The effect of seat belt legislation on injuries sustained by car occupants

Self-esteem following maxillofacial and orthopedic injuries: preliminary observations in sub-Saharan Africans

BACKGROUND

The face is a vital component of one's personality and body image while extremities are important in function (mobility, routine daily activities). Recovery and rehabilitation from acquired maxillofacial and orthopedic traumas are psychological in nature.

METHODS

This was a prospective study of recruited subjects in a Nigerian University teaching hospital. A total of 160 participants (80 with maxillofacial injuries and 80 with orthopedic injuries) had repeated review assessments within 1 week of arrival in the hospital (time 1), 4-8 weeks after initial contact (time 2), and 10-12 weeks thereafter (time 3), using Rosenberg's Self-Esteem Questionnaire.

RESULTS

Thirty-three (41.3%) participants in the maxillofacial injured and 12 (15.0%) in the orthopedic injured subjects scored between 0 and 14 at time 1. At time 2, 39 (51.3%) subjects in the maxillofacial fracture group and 20 (29.0%) in the orthopedic injured group scored between 0 and 14, while at time 3, 7 (9.2%) in the maxillofacial fracture group and 1 (1.5%) in the orthopedic injured group scored between 0 and 14. There was a statistical significant difference between the two groups when compared at times 1, 2, and 3 with p < 0.001, p = 0.006, and p = 0.041 respectively. Subjects with maxillofacial fracture consistently had lower self-esteem compared to subjects with orthopedic injured for times 1, 2, and 3.

CONCLUSIONS

Self-esteem may be reduced following maxillofacial injuries; therefore, measures should be taken by surgeons to minimize the risk of facial scarring by careful handling of tissues. Also, management of these injuries should integrate multidisciplinary care that will address psychological needs of patients.

TRIAL REGISTRATION

Not applicable.

Quantitative research: Designs relevant to nursing and healthcare

This paper gives an overview of the main quantitative research designs relevant to nursing and healthcare. It outlines some strengths and weaknesses of the designs, provides examples to illustrate the different designs and examines some of the relevant statistical concepts. The paper concludes with a brief discussion about the place of quantitative research in nursing.

Cervical status after neck sprains in frontal and rear-end car impacts

OBJECTIVE

To compare the cervical status after neck sprains in frontal and rear-end car impacts with respect to earlier proposed neck-sprain injury mechanisms, rotated head at impact, and the seat-belt geometry.

METHODS

A prospective, multidisciplinary, in-depth study was made based on 23 car occupants injured in frontal impacts and 108 injured in rear-end impacts. The active neck mobility was measured in protraction-retraction, flexion-extension, side bending right-left, and rotation right-left. This was done in the acute phase and then three and twelve months later. The maximum range, increase in pain, and level of pain were recorded for each movement. A subgroup with increased pain during movements towards the impact direction, but not in the opposite one, so-called isolated contra-directional pain (ICP), was further analysed. The side bending and rotation mobility were studied in another subgroup, in which the head was rotated inwards or outwards relative the car, i.e. away from or towards the diagonal part of the seat belt.

RESULTS

Rear-end impacts more often than frontal impacts caused greater restrictions of the cervical mobility and more frequently increased pain at the three different times that measurements were recorded, but, with few exceptions, the differences for each movement were not statistically significant. Increased pain during extension was more often noted after rear-end impacts. ICP during pro-/retraction was also more often noted after rear-end impacts. Head-inward rotation in rear-end impacts caused a more restricted mobility in the same direction at the primary examination than head-outward rotation.

CONCLUSIONS

The cervical status after neck sprains in frontal and rear-end car impacts is very similar, and the cervical range of movement in different directions and increased pain during cervical motions do not reveal any specific isolated injury mechanisms. Combined injury mechanisms should be considered, and further studies are recommended to investigate asymmetric loading during impact.

