Pedestrian Struck:

Trauma Radiology and the Car You Drive

A Sedlic, MD; S Gershony, BSc; D Tso, BSc; C Chingkoe, BSc; S Nicolaou, MD

Objectives
To present radiological manifestation of injuries

seen in cases of pedestrians struck by motor vehicles as demonstrated by plain film, CT, and ultrasound encountered injury patterns

To introduce and describe commonly

To compare mechanism of injury and

radiological findings in collisions involving different types and sizes of vehicles

Outline
Introduction

Mechanism of injury and vehicle type

Patterns of Injury: Collisions involving midsized vehicles seen as lower extremity injuries and head trauma Injury patterns involving sport utility vehicles or light trucks with an emphasis on blunt chest and abdominal trauma. Collisions involving small compact vehicles resulting in projection over the vehicle and secondary head and spine trauma

Introduction
Pedestrian motor vehicle collisions

account for 13% of all traffic injuries

(1)

The mechanism of injury is complex,

and patients often present with multiple traumas

Vehicle type can dictate injury pattern Structural and design characteristics

influence the mechanism of impact and resultant injury patterns.

(1)Peng RY, Bongard FS. J Am Coll Surg. 1999 Oct;189(4):343-

Injury Patterns: Sedan Type Vehicles

85% of patients are struck

laterally

Musculoskeletal injury accounts

for 41.4%

Lower extremity injuries are more

common than upper extremities

Most injuries are secondary to

bumper impact RY, Bongard FS. J Am Coll Surg. 1999 Oct;189(4):343-8. Peng

Simms CK, Wood DP. J. Auto Engin. 2006 May;220:1085-1100.

Mechanism of Injury: Automobile Type

Phase of Impact Phase 1 Sedans (mid-large sized vehicles) Initial pedestrian impact to lower extremity, lower extremity injury common Secondary impact with vehicle hood and/or windshield, head injury common Pedestrian impacts with the ground or accelerated into another object Light Truck Vehicles (Vans, trucks, and SUV) Initial pedestrian impact to lower pelvis and/or proximal femur, Secondary impact with vehicle front, hood and windshield, pelvic, abdominal and thoracic injury common Pedestrian impacts with the ground, accelerated into another object, or crush injury.

Phase 2

Phase 3

Peng RY, Bongard FS. J Am Coll Surg. 1999 Oct;189(4):343-8.

Likelihood of Injury: Sedan Type Vehicle Impact

Injury Type Head Overall Brain Contusion 34 5.1

%
4.9
0.9 21 15

Subarachnoid Hemorrhage*
Epidural Hematoma Abdomen Chest

Fractures

Tibia-Fibular
Pelvis Femur (most common in pediatric patients)

25.9
12.8 9.8 35

Spine Fractures Cervical (associated Thoracic injuries present in Lumbar 99% of patients) Sacral Mortality
*Increased incidence in elderly (>65)

19
37 27 22
Brainard BJ, et al. Ann Emerg Med. 1989 Aug;18(8):881-3 Demetriades D, et al. J Am Coll Surg. 2004 Sep;199(3):382-7. Vives MJ, et al. J Spinal Disord Tech. 2008 Jun;21(4):281-7.

Spinal Injuries
Spinal injuries are not uncommon

in pedestrian motor vehicle collisions

Reported in 8% of patients

Injuries distributed throughout the

spine

Vives MJ, et al. J Spinal Disord Tech. 2008 Jun;21(4):281-7.

Head and Extremity Injuries

MSK, Head, and external injuries

predominate in pedestrian motor vehicle collisions

86.3% of all injuries sustained

Consistently reproduced finding

in adult pedestrian trauma

Brainard BJ, et al. Ann Emerg Med. 1989 Aug;18(8):881-3

Lower Extremity Injuries

Sedan type passenger vehicles

result in lower extremity initial impact

Tibia-fibula fractures are most

common Tibia-Fibular fractures = 33.9% Pelvis fractures = 30.4% Femoral fractures = 27%
Brainard BJ, et al. Ann Emerg Med. 1989 Aug;18(8):881-3. Image source: www.theaa.com

36 yo male struck by mid-size sedan

A

Portable Radiograph demonstrates lateral plateau injury

CT: intra-articular fracture involving lateral tibial plateau and fibular head

Associated Head Trauma

A B

A. 36 y.o. male pedestrian struck with lateral tibial plateau fracture (previous slide) with associated depressed skull fracture of the left frontal bone B. 20 y.o. female struck by sedan type vehicle with right fibular neck fracture (not shown) and associated right fronto-parietal skull fracture.

