UDK 616.001:614.

86
DOI: 10.2298/ACI1203057B

I/STRUCNI RAD

Impact ofthe injury pattern on the pedestrian fatalities

in the city of Belgrade
Marko Z. Bumbairevie'"^, Ivan B. Milosevil'^, Vesna
Slavisa G. Zagorac'^, AleksandarR.
'university of Belgrade, School of Medicine, Belgrade
^Clinic for ortophedic surgery and traumatolgy, Clinical center of Serbia, Belgrade
'Center for anesthesiology and reanimatology. Clinical center os Serbia, Belgrade

QJ INTRODUCTION: In the city of Belgrade pedestrians are under the high risk to sustain injuries in
the road traffic accidents, they are often with mul* *'P'^ injuries, with long-term treatment and sigN nificant consequences. Most of them are in the
^
senior or in the school age group.
^
METHODS: We present the results of the epidemiological analysis of the mechanism of injury and
treatment outcome of the pedestrians who sustained
the lower limb injuries and additional, the injuries of
the other organic systems. We also analysed the relevant data about the moment of the collision.
RESULTS: Regarding the gender, male were significant more injured. , in the senior age of life. Patients
with multiple injuries, especially with the pelvic injuries or injuries of more than two systems were significant more likely to have a fatal outcome.
CONCLUSION: The pedestrians are the most vulnerable group in road traffic accidents. Thus, we need to
make actions on two levels: appropriate environment
conditions and effective prehospital and hospital treatment.
Key words: road traffie accidents, lower limb injuries

INTRODUCTION

ith

he beginning of 21 century is eharacterized by increased number of road traffic injuries (RTI) and according to the World Health Organization (WHO),
"RTI^ are projeeted to become the 3'^'' largest cause of
the global health burden"'. Almost half ofthe fatalitites
are pedesfrians, motorcyclist or bicyclist. It is estimated
that low- and middle - ineome countries are under high risk of increased RTI^ due to the rapid growth in the number of vehicles and due to the higher expose to the wellknown risk factors such as high speed (the most preventable eause of the road traffic accidents), alcohol intake .
Due to the high energy in the moment of eollision there is

a increased number of multiple injuried patients and the

road traffic accidents with 55% are the leading eause of
polytrauma '*. Pedestrians are under the high risk of traffic related injuries, especially severe injuries to the lower
extremities. This can be explained by speeifie pedestriancar relationship. Lower extremity injuries in traffie aeeident have usually long-term eonsequences and are accompanied with other injuries. Pedestrian deaths are the second largest eategory of motor vehicle deaths in the US ' .
AIM
Epidemiological analysis of traffic accident related injuries pattern, mechanism of injuries and outeome in multiple injuried patients whit lower extremity injuries, who
sustained the injuries as a pedesfrians
METHODS
Data sources
From 2008. to 2011. in the Emergency Center of Clinical Center of Serbia in Belgrade we evaluated 65 multiple
injured patients with lower exfremity injuries who have
been injured in a traffic accidents on the teritory of the city of Belgrade. Data were obtained from the medical and
police records. Demographic characteristics (gender, age),
elinical parameters (cause of injury. Injury Severity Score
(ISS), type of injuries, type of surgieal treatment) and
outeome (mortality) have been evaluated.
Injury classification
The fractures were classified aecording to the AO (rbeitsgemeinsehaft fur Osteosynthesefragen) classification
(based on radiographs, CT scans and intraoperative findings), and the open fracture have been classified according to the Gustilo elassification. The ISS is generally accepted for the multiple injuried patients. The ISS is the sum

