[Injuries from violence in young children--signs, management and diagnostics]

Inflicted injuries in infants and toddlers may easily be missed unless clinicians who care for children are alert to sometimes subtle clues in the history and physical exam. Any injury which is unexplained or incompatible with the developmental capabilities of the child or inconsistent with the given history should prompt a medical evaluation for suspected physical abuse. The most common cause of serious head injuries in infants younger than 12 months is child abuse. Shaking and blunt head trauma can result in injuries such as subdural hemorrhage, diffuse retinal hemorrhage, and brain and spine injury. Early detection of child physical abuse requires a systematic and careful diagnostic approach. The physician must be able to recognize suspicious injuries, as well as possess an understanding of the mimics that may be confused with inflicted injuries. Health care professionals are mandated by Swedish law to promptly report suspected abuse to child protective services.

The Influence of Neck Muscle Tonus and Posture on Brain Tissue Strain in Pedestrian Head Impacts

Pedestrians are one of the least protected groups in urban traffic and frequently suffer fatal head injuries. An important boundary condition for the head is the cervical spine, and it has previously been demonstrated that neck muscle activation is important for head kinematics during inertial loading. It has also been shown in a recent numerical study that a tensed neck musculature also has some influence on head kinematics during a pedestrian impact situation. The aim of this study was to analyze the influence on head kinematics and injury metrics during the isolated time of head impact by comparing a pedestrian with relaxed neck and a pedestrian with increased tonus. The human body Finite Element model THUMS Version 1.4 was connected to head and neck models developed at KTH and used in pedestrian-to-vehicle impact simulations with a generalized hood, so that the head would impact a surface with an identical impact response in all simulations. In order to isolate the influence of muscle tonus, the model was activated shortly before head impact so the head would have the same initial position prior to impact among different tonus. A symmetric and asymmetric muscle activation scheme that used high level of activation was used in order to create two extremes to investigate. It was found that for the muscle tones used in this study, the influence on the strain in the brain was very minor, in general about 1-14% change. A relatively large increase was observed in a secondary peak in maximum strains in only one of the simulated cases.

[Role of acute alcohol poisoning and craniocerebral trauma in the mechanism of death caused by subarachnoid hemorrhage]

OBJECTIVE

To investigate the relation between the expression of tPA, MMP-2, MMP-9 and AEG-1 in the human brain tissue and the ethanol concentration under the acute alcohol poison, and to analyze the role of alcohol and trauma in the mechanism of death of subarachnoid hemorrhage.

METHODS

Fifteen real cases were collected in this study. The brain tissues were researched by histological examination and the concentration of ethanol in heart blood were detected. The tPA, MMP-2, MMP-9 and AEG-1 in brainstem, brain and cerebellum were observed respectively by immunohistochemistry.

RESULTS

In alcohol poisoning groups with or without trauma, the acute alcohol toxicity resulted in the swelling of brain tissues. The tPA, MMP-2, MMP-9 and AEG-1 of brainstem, brain and cerebellum showed high expression in alcohol victims, and the tPA in cerebellum showed no difference. The expression of the MMP-2, MMP-9 and AEG-1 showed good relation with the ethanol concentration in blood (P < 0.05, r > 0.6).

CONCLUSION

The expressions of tPA, MMP-2, MMP-9 and AEG-1 are significant higher in alcohol victims, and expressions of MMP-2 and MMP-9 and AEG-1 have positive correlation with the alcohol concentration. The alcohol has acute toxicity to brain cells.

A possibility to identify the vehicle driver through complex forensic and criminalistic expertise--case report

Traffic accidents can have more or less dramatic consequences that involve penal and civil responsibility with amplitude extending over long periods of time. In many cases, substitution of the driver with the passenger in order to avoid criminal responsibility is often remarked. The substitution takes place with the passenger's agreement or, in cases with dramatic consequences (coma or death), without his/her consent. These situations are encountered in civil cases regarding insurance fraud. In addition to forensic medical expertise, to aid the experts, mathematical modeling and computer simulation of the dynamics of vehicle passengers is a tool that completes the criminal expertise of traffic accidents. This paper presents the method of identification of the person driving the vehicle based on the computer simulation of vehicle occupants' dynamics.

Stellate ganglion block used to treat symptoms associated with combat-related post-traumatic stress disorder: a case series of 166 patients

OBJECTIVE

Report the successful use of stellate ganglion blocks (SGBs) in 166 active duty service members with multiple combat deployments experiencing anxiety symptoms associated with post-traumatic stress disorder (PTSD).

BACKGROUND

Successful treatment of PTSD symptoms with SGB has been reported previously. This is the largest published case series evaluating SGB with a minimum of 3 months follow-up.

METHODS

Following clinical interview including administration of the PTSD Checklist (PCL), 166 service members with symptoms of PTSD elected to receive a SGB. All patients received a SGB on the right side at the level of the sixth cervical vertebrae (C6). The PCL was administered the day before treatment to establish a baseline, repeated 1 week later, and then monthly out to 3 months. A positive response was considered to be an improvement in the PCL score by 10 or greater points. Follow-up PCL scores from 3 to 6 months were obtained and analyzed for 166 patients.

RESULTS

In a military population with multiple combat deployments, over 70% of the patients treated had a clinically significant improvement in their PCL score which persisted beyond 3 to 6 months postprocedure.

CONCLUSION

Selective blockade of the right cervical sympathetic chain at the C6 level is a safe and minimally invasive procedure that may provide durable relief from anxiety symptoms associated with PTSD.

Bicycle helmets are highly effective at preventing head injury during head impact: head-form accelerations and injury criteria for helmeted and unhelmeted impacts

Cycling is a popular form of recreation and method of commuting with clear health benefits. However, cycling is not without risk. In Canada, cycling injuries are more common than in any other summer sport; and according to the US National Highway and Traffic Safety Administration, 52,000 cyclists were injured in the US in 2010. Head injuries account for approximately two-thirds of hospital admissions and three-quarters of fatal injuries among injured cyclists. In many jurisdictions and across all age levels, helmets have been adopted to mitigate risk of serious head injuries among cyclists and the majority of epidemiological literature suggests that helmets effectively reduce risk of injury. Critics have raised questions over the actual efficacy of helmets by pointing to weaknesses in existing helmet epidemiology including selection bias and lack of appropriate control for the type of impact sustained by the cyclist and the severity of the head impact. These criticisms demonstrate the difficulty in conducting epidemiology studies that will be regarded as definitive and the need for complementary biomechanical studies where confounding factors can be adequately controlled. In the bicycle helmet context, there is a paucity of biomechanical data comparing helmeted to unhelmeted head impacts and, to our knowledge, there is no data of this type available with contemporary helmets. In this research, our objective was to perform biomechanical testing of paired helmeted and unhelmeted head impacts using a validated anthropomorphic test headform and a range of drop heights between 0.5m and 3.0m, while measuring headform acceleration and Head Injury Criterion (HIC). In the 2m (6.3m/s) drops, the middle of our drop height range, the helmet reduced peak accelerations from 824g (unhelmeted) to 181g (helmeted) and HIC was reduced from 9667 (unhelmeted) to 1250 (helmeted). At realistic impact speeds of 5.4m/s (1.5m drop) and 6.3m/s (2.0m drop), bicycle helmets changed the probability of severe brain injury from extremely likely (99.9% risk at both 5.4 and 6.3m/s) to unlikely (9.3% and 30.6% risk at 1.5m and 2.0m drops respectively). These biomechanical results for acceleration and HIC, and the corresponding results for reduced risk of severe brain injury show that contemporary bicycle helmets are highly effective at reducing head injury metrics and the risk for severe brain injury in head impacts characteristic of bicycle crashes.

