, Medical Academy in Lublin, ul. Jaczewskiego 8, 20-090 Lublin, Poland Received 23 April 2001; accepted 26 July 2001
Abstract The pelvic girdles of 371 pedestrian victims of road traf®c accidents were evaluated during postmortem examinations. Additionally, 144 hip joints were opened. The pelvic injuries were found in 28% of the pedestrians hit exclusively in their upright position and 52% of the victims run over by a vehicle. The side of the body hit by a car was determined on the basis of the location of blood suffusions within the subcutaneous tissues and muscles of lower limbs as well as the character of injuries found in the knee and upper ankle joints. The ®ndings were veri®ed with the data from court records. It was shown that the injuries of the sacroiliac joints or vertical fractures of the posterior parts of iliac bones were useful parameters for determining the side (left or right) of the body hit by a vehicle. Moreover, it was found that a direct impact on the hip region was evidenced by the ipsilaterally localized fractures of the iliac ala, central hip fractures and intraosseous blood suffusions within the greater trochanter of the femur. The external dislocations of the hip joints (always) and bilateral injuries to the sacroiliac joints (usually) were observed in the victims run over by vehicles. # 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Traf®c accidents; Pedestrian victims; Pelvic injuries; Hip injuries; Mechanism of injury; Reconstruction of accident
It is generally understood that running over the hip region with a vehicle wheel often results in multi-site pelvis injuries [1,2]. The literature provides the results of studies concerning the resistance of the pelvis and pathomechanism of its injuries under static loads and dynamic crushing or compressive forces in drivers and passengers [3±5]. Moreover, the clinical and statistical studies show that pelvic injuries are often observed in pedestrians knocked down in the upright position [6±8]. The pelvic region comes into contact with the car body (usually the bonnet or boot) in the early stages of accidents. In the cases of box-shaped cars (vans, buses and lorries) the pelvis may even be the place of primary contact with the vehicle. Unfortunately, there are no detailed biochemical and statistical studies dealing with
the relations between the location of dynamic force application and pelvis discontinuation observed in pedestrians.1 Thus, it was fully justi®able to select the hip girdle as a structure in which the injuries useful for reconstructing car-topedestrian accidents are likely to be found. Our studies also included the hip joints injuries discussed earlier in literature as the ones which had resulted from knee-to-dashboard hits of drivers and passengers [1,9]. Their usefulness in reconstructing car-to-pedestrian accidents was based on the well known mechanism of so-called central dislocations of these joints [2] which might be expected in lateral impacts. For the same reasons, it was assumed that a strong impact on the greater trochanter could result in the injuries within its region [10]. Clinical observation shows [2] that hip girdle injuries occur in three mechanisms: direct (at the site of force application), indirect (at the site of the greatest tensions connected with its
* Corresponding author. Fax: 48-81-747-64-27. E-mail address: [email protected] (G. TeresinÂski).
1 E.g. Spitz was of the opinion [9] that fractures of the pubic rami occur contralaterally to the injury, while the findings of Nusholtz et al. [5] showed that such fractures were localized on the damaged side.
1. Introduction
0379-0738/01/$ ± see front matter # 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 7 9 - 0 7 3 8 ( 0 1 ) 0 0 5 6 7 - 9
G. TeresinÂski, R. MaÎdro / Forensic Science International 124 (2001) 68±73
Fig. 1. Pelvic injuries found in lateral impacts (X-impact side; Aseparation of the right sacroiliac joint; B-double vertical fracture of the pelvic girdle on the right Ð the so-called Malgaigne's fracture; C-fracture of the left iliac ala; D-vertical fracture of the left iliac bone and pubic symphysis separation).
Fig. 2. Mechanism of central fracture (A) or dislocation (B) of the hip acetabulum (X-impact side; S-intraosseous suffusions within the greater trochanter).
deformation) or avulsion-like (when rapid muscle strain breaks off a bone fragment at the place of tendon attachment). Only the ®rst two mechanisms are practically useful for determining the side of impact on the pedestrian's body since the third one occurs mainly in sportsmen. The direct mechanism involves isolated fractures of the iliac alae, central fractures of the hip acetabula and fractures of the sacral bone and coccyx. Fractures of single rami of the pubic or ischial bones, can occur in the direct and indirect mechanism while multi-site injuries of the osteo®brous ring of the pelvic girdle usually result from complex compressive forces (Figs. 1 and 2). Fractures of the proximal epiphyses of the femoral bones (neck and peritrochanteric fractures) usually occur when mechanical injury (or only an overloading factor) is combined with involutional changes [2,10]. 2. Material and methods The autopsies of 371 pedestrian victims of road traf®c accidents were performed in the Department of Forensic
69
Medicine, Medical Academy in Lublin from 1996 to mid 1999. The pelvic girdles (omitting the coccygeal vertebrae) were assessed after removing abdominal organs and preparing iliolumbar muscles. The fractures and injuries to the syndesmoses were then visible or palpable (pathological mobility or deformation), particularly when both sides of the pelvis were grasped by the iliac alae and moved. The blood suffusions in the ligamentous region were also indicative of its damage. The hip joints were opened in 144 cases. They were reached from the rear after preparing gluteal muscles. Then, the articular capsule around the femoral collum and ligament of the head were cut and the head was moved beyond the acetabulum. This allowed us to assess the content of the articular cavity, the acetabular base, its labrum and the surface of the head. Moreover, the intraosseous blood suffusions within the greater trochanter of femur were searched for (after sawing it through or chiselling). The fractures of the ischial