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M.Z. BumbaSirevi

ACI Vol. LIX

of the squares of the highest AIS codes (Abbreviated Injury Scale) in each of the three most severely injured AIS
body regions ' ' .
DATA ANALYSIS
For the purpose of data analysis we used SPSS (Statistical Package for tbe Social Sciences statistical software,
version 16.0. Chi square statistics, t tests, and odds ratios
(OR) with 95% confidence limits (CL) were used to assess statistical differences comparing pedesfrians with lower extremity injuries and abdominal, chest or bead injuries additional to those who had only lower extremity injuries. Differences were considered statistically significant at a p<0,05 level.
RESULTS
Injuries are dominant caused by car (p<0,05) (figure 1).
The fractures around tbe knee are tbe most frequent, but
statistically not significant (p>0,05), (figure 2). We identified 13 open fractures of the femur and 21 open fractures
of tbe tibia, all were freated by extemal fixation.
Males were significant frequently injured (p<0,05), but
the mortality regarding gender was not statistically significant (p>0,05) (table 1). The most vulnerable group are
tbe pedestrians in the senior group and tbis was statistically significant (p<0,05). The pedestrians who were injuried in tbe collision witb the vehicle weighing more than
l,5t were 2 times more likely to have fatal outcome
(p<0,05). Pedestrians who were injured by the vehicle
witb speed more tban 30km/h were 4 times more likely
to sustain tbe fatal injuries (p=0,03). We analyzed tbe relationship between injuries and mortality rate regarding
severity of the injury, i.e comparing pedestrians who sustained only the injuries of the lower extremities with those
who sustained injuries of more tban two systems (table 1).
Pedestrians with pelvic injury are under particular risk of
fatal outcome (OR=15,75, p<0,01) and tbose who sustained injuries of more tban 3 systems. (0R=18, p<0,01).
Time of surgery and non operative freatment seems to have not significant impact on tbe outcome (p>0,05).
DISCUSSION
RTA on the teritory of the Belgrade are associated with
a significant number of pedesfrian fatalities, especially
among the elderly, as we can see from tbe results of our
study. This is a big problem in well developed country as
well ("in Swiss 19% of all fatalities in RTA are pedesfrians) . Pedestrian crashes were found to be associated with high injury severity and mortality wben compared to
otber road users . Regarding specific relation between
pedesfrian and vehicle in tbe moment of collision, lower
extremity are under increased risk.
Injury pattern
In the study of Teresinski and Madro^', 80% of the pedestrians, and 94% of those subjected to a lateral impact,
sustained injuries around tbe knee. The same authors

mechanism of injury

tractor

| 1

tram

| | 2

bus

^^B

truck

motorcycle

10

20

30

FIGURE 1
MECHANISM OF INJURY

fractures of the lower extremity

foot

distal bla

tibial shaft

proximal tibia

^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^

distal femur

femoral shaft

^^^^^^^111

proximal femur

10

15

18

20

25

FIGURE 2
FRACTURE DISTRIBUTION OF THE LOWER EXTREMITY
identified vams-valgus sfrain as tbe most common mechanism of tbe injury and the collateral knee ligaments are
the most commonly injured ligamentous stmctures. In order to prevent lower extremity injuries in pedesfrian-automobile collisions, automobile manufacturers in Europe
are currently designing and testing front end components
with tbe aim to reduce the risk of severe injuries.
Speed of 20km/h in the moment of tbe collision are associated with increased risk of severe pedestrian injuries
for about 35%. Speed of 50km/b increase this risk on 40%
and when the speed is about 70km/b, 95% of pedesfrians
bave no chance to survive ' . In our study we founded
tbat the pedestrian who were injured with the speed of vehicle more than 30km/h bave 4 times biger risk to sustain
tbe fatal injuries. Average ISS in pedesfrians witb fatal
outcome was 36, which is more comparing with otber
di^^^^^
In the freatment of tbe lower exfremity injuries we performed extemal fixation, intemal fixation or non operative
freatment. In our study we did not analyzed the relationship between the type of tbe freatment and the outcome
,but tbe outcome regarding tbe time of surgery. State of
tbe art of tbe treatment of multiple injured patients are two
approacbes:ETC (Early Total Care) and ODC (Orthopaedic Damage Control). In our clinic we preferred ODC

59

Impact of the injury pattem on the pedesfrian fatalities

in the city of Belgrade

Br. 3

TABLE 3
DEMOGRAFIC, VEHICLE-RELATED AND INJURY-RELATED DATA

Gender

All (male/female)

Live (male/female)

Dead (male/female)

Statistical analysis

41-24 (Chi
square-4,446, p<0,05)

30/14 (Chi
swuare-5,818,p<0,05)

11/10 (Chi
square-0,048, p>0,05)