Factors predicting outcome after whiplash injury in subjects pursuing litigation

Records of 277 patients presenting for medicolegal reporting following isolated whiplash injury were studied retrospectively. A range of pre-accident, accident and response variables were recorded. Multivariate analysis was used to determine the main factors that predict physical and psychological outcome after whiplash injury. The factors that showed significant association with poor outcome on both physical and psychological outcome scales were pre-injury back pain, high frequency of General Practitioner attendance, evidence of pre-injury depression or anxiety symptoms, front position in the vehicle and pain radiating away from the neck after injury. The strongest associations were with factors that are present before impact. In this selected cohort of patients, there is a physical and a psychological vulnerability that may explain the widely varied response to low violence indirect neck injury.

Trends in the characteristics of maxillofacial fractures in Nigeria

PURPOSE

The study purpose was to assess the changes in the pattern of maxillofacial fractures in 2 different study periods.

PATIENTS AND METHODS

We conducted retrospective study of 341 patients treated for maxillofacial fractures between January 1978 and December 1982 and a prospective study of 483 patients treated between January 1995 and December 1999 at the Department of Oral and Maxillofacial Surgery, University College Hospital, Ibadan, Nigeria. Data were collected on age, gender, etiologic factor, and site of injury.

RESULTS

The male-to-female ratio reduced in the second period by a factor of 2.0. Patients in the age groups of 21 to 30 years and older than 60 years increased by a factor of 1.8 and 2.9, respectively, in the second period. Assaults, falls, sporting injuries, and industrial accidents in the second period increased by a factor of 1.4, 1.5, 3.5, and 1.5, respectively. The ratio between road traffic accidents and other causes changed from 3.4:1 to 2.2:1 in the second period. Mandibular fractures increased by 2% in the second study period.

CONCLUSION

The data confirmed that although other etiologic factors are increasing in number, road traffic accidents remains the major etiologic factor of maxillofacial fractures in Nigeria. There is a need to enforce seat belt use, speed limit, and drink driving laws to reduce maxillofacial injuries caused by road traffic accidents; to organize preventive programs to minimize assaults, and to legislate the wearing of headgear by industrial workers.

[Whiplash injury of the neck from concepts to facts]

OBJECTIVES

To focus on a topic of traumatology and rehabilitation becoming recently a much debated public health problem.

METHOD

A references search from Medline database with whiplash as keyword was carried out. Were selected articles with abstracts in french or english and focusing on accidentology, biomechanics, demonstrated lesions, epidemiology and treatments.

RESULTS

From 1664 references found, 232 were reviewed. The usual mechanism of crash is a rear-end collision inducing in the occupants of the bumped vehicle a sudden lower cervical spine extension with upper flexion followed by a global flexion. In nearly 50% of the cases, the stress occurring in the collision is comparable to that observed in bumper cars. The velocity changes are seldom up to 15 km/h. A headrest at the level of the center of gravity of the head restrict significantly the extension of the neck. Every structure of the cervical spine could be damaged and mainly the facet joints but the lesions were only demonstrated in severes traumatisms. The discrepancies in incidence among the different countries could be related to their medicolegal system. Although subjectives, the early symptoms are rather similar among patients suggesting true anatomical or functional disorders but the chronicity seems to be mainly related to social and psychological factors. The association of: no posterior midline cervical tenderness, no intoxication, normal alertness, no focal neurological deficit and no painful distracting injuries has a good predictive value of the lack of osteo-articular lesion on X-rays. Except the grade IV of the Quebec task Force (0, no symptom; 1, pain and stiffness; 2, neck complaint and physical signs; 3, neck complaint and neurological signs; 4, fracture or dislocation) the use of a collar should be avoided and the cervical spine should be mobilized.

CONCLUSION

In most whiplash injuries, the mildness should be early stated, mobilization encouraged, and procedures of compensation shortened.

Incidence and aetiology of facial injuries resulting from motor vehicle accidents in Queensland for a three-year period

BACKGROUND

No studies have been reported on the frequency and aetiology of facial injuries due to MVAs in Queensland. This study aims to investigate the incidence, aetiology, age and sex distribution of facial injuries resulting from MVAs for a period of three years.