Case study on possible falling patterns of a fatal fall from stairs

Considering a fatal case of an aged individual, who died due to falling down stairs, the cause of the fatal fall was investigated through experiments. A witness, who was with the victim, when the fatal accident occurred, stated that the aged individual had miss-footed, lost balance at the top of the stairs, and fell accidently from an upper floor to a lower floor. It was very questionable whether or not this witness's statements were true. The true cause of the fatal fall was unclear, because of the witness's inconsistent statements, which showed discrepancies between the initial and later statements. The cause of a fatal fall can be presumed from external and internal damages to the body and other circumstantial evidences. But it was difficult to prove the true cause of a fatal fall only from the results of the autopsy and investigation of circumstantial evidences. The author was officially requested to conduct experiments to elucidate possible falling patterns. Judging from the experimental results, deep questions about the witness's statements arose. These experimental methods and analyses in this paper could be applied to elucidate possible falling patterns of fatal falls from stairs where the fatal causes are controversial.

Office management of mild head injury in children and adolescents

OBJECTIVE

To provide family physicians with updated, practical, evidence-based information about mild head injury (MHI) and concussion in the pediatric population.

SOURCES OF INFORMATION

MEDLINE (1950 to February 2013), the Cochrane Database of Systematic Reviews (2005 to 2013), the Cochrane Central Register of Controlled Trials (2005 to 2013), and DARE (2005 to 2013) were searched using terms relevant to concussion and head trauma. Guidelines, position statements, articles, and original research relevant to MHI were selected.

MAIN MESSAGE

Trauma is the main cause of death in children older than 1 year of age, and within this group head trauma is the leading cause of disability and death. Nine percent of reported athletic injuries in high school students involve MHI. Family physicians need to take a focused history, perform physical and neurologic examinations, use standardized evaluation instruments (Glasgow Coma Scale; the Sport Concussion Assessment Tool, version 3; the child version of the Sport Concussion Assessment Tool; and the Balance Error Scoring System), instruct parents how to monitor their children, decide when caregivers are not an appropriately responsible resource, follow up with patients promptly, guide a safe return to play and to learning, and decide when neuropsychological testing for longer-term follow-up is required.

CONCLUSION

A thorough history, physical and neurologic assessment, the use of validated tools to provide an objective framework, and periodic follow-up are the basis of family physician management of pediatric MHI.

Bikes, helmets, and public health: decision-making when goods collide

How ought public officials address policy choices that entail trade-offs between desirable public health goods? Increasing cycling improves public health both by promoting physical activity and by decreasing vehicle use, thus reducing vehicular emissions. Proponents of bicycle helmets argue that, used properly, they protect individual cyclists; however, there is concern that mandating helmet use may result in a decrease in cycling. In 2012, New York City Mayor Michael Bloomberg opposed a bicycle helmet mandate, concerned that it would have a negative impact on the city's cycling rate, which he had sought to increase. The mayor did not explain his rationale, leaving constituents unsure why he opposed the proposal. This case study underscores the challenge of creating public policy in the context of competing public health goods.

Long-term use of zolpidem increases the risk of major injury: a population-based cohort study

OBJECTIVE

To estimate the risk of head injury or fracture requiring hospitalization in patients treated with zolpidem.

PATIENTS AND METHODS

We identified 8188 patients 18 years and older who had received a first prescription for zolpidem between January 1, 2000, and December 31, 2009, and compared them with 32,752 age- and sex-matched patients who had not used sedative-hypnotic agents. Both cohorts were followed up for at least 1 year or until hospitalization for head injury or fracture (major injury). Hazard ratios (HRs) and 95% CIs were calculated by comparing the incidence of major injury requiring hospitalization between the zolpidem user and comparison cohorts, including age groups 18 to 54 and 55 years or more, using a Cox proportional hazards regression analysis.

RESULTS

The adjusted HR for major injury in zolpidem users was 1.67 (95% CI, 1.19-2.34). The adjusted HR for major injury in zolpidem users in the younger cohort (aged 18-54 years) was 1.70 (95% CI, 1.15-2.51) and in the older cohort (aged ≥55 years) was 1.57 (95% CI, 0.78-3.13). The adjusted HR for major injury in zolpidem users increased when the zolpidem dosage increased (HR, 2.04; 95% CI, 1.32-3.13 for 71-800 mg/y; HR, 4.37; 95% CI, 2.12-9.01 for 801-1600 mg/y; and HR, 4.74; 95% CI, 2.38-9.42 for >1600 mg/y).

CONCLUSION

The long-term use of zolpidem is associated with a significantly greater risk of head injury or fracture requiring hospitalization than in patients who do not use sedative-hypnotic agents (P<.001), particularly in the younger (aged 18-54 years) patients.

Acute ischemic stroke in a 19 month old following minor head trauma: case report and review of the literature

Minor head trauma is a very rare cause of ischemic stroke in the pediatric population. We describe a nineteen month old patient who developed left hemiparesis and subsequently left facial palsy after a fall. MRI of the brain showed hypodensities in the basal ganglia, internal capsule and caudate nucleus consistent with stroke. Echocardiogram and MRA were normal. Hypercoaguable work up showed that the patient was a carrier for a single MTHFR gene. The patient was treated conservatively. On follow up two weeks later his facial palsy had resolved and strength in the extremities improved. Although a rare condition awareness about this is necessary as there can be considerable delay in its recognition.

The first concussion crisis: head injury and evidence in early American football

In the early 21st century, sports concussion has become a prominent public health problem, popularly labeled "The Concussion Crisis." Football-related concussion contributes much of the epidemiological burden and inspires much of the public awareness. Though often cast as a recent phenomenon, the crisis in fact began more than a century ago, as concussions were identified among footballers in the game's first decades. This early concussion crisis subsided-allowing the problem to proliferate-because work was done by football's supporters to reshape public acceptance of risk. They appealed to an American culture that permitted violence, shifted attention to reforms addressing more visible injuries, and legitimized football within morally reputable institutions. Meanwhile, changing demands on the medical profession made practitioners reluctant to take a definitive stance. Drawing on scientific journals, public newspapers, and personal letters of players and coaches, this history of the early crisis raises critical questions about solutions being negotiated at present.

The full spectrum of handlebar injuries in children: a decade of experience

BACKGROUND

Traumatic paediatric handlebar injury (HBI) is known to occur with different vehicles, affect different body regions, and have substantial associated morbidity. However, previous handlebar injury research has focused on the specific combination of abdominal injury and bicycle riding. Our aim was to fully describe the epidemiology and resultant spectrum of injuries caused by a HBI.

METHODS

Retrospective data analysis of all paediatric patients (<18 years) in a prospectively identified trauma registry over a 10-year period. Primary outcome was the HBI, its location and management. The effects of patient age, vehicle type, the impact region, and Injury Severity Score (ISS) were also evaluated. HBI patients were compared against a cohort injured while riding similar vehicles, but not having sustained a HBI.