rami were grouped together with the fractures of lower rami of the pubic bone. The vertical fractures of the hip bone or lateral parts of the sacral bones adjacent and parallel to the sacroiliac joints were treated as the injuries of these joints (the way orthopaedic surgeons deal with them). Furthermore, the material included the collum and trochanteric fractures of the femur bone and external dislocations of the hip joint. In Table 1 these injuries were listed with the side of impact (front, rear or lateral). The side was determined once the autopsy ®ndings were compared with the data found in the ®les of the Public Prosecutor's Of®ces and Courts. The oblique impacts (e.g. from the lateral and rear side) were grouped according to the dominant component. The lateral impacts (left or right) were divided into two subgroups. In the ®rst group the injuries occurred on the side hit by the car (ipsilaterally) while in the second one on the opposite side (contralaterally). 3. Results The injuries to the pelvic girdle were found in 127 cases, i.e. in 34% of all the victims examined (n 371); they were more frequently observed in the elderly. After preliminary evaluation the data concerning the victims run over by vehicles (n 90) were selected, even if they had previously been hit in the upright position and it was possible to determine the side of impact. It turned out that the pelvic injuries in those run over were observed twice as frequently (52%) compared to the victims hit exclusively in the position close to the upright one (28%). Table 1 shows that in the pedestrians hit by vehicles in the upright position (and who were not secondarily run over), the fractures of the upper rami of the pubic bones (n 69) and injuries to the sacroiliac joints (n 45) were most commonly observed; less frequent were the fractures of the lower rami of the pubic bones or rami of the ischial bones (n 21) and disruptions of the pubic symphysis
G. TeresinÂski, R. MaÎdro / Forensic Science International 124 (2001) 68±73
70
Table 1 Pelvic injuries in pedestrian victims according to the side of impact Impact sidea From lateral Ipsilateral Number of cases examined Number of cases with pelvic injuries Damageb Pubic symphysis Upper ramus of pubic bone Lower ramus of pubic bonec Iliac ala Sacroiliac joint Trochanteric and collum fractures Complete dislocations of hip joint
Contralateral
146 49
28 11 3 31 3 0
10
14 5 1d 2e 2f 0
Run over
Total
From rear
From front
Not determined
86 24
23 3
26 4
90 47
371 127
5 23 2 1 7 0 0
2 1 0 0 3 0 0
2 3 3 0 2 0 0
18 42 15 14 33 2 4
37 111 36 19 78 7 4
a
All cases with secondary running over were excluded. If a victim sustained several injuries, each of them was considered in the table. c With fractures of the ramus of ischium. d Due to oblique±tangent lateral impact on the lower limb, the victim's body rotated and was thrown onto the bonnet hitting it with the right gluteal region. e In the ®rst case Ð bilateral disruption (a man weighing 140 kg hit by Fiat 126), in the second one Ð contralateral damage to the sacroiliac joint accompanied by complete disruption of the pedestrian's lower trunk caused by the front roof edge of a speeding car. f Elderly victims. b
(n 19) while the fractures of the iliac alae were very rare (n 5). No fractures of the central sacral bones were found. In lateral impacts (left or right), the fractures of the pubic and ischial bones were about twice as frequently observed on the side hit by the car. It is noteworthy, however, that 33 out of 45 injuries to the sacroiliac joints were found in lateral impacts and 31 of them were localized on the side of impact, i.e. ipsilaterally. Furthermore, in the group of victims with sacroiliac injuries hit from the front or the rear (n 10) in eight cases the ``bumper'' injuries to soft tissues (indicating the places of contact with a car) were localized only within one lower limb2 Ð always on the side of the damaged joint. In the whole group examined (n 371) only seven collum and trochanteric fractures of the femur and four external hip dislocations were found. It should be stressed that the external dislocations occurred exclusively in the run over victims. The collum and trochanteric fractures were observed in ®ve cases of lateral impacts; in two of them (the elderly) they were localized contralaterally. Among ®ve iliac ala fractures in the victims hit in their upright position from the lateral side four injuries were localized ipsilaterally while one was localized contralaterally.3 Since in the majority of cases the discontinuation of the pelvic girdle occurred in more than one place, the most frequent complexes of its injuries were selected and 2
The hits with a corner of cars. The oblique±corner±like injury in which the body rotated and the opposite side of the pelvic girdle hit the car. 3
analyzed (Table 2). However, such a sub-grouping did not increase the possibilities of deducing on the side of impact in the upright position. Thus, the best parameters to determine the side of impact in lateral hits (right or left) were the injuries to the sacroiliac joints4. This conclusion is consistent with the ®ndings of Voigt5 [11], Spitz6 [9] and Nusholtz et al.7 [5]. However, there were no pelvic injuries found which would enable us to differentiate between the front and rear impacts. Moreover, the results presented in Table 2 allow to assume that bilateral injuries to the sacroiliac joints are highly indicative of running over as such injuries were observed in 11 out of 90 victims run over (12%) and in only two out of 281 pedestrians knocked down in the upright position (0.7%). 4 Irrespective of the location of possible further damage to the pelvic girdle. 5 Who examined macerated pelvic girdles of 24 pedestrian victims of road traf®c accidents (including three victims run over in the lying down position) but analyzed them with other victims (cyclists and motor cyclists) to classify the mechanisms of injuries rather than to reconstruct the accidents. 6 Mentioning possible injuries to the sacroiliac joints in pedestrians, he only stated that ``the ilium, particularly the sacroiliac joint, on the same side as the impact, is rarely spared''. 7 Who hit the slung cadavers with a pendulum (to assess the forces acting on drivers and passengers in lateral and front impacts).
