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Medico-Legal Update

Study of pattern of skull fractures in fatal accidents in northeast Delhi

Author(s): Abhishek Yadav, Anil Kohli, N.K. Aggarwal

Vol. 8, No. 2 (2008-07 - 2008-12)

Abhishek Yadav٭, Anil Kohli٭٭, N.K. Aggarwal٭٭٭

٭ Senior Demonstrator, Deptt. of Forensic Medicine and Toxicology, Lady Harding Medical College, New Delhi 110 001,
٭٭ Reader, Deptt. of Forensic Medicine, University College of Medical Sciences, Dilshad Garden, New Delhi 110 095,
٭٭٭ Professor and Head of Department, University College of Medical Sciences, Dilshad Garden, New Delhi 110 095

Abstract

Head injuries are the most serious injuries in the term of morbidity and mortality. We wish to give our contribution to the already ongoing research studies on head trauma and its components. Hence this study of studying the pattern of skull fractures in fatal head injury cases in Northeast district of Delhi, their age and sex distribution, site distribution of different type of fractures and also the manner of death.

Keywords: Skull fractures, linear fractures, basal fractures, depressed fractures, manner of death

Introduction

Head accommodates one of the most vital parts of the body, the brain. Although it is well protected in a bony cranial cage, it still remains one of the most vulnerable parts of the body.

Head injury, a common term that is actually craniocerebral damage, has been recognized since ages. In medicolegal practice blunt head injuries are most frequently caused by traffic accident, fall from height, assault, train accident etc. The manner of death in cases of craniocerebral trauma may be accidental, homicidal or suicidal1. Accidental deaths are by far the most common and road traffic accidents are the main component, followed by falls from height and railway accidents.

In India, for individuals more than four years of age, more life years are lost due to traffic accidents than due to cardiovascular diseases2. New Delhi is the capital city of India and is still growing in every conceivable way leading to a sharp increase in educational establishments, roads, buildings, business, infrastructures and population. So just like every other developed city, it also has its drawbacks like an increase in crimes like assault, suicides by fall, vehicular accidents etc. In Northeast district these problems are more significant as thirteen percent of the population of Delhi is living in this district, as per census of Delhi government in 2001.

After trauma lesions such as skull fractures and cerebral injuries may develop. Though the effects of blunt force impact on head were recognized long back, their true nature was revealed gradually in the studies of 19th and 20th century, with the advancement in the diagnostic techniques like Skull X-Ray, CT scan and MRI etc. Also the increased number of autopsy studies led to the unfolding of the complex nature of cranial contents and their behavior to trauma.

In this study our purpose was to advance the understanding of mechanisms of craniocerebral trauma by focusing on the age and sex distribution of skull fractures and the frequency of their occurrence at various anatomical sites on the skull.

Materials and methods

The study was conducted in the Department of Forensic Medicine, University College of Medical Sciences and Guru Teg Bahadur Hospital, Shahdara, Delhi between March 2005 and April 2006.

One hundred and nineteen cases of fatal head injury where the cause of death was craniocerebral damage were included in the study. All cases having pathological disorders relating to the skull bones and brain matter or crush injuries to head were excluded from the study. Brief history was taken from the relatives of the victims, the accompanying police personnel, hospital records and inquest papers.

Observations and results

The age of the victims varied from 1 to 96 years. Out of 119 cases, the peak incidence was in the age group of 21 to 30 years, comprising 27.7% of the total cases. Age group of 31 to 40 years was next in number comprising 20.2% of the cases. It was closely followed by the age group of 41 to 50 years which made up 19.3% of cases. If we consider the age group of 21 to 30 years and 31 to 40 years in combination then 47.9% of cases were of young adults. A decreasing trend was seen as the age proceeds to both the extremes. The 0 to 10 years age group and 11 to 20 years age group were made up of 5.9% and 15.1% of the cases respectively. The older age groups combined together constituted only 3.4% of the cases (Table 1).

The sex distribution of the victims clearly showed a male predominance. Males constituted 98 of the total cases (82.4%), while females constituted 21 cases (17.6%). The ratio of male to female was 4.7:1. Males follow the same age distribution pattern as the total cases, with maximum presence in 21-40 year age group and minimum presence in ages above 60 years. Females showed a more equitable distribution in all the age groups. Male to female ratio in the most commonly affected age group of 21-30 years was 5.6:1.