RESULTS

1990 patients were admitted with a handlebar-equipped vehicle trauma; 236 (11.9%) having sustained a HBI. HBI patients were twice as likely to be aged between 6 and 14 years old compared with non-HBI patients (OR 2.2; 95% CI 1.5-3.2). 88.6% of the HBI patients sustained an isolated injury, and 45.3% had non-abdominal handlebar impact. There were no significant differences in median ISS (p=0.4) or need for operative intervention (OR 1.1; 95% CI 0.9-1.5) between HBI and non-HBI patients. HBI patients had a significantly longer LOS (1.8 days vs. 1.2 days; p=0.001), and more frequently required a major operation (OR 3.4; 95% CI 2.2-5.4). The majority of splenic, renal and hepatic injuries were managed conservatively.

CONCLUSIONS

Although the majority of paediatric HBI is associated with both intra-abdominal injury and bicycle riding, it produces a spectrum of potentially serious injuries and patients are more likely to undergo major surgery. Therefore these patients should always be treated with a high degree of suspicion.

Rotational acceleration during head impact resulting from different judo throwing techniques

Most severe head injuries in judo are reported as acute subdural hematoma. It is thus necessary to examine the rotational acceleration of the head to clarify the mechanism of head injuries. We determined the rotational acceleration of the head when the subject is thrown by judo techniques. One Japanese male judo expert threw an anthropomorphic test device using two throwing techniques, Osoto-gari and Ouchi-gari. Rotational and translational head accelerations were measured with and without an under-mat. For Osoto-gari, peak resultant rotational acceleration ranged from 4,284.2 rad/s(2) to 5,525.9 rad/s(2) and peak resultant translational acceleration ranged from 64.3 g to 87.2 g; for Ouchi-gari, the accelerations respectively ranged from 1,708.0 rad/s(2) to 2,104.1 rad/s(2) and from 120.2 g to 149.4 g. The resultant rotational acceleration did not decrease with installation of an under-mat for both Ouchi-gari and Osoto-gari. We found that head contact with the tatami could result in the peak values of translational and rotational accelerations, respectively. In general, because kinematics of the body strongly affects translational and rotational accelerations of the head, both accelerations should be measured to analyze the underlying mechanism of head injury. As a primary preventative measure, throwing techniques should be restricted to participants demonstrating ability in ukemi techniques to avoid head contact with the tatami.

Evaluation of near-side oblique frontal impacts using THOR with SD3 shoulder

OBJECTIVE

Within the EC Seventh Framework project THORAX, the Mod-Kit THOR was upgraded with a new thorax and shoulder. The aim of this study was to investigate whether the THOR ATD met a set of prerequisites to a greater extent than Hybrid III and by that measure whether the dummy could serve as a potential tool for future evaluation of serious head and chest injuries in near-side oblique frontal impacts.

METHOD

A small-overlap/oblique sled system was used to reflect occupant forces observed in oblique frontal crashes. The head and thoracic response from THOR was evaluated for 3 combinations: belt only with no deformation of the driver's side door (configuration A), belt only in combination with a predeformed door (configuration B), and prepretensioning belt and driver airbag (PPT+DAB) in combination with a predeformed door (configuration C). To evaluate head injury risk, the head injury criterion (HIC) and brain injury criteria (BrIC) were used. For evaluation of the thoracic injury risk, 3 injury criteria proposed by the THORAX project were evaluated: Dmax, DcTHOR, and strain (dummy rib fractures).

RESULTS

Unlike Hybrid III, the THOR with SD3 shoulder interacted with the side structure in a near-side oblique frontal impact. HIC values for the 3 test configurations corresponded to a 90% (A) and 100% (B and C) risk of Abbreviated Injury Scale (AIS) 2+ head injury, and BrIC values resulted in a 100% risk of AIS 2+ head injury in configurations A and B. In C the risk was reduced to 75%. The AIS 2+ thoracic injury risks based on Dmax were similar (14-18%) for all tests. Based on DcTHOR, AIS 2+ injury risk increased from 29 to 53% as the predeformed door side was introduced (A to B), and the risk increased, to 64%, as a PPT+DAB was added (C). Considering the AIS 2+ injury risk based on strain, tests in A resulted in an average of 3 dummy rib fractures (17%). Introducing the predeformed door (B) increased the average of dummy fractures to 5 (39%), but in C the average number of dummy rib fractures decreased to 4 (28%).

CONCLUSIONS

THOR with an SD3 shoulder should be the preferred ATD rather than the Hybrid III for evaluating head and thorax injuries in oblique frontal impacts. Thoracic interaction with the predeformed door was not well captured by the 3D IR-Traccs; hence, use of deflection as an injury predictor in oblique loading is insufficient for evaluating injury risk in this load case. However, injury risk evaluation may be performed using the strain measurements, which characterize loading from seat belt and airbag as well as the lateral contribution of the structural impact in the loading condition used in this study.

[Resuscitation for myocardial infarction and head injury: first the heart or first the head?]

Loss of circulation in a patient results in collapse and therefore possible head injury. After percutaneous coronary intervention (PCI) including anticoagulation, comatose patients are sedated for mild therapeutic hypothermia. Recognised or unrecognised head trauma may have dramatic clinical consequences. A 42-year-old male with unrecognised head trauma died due to a massive intracranial haemorrhage (ICH) during the hypothermia phase after being treated with PCI. A 76-year-old female, on anticoagulation for atrial fibrillation, with recognised ICH which resulted in an adjusted PCI, died after five days due to a lethal re-bleed. In a 55-year-old male with neurological abnormalities after mild head trauma, the PCI was postponed for a (negative) head CT which might have increased cardiac muscle damage. Nowadays more patients reach hospital after being resuscitated for cardiac arrest and possible head trauma should be considered in all these patients. This could lead to adjustments being made in the treatment protocol.

Comparative performance of forward-facing child restraint systems on the C/FMVSS 213 bench and vehicle seats

OBJECTIVE

The objective of this study was to evaluate the fidelity of the C/FMVSS 213 test bench, by comparing the dynamic performance of forward-facing child restraint systems (FFCRS) mounted on the C/FMVSS 213 sled bench versus mounted on a selection of production vehicle seats.

METHODS

The C/FMVSS 213 bench or one of 3 second-row original equipment manufacturer vehicle seats was mounted to the deck of acceleration crash sled. An FFCRS with a restrained anthropomorphic test device (ATD) was secured by 3-point belt (3-PT) or LATCH lower anchor (LLA) on the C/FMVSS 213 bench or vehicle seat, with or without a tether. The sled was then exposed to a 48 km/h acceleration pulse. Three unique make and model vehicle seats and FFCRS were tested. Fifty-three sled tests were performed.