G. TeresinÂski, R. MaÎdro / Forensic Science International 124 (2001) 68±73
71
Table 2 Pelvic injuries complexes in pedestrian victims according to the side of impact Impact sidea From lateral
Damageb Both sacroiliac joints Upper ramus of both pubic bones Lower ramus of both pubic bonesc Both rami of one pubic bonec Both rami of both pubic bonesc Sacroiliac joint and pubic symphysis Sacroiliac joint and pubic or ischial bone on the same side Sacroiliac joint and pubic or ischial bone on opposite sides Both iliac alae
9 7d 21d 13d 0
Total
From rear
From front
Not determined
146 49
86 24
23 3
26 4
90 47
371 127
1 8 4
0 3 0 1 0 3 1 1 0
1 0 0 0 0 2 1 1 0
0 1 1 2 1 1 0 0 0
11 13 5 8 5 12 19 20 1
13 25 10 23 8 26 42 36 1
Ipsilateral Number of cases examined Number of cases with pelvic injuries
Run over
2
Contralateral
3 1d 0 1d,e 0
a
All cases with secondary running over were excluded. If a victim sustained several complexes of injuries, each of them was considered in the table. c Or the ramus of the ischial bone instead of the lower ramus of pubic bone. d The side of impact in relation to location of the damaged sacroiliac joint. e The impact by a speeding car resulted in complete disruption of the trunk, disruption of the right sacroiliac joint and fracture of the left pubic bone, damage to the lower limbs undoubtedly indicated the impact from the left side (see footnote (e) to Table 1). b
The separation of impacts caused by passenger cars did not signi®cantly change the above mentioned relationship. The frequency of pelvic injuries in impacts caused by box-shaped cars was similar. Thus, these ®ndings do not allow to assume that there is a connection between types of vehicles (the shape of the front) and kinds of pelvic injuries. In the ®nal stage of the analysis, the authors additionally checked if there was any relationship between the location of damage to the sacroiliac joint and the load of the lower limbs
on collision. It was assumed that the loaded limb was the one in which the compression symptoms in the epiphyses of the knee joints [12,13] or injuries to the ankle joints [12,14,15] were observed. It was revealed that in 29 out of 45 victims knocked down in the upright position, the sacroiliac injuries were localized on the side of the limb loaded by body weight. Only in ®ve cases the sacroiliac injuries were found on the unloaded limb. In the remaining 11 cases we failed to determine which limb was loaded on impact. It was also found that 23 out of 29 sacroiliac injuries which occurred
Fig. 3. Intraosseous suffusion within the greater trochanter after ``chiselling'' its external part.
G. TeresinÂski, R. MaÎdro / Forensic Science International 124 (2001) 68±73
72
Table 3 Injuries found in 13 out of 144 pedestrian victims in whom hip joints were opened and greater trochanters sawn No.
Hip joint injuries
Pelvic injuries
Circumstances and comments
1.
Central fracture of the right hip
Disruption of the pubic symphysis
2.
Central fracture of the left hip
3.
Central fracture of the right hip
4.
Multifragmental acetabular fracture of the right hip bone
Fracture of the right femoral collum and subtrochanteric on the left side (the victim survived 3 months) Injury to the right sacroiliac joint, fractures of upper rami of both pubic bones and ramus of the left ischial bone Injuries to both sacroiliac joints, disruption of the pubic symphysis
A 45-year-old man hit from the right side by a passenger car A 77-year-old woman probably hit and run over by a backing van
5.
9.
Profuse intraosseous suffusions on the section of the greater trochanter of right femur Profuse intraosseous suffusions on the section on the right greater trochanter Profuse intraosseous suffusions on the section of the right greater trochanter Central dislocation of the right hip, abundant haematoma of the right hip joint, profuse intraosseous suffusion on the section of the right greater trochanter Central dislocation of the left hip
10.
Central dislocation of the right hip
11.
Central dislocation of the right hip
12.
Central dislocation of the left hip
13.
Central dislocation of the right hip
6. 7. 8.
