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ORIGINAL ARTICLE
Year : 2017  |  Volume : 20  |  Issue : 4  |  Page : 187-191

An autopsy review of abdominal injuries resulting from road traffic accidents: The Ile-Ife experience


1 Department of Morbid Anatomy and Histopathology, Ladoke Akintola University of Technology Teaching Hospital, Osogbo, Nigeria
2 Department of Morbid Anatomy and Forensic Medicine, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun-State, Nigeria
3 Department of Morbid Anatomy and Histopathology, Ladoke Akintola University of Technology, Ogbomosho, Oyo State, Nigeria

Date of Web Publication17-Apr-2018

Correspondence Address:
Dr. Donatus Sabageh
Department of Morbid Anatomy and Histopathology, Ladoke Akintola University of Technology, Ogbomosho, Oyo State
Nigeria
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DOI: 10.4103/1118-8561.230262

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  Abstract 


Background: Road traffic accidents (RTAs) are a leading cause of blunt force trauma to the abdomen. They remain an important cause of death globally and especially in Nigeria. Aims: The aim was to review the autopsy findings of victims with abdominal injuries following RTAs. Subjects and Methods: The autopsy records and case notes of victims of RTAs fatalities who sustained abdominal injuries over a 10-year period were reviewed. This was carried out at a tertiary health institution in Sub-Saharan Africa. Statistical Analysis Used: Statistical Package for Social Sciences version 15.0. Results: Seventy-six cases were reviewed. The male to female ratio was 4.1:1. The mean age of the victims was 34.2 years while the age range was from 4 to 85 years. The 30–40-year age group accounted for 34.2% of cases. About 53.9% of the victims died at the accident scene, whereas 34.2% died while on hospital admission. About 42.1%, 32.9%, and 21.1% of the victims were passengers, drivers, and pedestrians, respectively. The spleen was injured in 67.1% of cases while the liver and intestines were injured in 22.4% and 15.8% of cases, respectively. Death was due to the combined effects of multiple injuries in 67.1% of cases, whereas 26.3% of victims died as a result of severe hypovolemia. Conclusions: Abdominal injuries in RTAs fatalities are more common in males and the most productive young adult population. The spleen is the most frequently injured intra-abdominal organ. The majority of deaths in this group of patients are due to the combined effects of multiple injuries in various body structure. Rapid management of patients with abdominal injuries is essential and particular consideration must be placed on those injuries involving other body parts.

Keywords: Abdomen, accidents, autopsy, Ile-Ife, injuries


How to cite this article:
Olaofe OO, Odesanmi WO, Adelusola KA, Komolafe AO, Sabageh D. An autopsy review of abdominal injuries resulting from road traffic accidents: The Ile-Ife experience. Sahel Med J 2017;20:187-91

How to cite this URL:
Olaofe OO, Odesanmi WO, Adelusola KA, Komolafe AO, Sabageh D. An autopsy review of abdominal injuries resulting from road traffic accidents: The Ile-Ife experience. Sahel Med J [serial online] 2017 [cited 2018 Sep 24];20:187-91. Available from: http://www.smjonline.org/text.asp?2017/20/4/187/230262




  Introduction Top


Road traffic accident (RTA), a leading cause of blunt force trauma to the abdomen, remains a major cause of death globally and especially in Nigeria and other developing countries despite all preventive measures to ensure otherwise.[1],[2],[3],[4],[5] Reports from various parts of the world have shown that virtually every organ in the abdominal cavity is susceptible to injury following RTA.[6],[7] Nevertheless, most abdominal organs are well-protected, and injuries to these organs are relatively less frequent causes of death when compared to those involving structures in the head and neck.[8],[9],[10]

For various reasons, many of which are related to a background pathological enlargement of the organ, the spleen has been shown to be the most vulnerable intra-abdominal organ involved in RTAs.[11],[12],[13] Although male accident victims are about four times more likely to sustain injuries to their spleen, mortality appears to be higher in females.[11] In contrast, the liver is a relatively less commonly injured organ in RTA because of its size, consistency, and location within the abdominal cavity, being well-protected by the right lower rib cage. Moreover, mortality from such splenic and liver injuries appear to be directly correlated with the number of concomitant injuries in other organs both within and outside the abdomen and increases with the severity of the force applied as well as with the quality of the treatment received, especially at nonspecialized medical units.[11],[14]

Similarly, the stomach, pancreas, small and large intestines, as well as the great vessels, are not commonly affected in RTA although RTA remains the most common cause of injury to these organs.[15],[16] The kidneys, because of their retroperitoneal location and protection by the rib cage, are seldom injured in RTA although an isolated report from Norway seems to contradict this view.[17]

Very few published work has been carried out on RTA in developing countries, including Nigeria, where there is a high incidence of RTA related fatalities. It is, therefore, important that more research work be conducted on RTA to critically evaluate its impact on the socioeconomic life of the citizens. This study seeks to determine the pattern of abdominal injuries, the categories of affected victims, and the cause of death in fatal RTAs involving injury to the abdomen as seen at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife, Nigeria over a 10-year period.