RESULTS

When FFCRS were secured with LLA and no tether, little difference between the vehicle seats and 213 bench was observed. Similarly, when FFCRS were affixed with 3-PT and no tether, few kinematic variable differences achieved statistical significance; chest resultant acceleration was, on average, 9.1 g (SD=6.6, P=.006) higher on the vehicle seats compared to the bench, as was CRS seatback excursion (difference [Δ] of 39.8 mm, SD=32.7, P=.011) and ATD knee excursion (Δ=36.4 mm, SD=12.0, P<.001). However, when the tether was added to either the 3-PT or LLA attachment methods, the difference between the bench and vehicle seats was more pronounced. ATD kinematic measures such as head resultant acceleration (Δ=14.6 g, SD=7.2, P<.001) and pelvis resultant acceleration (Δ=8.6 g, SD=6.0, P=.005) were higher on the vehicle seats compared to the bench, as were the injury metrics for head and chest injury: ΔHIC15=162.2 (SD=87.4, P=.001) and ΔChest 3 ms clip=5.5 g (SD=6.2, P=.040). Of note, CRS (Δ=62.8 mm, SD=32.7, P=.000) and ATD head (Δ=66.3 mm, SD=30.9, P=.000) and knee (Δ=46.9 mm, SD=25.8, P=.001) forward excursion were all higher on the vehicle seats compared to the bench in 3-PT with tether condition.

CONCLUSIONS

Without the tether attached, we observed few kinematic and kinetic differences between the vehicle seat and the C/FMVSS 213 bench, suggesting that the bench is an adequate surrogate for the vehicle seat in this condition. With the tether attached, we found significant differences between the C/FMVSS 213 bench and vehicle seats, suggesting that the fidelity of the bench could be improved in the tethered mode. When differences were statistically significant, excursion and injury metrics were generally greater on the vehicle seats than on the C/FMVSS 213 bench.

Head injury--a neglected public health problem: a four-month prospective study at Jimma University Specialized Hospital, Ethiopia

BACKGROUND

Trauma, especially head trauma, is an expanding major public health problem and the leading cause of death of the young and productive part of the world's population. Research is mainly done in high-income countries where only a small proportion of the worldwide fatalities occur. The intention of this study was to analyze head injury in a setting where most patients in low- and middle-income countries receive treatment, a referral hospital with general but no neurosurgical service like Jimma University Specialized Hospital. The study aims to provide surgeons, hospital managers and health planners working in similar set-ups with baseline information for further investigation and prevention programs intending to reduce the burden of head injury.

METHODS

All head injury patients presented to Jimma University Specialized Hospital between March and June 2010 were included in this prospective research. Epidemiological, clinical and management data were collected for the study.

RESULTS

Out of 52 patients, 47 were males. The median age was 20.0 years (SD=13.3). Fights (n=20, 38.5%) and road traffic accidents (n=19, 36.5%) were the most common causes of head injury. Half of the patients sustained mild and 36.5% sustained severe head injury. The initial GCS had a significant correlation with the outcome. The mortality rate was 21.2%. Of all patients 76.9% were managed conservatively.

CONCLUSION

Prevention of road traffic accidents and improvement of conservative care were identified as major methods to reduce the burden of head injury in a set-up similar to Jimma. Further studies on head injury patients in low-income countries should be done.

Crash characteristics and injury patterns of restrained front seat occupants in far-side impacts

OBJECTIVE

The study was conducted to determine the association between vehicle-, crash-, and demographic-related factors and injuries to front seat far-side occupants in modern environments.

METHODS

Field data were obtained from the NASS-CDS database for the years 2009-2012. Inclusion factors included the following: adult restrained front outboard-seated occupants, no ejection or rollovers, and vehicle model years less than 10 years old at the time of crash. Far-side crashes were determined by using collision deformation classification. Injuries were scored using the Abbreviated Injury Scale (AIS). Injuries (MAIS 2+, MAIS 3+, M denotes maximum score) were examined based on demographics, change in velocity, vehicle type, direction of force, extent zone, collision partner, and presence of another occupant in the front seat. Only weighted data were used in the analysis. Injuries to the head and face, thorax, abdomen, pelvis, and upper and lower extremity regions were studied. Odds ratios and upper and lower confidence intervals were estimated from multivariate analysis.

RESULTS

Out of 519,195 far-side occupants, 17,715 were MAIS 2+ and 4,387 were MAIS 3+ level injured occupants. The mean age, stature, total body mass, and body mass index (BMI) were 40.7 years, 1.7 m, 77.2 kg, and 26.8 kg/m2, respectively. Of occupants with MAIS 2+ injuries, 51% had head and 19% had thorax injuries. Of occupants with MAIS 3+ injuries, 50% had head and 69% had thorax injuries. The cumulative distribution of changes in velocities at the 50th percentile for the struck vehicle for all occupants and occupants with MAIS 2+ and MAIS 3+ injuries were 19, 34, and 42 km/h, respectively. Furthermore, 73% of MAIS 2+ injuries and 86% of MAIS 3+ injuries occurred at a change in velocity of 24 km/h or greater. Odds of sustaining MAIS 2+ and MAIS 3+ injuries increased with each unit increase in change in velocity, stature, and age, with one exception. Odds of sustaining injuries were higher with the presence of an occupant in the front seat at the MAIS 3+ level, although it was reversed at the lower level. The extent zone of 3+ increased the odds compared to the extent zones of 1 to 2 at both MAIS 2+ and MAIS 3+ injuries. Odds ratios and confidence intervals are given.

CONCLUSIONS

The findings are as follows: head and thorax are the more frequently injured body regions, and the prevalence of cranium injuries is similar at both injury severities; thoracic injuries are more prevalent at the MAIS 3+ level; the presence of another front seat occupant plays a role in MAIS 3+ trauma; injuries continue to occur at changes in velocity representative of side impact environments; and mean demographic factors are close to mid-size automotive anthropometry, indicating the need to pursue this line of study. Because data were gathered from only 4 years, it would be important to include additional NASS-CDS database years, rescore injuries from previous years, and analyze other international databases to reinforce these findings for advancing safety for far-side occupants.

Ophthalmic complications among cases of head trauma in north-eastern Iran

The aim of this study was to investigate the prevalence and pattern of ocular complications in patients with head trauma admitted to the main trauma centre in north-eastern Iran. A total of 459 head-injured patients (36.56 ± 19.30 years of age) with at least one ocular manifestation were recruited. Each individual patient was examined by a neurosurgeon and an ophthalmologist to confirm the type of ocular complication. In addition, all patients were analysed for age, gender, and cause of head injury in addition to the ophthalmic and neurosurgical examinations. Of the 459 patients, 142 (31 %) were female and 317 (69 %) were male. The maximum rate of ocular complications was during the third decade of life and minimum during childhood and in the elderly (>71 years) population. The leading cause of head trauma was motor vehicle accidents, predominant in male adults aged 21-40 years. Ocular complications observed were classified into three major groups: soft-tissue injuries to the globe and adnexae (n = 434), orbital complications (n = 45) and neuro-ophthalmic complications (n = 152). In conclusion, our data provides a useful estimation of the rate and pattern of ocular complications among patients with head injuries seen in trauma centres in north-eastern Iran. Understanding the pattern of ocular complications helps us to design more appropriate preventive methods.