Table 1: Age and sex distribution of cases

AGE
(YEARS)
MALE FEMALE TOTAL
0-10 5 2 7
11-20 13 5 18
21-30 28 5 33
31-40 22 2 24
41-50 20 3 23
51-60 7 3 10
61-70 1 0 1
>70 2 1 3
Total 98 21 119

Table 2: Sex distribution of fractures

LINEAR
FRACTURES+
DEPRESSED
DEPRESSED
FRACTURES
LINEAR
FRACTURES
COMMINUTED
FRACTURES
  M F T M F T M F T M F T
  - - 0 - - 0 5 2 7 - - 0
  2 0 2 1 0 1 9 5 14 1 0 1
  1 0 1 1 0 1 25 5 30 1 0 1
  2 0 2 - - 0 20 2 22 - - -
  2 0 2 2 0 2 15 3 18 1 0 1
  - - - - - - 7 3 10 - - -
  - - - - - - 1 0 1 - - -
  - - - - - - 2 1 3 - - -
Total 7 0 7 4 0 4 84 21 105 3 0 3

Females were having linear fractures of the skull and no depressed or comminuted fracture was found in them (Table 2). Depressed and comminuted fractures were relatively fewer in number and found in males only. The cases in which the depressed fractures were present along with the linear fractures (7 cases) were also found in males only.

Basal plus linear fracture of vertex constituted 41cases (34.4%) out of 119 cases of total skull fractures. Linear fractures comprised 35 cases (29.4%), followed by fractures of the base only (24.4%). Depressed fractures of vertex only and depressed plus basal fractures were present in 3.4% and 5.9% cases respectively. Comminuted fractures were the least common (2.5% cases). (Table 3)

Linear fractures of vertex only were found in 35 cases. Parietal regions alone had the maximum fracture sites (28.6%). Fractures involving more than two region of vertex were uncommon. Temporo-parietooccipital region had only one case while fronto-parietotemporal had two cases (Table 4).

There were 41 cases where both basal fractures and linear fractures of vertex were found. Basal fractures were associated with fractures in the occipital region in six cases and with fractures at the temporo-parietal region in eleven cases (Table 5).

Basal fractures were divided according to regions as anterior cranial fossa fractures (ACF), middle cranial fossa fractures (MCF) and posterior cranial fossa fractures (PCF). The rest were grouped under the different combinations of the above three regions. There were 29 cases of basal fracture. PCF had the maximum number of cases, 12 (41.4%). ACF and MCF were involved in similar number of cases. Twenty-two cases out of twenty-nine were present in single region of the base of the skull while only four cases involved multiple regions (Table 6).

Depressed fractures alone were found on the vertex only. A total of four cases of depressed fractures alone were found. Out of these, two cases were in the frontal region, one was present in the parietal region and the last was present in frontoparietal region (Table 7).

Table 3: Types of fractures

Type of Fractures No. Percentage
LINEAR FRACTURES OF
VERTEX ONLY
35 29.4%
DEPRESSED FRACTURES
OF VERTEX ONLY
4 3.4%
COMMINUTED FRACTURES
OF VERTEX ONLY
3 2.5%
BASAL FRACTURES ONLY 29 24.4%
BASAL+LINEAR
FRACTURES OF VERTEX ONLY
41 34.4%
DEPRESSED+BASAL FRACTURES 7 5.9%
TOTAL 119 100%

Table 4: Localization of linear fractures of vertex only

SITE TOTAL
FRONTAL 4
PARIETAL 10
OCCIPITAL 5
TEMPORAL 3
FRONTO PARIETAL 3
PARIETO TEMPORAL 5
TEMPORO OCCIPITAL 2
FRONTO PARIETOOCCIPITAL 2
TEMPORO PARIETOOCCIPITAL 1
TOTAL 35

Table 5: Localization of basal plus linear fractures of vertex

SITE TOTAL
BASAL+FRONTAL 5
BASAL+ PARIETAL 3
BASAL+OCCIPITAL 6
BASAL+TEMPORAL 4
BASAL+FP 2
BASAL+FT 4
BASAL+PT 11
BASAL+PO 1
BASAL+TPO 3
BASAL+FPT 1
BASAL+FPO 1
TOTAL 41