Not found Not found Not found Fracture of the right iliac ala and both upper rami of pubic bones and injuries to both sacroiliac joints Fracture of the left sacroiliac joint, rami of the pubic and ischial bones on the left Not found Fractures of both rami of the right pubic bone and lower ramus of the left pubic bone Injury to the left sacroiliac joint, fractures of upper rami of both pubic bones Injuries to both sacroiliac joints and pubic symphysis
on the loaded limb side resulted from the lateral impacts while the remaining six from the front or rear impacts. The analysis presented above suggests that, irrespective of the side of impact, the injuries to the sacroiliac joints occur most frequently on the side of the loaded limb. The injuries to the hip joints were found in 13 (Table 3) out of 144 victims (80 were knocked down from the lateral side Ð right or left). The central fractures (dislocations) of the hip joints were observed in 10 cases, in eight of them (1, 3, 8±13 Ð Table 3) they resulted from the direct impact at the joint level. In the cases 1, 3, 9±12 and 13 this mechanism was unquestionable considering the remaining postmortem ®ndings. In the case no. 8, however, such a hypothesis was justi®able since, beside some other features of impact from the right side (intravital), the abundant, deep blood suffusions were found on the cross-section of the greater trochanter (Fig. 3) while all the injuries caused by running over (among others, fractures of spinous processes, cranial crushes, fragmentation of the left scapula and
A 38-year-old woman hit from the right side by a passenger car A 65-year-old drunk man (3.2 % blood ethanol) run over by a van, no signs of impact in the upright position A 42-year-old man hit from the right side by a lorry An 18-year-old man hit from the right side by a passenger car A 47-year-old man hit from the right side by a van A 68-year-old woman hit from the right by a passenger car and then run over after death (some injuries without bloody suffusions in their regions) A 26-year-old man hit by a passenger car from the left side A 60-year-old man hit from the right side by a lorry A 68-year-old woman hit from the right side by a passenger car A middle-aged man hit from the left side by a passenger car A 47-year-old man hit from the right side by a passenger car
laceration of the left thigh) did not show any intravital features. The injuries to the hip joint and girdle observed in the case no. 4 undoubtedly resulted from crushing of the pelvis due to running over. Central dislocations of the hip joints in the case no. 2 were treated as a result of falling and hitting a hard surface (or running over the hip region with a car wheel) since the speed of the backing vehicle was too small to bring about such an effect due to direct trauma. The cases 5, 6 and 7 (like case 8) reveal that blood suffusions within the greater trochanter region should be treated similarly to central dislocations of the hip joint, i.e. as a result of direct damage to this region. 4. Conclusions The ®ndings of 371 autopsies show that the examinations of the pelvic girdle and hip joints (including the
G. TeresinÂski, R. MaÎdro / Forensic Science International 124 (2001) 68±73
cross-sections of the greater trochanter) are useful tools in reconstructing the circumstances of car-to-pedestrian accidents as bilateral injuries to the sacroiliac joints and external dislocations of the hip joints are indicative of running over in the lying down position8 while unilateral injuries to the sacroiliac joints, central dislocations of the hip joints and intraosseous suffusions within the greater trochanter allow to differentiate between the left and right impacts in the upright position (i.e. to reconstruct the side from which a pedestrian crossed the road seen by a driver).9 The diagnostic usefulness of the injuries to the hip girdle is not limited to autopsies since they can be easily detected during routine X-ray examinations.
[6]
[7] [8] [9] [10] [11]
References [1] W. DuÈrwald, Gerichtsmedizinische Untersuchungen bei VerkehrsunfaÈllen, VEB Georg Thieme, Leipzig, 1966, pp. 270±376. [2] R. Watson-Jones, Fractures and joint injuries, E. & S. Livingstone Ltd., 1957, pp. 664±712 and 934±945. [3] G.F. McCoy, R.A. Johnstone, J. Kenwright, Biomechanical aspects of pelvic and hip injuries in road traf®c accidents, J. Orthop. Trauma 3 (1989) 118±123. [4] G. Fleischer, D. Kallieris, R. Kappner, G. Schmidt, Zur quantitativen Traumatomechanik der Beckenfraktur, Unfallchirurg. 98 (1995) 398±405. [5] G.S. Nusholtz, N.M. Alem, J.W. Melvin, Impact response and injury of the pelvis, in: S.H. Backaitis (Ed.), Biomechanics of
8 In Poland, a serious issue concerns the so-called ``primary running over'' case in which victims (usually intoxicated) are run over in the lying down position without being previously knocked down in the upright position. The accidents are caused by hit-andrun drivers and the inspection of vehicles is often impossible. 9 Which is relevant to legal assessment of an accident.
[12]
[13]
[14] [15]
73
Impact Injury and Injury, Society of Automotive Engineers, Inc., Warrendale, PT-56, 1996, pp. 319±360. B.J. Brainard, J. Slauterbeck, J.B. Benjamin, Fracture patterns and mechanisms in pedestrian motor-vehicle trauma: the ipsilateral dyad, J. Orthop. Trauma 6 (1992) 279±282. R.W. Bucholz, The pathologic anatomy of Malgaigne fracture-dislocation of the pelvis, J. Bone Joint Surg. A63 (1981) 400±404. J.R. McCarroll, P.W. Brauntstein, W. Cooper, Fatal Pedestrian automotive accidents, JAMA 180 (1962) 127±133. W.U. Spitz, Essential postmortem ®ndings in the traf®c accident victim, Arch. Path. 90 (1970) 451±457. M.H. Meyers, Fractures of the hip, Year Book Medical Publishers, Inc., Chicago, 1985, pp. 38±73. G.E. Voigt, Untersuchungen zur Mechanik der Beckenfrakturen und Ð luxationen, H. Unfallheilkd. 85 (1965) 1±92. G. TeresinÂski, The knee, ankle, hip, pelvis and neck injuries in pedestrian victims of road traf®c accidents Ð their detection and usefulness for reconstructing the accidents, a doctoral thesis, Medical Academy in Lublin, 2001(in Polish). R. MaÎdro, G. TeresinÂski, On the possibility of deducing the circumstances of a road traf®c accident from the knee injuries of pedestrian victims, Problems Forensic Sci. 35 (1997) 83± 102. G. TeresinÂski, R. MaÎdro, Ankle joint injuries as a reconstruction parameter in car-to-pedestrian accidents, Forensic Sci. Int. 118 (2001) 65±73. G. TeresinÂski, R. MaÎdro, Spuren an Schuhsohlenober¯aÈchen von FuûgaÈngerunfallopfern und Verletzungen der Sprunggelenke, Verkehrsunfall und Fahrzeugtechnik 39 (2001) 190± 197.