Development/global validation of a 6-month-old pediatric head finite element model and application in investigation of drop-induced infant head injury

Drop is a frequent cause for infant head injury. To date, finite element (FE) modeling was gradually used to investigate child head dynamic response under drop impact conditions, however, two shortages still exist on this topic: (1) due to ethical reasons, none of developed 6-month-old (6MO) head FE model was found to be quantitatively validated against child cadaver tests at similar age group; (2) drop height and impact surface stiffness effects on infant head responses were not comprehensively investigated. In this study, motivated by the recently published material properties of soft tissues (skull and suture, etc.) and reported pediatric head global cadaver tests, a 6MO child head FE model was developed and simulated results compared with the child cadaver experimental data under compression and drop conditions. Comparison of results indicated that the FE model showed a fairly good biofidelic behavior in most dynamic responses. The validated FE model was further used to investigate effects of different drop heights and impact surface stiffness on the head dynamic responses. Numerical results show that the pediatric head mechanical parameters (peak acceleration, HIC, maximal vonMises stress and maximal first principal strain of skull) keep increasing with the increase in drop height, and exhibit "logarithmic function" shapes at "fast-slow" trends with increase in impact surface stiffness. Based on above analysis, the regressions were conducted to describe the relationship between drop height and impact surface stiffness and head global injury predictors (head peak acceleration, HIC, etc.). This paper provides a fundamental study of child head injury mechanism and protection under drop conditions.

Pediatric bed fall computer simulation model: parametric sensitivity analysis

Falls from beds and other household furniture are common scenarios that may result in injury and may also be stated to conceal child abuse. Knowledge of the biomechanics associated with short-distance falls may aid clinicians in distinguishing between abusive and accidental injuries. In this study, a validated bed fall computer simulation model of an anthropomorphic test device representing a 12-month-old child was used to investigate the effect of altering fall environment parameters (fall height, impact surface stiffness, initial force used to initiate the fall) and child surrogate parameters (overall mass, head stiffness, neck stiffness, stiffness for other body segments) on fall dynamics and outcomes related to injury potential. The sensitivity of head and neck injury outcome measures to model parameters was determined. Parameters associated with the greatest sensitivity values (fall height, initiating force, and surrogate mass) altered fall dynamics and impact orientation. This suggests that fall dynamics and impact orientation play a key role in head and neck injury potential. With the exception of surrogate mass, injury outcome measures tended to be more sensitive to changes in environmental parameters (bed height, impact surface stiffness, initiating force) than surrogate parameters (head stiffness, neck stiffness, body segment stiffness).

A computational simulation study of the influence of helmet wearing on head injury risk in adult cyclists

Evidence for the effectiveness of cycle helmets has relied either on simplified experiments or complex statistical analysis of patient cohorts or populations. This study directly assesses the effectiveness of cycle helmets over a range of accident scenarios, from basic loss of control to vehicle impact, using computational modelling. Simulations were performed using dynamics modelling software (MADYMO) and models of a 50% Hybrid III dummy, a hybrid cross bicycle and a car. Loss of control was simulated by a sudden turn of the handlebars and striking a curb, side and rear-on impacts by a car were also simulated. Simulations were run over a representative range of cycle speeds (2.0-14.0 m s(-1)) and vehicle speeds (4.5-17.9 m s(-1)). Bicycle helmets were found to be effective in reducing the severity of head injuries sustained in common accidents. They reduced the risk of an AIS>3 injury, in cases with head impacts, by an average of 40%. In accidents that would cause up to moderate (AIS=2) injuries to a non-helmeted rider, helmets eliminated the risk of injury. Helmets were also found to be effective in preventing fatal head injuries in some instances. The effectiveness of helmets was demonstrated over the entire range of cycle speeds studied, up to and including 14 m s(-1). There was no evidence that helmet wearing increased the risk of neck injury, indeed helmets were found to be protective of neck injuries in many cases. Similarly, helmets were found to offer an increase in protection even when an increase in cycle speed due to risk compensation was taken into consideration.

Prevalence of and factors associated with head impact during falls in older adults in long-term care

BACKGROUND

Falls cause more than 60% of head injuries in older adults. Lack of objective evidence on the circumstances of these events is a barrier to prevention. We analyzed video footage to determine the frequency of and risk factors for head impact during falls in older adults in 2 long-term care facilities.

METHODS

Over 39 months, we captured on video 227 falls involving 133 residents. We used a validated questionnaire to analyze the mechanisms of each fall. We then examined whether the probability for head impact was associated with upper-limb protective responses (hand impact) and fall direction.

RESULTS

Head impact occurred in 37% of falls, usually onto a vinyl or linoleum floor. Hand impact occurred in 74% of falls but had no significant effect on the probability of head impact (p = 0.3). An increased probability of head impact was associated with a forward initial fall direction, compared with backward falls (odds ratio [OR] 2.7, 95% confidence interval [CI] 1.3-5.9) or sideways falls (OR 2.8, 95% CI 1.2-6.3). In 36% of sideways falls, residents rotated to land backwards, which reduced the probability of head impact (OR 0.2, 95% CI 0.04-0.8).

INTERPRETATION

Head impact was common in observed falls in older adults living in long-term care facilities, particularly in forward falls. Backward rotation during descent appeared to be protective, but hand impact was not. Attention to upper-limb strength and teaching rotational falling techniques (as in martial arts training) may reduce fall-related head injuries in older adults.

The relationship between head injury and facial trauma: a case-control study

INTRODUCTION

In spite of anatomic proximity of the facial skeleton and cranium, there is paucity of information in the literature regarding the relationship between head injuries and facial trauma. The objective of our investigation was to evaluate the pattern of head injuries in patients with maxillofacial trauma, and to study their relationship.

MATERIAL AND METHODS

We evaluated 2,692 patients with maxillofacial trauma admitted to the Besat hospital, Hamedan, Iran between 2007 and 2010. Patients with associated head injury (302 cases; study group) were compared with those without head injury (2,390 cases; control group).

RESULTS

In our cohort, the rate of head injuries associated with facial bone fractures was 23.3 %. The most common associated head injury was concussion, followed by cerebral contusion and skull fractures. In the unadjusted analysis, motorcycle and car accidents were significantly more frequent in the study group, while stumbling, sports injuries, and work-related injuries were significantly more common in the control group (p < 0.001). Except for Lefort III fractures which was not significantly different between groups, all facial fractures occurred more frequently in the study group (p < 0.001). Logistic regression analysis demonstrated that motorcycle accidents (211-fold), car accidents (139-fold), violence (69-fold), falls (66-fold), frontal sinus fractures (84.5-fold), and Lefort II fractures (27-fold) were the strongest predictors of head injuries.

DISCUSSION

Present study revealed that fracture of facial bones, especially bones that are in anatomic proximity to the cranium and need a high magnitude of trauma energy to be fractured, was marker for an increased risk of head injuries.

Motorcycle helmets--a state of the art review

This paper tries to make an overview of the work carried out by scientific community in the area of road helmets safety. In an area that is constantly being pushed forward by market competition, self-awareness of danger and tighter standards, several research groups around the world have contributed to safety gear improvement. In this work concepts related to head impact protection and energy absorption are explained. It also makes reference to the theories related to the development of helmets, as well as to the different existing types nowadays. The materials that are typically used in impact situations and new design concepts are also approached. In addition, it is presented a literature review of current--and most commonly used--helmet test standards, along with new tests and helmet concepts to assess the effects of rotational motion. In a non-restrictive, and never up-to-date report, a state-of-art review on road helmets safety is done, with a special insight into brain injury, helmet design and standards.