  Subjects and Methods Top


This was a descriptive retrospective study of the autopsy findings from postmortem examinations conducted on cases of RTA at the Department of Morbid Anatomy and Forensic Medicine, OAUTHC, Ile-Ife, Nigeria between January 1, 2000, and December 31, 2009. The cases selected for the study were those in which the victims sustained injuries to the abdomen. Data for this study were obtained from the departmental autopsy records and register as well as from the victims' clinical records for those who died while on admission in the hospital. Information such as the victim's age, sex, sitting position in the vehicle, type of vehicle, nature of the abdominal injury, the final anatomic cause of death, among others, was extracted.

In Nigeria, the law requires that all cases of death following RTA be investigated by the coroner using the autopsy as one of the investigative tools.

All cases with incomplete bio-data and/or documentation of the various injuries sustained were excluded from the study.

The data obtained were analyzed for differences in proportion using Chi-square by the Statistical Package for Social Sciences version 15.0 (SPSS Inc., Chicago, IL, USA).

Ethical approval for this study was obtained from the Ethics and Research Committee of the OAUTHC, Ile-Ife, Nigeria.


  Results Top


Postmortem examination was conducted on a total of 685 cases of RTA-related deaths during the study. Of these, only 76 cases (12.0%) had at least one form of abdominal injury or the other. There were 61 males (80.3%) and 15 females (19.7%) giving a male to female ratio of 4.1:1. The mean age of the victims was 34.2 years (±17.0 years standard deviation [SD]), whereas the median age was 30.0 years. The ages of the victims ranged from 4 to 85 years [Figure 1]. The mean age for male victims was 35.0 years (±16.2 years SD) while that for female victims was 30.8 years (±20.1 years SD). [Figure 2] shows the relationship between the mean ages for male and female victims. The most commonly affected age group was the 30–40-year age group which accounted for 26 cases (34.2%) while the 20–30 and 40–50-year age groups accounted for 15 cases (19.7%) and 9 cases (11.8%), respectively. Indeed, about 73.6% of victims were between the ages of 20 and 60 years. Only 17.1% of cases were younger than 20 years old while only 9.2% of cases were older than 60 years old.
Figure 1: Age distribution of road traffic accident victims

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Figure 2: Relationship between age and sex of accident victims

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In 41 cases (53.9%), the victims died at the accident scene while 26 victims (34.2%) died within 3 days of admission to our hospital. In nine cases (11.8%), death occurred en route the hospital.

According to [Figure 3], 27 (35.5%) of the victims were in commercial minibuses at the time of the accident while 14 (18.4%) were in saloon cars and 19 (25.0%) were on motorcycles. Heavy duty timber-carrying lorries accounted for ten cases (13.2%) while there was one case (1.3%) of an articulated vehicle. In five cases (6.6%), the type of vehicle was unknown.
Figure 3: Types of vehicles involved in road traffic accidents

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About 32 victims (42.1%) were passengers, whereas 25 (32.9%) were the drivers of the vehicle and 16 (21.1%) were pedestrians. In three cases (3.9%), the victim's category was not indicated. There was no adequate information on the exact sitting position of the passengers within the vehicles. A total of 42 (55.3%) of the accidents occurred within inter-city routes, whereas 30 (39.5%) occurred along intra-city routes. The route was not indicated in four cases (5.3%).

The most frequently injured organ was the spleen [Table 1]. It was lacerated in 51 cases (67.1%). This was followed by injuries to the liver and intestines which occurred in 17 (22.4%) and 12 (15.8%) cases, respectively. The kidney was damaged in only four cases (5.3%).
Table 1: Pattern of abdominal injuries, final anatomic cause, and place of death in road traffic accident victims

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According to [Table 2], hemoperitoneum was associated with damage to the intra-abdominal organs in 58 cases (76.3%). Splenic laceration was associated with hemoperitoneum in 39 cases (76.5%), 16 (31.4%) of which died from severe hypovolemia while 34 (66.7%) died as a result of the combined effects of all the multiple injuries sustained in different parts of the body. In addition, 27 (52.9%) of the victims with splenic laceration died at the scene of the accident while the remaining 24 (47.1%) died while on admission in our hospital.
Table 2: Various parameters associated with the occurrence of hemoperitoneum

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Of the 17 cases with laceration of the liver, there were 14 males (82.4%) and 3 females (17.6%) while 11 cases (64.7%) in all were associated with the presence of hemoperitoneum. Laceration of the liver was associated with injury to the kidney in two cases (11.8%) and rupture of the spleen in 6 (35.5%) cases (P = 0.002). In 13 (76.5%) of the victims with liver laceration, death was due to multiple injuries while 12 (70.6%) died before reaching the hospital.