Pelvis and hip joint injuries as a reconstructive factors in car-to-pedestrian accidents Grzegorz TeresinÂski*, Roman MaÎdro Department of Forensic Medicine, Medical Academy in Lublin, ul. Jaczewskiego 8, 20-090 Lublin, Poland Received 23 April 2001; accepted 26 July 2001
Abstract The pelvic girdles of 371 pedestrian victims of road traf®c accidents were evaluated during postmortem examinations. Additionally, 144 hip joints were opened. The pelvic injuries were found in 28% of the pedestrians hit exclusively in their upright position and 52% of the victims run over by a vehicle. The side of the body hit by a car was determined on the basis of the location of blood suffusions within the subcutaneous tissues and muscles of lower limbs as well as the character of injuries found in the knee and upper ankle joints. The ®ndings were veri®ed with the data from court records. It was shown that the injuries of the sacroiliac joints or vertical fractures of the posterior parts of iliac bones were useful parameters for determining the side (left or right) of the body hit by a vehicle. Moreover, it was found that a direct impact on the hip region was evidenced by the ipsilaterally localized fractures of the iliac ala, central hip fractures and intraosseous blood suffusions within the greater trochanter of the femur. The external dislocations of the hip joints (always) and bilateral injuries to the sacroiliac joints (usually) were observed in the victims run over by vehicles. # 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Traf®c accidents; Pedestrian victims; Pelvic injuries; Hip injuries; Mechanism of injury; Reconstruction of accident
It is generally understood that running over the hip region with a vehicle wheel often results in multi-site pelvis injuries [1,2]. The literature provides the results of studies concerning the resistance of the pelvis and pathomechanism of its injuries under static loads and dynamic crushing or compressive forces in drivers and passengers [3±5]. Moreover, the clinical and statistical studies show that pelvic injuries are often observed in pedestrians knocked down in the upright position [6±8]. The pelvic region comes into contact with the car body (usually the bonnet or boot) in the early stages of accidents. In the cases of box-shaped cars (vans, buses and lorries) the pelvis may even be the place of primary contact with the vehicle. Unfortunately, there are no detailed biochemical and statistical studies dealing with
the relations between the location of dynamic force application and pelvis discontinuation observed in pedestrians.1 Thus, it was fully justi®able to select the hip girdle as a structure in which the injuries useful for reconstructing car-topedestrian accidents are likely to be found. Our studies also included the hip joints injuries discussed earlier in literature as the ones which had resulted from knee-to-dashboard hits of drivers and passengers [1,9]. Their usefulness in reconstructing car-to-pedestrian accidents was based on the well known mechanism of so-called central dislocations of these joints [2] which might be expected in lateral impacts. For the same reasons, it was assumed that a strong impact on the greater trochanter could result in the injuries within its region [10]. Clinical observation shows [2] that hip girdle injuries occur in three mechanisms: direct (at the site of force application), indirect (at the site of the greatest tensions connected with its
* Corresponding author. Fax: 48-81-747-64-27. E-mail address: [email protected] (G. TeresinÂski).
1 E.g. Spitz was of the opinion [9] that fractures of the pubic rami occur contralaterally to the injury, while the findings of Nusholtz et al. [5] showed that such fractures were localized on the damaged side.
1. Introduction
0379-0738/01/$ ± see front matter # 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 7 9 - 0 7 3 8 ( 0 1 ) 0 0 5 6 7 - 9
G. TeresinÂski, R. MaÎdro / Forensic Science International 124 (2001) 68±73
Fig. 1. Pelvic injuries found in lateral impacts (X-impact side; Aseparation of the right sacroiliac joint; B-double vertical fracture of the pelvic girdle on the right Ð the so-called Malgaigne's fracture; C-fracture of the left iliac ala; D-vertical fracture of the left iliac bone and pubic symphysis separation).
Fig. 2. Mechanism of central fracture (A) or dislocation (B) of the hip acetabulum (X-impact side; S-intraosseous suffusions within the greater trochanter).