METHOD

Cases were identified from the Motor Accident Insurance Commission, Queensland. Information including the type of injury sustained, the time, age and role of the patient in the accident were recorded and analysed.

RESULTS

There was an average maxillofacial injury incidence of 4.8/100,000 per year, 53.5 per cent in males and 46.5 per cent in females. A peak incidence was found for both sexes aged 18 to 22 years. In males, 57 per cent of facial injuries occurred in this age group compared to 41 per cent in females.

CONCLUSIONS

Maxillofacial injuries as a result of MVAs are still relatively high regardless of the legislation for compulsory seatbelt use. Recent advances in seatbelt systems have the potential to reduce the risk of head and face impacts. The airbag is also well established as an effective means of preventing serious head and face injury. However, more research is required to further reduce the incidence of maxillofacial injuries as a result of MVAs.

Factors affecting injury severity to rear-seated occupants in rural motor vehicle crashes

Injury to rear-seat occupants (RSOs) has received little systematic study in the literature. Past studies have focused on patterns of injury presented to the emergency department, various aspects of restraint usage and injury, or specific populations of RSOs. This is the first systematic analysis of injury severity to RSOs. RSOs involved in motor vehicle crashes (MVCs) sustain injuries of equal severity as do front-seated occupants (FSOs) involved in the same crash. The setting was a rural North Carolina emergency department where patients were evaluated at the sole hospital for the county. The design was a 2-year retrospective review of all MVCs with RSOs occurring in Pitt County North Carolina in calendar years 1988 and 1989. The Wilcoxon Rank-Sum Test and Logistic Regression Analysis with Injury Severity Score (ISS) as the dependent variable were performed. Three hundred forty-six crashes involving 367 vehicles with RSOs and 1,273 occupants that sent 222 patients to the hospital. ISS was higher for unrestrained occupants (1.87 versus 0.51), occupants of vehicles driven by legally intoxicated drivers (4.04 versus 0.73), occupants between the ages of 30 and 59 years (1.06 versus 0.65) and FSOs (1.04 versus 0.85) (Wilcoxon Rank-Sum test P <.0002). Logistic regression analysis confirmed these findings with the exception of more severe injuries for the 30 to 59 age range and impact speed. The analysis failed in these 2 cases. Restraint usage offered the greatest protective effect (OR 0.37). Lesser protective effects were noted with rear seat occupancy (OR 0.43) and age < 13 years (OR 0.77). More severe injuries were predicted by driver intoxication (OR 2.5), and age > 60 years (OR 1.25). In our rural population, RSOs sustain less severe injuries than FSOs. Restraint usage and sober drivers provide a greater protective effect however. Seat location does not replace restraint usage or sobriety.

The nosologic status of the whiplash syndrome: a critical review based on a methodological approach

STUDY DESIGN

Empirical studies concerning the whiplash syndrome are reviewed from the point of view of epidemiologic methodology.

OBJECTIVE

To assess the nosologic status of the whiplash syndrome.

SUMMARY OF BACKGROUND DATA

Although a large number of studies concerning the syndrome exist, there is still controversy concerning the existence of the syndrome.

METHODS

The manner in which each study contributes to the validity of the syndrome is determined on the basis of the methodologic design (descriptive, case-control, cohort, and intervention/experimental) of the study.

RESULTS

Whereas the face validity of the syndrome is excellent, the descriptive, construct, and predictive validity are rather poor. In particular, convincing empirical evidence for a causal link (construct validity) between the trauma mechanism and chronic symptoms is sparse.

CONCLUSIONS

Carefully conducted studies designed to assess the degree to which head and nec trauma contribute to the development of chronic pain, particularly head and neck pain, are urgently needed.