FP=Fronto-parietal, FT=Fronto-temporal, PT=Parietotemporal,
PO= Parieto-occipital, TPO= Temporo- parietooccipital,
FPT=Fronto- parieto-temporal, FPO= Fronto-parietooccipital

Table 6: Localization of basal fractures only

SITE TOTAL
ANTERIOR CRANIAL FOSSA (ACF) 7
MIDDLE CRANIAL FOSSA (MCF) 6
POSTERIOR CRANIAL FOSSA (PCF) 12
ACF + MCF 2
ACF + PCF 1
AIF + MCF + PCF 1
TOTAL 29

Comminuted fractures were also present on the vertex only. Out of the total of three cases, one case was in parietal region while two were in parietotemporal region (Table 7). In the category of depressed plus basal fractures, 7 cases were present. Basal plus frontal regions, basal plus frontoparietal regions, basal plus temporal regions had one case each. Two cases were present in basal plus parietal and in basal plus parietotemporal regions (Table 8).

In regard to manner of death, accidents were the leading cause in 110 cases out of 119 (92.4%). Homicidal cases were 8 in number (6.7%) and only 1 case (0.9%) was suicidal (Table 9).

Discussion

The pattern of age distribution in skull fractures showed that all ages were affected (Table 1). A peak incidence was seen in third decade, closely followed by fourth decade and then fifth decade of life. This is in accordance with the studies done by Tyagi et al3 and Sharma et al4. Individuals in the extremes of life were least affected. This was also in accordance with studies of the above-mentioned authors and Freytag5 and Gallagher and Browder6, who conducted their studies outside India. The reason for this is that young adults are the most active and prime bread earners of the family and remain outdoors during most of the day thus becoming more vulnerable to trauma, while persons in extremes of the age usually remain indoors.

Table 7: Localization of depressed and comminuted fractures

SITE ON VERTEX DEPRESSED FRACTURE COMMINUTED FRACTURES
FRONTAL 2 -
PARIETAL 1 1
OCCIPITAL - -
TEMPORAL - -
FRONTO PARIETAL 1 -
PARIETO-TEMPORAL - 2

Table 8: Localization of depressed plus basal fractures

SITE TOTAL
BASAL+FRONTAL 1
BASAL+ PARIETAL 2
BASAL+TEMPORAL 1
BASAL+OCIPRITAL -
BASAL+FRONTO PARIETAL 1
BASAL+PARIETO TEMPORAL 2
TOTAL 7

Table 9: Incidence of manner of death

MANNER OF DEATH NO OF CASES PERCENTAGE %
(1) ACCIDENTAL 110 92.4%
ROAD SIDE ACCIDENTS 75 63%
RAILWAY ACCIDENTS 13 10.9%
FALL FROM HEIGHT 20 16.8%
BURIED IN EXCAVATION 2 1.7%
(2) HOMICIDAL 8 6.7%
(3) SUICIDAL 1 0.9%
TOTAL 119 100%

Males comprise 98 cases while females constituted 21 cases (Table 1). The male: female ratio was 4.7:1 overall and 5.6:1 in the most commonly affected age group. These results were in accordance with the previous studies by Vance7, Freytag5, Jamieson and Yelland8, Kraus et al9, Young and Schmidek10, Edna11, Tyagi et al3, Baris et al12, Hartshone et al13, Equabual et al14, Menon and Nagesh15. A reason for the male majority is that men everywhere are more exposed to outdoor activities, traveling between home and their place of work to earn for the family, while women remain mainly at home. Greater prevalence of alcohol addiction in males is another reason. After the consumption of alcohol people are more prone to road traffic accidents due to error in judgments while driving or crossing the road etc. There is also an increased risk of falling from height under alcohol intoxication.

Females had more equitable distribution in all the age groups indicating that no special trend is present in the female population. This is because females of all the age groups are equally exposed to the outdoor activities and furthermore are generally assigned the role of looking after the children at home. Yavuz et al16 reported that 39 cases were present in the 0 10 year age groups while a decreasing trend was seen there after. This difference could be due to smaller number of female cases in our study and the cultural difference between their and our societies.

Females were found to be having linear fractures only. No case of females having depressed or comminuted fractures was reported (Table 2). This could be explained by the fact that the female skull is weaker and more flexible with evenly distributed impact energy16.

