1. Transportation injuries
Dr. Ravi Nanayakkara

2. Transportation injuries.
Road traffic injuries
Railway injuries
Aircraft Fatalities
Navigational Injuries

3. Objectives
Discuss the role of a judicial medical officer in a case of road traffic accidents
Describe the injury pattern of each road user
Medico – legal investigation of a death due to transportation injuries
Describe the injury pattern in victims of train accidents

4. Road Traffic Injuries
17th August 1896 in London,
Continued…..

5. The World's First Death by Motor Vehicle
On 17th August 1896, Bridget Driscoll, a 44 year old mother of two, became the first person ever killed by a motor vehicle. She and her teenage daughter were on their way to see a dance performance at Crystal palace in London. She was struck by a car as they crossed palace grounds. Witness said the car was going “at tremendous speed”. It may have been going at 8 miles/h (12.8 Km/h), though it was meant to be going no more than 4 miles/h (6.4 Km/h). A young man driving, giving free rides to demonstrate the new invention and , according to some, trying to impress a young female passenger. At the inquest, the coroner said, “This must never happen again”.
Source: World’s first road death. London, Roadpeace. (
-accessed on 11th December 2003.

6. Every day more than 3000 people die of RTA
1.2 million died from RTA,
Over 70 % - age less than 45
2.1% of all global deaths - 11th leading cause
of global deaths

10. Road Traffic Deaths Worldwide by Sex and Age Group

11. Global burden of disease and injuries 1990 rank for RTA 9th 2020 rank for RTA 3rd
50 million people injured each year.
85% deaths due to RTA are in Low income & Middle income countries.

12. Top 10 Leading Contributors to the Global Burden of Disease*
2020
Disease or injury
1990
Disease or Injury
Lower res. tract infections
Diarrhoeal disease
Perinatal conditions
Unipolar major depression
Ischaemic heart disease
Cerebrovascular disease
Tuberculosis
Measles
Road traffic injuries
Congenital abnormalities
Ischaemic heart disease
Unipolar major depression
Road traffic injuries
Cerebrovascular disease
COPD
Lower res. tract infections
Tuberculosis
War
Diarrhoeal disease
HIV
continued…..

13. Every hour 34 RTI deaths take place in South East Asia.
By 2020 this will rise by 144 % compared to 2000.
Every second six persons across the world either die or suffer severe injuries due to RTI

14. Sri Lanka 2009
Every hour at least 6 road crashes
3 injured every hour - 1 killed every 4 1/2 hours
6 per day
33302 lives lost last 20 years per year
Each death costs US$ 1912 (60 times monthly per capita income of US$ 33)

15. Sri Lanka Road traffic deaths - 2500 deaths - 2400 deaths

18. Why should we know about transportation injuries?
To assess injuries for the purpose of treatment.
To evaluate the role of natural disease in the causation of accidents.
To reconstruct the accident.

19. 4. To collaborate, evidence of eyewitnesses. 5
4. To collaborate, evidence of eyewitnesses. 5. To assist in identification of the vehicle. 6. To predict the state of the person involved in the accident. E.g. drunk or drugged. 7. Identification of the victim.

20. 8. Documentation of injuries for the purpose of compensation claims.
9. To determine the cause of death.
10. To evaluate the circumstances of death.
Homicide?
Suicide?
Accidental?

21. Factors affecting the outcome of a RTA
Road + Environment
Vehicle
Human Factors of the road user
Driver
Pedestrian

22. Road + Environment
Road Density ( Vehicle population
on the road )
Condition
Bends, narrow, Steep,
Slippery, Pit holes
Environment
Night, rain, mist, fog,
Snow, Sand­stones, Smog,
Poor lighting at night etc.)

23. Condition (whether road - worthy!) E.g. Absence of breaks Head lamps
Vehicle
Speed
Condition (whether road - worthy!)
E.g. Absence of breaks
Head lamps
Horn
Signal etc.
Continued……

24. Safety devices
They do not reduce the number of
accidents, though will reduce the
fatality rate and morbidity.
E.g. Seat Belt
Head Rests
Crash Helmets (in motor - cyclist)
Collapsible steering wheels
Safety Windscreen glass
Breaking system (ABS)
Air Bags
Locking system etc.

25. Human factors (Commonest cause in Sri Lanka) Driver a) General Health
Old age
Poor vision
Poor hearing
Prolong reaction time
Co-morbid factors such as HTN, DM,
IHD etc.
Continued………

26. b. ) Alcohol Consumption/Intoxication
Alcohol is incriminated for > l/3 of all RTA
Legal Limit < 80 mg / dl in Blood

27. c) Fatigue DROWSINESS TIREDNESS LACK OF ALERTNESS SLEEPINESS
Taking more risks
Frequent yawning, nodding, blinking
Disinterest in carrying on a conversation

28. FATIGUE RELATED TRAFFIC ACCIDENTS
Common examples:
Pilgrimages
Airport drops
Weddings
Holidaymakers
Taxi drivers
Long distance bus drivers
Van drivers