Traumatic Brain Injury

Right posterior subdural haemorrhage and left frontal contusion (white arrow) in a pedestrian stuck.

Frontal hemorrhagic contusions In a 41 yo male pedestrian struck

Traumatic Brain Injury

Right frontal hemorrhagic contusion and a left sided epidural hematoma (green arrow) in 27 y.o. female pedestrian with no additional injury.

66 yo male pedestrian struck with bilateral subarachnoid hemorrhage (non-contrast CT)

Light Truck Vehicles

Light truck vehicles (LTV) or larger

vehicles includes sport utility vehicles, minivans, and pick-up trucks increased bumper height, and increased stiffness of the front bumper

LTVs have a greater mass,

Light Truck Vehicle Impact

Increased bumper height relates to more

severe initial impact to the upper leg and pelvis, as well as doubling of injuries to head, thorax, and abdomen higher and much closer to the pedestrian centre of gravity (57% of height from ground)
62% of impact velocity for cars compared to 96% impact velocity for SUVs rotation

SUV impact occurs approximately 30 cm

Following impact, centre of gravity velocity is

There is also less amelioration of impact by

Roudsari, B., et al. Injury Prev., 2004, 10, 154158.

Light Truck Vehicle Impact and Injury Severity

Greater mass translates to higher inertia

and force at the time of impact, often leading to more severe injuries. LTV-caused accidents*

Threefold increase in injury severity with

AIS > 3 more common at all speeds**

LTV-struck pedestrians have an increased

11.5% vs 4.5%***

risk of death for pedestrians struck by cars

*Roudsari, B., et al. Injury Prev., 2004, 10, 154158. **Longhitano, D., et al. SAE paper 2005-01- 1876, 2005. ***Leer, D. E. and Gabler, H. C. Accid. Analysis Prev., 2004, 36(2).

Head injuries by LTV

Overall, large vehicles cause a slightly higher

rate of head injuries at 54% in contrast to the 46% caused by small vehicles

Speed as a factor: Cars are more likely to cause head injuries at lower speeds (18km/h) Larger vehicles are more common culprits at higher speeds (54km/h) Ground contact accounts for more head injuries

in SUV impact (39%) compared with cars (7%)

Longhitano, D., et al. SAE paper 2005-01- 1876, 2005. Liu, X. J., et al. Traff. Injury Prev., 2002, 3(31), 42. Simms CK, Wood DP. J. Auto Engin. 2006 May;220:1085-1100.
Bhalla, K., et al. In Proceedings of IRCOBI Conference, Munich, Sept 2002.

Head injuries by LTV

20 yo female, struck by SUV with impact to ground injuries: Left fronto-parietal epidural hematoma with an open basal skull fracture, evidenced by gas locules (arrow) within the hematoma.

40 yo pedestrian struck by light truck Right fronto-parietal depressed skull fracture.Right parietal cortical irregularity (arrow) secondary to dragging following impact by SUV

Chest injuries due to LTV

Hemothoraces, pneumothoraces, and

pulmonary contusions are most common intra-thoracic injuries

Traumatic aortic injuries are rare and

are most commonly seen in elderly pedestrians (> 65), incidence = 1.5% compared with 20% for car impacts

37% chance of thoracic injury in SUVs

Demetriades D, et al. J Am Coll Surg. 2004 Sep;199(3):382-7.

LTV Pedestrian Impact Chest Injuries

72 yo female struck by SUV Portable supine chest radiograph demonstrating a right pneumothorax seen as a deep sulcus (arrowheads)

Chest CT demonstrating right pneumothorax with pulmonary contusions involving both lungs. Six contiguous rib fractures not shown

LTV Impact: Thoracic Trauma

32 yo male struck by SUV - right sided impact Coronal reformat CT image showing a right-sided pulmonary contusion (black arrows)

CT of the same patient showing small pneumothorax (green arrow) with pulmonary contusion (blue arrow) and right hemothorax.

Abdominal and Pelvic Injuries

Vehicle acceleration tests involving

cadavers show that pelvic and chest accelerations are approximately half as much as for thigh and head accelerations

Suggests that pelvis and chest are

relatively protected during impact

Abdominal and Pelvic Injuries

Demetriades et al. demonstrated a

specific organ pattern

Liver 2.4% of all injuries Spleen: 1.7% of all injuries Renal: 0.8% of all injuries

Gastrointestinal: 4.1% of all injuries

Simms et al. reported 33% chance

of abdominal injury for LTVs compared with 18% for cars

Demetriades D, et al. J Am Coll Surg. 2004 Sep;199(3):382-7. .Simms CK, Wood DP. J. Auto Engin. 2006 May;220:1085-