Hyperextension soft tissue injuries of the cervical spine--a review

While a full understanding of continuing symptoms following a soft tissue hyperextension injury of the cervical spine remains elusive, recent research has shown that the explanation may lie with occult lesions beyond the musculoskeletal structures of the neck. The balance of the roles of injury, psychological factors, and the effects of litigation has shifted towards the former. However this injury would be unique if the latter two played only a minor role in determining recovery. It seems likely that among the large numbers of patients presenting with symptoms after hyperextension soft tissue injuries, a proportion will have occult bone, joint, or intervertebral disc lesions. Improvements in medical imaging techniques may allow better definition of these specific injuries and the development of more appropriate treatment. The search for a central nervous system lesion in humans continues and until this is demonstrated, many will dispute the existence of an organic brain syndrome. Evidence for significant injury to the temporomandibular joints, ear, and ophthalmic system has been found and this may be amenable to specialist intervention. While there is little evidence for effective treatments of the established injury, reduction in related disability appears most likely to be achieved by prevention. Improvements in automobile design, with particular reference to head restraints, could limit the cost to society of this common and disabling injury.

Long-term outcome after whiplash injury. A 2-year follow-up considering features of injury mechanism and somatic, radiologic, and psychosocial findings

With the increased incidence of whiplash injury following the introduction of compulsory car seat belts, a large number of reports have dealt with the aftermath of this condition. Previous studies, however, focused on somatic symptoms on the one hand or considered only psychological or neuropsychological variables on the other hand, often in loosely defined or selected groups of patients. No study so far has analyzed the long-term outcome in a nonselected group of patients using a clear injury definition considering patient history; somatic, radiologic, and neuropsychological findings; and features of the injury mechanisms assessed soon after trauma and during follow-up. the present investigation was designed to assess these combined factors. According to a strict definition of whiplash injury, we assessed a consecutive nonselected sample of 117 patients with recent injury who had similar sociocultural and educational backgrounds. The patients had been in automobile crashes and were all equally covered by accident insurance according to the country-wide scheme. Initial examination was performed 7.2 +/- 4.2 days after trauma, and follow-up examinations 3, 6, 12, and 24 months later. At baseline, features of injury mechanism, subjective complaints, and different aspects of patient history were documented and cervical spine X rays performed. At all examinations patients underwent neurologic examination and cognitive and psychosocial factor assessment. At 2 years, patients were divided into symptomatic and asymptomatic groups and then compared with regard to the initial findings. In addition, symptomatic patients who were disabled at the 2-year follow-up examination and symptomatic patients not disabled (that is, they were able to work at the pretraumatic level) were compared regarding initial and 2-year findings. At 2 years, 18% of patients still had injury-related symptoms. With regard to baseline findings the following significant differences were found: Symptomatic patients were older, had higher incidence of rotated or inclined head position at the time of impact, had higher prevalence of pretraumatic headache, showed higher intensity of initial neck pain and headache, complained of a greater number of symptoms, had a higher incidence of symptoms of radicular deficit and higher average scores on a multiple symptom analysis, and displayed more degenerative signs (osteoarthrosis) on X ray. In addition, symptomatic patients scored higher with regard to impaired well-being and performed worse on tasks of attentional functioning and showed more concern with regard to long-term suffering and disability.(ABSTRACT TRUNCATED AT 400 WORDS)

Air bag safety

STUDY OBJECTIVE

To describe injuries associated with deployment of air bag passive-restraint systems in use in the United States.

DESIGN

Retrospective review of data collected by the National Highway Traffic Safety Administration (NHTSA) from 1980 to 1994.

PARTICIPANTS

Occupants of air bag-equipped vehicles who were involved in crashes on US roads.

RESULTS

Of 618 reported occupant injuries related to air bag deployment, an overwhelming majority were classified as minor (96.1%). Most occupants sustained abrasions, contusions, and lacerations. The face (42.0%), wrist (16.8%), forearm (16.3%) and chest (9.6%) were the most frequently injured body areas.

CONCLUSION

Most injuries related to air bag deployment are minor and must be viewed in the context of the potentially life-threatening injuries they prevent.

The effect of legislation on injuries sustained by rear seat car passengers

A study of 206 injured rear seat passengers was undertaken over two 4-month periods before and after the introduction of legislation enforcing use of rear seat-belts on 1 July 1991. The proportion of both adults and children using rear seat-belts increased after the law. Those wearing belts were less likely to suffer serious injury. The majority of passengers comply with the law but many rear seat passengers remain unrestrained because cars are not fitted with belts.