29. FATIGUE RELATED TRAFFIC ACCIDENTS
Alcohol Fatigue
Particular group Every driver
Measurable No tests
Preventable No warning
Curable Very few treatable

30. Pedestrians
Intoxicated (Alcohol, Drugs)
Impaired Vision / Hearing
Incapacitation due to,
Extremes of age.
Illness
Injuries
Breech of road rules

31. Road traffic injuries
Pedestrians
Car / Vehicle drivers and occupants
Motor cycle users
Pedal cycle users
Three wheeler drivers and occupants
Others - Heavy vehicles, Tractors
Bullock carts and hand carts users

32. Pedestrians account for more than half of the road fatalities.

33. The commonest RTA fatalities How ? Towards vehicle Opposite Direction
Pedestrian injuries.
The commonest RTA fatalities
How ?
Towards vehicle
Opposite Direction
Crossing the road
Continued……

34. Nature and severity depend on,
1. Nature of the vehicle (car/ van/ bus etc. )
Height of the vehicle.
Below the centre of the gravity of the victim
Above the centre of the gravity of the victim
Type of the vehicle (Heavy lorry, van…)
Speed of the vehicle.
Nature of the striking surface of the vehicle.

35. 2. Victim
Orientation of the victim.
Height of the victim (Centre of gravity).
Personal factors.
Movements after impact (thrown on to path of moving vehicle)

36. 3. Road surface
Nature of the surface
Objects – stationary / moving

37. Injuries.
1. Impact injuries
Primary impact
Secondary impact
2. Secondary injuries
3. Tertiary injuries
Run over injuries
Run under injuries
Drag injuries

38. Primary impact injuries
As a result of first contact with the vehicle.

39. Types of injuries
Imprint abrasions
Lacerations
Fractures
Contusions

40. Area of the body
Knee level
Thigh
Hip
Elbow
Shoulder
Chest or head

41. When the impact is below the center of gravity
E.g. Car
Primary impact at knee level
Bumper fractures occur at 14 MPH in young adults.
Victim is scooped up
Secondary impact injuries.
Speed > 25km/h

42. Secondary impact injuries (not a must)
Small cut injuries due to shattered windscreen glass
Skull fracture
Rib fracture
Lacerations
contusions

43. When the Impact is above the center of gravity
E.g. Van, Bus
Injuries to pelvis, abdomen, arms, head
Victim may be projected forward ( forward projection ) or run over.

44. Found in impact with any vehicle.
Secondary injuries
As a result of victim falling on the ground after the Primary or Secondary impact.
Found in impact with any vehicle.
Are often more lethal, esp. to head, chest, pelvis
Distance thrown : Throw distance
Continued…..

45. Depends on,
Force of the fall.
Nature of the object struck.
Injuries,
Grazed abrasions
Contusions
Lacerations
Fractures
Contre-coup injuries to the brain
Internal injuries

46. A wheel passes over the body Chest and abdomen - tire marks imprinted
Run over injuries
A wheel passes over the body
Chest and abdomen - tire marks imprinted
Limbs ,
Tears of skin & muscles
De-gloving injuries
Continued…….

47. Features,
Clothes - Tire marks, grease, oil
Skin - Tire marks
- Flattening of affected area
- Soft tissue ooze
Crushing and degloving of limbs
Multiple fractures.
Internal injuries

48. Run under injuries
Vehicle goes over the body but no run over by tires
Body gets pinned between under surface of the vehicle & road
Any type of fracture, crush injuries

49. Drag injuries
Victim gets entangled and dragged along the road
Grazed abrasions with mud and dirt from road.

50. 80% are frontal impacts – with another vehicle or object
Injuries to vehicle occupants
80% are frontal impacts – with another vehicle or object
Severe deceleration
Less commonly vehicle is hit from behind
Acceleration
Side impacts
Roll over

51. Occupants of vehicles Driver Front seat passenger
Rear seat passengers / other occupants
Tissue injury depend on G force applied per unit area - Larger the area lesser the injury
G=C(V)2
C = V – Velocity km/h

52. Additional injuries depend on subsequent behavior of the victim and vehicle.

53. Injuries depend on,
Change in rate of movement ( G forces )
Speed of the vehicle.
Speed of the offending vehicle.
Nature of the impact.
Design or the interior of the vehicle / cabin.
Availability / usage of safety devices.
Trapped within / thrown out.
Subsequent behavior of the vehicle
Vehicle catching fire

54. Head and face hit the windscreen glass, frame or side pillars.
Injuries to the driver,
Head and face hit the windscreen glass,
frame or side pillars.
-Blunt and sharp injuries.
Neck - Whip lash injuries , Fracture dislocation of cervical spine.
-Due to hyper flexion and hyper extension
( Hyperextension more serious )
Continued………

55. Bleeding into surrounding muscles
Rupture of anterior longitudinal ligament of vertebra
Tear of intervertebral discs
Compression of nerve roots
Ischemic haemorrhages and pulping of spinal cord
Commonest site upper two cervical vertebrae