deformation) or avulsion-like (when rapid muscle strain breaks off a bone fragment at the place of tendon attachment). Only the ®rst two mechanisms are practically useful for determining the side of impact on the pedestrian's body since the third one occurs mainly in sportsmen. The direct mechanism involves isolated fractures of the iliac alae, central fractures of the hip acetabula and fractures of the sacral bone and coccyx. Fractures of single rami of the pubic or ischial bones, can occur in the direct and indirect mechanism while multi-site injuries of the osteo®brous ring of the pelvic girdle usually result from complex compressive forces (Figs. 1 and 2). Fractures of the proximal epiphyses of the femoral bones (neck and peritrochanteric fractures) usually occur when mechanical injury (or only an overloading factor) is combined with involutional changes [2,10]. 2. Material and methods The autopsies of 371 pedestrian victims of road traf®c accidents were performed in the Department of Forensic
69
Medicine, Medical Academy in Lublin from 1996 to mid 1999. The pelvic girdles (omitting the coccygeal vertebrae) were assessed after removing abdominal organs and preparing iliolumbar muscles. The fractures and injuries to the syndesmoses were then visible or palpable (pathological mobility or deformation), particularly when both sides of the pelvis were grasped by the iliac alae and moved. The blood suffusions in the ligamentous region were also indicative of its damage. The hip joints were opened in 144 cases. They were reached from the rear after preparing gluteal muscles. Then, the articular capsule around the femoral collum and ligament of the head were cut and the head was moved beyond the acetabulum. This allowed us to assess the content of the articular cavity, the acetabular base, its labrum and the surface of the head. Moreover, the intraosseous blood suffusions within the greater trochanter of femur were searched for (after sawing it through or chiselling). The fractures of the ischial rami were grouped together with the fractures of lower rami of the pubic bone. The vertical fractures of the hip bone or lateral parts of the sacral bones adjacent and parallel to the sacroiliac joints were treated as the injuries of these joints (the way orthopaedic surgeons deal with them). Furthermore, the material included the collum and trochanteric fractures of the femur bone and external dislocations of the hip joint. In Table 1 these injuries were listed with the side of impact (front, rear or lateral). The side was determined once the autopsy ®ndings were compared with the data found in the ®les of the Public Prosecutor's Of®ces and Courts. The oblique impacts (e.g. from the lateral and rear side) were grouped according to the dominant component. The lateral impacts (left or right) were divided into two subgroups. In the ®rst group the injuries occurred on the side hit by the car (ipsilaterally) while in the second one on the opposite side (contralaterally). 3. Results The injuries to the pelvic girdle were found in 127 cases, i.e. in 34% of all the victims examined (n 371); they were more frequently observed in the elderly. After preliminary evaluation the data concerning the victims run over by vehicles (n 90) were selected, even if they had previously been hit in the upright position and it was possible to determine the side of impact. It turned out that the pelvic injuries in those run over were observed twice as frequently (52%) compared to the victims hit exclusively in the position close to the upright one (28%). Table 1 shows that in the pedestrians hit by vehicles in the upright position (and who were not secondarily run over), the fractures of the upper rami of the pubic bones (n 69) and injuries to the sacroiliac joints (n 45) were most commonly observed; less frequent were the fractures of the lower rami of the pubic bones or rami of the ischial bones (n 21) and disruptions of the pubic symphysis
G. TeresinÂski, R. MaÎdro / Forensic Science International 124 (2001) 68±73
70
Table 1 Pelvic injuries in pedestrian victims according to the side of impact Impact sidea From lateral Ipsilateral Number of cases examined Number of cases with pelvic injuries Damageb Pubic symphysis Upper ramus of pubic bone Lower ramus of pubic bonec Iliac ala Sacroiliac joint Trochanteric and collum fractures Complete dislocations of hip joint
Contralateral
146 49
28 11 3 31 3 0
10
14 5 1d 2e 2f 0
Run over
Total
From rear
From front
Not determined
86 24
23 3
26 4
90 47
371 127
5 23 2 1 7 0 0
2 1 0 0 3 0 0
2 3 3 0 2 0 0
18 42 15 14 33 2 4
37 111 36 19 78 7 4
a
All cases with secondary running over were excluded. If a victim sustained several injuries, each of them was considered in the table. c With fractures of the ramus of ischium. d Due to oblique±tangent lateral impact on the lower limb, the victim's body rotated and was thrown onto the bonnet hitting it with the right gluteal region. e In the ®rst case Ð bilateral disruption (a man weighing 140 kg hit by Fiat 126), in the second one Ð contralateral damage to the sacroiliac joint accompanied by complete disruption of the pedestrian's lower trunk caused by the front roof edge of a speeding car. f Elderly victims. b
(n 19) while the fractures of the iliac alae were very rare (n 5). No fractures of the central sacral bones were found. In lateral impacts (left or right), the fractures of the pubic and ischial bones were about twice as frequently observed on the side hit by the car. It is noteworthy, however, that 33 out of 45 injuries to the sacroiliac joints were found in lateral impacts and 31 of them were localized on the side of impact, i.e. ipsilaterally. Furthermore, in the group of victims with sacroiliac injuries hit from the front or the rear (n 10) in eight cases the ``bumper'' injuries to soft tissues (indicating the places of contact with a car) were localized only within one lower limb2 Ð always on the side of the damaged joint. In the whole group examined (n 371) only seven collum and trochanteric fractures of the femur and four external hip dislocations were found. It should be stressed that the external dislocations occurred exclusively in the run over victims. The collum and trochanteric fractures were observed in ®ve cases of lateral impacts; in two of them (the elderly) they were localized contralaterally. Among ®ve iliac ala fractures in the victims hit in their upright position from the lateral side four injuries were localized ipsilaterally while one was localized contralaterally.3 Since in the majority of cases the discontinuation of the pelvic girdle occurred in more than one place, the most frequent complexes of its injuries were selected and 2
The hits with a corner of cars. The oblique±corner±like injury in which the body rotated and the opposite side of the pelvic girdle hit the car. 3
analyzed (Table 2). However, such a sub-grouping did not increase the possibilities of deducing on the side of impact in the upright position. Thus, the best parameters to determine the side of impact in lateral hits (right or left) were the injuries to the sacroiliac joints4. This conclusion is consistent with the ®ndings of Voigt5 [11], Spitz6 [9] and Nusholtz et al.7 [5]. However, there were no pelvic injuries found which would enable us to differentiate between the front and rear impacts. Moreover, the results presented in Table 2 allow to assume that bilateral injuries to the sacroiliac joints are highly indicative of running over as such injuries were observed in 11 out of 90 victims run over (12%) and in only two out of 281 pedestrians knocked down in the upright position (0.7%). 4 Irrespective of the location of possible further damage to the pelvic girdle. 5 Who examined macerated pelvic girdles of 24 pedestrian victims of road traf®c accidents (including three victims run over in the lying down position) but analyzed them with other victims (cyclists and motor cyclists) to classify the mechanisms of injuries rather than to reconstruct the accidents. 6 Mentioning possible injuries to the sacroiliac joints in pedestrians, he only stated that ``the ilium, particularly the sacroiliac joint, on the same side as the impact, is rarely spared''. 7 Who hit the slung cadavers with a pendulum (to assess the forces acting on drivers and passengers in lateral and front impacts).