Linear fractures of vertex only, basal fractures, basal plus linear fractures of vertex comprised majority of cases (Table 3). Depressed and comminuted fractures were present in relatively fewer cases. Young and Schmidek10 also reported that linear fractures were the most common and depressed the least common in 134 patients with occipital fractures. Jamieson and Yelland8 reported that out of 109 fracture cases, 23 were depressed and the rest were linear (78.9%). All the abovementioned studies are more or less consistent with our study.

The reason could be that linear fractures are more frequent among young adults due to the flexibility of skull bones16 and young adults constitutes a major proportion of the cases in our study (Table 1).

It was observed that in linear fractures of vertex only, parietal bone was most commonly affected (Table 4). Parietal bone was involved in 21 cases out of 35 cases (60%). When the single site was affected, it was affected in 45% (10/22), and in fractures involving multiple sites, it was affected in 84.6% (21/22). Vance7 reported similar findings. Tyagi et al3 also found parietotemporal region to be the most commonly involved region, a finding consistent with our study. Sharma et al4 also found 51.6% of parietal fracture cases in their study, which is similar to our study.

Basal fractures plus fracture of parietotemporal region involved 27% cases, i.e. 11 out of 41 (Table 5). This was consistent with findings of Vance7 who reported that in the category of fractures involving both vault and base, posterior fractures occurred in about 35% of cases.

Fractures confined to the base of the skull only were 29 in number (24.40%) (Table 6). Such a large proportion of the fractures of base are due to the occurrence of contrecoup fractures as reported by Hirsch and Kaufman17. The most likely mechanism of causing contrecoup fractures in closed head injuries is transmission of forces from the point of impact through the brain to the floor of the skull18.

Vance7 in their study of 507 cases of skull fractures reported that depressed and comminuted fractures were present on the vertex only. In our study also, both these types of fractures alone were present on the vertex only (Table 7).

There were 92.4% victims of accidents (110 cases), 6.7% of homicides (8 cases) and only one victim committed suicide (0.9%) (Table 9). Freytag5 and Tyagi et al3 reported the accident rate as 84% and 95% respectively. They also reported homicide rate among head injury patients as 12% and 4% respectively.

These figures are consistent with our study. Among the persons who died in accidents, 63% of total cases died in road traffic accidents. This is also consistent with the findings of Freytag5 and Sharma6 who reported traffic accident victims as 43% and 47.8%. The increase in the percentage of road traffic accidents as compared to study of Freytag and Sharma is due to the fact that road traffic accidents are increasing continuously due to the rising number of vehicles and increase in population. The incidence of falls was 20%, which was also in accordance with the above-mentioned studies. Falls generally occurred in or about the decedents own home, as was evident by the history.

The assault cases were less in number due to the use of weapons like knives, etc. for homicide rather than the old fashioned heavy objects, which imparted blunt force impact to the head. Suicide was present in only one case, when a person jumped in front of train. The reason behind this is the availability of less painful means of suicide like hanging and poisoning.

Our study is based on the examination of skull and brain of those individuals, who have died after head injury. The results may therefore differ from some of the previous studies where the findings were based on head injuries irrespective of the fact whether fatality occurred or not (hence patients who survived because they had less severe head injuries were also taken up in their studies).

Conclusions

  1. Though the age of the victims varied from 1 to 96 years, peak incidence was found in third decade (27.7%), followed by fourth decade (20.2%) and fifth decade (19.3%). Extremes of life were least affected.
  2. The sex distribution showed a male predominance. Male: female ratio was 4.7:1 overall and 5.6:1 in most commonly affected age group.
  3. Amongst individual fracture types, basal plus linear fractures of vertex were the most common type (39.40%) followed by linear fractures of vertex only (29.40%). Least common type was comminuted fractures.
  4. In linear fractures of vertex only, parietal was the most commonly affected region.
  5. In basal plus linear fractures of vertex, basal fractures along with parietotemporal fractures were the most common.
  6. In basal fractures only, posterior cranial fossa was involved in the maximum number of cases.
  7. Accidental cases were 92.4%. Amongst them, road traffic accidents had the highest frequency (63%). Homicidal cases were only 6.7% and only one case of suicide was present.
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