Finite element analysis of occupant head injuries: parametric effects of the side curtain airbag deployment interaction with a dummy head in a side impact crash

In this study, we investigated and assessed the dependence of dummy head injury mitigation on the side curtain airbag and occupant distance under a side impact of a Dodge Neon. Full-scale finite element vehicle simulations of a Dodge Neon with a side curtain airbag were performed to simulate the side impact. Owing to the wide range of parameters, an optimal matrix of finite element calculations was generated using the design method of experiments (DOE); the DOE method was performed to independently screen the finite element results and yield the desired parametric influences as outputs. Also, analysis of variance (ANOVA) techniques were used to analyze the finite element results data. The results clearly show that the influence of moving deformable barrier (MDB) strike velocity was the strongest influence parameter on both cases for the head injury criteria (HIC36) and the peak head acceleration, followed by the initial airbag inlet temperature. Interestingly, the initial airbag inlet temperature was only a ~30% smaller influence than the MDB velocity; also, the trigger time was a ~54% smaller influence than the MDB velocity when considering the peak head accelerations. Considering the wide range in MDB velocities used in this study, results of the study present an opportunity for design optimization using the different parameters to help mitigate occupant injury. As such, the initial airbag inlet temperature, the trigger time, and the airbag pressure should be incorporated into vehicular design process when optimizing for the head injury criteria.

The effectiveness of helmets in bicycle collisions with motor vehicles: a case-control study

There has been an ongoing debate in Australia and internationally regarding the effectiveness of bicycle helmets in preventing head injury. This study aims to examine the effectiveness of bicycle helmets in preventing head injury amongst cyclists in crashes involving motor vehicles, and to assess the impact of 'risky cycling behaviour' among helmeted and unhelmeted cyclists. This analysis involved a retrospective, case-control study using linked police-reported road crash, hospital admission and mortality data in New South Wales (NSW), Australia during 2001-2009. The study population was cyclist casualties who were involved in a collision with a motor vehicle. Cases were those that sustained a head injury and were admitted to hospital. Controls were those admitted to hospital who did not sustain a head injury, or those not admitted to hospital. Standard multiple variable logistic regression modelling was conducted, with multinomial outcomes of injury severity. There were 6745 cyclist collisions with motor vehicles where helmet use was known. Helmet use was associated with reduced risk of head injury in bicycle collisions with motor vehicles of up to 74%, and the more severe the injury considered, the greater the reduction. This was also found to be true for particular head injuries such as skull fractures, intracranial injury and open head wounds. Around one half of children and adolescents less than 19 years were not wearing a helmet, an issue that needs to be addressed in light of the demonstrated effectiveness of helmets. Non-helmeted cyclists were more likely to display risky riding behaviour, however, were less likely to cycle in risky areas; the net result of which was that they were more likely to be involved in more severe crashes.

[Neonatal subgaleal haemorrhage causing fatal course after vacuum-assisted extraction]

We present a case that emphasizes the importance of early recognition of neonatal subgaleal haemorrhage through knowledge of risk factors and adequate communication within the health team treating the woman in labour. Especially vacuum-assisted extraction of the child significantly multiplies the incidents of subgaleal haemorrhage. The high mortality is directly associated with disseminated intravascular coagulation and bleeding. Early monitoring and treatment with replacement of blood volume is crucial. Education concerning this condition is therefore of great importance.

Bicycle helmets: head impact dynamics in helmeted and unhelmeted oblique impact tests

OBJECTIVE

To assess the factors, including helmet use, that contribute to head linear and angular acceleration in bicycle crash simulation tests.

METHOD

A series of laboratory tests was undertaken using an oblique impact rig. The impact rig included a drop assembly with a Hybrid III head and neck. The head struck a horizontally moving striker plate. Head linear and angular acceleration and striker plate force were measured. The Head Injury Criterion was derived. The following test parameters were varied: drop height to a maximum of 1.5 m, horizontal speed to a maximum of 25 km/h, helmet/no helmet, impact orientation/location, and restraint adjustment. Additional radial impacts were conducted on the same helmet models for comparison purposes. Descriptive statistics were derived and multiple regression was applied to examine the role of each parameter.

RESULTS

Helmet use was the most significant factor in reducing the magnitude of all outcome variables. Linear acceleration and the Head Injury Criterion were influenced by the drop height, whereas angular acceleration tended to be influenced by the horizontal speed and impact orientation/location. The restraint adjustment influenced the outcome variables, with lower coefficients of variation observed with the tight restraint.

CONCLUSIONS

The study reinforces the benefits of wearing a bicycle helmet in a crash. The study also demonstrates that helmets do not increase angular head acceleration. The study assists in establishing the need for an agreed-upon international oblique helmet test as well as the boundary conditions for oblique helmet testing.

An investigation on the head injuries of adult pedestrians by passenger cars in China

OBJECTIVE

To investigate the relative likelihood of pedestrian head injuries based on person, vehicular, and environmental factors in China.

METHODS

A team was established to collect passenger car-pedestrian accident cases occurring between 2006 and 2011 in Beijing, Shanxi Province, and Chongqing, China. Some key variables for person-, vehicle-, and environment-related factors on head injuries were analyzed using multivariate logistic regression analysis to determine relative risk/likelihood. Pedestrians were classified according to injury outcome and age. Pedestrian head injuries were scored using the Abbreviated Injury Scale (AIS).

RESULTS

A total of 285 vehicle-pedestrian crashes were collected and analyzed: 30 in Beijing, 20 in Shanxi Province, and 235 in Chongqing. The distribution in age and road type by study location differed. The injury outcome, head injury severity, and head contact site were different among 4 age groups. The variables including head contact site and impact speed were the common determinants for head injury severity. A higher pedestrian fatality risk was associated with age over 46, impact speeds over 40 km/h, and higher likelihoods of the victim's head striking the windscreen frame/A pillar and of the victim sustaining a head injury. Similarly, a higher risk of head injury was associated with being female, age over 60, impact speeds over 40 km/h, and a likelihood of the victim's head striking the vehicle rather than the ground. Impact speeds of over 40 km/h and head contact site on windscreen frame/A pillar retained a strong association with severe head injury (AIS 5-6) rate.

CONCLUSIONS

Pedestrian age, vehicle impact speed, and head contact site were common pertinent factors for the risk of pedestrian head injury and the risk of death. Further studies would be valuable to fully characterize vehicle-pedestrian crashes in China and to develop targeted injury prevention strategies based on surveillance results.

Rotational head trauma with callosal contusion and C6 fracture: a high-speed motorcycle accident

We present the case of a 34-year-old Albanian male who was riding a motorcycle when he collided at high-speed with a four-wheel vehicle. After a triple pivotal rotation in the air at the moment of impact, he fell from the motorcycle to the ground. The clinical picture thereafter was one of deep coma, treated in the intensive care unit for nine days, until he regained consciousness and long-term rehabilitation procedures were put in place. The magnetic resonance and computed tomography images were very illustrative of a rotational head trauma mechanism, since in addition to multiple callosal hemorrhages and the lack of cranial fractures, a linear complex fracture of the C6 vertebra was seen, justifying orthopedic treatment through immobilization of the cervical spine. Rotational angular acceleration seems to be an important causative factor toward provoking diffuse brain and/or axonal injury; the etiological importance on the direct skull impact is controversial, but in any case not negligible.