G. TeresinÂski, R. MaÎdro / Forensic Science International 124 (2001) 68±73
71
Table 2 Pelvic injuries complexes in pedestrian victims according to the side of impact Impact sidea From lateral
Damageb Both sacroiliac joints Upper ramus of both pubic bones Lower ramus of both pubic bonesc Both rami of one pubic bonec Both rami of both pubic bonesc Sacroiliac joint and pubic symphysis Sacroiliac joint and pubic or ischial bone on the same side Sacroiliac joint and pubic or ischial bone on opposite sides Both iliac alae
9 7d 21d 13d 0
Total
From rear
From front
Not determined
146 49
86 24
23 3
26 4
90 47
371 127
1 8 4
0 3 0 1 0 3 1 1 0
1 0 0 0 0 2 1 1 0
0 1 1 2 1 1 0 0 0
11 13 5 8 5 12 19 20 1
13 25 10 23 8 26 42 36 1
Ipsilateral Number of cases examined Number of cases with pelvic injuries
Run over
2
Contralateral
3 1d 0 1d,e 0
a
All cases with secondary running over were excluded. If a victim sustained several complexes of injuries, each of them was considered in the table. c Or the ramus of the ischial bone instead of the lower ramus of pubic bone. d The side of impact in relation to location of the damaged sacroiliac joint. e The impact by a speeding car resulted in complete disruption of the trunk, disruption of the right sacroiliac joint and fracture of the left pubic bone, damage to the lower limbs undoubtedly indicated the impact from the left side (see footnote (e) to Table 1). b
The separation of impacts caused by passenger cars did not signi®cantly change the above mentioned relationship. The frequency of pelvic injuries in impacts caused by box-shaped cars was similar. Thus, these ®ndings do not allow to assume that there is a connection between types of vehicles (the shape of the front) and kinds of pelvic injuries. In the ®nal stage of the analysis, the authors additionally checked if there was any relationship between the location of damage to the sacroiliac joint and the load of the lower limbs
on collision. It was assumed that the loaded limb was the one in which the compression symptoms in the epiphyses of the knee joints [12,13] or injuries to the ankle joints [12,14,15] were observed. It was revealed that in 29 out of 45 victims knocked down in the upright position, the sacroiliac injuries were localized on the side of the limb loaded by body weight. Only in ®ve cases the sacroiliac injuries were found on the unloaded limb. In the remaining 11 cases we failed to determine which limb was loaded on impact. It was also found that 23 out of 29 sacroiliac injuries which occurred
Fig. 3. Intraosseous suffusion within the greater trochanter after ``chiselling'' its external part.
G. TeresinÂski, R. MaÎdro / Forensic Science International 124 (2001) 68±73
72
Table 3 Injuries found in 13 out of 144 pedestrian victims in whom hip joints were opened and greater trochanters sawn No.
Hip joint injuries
Pelvic injuries
Circumstances and comments
1.
Central fracture of the right hip
Disruption of the pubic symphysis
2.
Central fracture of the left hip
3.
Central fracture of the right hip
4.
Multifragmental acetabular fracture of the right hip bone
Fracture of the right femoral collum and subtrochanteric on the left side (the victim survived 3 months) Injury to the right sacroiliac joint, fractures of upper rami of both pubic bones and ramus of the left ischial bone Injuries to both sacroiliac joints, disruption of the pubic symphysis
A 45-year-old man hit from the right side by a passenger car A 77-year-old woman probably hit and run over by a backing van
5.
9.
Profuse intraosseous suffusions on the section of the greater trochanter of right femur Profuse intraosseous suffusions on the section on the right greater trochanter Profuse intraosseous suffusions on the section of the right greater trochanter Central dislocation of the right hip, abundant haematoma of the right hip joint, profuse intraosseous suffusion on the section of the right greater trochanter Central dislocation of the left hip
10.
Central dislocation of the right hip
11.
Central dislocation of the right hip
12.
Central dislocation of the left hip
13.
Central dislocation of the right hip
6. 7. 8.