Overall, the cause of death was severe multiple injuries in 51 cases (67.1%) while hypovolemia was the cause in 20 cases (26.3%). In three cases, death was due to injuries not related in any way to the abdominal injuries sustained in the RTA, and this included a case each resulting from severe chest injury with respiratory failure, cervical spine fracture with respiratory arrest, and severe burns. The cause of death was unknown in two cases (2.6%).

The cause of the RTA was attributed to a burst tyre 14 cases (18.4%), head on collision in 9 cases (11.8%), and over-speeding in 2 cases (2.6%) while it was unknown in 51 cases (67.1%). Finally, there was no statistically significant association between the victim's sex and presence of splenic laceration (P = 0.24), liver laceration (P = 0.81), intestinal injury (P = 0.28), renal injury (P = 1.31), or hemoperitoneum (P = 0.49).


  Discussion Top


This study, just like many others the world over, shows that the spleen is the most commonly damaged intra-abdominal organ in RTAs.[11],[12],[13],[18],[19],[20],[21] We recorded splenic laceration in 51 (67.1%) of the 76 cases reviewed. This is not surprising as the spleen is a very soft organ which in many cases is found to be pathologically enlarged, albeit mildly, possibly as a result of the repeated bouts of malaria infection.[11],[12],[13] Moreover, this study showed that splenic laceration was three times more common in male victims and was associated with hemoperitoneum in about 76.5% of cases. It is well known that males are more frequently involved in RTAs, and this may be due either to the fact that there are more male road users or that males are poorer road users. We found that splenic injury was associated with laceration of the liver in about 11.8% of cases and subdural hematoma in about 39.2% of cases. It, therefore, becomes important that patients with splenic injury be properly evaluated for such possible life-threatening injuries which would otherwise reduce their chances of survival if left undetected.

The liver was lacerated in about 22.4% of cases making it the second most commonly injured intra-abdominal organ. This is similar to many reports from within and outside Nigeria.[14],[15],[21],[22] Expectedly, the liver is relatively less prone injury because of its consistency, position in the abdomen and protection by the rib cage. In many instances, therefore, it takes a great amount of blunt force trauma to cause injury to the liver. Such traumatic forces are such that will inadvertently cause severe damage to other intra-abdominal structures in addition to those in other parts of the body. Our study showed that liver damage was significantly associated with the presence of injury to other intra-abdominal organs, particularly the kidney and the spleen. Thus, patients with laceration of the liver typically die from the combined effects of the severe multiple injuries. Our study showed that about 82.4% of victims with laceration of the liver died from multiple injuries.

Our study showed that injury to the intestines was relatively less common compared to the spleen and the liver. Many authors have previously shown that injury to the stomach, duodenum, jejunum, ileum, and pancreas following is less commonly seen in RTA patients who present to the hospital. Bergqvist et al. in their analysis of upper gastrointestinal trauma in Sweden over a 30-year period found only 45 cases of gastric, duodenal, and pancreatic injury.[15] According to their study, RTA was the most common cause of such injuries with the most obvious mechanism being a steering wheel blow to the abdomen. Blunt force trauma to the abdomen, especially by seatbelt injury, may also compress the pancreas over the vertebral column and cause pancreatic disruption. The rarity of small intestinal injury may be related to its high elasticity and mobility within the abdominal cavity while the ascending and descending colon are well-protected by the thick muscles of the lateral abdominal wall. It is interesting to note that, just like various authors have previously indicated, we did not record any case of gastric or esophageal injury.[9],[10],[13],[15],[17] These injuries are known to be extremely rare in RTA victims.

Our study showed that injury to the kidneys was also very uncommon accounting for only 4 of the 76 cases. This may be due to the fact that the kidneys are well-protected by their retroperitoneal location in addition to the protection offered by the rib cage. Many authors have reported similar findings. On the contrary, Edna et al. in Norway, who reviewed abdominal injuries in 221 patients, reported that the kidneys and spleen were the two most commonly injured organs.[17] Reasons for this strange “Norwegian” occurrence are, however, unknown.

About 53.9% of the RTA victims in this study died at the scene of the accident while 67.1% died from the combined effect of the several multiple injuries sustained. Although abdominal injury is an important cause of death in RTA victims, mortality has been strongly correlated with a delay in the institution of appropriate surgical intervention, the presence, and severity of concomitant injuries, the urgent need for blood transfusion and the amount of time it takes for the victims to be admitted to the hospital.[9] It, therefore, becomes imperative that the appropriate management be promptly instituted for RTA victims to reduce mortality from these events.


  Conclusions Top


This study showed that abdominal injury, and indeed RTA, was more common in males, especially in the active young adult population. The most common pathology found in the abdomen was hemoperitoneum, and this was predominantly caused by injury to the spleen. Death in RTA victims who sustained abdominal injuries was most commonly due to the combined effects of the multiple injuries sustained in various parts of the body with a majority of victims dying at the accident scene. Injury to the kidneys, stomach, and pancreas, are relatively less common. There is a need for rapid management of RTA victims who sustain abdominal injuries, and particular consideration must be placed on those injuries involving other body structures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

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