Abdominal Trauma

38 yo male hit by delivery truck. Coronal CT reformat showing a complex hepatic laceration (arrow) and extensive hemoperitoneum (green arrows)

29 yo female hit by SUV. Coronal formal CT showing a grade IV splenic laceration (black arrow) with hemoperitoneum (green arrows)

Abdominal injuries

44 yo pedestrian struck by small truck Multiple splenic pseudoaneurysms (arrows)

37 yo pedestrian struck by minivan at 55 km/h Grade IV laceration of the liver (green arrows)

Abdominal injuries

50 yo pedestrian struck by an SUV Perinephric hematoma (green arrow) and active contrast extravasation (black arrow)

Pelvic Trauma
High impact required for pelvic

fracture

Often seen accompanying

abdominal injuries

SUVs = elevated bumper height

(approximately 25 cm above that of a car) results in doubling of the impulse to pelvis and upper thighs

Simms CK, Wood DP. J. Auto Engin. 2006 May;220:1085-1100.

Pelvic injuries

36 yo pedestrian struck by an SUV. Plain radiographs show bilateral pelvic fractures

Coronal CT reformat of 40 yo pedestrian struck by a light truck. Right acetabular fracture (black arrow) and liver laceration (green arrows)

Pelvic injuries

41 y.o. male struck by minivan Portable radiograph showing an intraarticular acetabular fracture (arrow) as well as widened pubis symphysis (arrowheads)

55 yo pedestrian struck Coronal CT reformat showing left superior pubic ramus fracture and adjacent hematoma

Conclusion
Pedestrians struck by motor vehicles

often presenting with multiple injuries trauma.

Vehicle type influences mechanism of

Mechanism of trauma dictates

pattern of injuries

Sedan pedestrian impact commonly causes lower extremity trauma and associated head injury

Conclusion
Light truck vehicle collisions result in

significantly increased force of impact; point of impact higher

sedan type vehicles

Pattern of injuries differs from Pelvic and femoral trauma more common with increased incidence of associated blunt abdominal and thoracic trauma

References
1.

Peng RY, Bongard FS. Pedestrian versus motor vehicle accidents: an analysis of 5,000 patients. J Am Coll Surg. 1999 Oct;189(4):343-8.

2.

Simms CK, Wood DP. Pedestrian risk from cars and sport utility vehicles- a comparitive analytical study. J. Auto Engin. 2006 May;220:1085-1100.

3.

Brainard BJ, Slauterbeck J, Benjamin JB, Hagaman RM, Higie S. Injury profiles in pedestrian motor vehicle trauma. Ann Emerg Med. 1989 Aug;18(8):881-3.

4.

Demetriades D, Murray J, Martin M, Velmahos G, Salim A, Alo K, Rhee P. Pedestrians injured by automobiles: relationship of age to injury type and severity. J Am Coll Surg. 2004 Sep;199(3):382-7.

5.

Vives MJ, Kishan S, Asghar J, Peng B, Reiter MF, Milo S, Livingston D. Spinal injuries in pedestrians struck by motor vehicles. J Spinal Disord Tech. 2008 Jun;21(4):2817.

6.

Leer, D. E. and Gabler, H. C. The fatality and injury risk of light truck impacts with pedestrians in the United States. Accid. Analysis Prev., 2004, 36(2).

7.

Roudsari, B., Mock, C., Kaufmann, R., Grossman, D., Henary, B., and Crandall, J. Pedestrian crashes: higher injury severity and mortality rate for light truck vehicles compared with passenger vehicles. Injury Prev., 2004, 10, 154158.

8.

Longhitano, D., Henary, B., Bhalla, K., Ivarsson, J., and Crandall, J. Inuence of vehicle body type on pedestrian injury distribution. SAE paper 2005-01- 1876, 2005.

9.

Liu, X. J., Yang, J. K., and Lovsund, P. A study of inuences of vehicle speed and front structure on pedestrian impact responses using mathematical models. Tra. Injury Prev., 2002, 3(31), 42.

10.

Anderson, R. W. G., McClean, A. J., Farmer, M. J. B., Lee, B. H., and Brooks, C. G. Vehicle travel speeds and the incidence of fatal pedestrian crashes. Accid. Analysis Prev., 1997, 29(5), 667674.

11.

Bhalla, K., Montazemi, P., Crandall, J., Yang, J., Liu, X., Dokko, Y., Takahashi, Y., Kikuchi, Y., and Longhitano, D. Vehicle impact velocity prediction: trade os between throw formulae, crash simulators and detailed multi-body modelling. In Proceedings of the IRCOBI Conference, Munich, September 2002.