Equestrian injury is costly, disabling, and frequently preventable: the imperative for improved safety awareness

Horse-related injury can be severe and disabling. We investigated the causes, severity, and costs of equestrian injury with the goal of injury prevention. A retrospective review of horse-related injuries from 2001 to 2008 identified 231 patients with a mean age of 38 years and a mean Injury Severity Score of 11 (range, 1 to 45). Mean length of stay was 5.5 days. Fifty-nine patients (25%) required 84 surgeries. Helmet use was 20 per cent and of the 172 patients not wearing a helmet while mounted, 38 per cent received potentially preventable head injuries. There were three deaths of which two were the result of intracranial hemorrhage in riders not wearing a helmet. Mean hospital charge was $29,800 for a total of $6.9 million. Ninety-one patients completed a survey regarding causation and disability. Thirty-four per cent reported wearing a helmet at the time of injury. Forty per cent reported that poor environmental factors contributed, 30 per cent reported poor horse and rider pairing, and 9 per cent reported equipment failure. Fifty-nine per cent reported long-term disabilities. Compared with the general population, respondents had diminution in their ability to perform usual daily activities associated with physical problems, diminution in social function, and higher bodily pain. We conclude that equestrian injury is costly, disabling, and frequently preventable.

Source of head injury for pedestrians and pedal cyclists: Striking vehicle or road?

The potential effectiveness of vehicle-based secondary safety systems for the protection of pedestrians and pedal cyclists is related to the proportion of cases where injury arises by contact with the road or ground rather than with the striking vehicle. A detailed case review of 205 accidents from the UK On-the-Spot study involving vulnerable road users with head injuries or impacts indicated that contact with the road was responsible in 110 cases. The vehicle however was associated with a majority of more serious casualties: 31 (vehicle) compared with 26 (road) at AIS 2+ head injury level and 20 (vehicle) compared with 13 (road) at AIS 3+ level. Further analysis using a multivariate classification model identified several factors that correlated with the source of injury, namely the type of interaction between the striking vehicle and vulnerable road user, the age of the vulnerable road user and the nature of injury.

A study of adult pedestrian head impact conditions and injury risks in passenger car collisions based on real-world accident data

OBJECTIVE

The aim of the current study was to study the kinematics of adult pedestrians and assess head injury risks based on real-world accidents.

METHODS

A total of 43 passenger car versus pedestrian accidents, in which the pedestrian's head impacted the windscreen, were selected from accident databases for simulation study. According to real-world accident investigation, accident reconstructions were conducted using multibody system (MBS) pedestrian and car models under MADYMO environment (Strasbourg University) to calculate head impact conditions in terms of head impact velocity, head position, and head orientation. Pedestrian head impact conditions from MADYMO simulation results were then used to set the initial conditions in a simulation of a head striking a windscreen using finite element (FE) approach.

RESULTS

The results showed strong correlations between vehicle impact velocity and head contact time, throw distance, and head impact velocity using a quadratic regression model. In the selected samples, the results indicated that Abbreviated Injury Scale (AIS) 2+ and AIS 3+ severe head injuries with probability of 50 percent were caused by head impact velocity at about 33 and 49 km/h, respectively. Further, the predicted head linear acceleration (head injury criterion, HIC) value, resultant angular velocity, and resultant angular acceleration for 50 percent probability of AIS 2+ and AIS 3+ head injury risk were 116 g, 825, 40 rad/s, 11,368 rad/s(2) and 162 g, 1442, 55 rad/s, 18,775 rad/s(2), respectively, and the predicted value of 50 percent probability of skull fracture was 135 g.

CONCLUSIONS

The present study provides new insight into pedestrian head impact conditions in terms of velocity, angle, and impact location based on a number of real-world cases. Therefore, it may perform a critical analysis for current pedestrian head standard tests.

[Analysis of 28 death cases involved with tumbling injury]

OBJECTIVE

To explore the general features and the keypoints of forensic medical examination in tumbling injury cases.

METHODS

Twenty-eight cases dying of tumbling injury were collected and the locations and features of injury were analyzed.

RESULTS

The occiput of head was the common position for the tumbling injury cases. Force, disease and alcohol were the main reasons for tumbling injury.

CONCLUSION

The injury is mild outside and severe inside from tumbling injury cases. The craniocerebral contrecoup is the significant feature in tumbling injury cases.

Clinical clues for head injuries amongst Malaysian infants: accidental or non-accidental?

Identifying the differences between infants with non-accidental head injuries (NAHI) and accidental head injuries (AHI) may help alert clinicians to recognize markers of abuse. A retrospective review of infants <1 year of age admitted to a tertiary referral centre in Malaysia over a two year period with a diagnosis of head injury or abnormal computed tomography head scans was conducted to identify the clinical features pointing towards a diagnosis of NAHI by comparing the socio-demographics, presenting complaints, clinical features and the extent of hospital investigations carried out. NAHI infants were more likely to be symptomatic, under a non-related caregiver's supervision, and presented with inconsistent or no known mechanism of injury. Subdural haemorrhages were more common in NAHI infants. The history, mechanism of injury, presenting signs and symptoms as well as the nature of the injuries sustained are all valuable clues as to whether a head injury sustained during infancy is likely to be accidental or not.

The prevalence of neurocranium injury in children in Brod-Posavina County

Head injuries are very common in children and are the most frequent cause of disability and death among children. This retrospective study included 350 children hospitalized for injury of neurocranium over a 5-year period at Dr Josip Bencević General Hospital in Slavonski Brod. Boys were more commonly injured (63.4%) than girls. The most common injuries were recorded in children aged 7-14 (47.1%), followed by those aged 1-6 (33.8%) years. The injuries occurred slightly more often in urban (50.9%) than in rural (46.6%) setting. Children were more commonly injured in the street or on the road (38.6%), followed by injuries sustained at home (35.2%), at school (9.3%) and on playgrounds (5.7%). They were most commonly injured by fall (50%), followed by traffic injuries (33.5%). Statistically significant differences were found in the following age groups: all children younger than one year were injured by fall; children aged 1-14 were mostly injured by fall (less in traffic, and due to hitting), and those aged 15-18 mostly in traffic (less by fall and due to hitting). Children were mostly injured in the street or on the road (in traffic accidents), followed by injuries at home (mostly by fall), at school and around the house or in the yard (mostly by fall); on the playground (due to hitting) and on the road (in traffic accidents) (statistically significant difference). Most of them had head contusion and cerebral commotion combined (46.8%), followed by head contusion alone (12.5%) and skull fractures (10.5%). Hemorrhages and hematomas were rare (epidural, subdural, subarachnoid hemorrhage), found in 3.2% of cases. We hope that our results will prove helpful in planning preventive measures and treatment of injured children.