Not found Not found Not found Fracture of the right iliac ala and both upper rami of pubic bones and injuries to both sacroiliac joints Fracture of the left sacroiliac joint, rami of the pubic and ischial bones on the left Not found Fractures of both rami of the right pubic bone and lower ramus of the left pubic bone Injury to the left sacroiliac joint, fractures of upper rami of both pubic bones Injuries to both sacroiliac joints and pubic symphysis
on the loaded limb side resulted from the lateral impacts while the remaining six from the front or rear impacts. The analysis presented above suggests that, irrespective of the side of impact, the injuries to the sacroiliac joints occur most frequently on the side of the loaded limb. The injuries to the hip joints were found in 13 (Table 3) out of 144 victims (80 were knocked down from the lateral side Ð right or left). The central fractures (dislocations) of the hip joints were observed in 10 cases, in eight of them (1, 3, 8±13 Ð Table 3) they resulted from the direct impact at the joint level. In the cases 1, 3, 9±12 and 13 this mechanism was unquestionable considering the remaining postmortem ®ndings. In the case no. 8, however, such a hypothesis was justi®able since, beside some other features of impact from the right side (intravital), the abundant, deep blood suffusions were found on the cross-section of the greater trochanter (Fig. 3) while all the injuries caused by running over (among others, fractures of spinous processes, cranial crushes, fragmentation of the left scapula and
A 38-year-old woman hit from the right side by a passenger car A 65-year-old drunk man (3.2 % blood ethanol) run over by a van, no signs of impact in the upright position A 42-year-old man hit from the right side by a lorry An 18-year-old man hit from the right side by a passenger car A 47-year-old man hit from the right side by a van A 68-year-old woman hit from the right by a passenger car and then run over after death (some injuries without bloody suffusions in their regions) A 26-year-old man hit by a passenger car from the left side A 60-year-old man hit from the right side by a lorry A 68-year-old woman hit from the right side by a passenger car A middle-aged man hit from the left side by a passenger car A 47-year-old man hit from the right side by a passenger car
laceration of the left thigh) did not show any intravital features. The injuries to the hip joint and girdle observed in the case no. 4 undoubtedly resulted from crushing of the pelvis due to running over. Central dislocations of the hip joints in the case no. 2 were treated as a result of falling and hitting a hard surface (or running over the hip region with a car wheel) since the speed of the backing vehicle was too small to bring about such an effect due to direct trauma. The cases 5, 6 and 7 (like case 8) reveal that blood suffusions within the greater trochanter region should be treated similarly to central dislocations of the hip joint, i.e. as a result of direct damage to this region. 4. Conclusions The ®ndings of 371 autopsies show that the examinations of the pelvic girdle and hip joints (including the
G. TeresinÂski, R. MaÎdro / Forensic Science International 124 (2001) 68±73
cross-sections of the greater trochanter) are useful tools in reconstructing the circumstances of car-to-pedestrian accidents as bilateral injuries to the sacroiliac joints and external dislocations of the hip joints are indicative of running over in the lying down position8 while unilateral injuries to the sacroiliac joints, central dislocations of the hip joints and intraosseous suffusions within the greater trochanter allow to differentiate between the left and right impacts in the upright position (i.e. to reconstruct the side from which a pedestrian crossed the road seen by a driver).9 The diagnostic usefulness of the injuries to the hip girdle is not limited to autopsies since they can be easily detected during routine X-ray examinations.
[6]
[7] [8] [9] [10] [11]
References [1] W. DuÈrwald, Gerichtsmedizinische Untersuchungen bei VerkehrsunfaÈllen, VEB Georg Thieme, Leipzig, 1966, pp. 270±376. [2] R. Watson-Jones, Fractures and joint injuries, E. & S. Livingstone Ltd., 1957, pp. 664±712 and 934±945. [3] G.F. McCoy, R.A. Johnstone, J. Kenwright, Biomechanical aspects of pelvic and hip injuries in road traf®c accidents, J. Orthop. Trauma 3 (1989) 118±123. [4] G. Fleischer, D. Kallieris, R. Kappner, G. Schmidt, Zur quantitativen Traumatomechanik der Beckenfraktur, Unfallchirurg. 98 (1995) 398±405. [5] G.S. Nusholtz, N.M. Alem, J.W. Melvin, Impact response and injury of the pelvis, in: S.H. Backaitis (Ed.), Biomechanics of
8 In Poland, a serious issue concerns the so-called ``primary running over'' case in which victims (usually intoxicated) are run over in the lying down position without being previously knocked down in the upright position. The accidents are caused by hit-andrun drivers and the inspection of vehicles is often impossible. 9 Which is relevant to legal assessment of an accident.
[12]
[13]
[14] [15]
73
Impact Injury and Injury, Society of Automotive Engineers, Inc., Warrendale, PT-56, 1996, pp. 319±360. B.J. Brainard, J. Slauterbeck, J.B. Benjamin, Fracture patterns and mechanisms in pedestrian motor-vehicle trauma: the ipsilateral dyad, J. Orthop. Trauma 6 (1992) 279±282. R.W. Bucholz, The pathologic anatomy of Malgaigne fracture-dislocation of the pelvis, J. Bone Joint Surg. A63 (1981) 400±404. J.R. McCarroll, P.W. Brauntstein, W. Cooper, Fatal Pedestrian automotive accidents, JAMA 180 (1962) 127±133. W.U. Spitz, Essential postmortem ®ndings in the traf®c accident victim, Arch. Path. 90 (1970) 451±457. M.H. Meyers, Fractures of the hip, Year Book Medical Publishers, Inc., Chicago, 1985, pp. 38±73. G.E. Voigt, Untersuchungen zur Mechanik der Beckenfrakturen und Ð luxationen, H. Unfallheilkd. 85 (1965) 1±92. G. TeresinÂski, The knee, ankle, hip, pelvis and neck injuries in pedestrian victims of road traf®c accidents Ð their detection and usefulness for reconstructing the accidents, a doctoral thesis, Medical Academy in Lublin, 2001(in Polish). R. MaÎdro, G. TeresinÂski, On the possibility of deducing the circumstances of a road traf®c accident from the knee injuries of pedestrian victims, Problems Forensic Sci. 35 (1997) 83± 102. G. TeresinÂski, R. MaÎdro, Ankle joint injuries as a reconstruction parameter in car-to-pedestrian accidents, Forensic Sci. Int. 118 (2001) 65±73. G. TeresinÂski, R. MaÎdro, Spuren an Schuhsohlenober¯aÈchen von FuûgaÈngerunfallopfern und Verletzungen der Sprunggelenke, Verkehrsunfall und Fahrzeugtechnik 39 (2001) 190± 197.