OR=1,94(0.67-5,65)
Z-2.032p<0.01

Age
10-19

20-29

30-39

40-49

50-59

12

60-69

19

10

70-79

>80

Vehicle <I.5t

39

29

10

OR=2.13

Vehicle >I.5t

26

15

CI=0.74-6.13

Speed <30km/h

22

19

OR=4.56

Speed >30km/h

43

25

18

CI=I.17-17.7

Ext

50

45

Ext+head injuries

OR=3.37 (0.67-17)

Ext+cgest injuries

10

0R=6 (1.25-28.7)

0R=9 (1.70-47.6)

Ext+spine injury

OR=3.6 (0.54-23.6)

Ext+pelvis injury

11

OR=15.75
(3.38-73.2)

Ext+>2systems

12

OR=12.6
(2.88-54.9)

Ext+>3 systems

0R=18 (2.60-124.3)

19(5-50)

36 (12-75)

Surgery <24h

19

OR=1.30 0.39-4.33)

Surgery>24h

32

11

OR=1.21 0.37-3.92)

Non operative

14

Ext+abdomen

injuries

ISS (mean, range)

concept,but the results of our study showed that there is

no significant difference in mortality regarding the time
of the surgery and the type of the treatment, as well. It
seems that prehospital treatment and freatment on the Intensive Care Unit-ICU play the significant role in the definitive outcome.'^''^. Three impact phases are described
during pedestrian injury ' :
a) bumper impact: initial impact is usually on the lower
limbs
b) windscreen impact: upper part of the body are under
the higher risk

c) ground impact: injuries occur when the pedestrian

hits the ground (mostly head injuries).
Our study shows significant mortality rate when lower
exfremity are associated with pelvic injuries. Acccording
to the some studies, pelvic injuries are associated with
long bone fractures in 50% of cases and with head injuries
in 5 1 % as well^'. As expect, the injuries of more than two
systems are associated with high mortality rate .
Our study has some weaknesses. First, we did not analyzed the moment of the collision (hard or soft ground ,
side of the impact). As we see, the elderly population is at

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M.Z. Bumbasirevi

increased risk. Significant impact on the definitive outcome have prehospital comorbidities, which is not analyzed in our study.
CONCLUSION
Increased number of motor vehicles and increased number of the residents aged more then 70 are associated with
high incidence of pedestrian fatalities in the cify of Belgrade. Our study showed some issues that must be discussed in order to decrease the incidence of RTA and
morialify of the pedestrians.
The problem must be resolved on two main levels. We
need to make some appropriate and reasonable changes of
environment in order to protect the most vulnerable group
in the road traffic activities (i.e, longer crossing time at
particulary dangerous crosswalks, up dated car technology
with high securify systems regarding specific collision
moment between pedestrian and the vehicle, education).
On the other hand, the improvement of the system of
prehospital treatment of injured pedestrians may have the
main impact on the definitive outcome of the treatment.
SUMMARY
Uvod: Na teritoriji Beograda saobraajni traumatizam
naroito ugroava pesake, povrede su najesoe udruzene,
a leenje je dugotrajno sa znaajnim posledicama, a pogotovu zbog Cinjenice da se radi najoese o starijoj populaciji ili deci skolskog uzrasta. Mtodologija: U radu je
prikazana epidemioloska analiza mehanizma povredjivanja i rezultata lecenja pesaka koji su imali povrede donjih ekstremiteta udruene sa povredama nekog drugog organskog sistema. Osim toga analizirani su i podaci koji se
ticu samog desavanja na mestu nesree. Rezultati: Dominantno su povredjivane osobe muskog pola, starije
zivotne dobi. Pacijenti sa udruenim povredama, naroito
sa povredama karlice i povredom vise od dva organska
sistema su imali najvei mortalitet. Zakljuak: Pesaci
predstavljaju najugrozenije ucesnike u saobraaju, te je
stoga neophodno preduzeti mere na dva glavna nivoa:
adekvatna saobraajna infrastruktura i koncept efikasnog
prehospitalnog i hospitalnog tretmana
Kljune rei: saobraajni traumatizam, povrede donjih
ekstremiteta.
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Acknowledgetnent: The artiele is supported by funds-project number

175095 Ministry of Science, Republic of Serbia

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