Investigating occupant safety through simulating the interaction between side curtain airbag deployment and an out-of-position occupant

The objective of this research is to elucidate the effect of side curtain airbag deployment on occupant injuries and safety when the occupant is either in-position or out-of-position (OOP). We used side impact vehicle collision simulations with a 1996 Dodge Neon model, which was further modified to include a side curtain airbag, a seatbelt, and a 50th percentile Hybrid III dummy. The airbag used in the study was inflated using both the uniform pressure (UP) and smooth particle hydrodynamics (SPH) methods. In-position and OOP simulations were performed to assess and establish guidelines for airbag aggressivity thresholds and occupant position versus risk of injury. Three different OOP scenarios (OOP1, OOP2, OOP3) were initially setup following the work of Lund (2003), then modified such that the dummy's head was closer to the airbag, increasing the chance of injury caused by the airbag. The resultant head acceleration as a function of time for in-position and OOP simulations shows that both UP and SPH methods produce similar peak accelerations in cases where the airbag is fully inflated prior to impact. In all cases, the head peak accelerations and the head injury criteria for simulations with an airbag were significantly lower when compared with the no airbag case, which would typically indicate that the use of an airbag results in improved occupant protection during side impact. However, in the case of OOP2 and OOP3, the neck flexion forces actually increase significantly when compared with the no airbag case. This finding indicates that the HIC and neck flexion forces criterion are in conflict and that there may be a tradeoff in terms of occupant injury/safety with a side curtain airbag that is strongly correlated to the occupant position. Consequently, this study shows that safety devices result in a significant effect on occupant injury/safety when the occupant is in OOP conditions. Moreover, in some cases, simulation results show that the side curtain airbag may not make the occupant safer. This study requires further investigation of the vehicle-specific airbag and its interaction with an occupant in various OOP conditions.

Injuries among powered two-wheeler users in eight European countries: a descriptive analysis of hospital discharge data

Powered two-wheelers (PTWs--mopeds, motorcycles, and scooters) remain the most dangerous form of travel on today's roads. This study used hospital discharge data from eight European countries to examine the frequencies and patterns of injury among PTW users (age≥14 years), the predicted incidence of the loss of functional ability, and the mechanisms of the head injuries observed (all in light of increased helmet use). Of 977,557 injured patients discharged in 2004, 12,994 were identified as having been injured in PTW collisions. Lower extremity injuries accounted for 26% (25.6-26.7, 95% C.I.) of the total injuries, followed by upper extremity injuries (20.7%: 20.3-21.2), traumatic brain injuries (TBI) (18.5%: 18-19), and thoracic injuries (8.2%: 7.8-8.5). Approximately 80% of the lower extremity injury cases were expected to exhibit some functional disability one year following discharge (predicted Functional Capacity Index, pFCI-AIS98<100), compared to 47% of the upper extremity injury cases and 24% of the TBI cases. Although it occurred less frequently, patients that were expected to experience some functional limitation from TBI were predicted to fair worse on average (lose more functional ability) than patients expected to have functional limitations from extremity injuries. Cerebral concussion was the most common head injury observed (occurring in 56% of head injury cases), with most concussion cases (78%) exhibiting no other head injury. Among the AIS3+ head injuries that could be mapped to an injury mechanism, 48% of these were associated with a translational-impact mechanism, and 37% were associated with a rotational mechanism. The observation of high rates of expected long-term disability suggests that future efforts aim to mitigate lower and upper extremity injuries among PTW users. Likewise, the high rates of concussion and head injuries associated with a rotational mechanism provide goals for the next phase of PTW user head protection.

Does wearing helmets reduce motorcycle-related death? A global evaluation

BACKGROUND

The high risk of injury and death of motorcycle riders is a major global health problem. This study aimed to evaluate the effect of helmet wearing on motorcycle riders' death rates on a global level.

METHODS

Data for motorcycle riders were collected from 70 countries. These data included motorcycle-related death rates per 100,000 population, helmet non-usage percentage, Gross National Income per capita (GNI), number of registered motorized 2-3 wheelers, the effectiveness of law enforcement in each country, and whether there was standards for helmets use or not. Correlations between studied variables were done using Pearson correlation. Multiple linear regression models were used to define factors affecting motorcycle-related death rates.

RESULTS

The correlation between motorcycle-related death rate and helmet non-usage, was almost significant (p=0.056, r=0.28). Helmet non-usage percentage was significantly correlated with GNI (p<0.0001, r=-0.61) and effectiveness of the law (p<0.0001, r=-0.73). A multiple linear regression model which was highly significant (adjusted R-squared=0.3, F=6.69, p<0.001) has shown that helmet non-usage percentage (p=0.003), motorcycle per person ratio (p=0.01) and the presence of helmet standards (p=0.05) were positively associated with motorcycle-related death rates. A simple linear regression model between helmet usage and road traffic death rate has shown that for each 10% increase in helmet usage, one life per 1,000,000 inhabitants can be saved per year.

CONCLUSION

Helmet non-usage percentage was the most significant factor affecting motorcyclists' death rate. Wearing a motorcycle helmet reduces the risk of death from a motorcycle crash. Enforcement of motorcycle helmet laws should be effectively supported by motorcycle safety programs.

Risk of maltreatment-related injury: a cross-sectional study of children under five years old admitted to hospital with a head or neck injury or fracture

Objectives

To determine the predictive value and sensitivity of demographic features and injuries (indicators) for maltreatment-related codes in hospital discharge records of children admitted with a head or neck injury or fracture.

Methods

Study design: Population-based, cross sectional study. Setting: NHS hospitals in England. Subjects: Children under five years old admitted acutely to hospital with head or neck injury or fracture. Data source: Hospital Episodes Statistics, 1997 to 2009. Main outcome measure: Maltreatment-related injury admissions, defined by ICD10 codes, were used to calculate for each indicator (demographic feature and/or type of injury): i) the predictive value (proportion of injury admissions that were maltreatment-related); ii) sensitivity (proportion of all maltreatment-related injury admissions with the indicator).

Results

Of 260,294 childhood admissions for fracture or head or neck injury, 3.2% (8,337) were maltreatment-related. With increasing age of the child, the predictive value for maltreatment-related injury declined but sensitivity increased. Half of the maltreatment-related admissions occurred in children older than one year, and 63% occurred in children with head injuries without fractures or intracranial injury.

Conclusions

Highly predictive injuries accounted for very few maltreatment-related admissions. Protocols that focus on high-risk injuries may miss the majority of maltreated children.

A decade of serious non-fatal assault in New Zealand

AIM

To describe the distribution of, and trends in, the characteristics of serious non-fatal assault injury for the period 2000-2009.

METHODS

Serious non-fatal hospitalised assault injury for the 2000-2009 period were identified and described by: sociodemographic characteristics, location of incidents, methods used to inflict injury, alcohol involvement, and nature of injury. Trends in assault by age, gender, and method were examined.

RESULTS

Males, 15-24 year olds, Maori, Pacific Islanders, and those from deprived neighbourhoods had markedly elevated assault rates. Assault by bodily force and head injuries predominated with the former being the major category of assault that increased the most over time

CONCLUSIONS

There is a disturbing level of serious assault in New Zealand and the situation is getting worse. We need to review current efforts to prevent these incidents.

Infant abusive head trauma - incidence, outcomes and awareness

BACKGROUND

Abusive head trauma of infants is a significant cause of morbidity and mortality. The incidence in Australia has been estimated at 29.6 cases of abusive head trauma for which hospital admission is required per 100 000 infants aged 0-24 months and under per year; more frequent than low speed runovers, drowning and childhood neoplasms.

OBJECTIVE

This article provides a review of the significant incidence and outcomes of abusive head trauma and seeks to raise awareness of the potential of evidence based interventions to reduce infant injury and its consequences in the community.

DISCUSSION

An evidence based program, the Period of PURPLE Crying®, has been shown to reduce infant injury. An evaluation of the suitability of program materials for different cultural groups in Australia needs to be assessed. Such a scoping project is proposed as a necessary prerequisite to a pilot clinical intervention.