56. Fractures of ribs, contusions lacerations of lungs
Chest injuries
Fractures of ribs, contusions lacerations of lungs
Heart compressed between sternum and vertebra
Abdominal injuries
Rupture of rectus abdominis , liver, duodenum, bowels
Knee injuries due to hitting of dash board.
Driver hit brake or clutch pedals
Posterior dislocation of hip
Fractures of pelvis , lower limbs, ankle
Broken windscreen glass - superficial lacerations(sparrow foot marks)
Continued………

57. Tightly hold the steering wheel - upper limb fractures ( shoulder, forearm, humerus )
Thrown out injuries – Fatality X 5
Sudden deceleration cause a pendulous effect on heart resulting in step ladder tears of aorta
Side impacts

58. Injuries to front seat passenger
Nothing between body and windscreen
Risk of thrown forward
Less anticipation than driver
Forward projection may hit front parts of cabin.

59. Injuries to front seat passenger
Hyper flexion and hyper extension resulting whip lash injuries.
Injuries due to windscreen glass and windscreen pillar. (Sparrow foot cuts)
Knees hit the dashboard as in driver.
Thrown out more common (unrestrained without seat belt ).
Side impacts.

60. Rear seat passenger
Injury to face and head due to impact on front seats.
Dislocation of hip if sitting legs crossed
Thrown between seats and ejected to the windscreen.
Thrown out.

61. Passenger Vehicles Vans, Buses, etc. Passenger injuries depend on
Nature of impact
Relative position of the victim to impact
subsequent behavior of the vehicle.

62. Function of seat belts
It restrains the body against severe deceleration.
It spreads the deceleration over a considerable area – G forces.
The strap stretches appreciably during severe deceleration.
The belt prevent ejection into the road.

63. Function of Air bags
These are designed to interpose itself between the occupant and frontal structures of the passenger cabin.
It helps to cushion the impact and prevent
forceful contact and hyper flexion.

64. Injury to motor cycle users Rider / Pillion rider Traveling openly
Balancing on two wheels
Risk of thrown forward
Easily can speed, maneuver
Risk of run over by other vehicles
Mostly used by young people
Pillion rider has a greater risk of being thrown off on impact
Continued…….

65. Injuries Fall on ground Projection forwards Side impacts
Run over injuries
Continued……

66. Rider Injuries to Head ,chest and abdomen Upper limb injuries
Fracture femur, tibia, fibula
Pelvis injuries
Ankle injuries

67. Head and neck injuries
In spite of usual wearing of crash helmet.
Worse when riders are not wearing crash helmets.
Skull fractures and intracranial injuries
Chin hitting the ground causing hinge fracture
Contre-coup injuries
Cervical spine fracture dislocation

68. Limb injuries
Grazed abrasions
Contusions
Lacerations
Fractures
Silencer burns

69. Pillion rider Nothing to hold on Risk of thrown forward
Often escapes from primary impact from front
Similar injuries as rider

70. Pedal cycle users
Injuries are very common
Less severe due to low speed
Primary injuries occur from impacts by other vehicles – speed of other vehicle
Secondary injuries due to fall on ground
Run over injuries

71. Impact injuries from the offending vehicle
Secondary injuries due to hitting on road surface, sliding across the road
Run over injuries by same vehicle or another
Head injuries with intracranial injuries
Unlikely wear helmet
Bicycle spoke injuries

72. More hazard to other road users
Three wheeler users
More hazard to other road users
The offending vehicle of the most pedestrian injuries
Lively hood of many adult males – Attempt to get more hires as possible during rush hours
Continued…..

73. Head on collision
Can topple
Passengers can thrown out

74. Injuries are more prone
Small and compact nature of the vehicle
Overloading
No safety devises
Drivers are young and takes more risks

75. Medico legal investigation of a case of
Road Traffic Accident (Hit & run)
History
Scene visit
Identification
Preliminary procedures

76. Examination of clothing
General external examination
Specific external examination
Complete internal examination
Specific investigations
10. Documentation

77. Railway accidents Impact with the train Injuries to passengers
Falling from train

78. Impact with a train
Suicide
Jump to moving train
Accident
Walking or crossing the rail tract
Vehicles crossing unprotected rail tract
Homicide
Push to the moving train (rare)
Post mortem disposal
Murder and leave on the tract(PM injuries)

79. 2. Injuries to the passengers
Collide with another train
Derails
3. Persons falling from train
Accidental
Homicidal
Suicidal

80. Injuries following impact are usually fatal.
Extensive musculoskeletal injuries.
Decapitation
Dismemberment / Amputation
Bizarre injuries

81. Investigation of a body found in Rail tract ?

82. Unrelated to impact the train
Electrocution from overhead cables
Natural diseases (IHD, Epilepsy…)
Snake bite
Lightening

83. Rail tract injuries
Aviation injuries
Navigational injuries
Read…..

84. Mechanisms of injury in an adult pedestrian struck by a car at high speed

85. Summary Statistics Pedestrian injuries
Vehicle occupants (car/passenger vehicle)
Motor cycle rider
Pedal cycle user
Three wheeler occupants
Train accidents
Medico legal investigation

86. Case 1

87. Case 2

88. Thank you.