Evaluation of whiplash injuries by technetium 99m isotope scanning

Despite the frequency with which whiplash injuries present to accident and emergency (A&E) departments, there lacks an objective investigation to define the severity of the initial injury or the morbidity that may ensue. Following reports on the effectiveness of isotope bone scanning for soft tissue and ligament injuries a study was undertaken of isotope scanning of whiplash injuries. The objectives of the study were to isolate the anatomic site of the injury and to quantify the severity of the injury with relation to the concentration of isotope uptake and subsequent morbidity.

Incidence of temporomandibular joint symptoms following whiplash injury

Recently there has been considerable litigation involving the development of temporomandibular joint (TMJ) pain and dysfunction following cervical musculoskeletal injury (whiplash). The purpose of this investigation was to interview, examine, and follow up patients with a diagnosis of whiplash injury to determine the incidence of associated temporomandibular disorders. Patients were divided into two categories: those with and those without radiologic evidence of cervical skeletal injury. In the 63 patients with radiographic evidence of cervical skeletal injury (group 1), none had clicking at the time of initial examination. In the 92 patients without positive radiographs (group 2), only one had clicking. At 1 month follow-up by telephone, 2 of 51 available patients in group 1 had developed clicking, but no new TMJ symptoms were reported by the 78 patients in group 2 contacted by phone. Seventy percent of the initial follow-up group (44 patients) with radiographic evidence of injury were contacted by telephone at 1 year and none reported new symptoms of TMJ pain or clicking. Sixty-five percent of the initial follow-up group without radiographic evidence of injury (60 patients) were interviewed and also reported no new TMJ symptoms. These data indicate that the incidence of TMJ pain and clicking following whiplash injury is extremely low, and that patients who do not have clicking on resolution of their initial pain/dysfunction subsequently do not develop this problem.

Maxillofacial injuries following steering wheel contact by drivers using seat belts

Maxillofacial injuries are common sequelae in road traffic accidents. For the restrained driver, impact against the steering wheel is the most prevalent cause of injury. A sample of drivers restrained by seat belts with facial injury caused by the steering wheel was taken from data at the Accident Research Unit, University of Birmingham, UK. Two hundred and forty facial injuries occurred in 135 drivers, and these are described. Superficial contusion, laceration and nasal fractures predominated. There were 504 injuries at other body regions, and these were often caused by other vehicle components. These were, for 57% of drivers, no more serious than the facial injury caused by steering wheel contact. The role of steering wheel design in maxillofacial trauma is discussed and new solutions briefly reviewed.

Anterior dislocation of the restrained shoulder: a seat-belt injury

The reduction in morbidity and mortality since the enforcement of seat-belt usage is well documented. Complications from the belt are also reported and the authors present anterior dislocation of the restrained shoulder, an injury not previously described. The mechanism of injury is explained and a change to the present standard of restraints is suggested.

Prospective study of the effect of safety belts in motor vehicle crashes

Trauma resulting from motor vehicle crashes (MVCs) is the leading cause of death in persons 1 to 38 years old. The following prospective study was undertaken to assess the effect of safety belts on the types of injuries sustained in MVCs. A total of 1,364 patients from four Chicago-area hospitals were evaluated prospectively during a six-month period. Safety belts reduced the incidence of head, facial, thoracic, abdominal, and extremity injuries sustained in MVCs. Spinal injuries comprised the only group in which safety belt wearers sustained injuries more frequently than safety belt nonwearers. Further research on the different safety belt designs and effects of air bags is needed to reduce the incidence of cervical and lumbar strain in restrained patients.

Protective effect of rear-seat restraints during car collisions

The nature of injuries to 2684 car occupants involved in 1055 car accidents were analysed. Less than 1% front-seat occupants were children, compared with 25% of rear-seat passengers. Nearly all (97%) rear-seat passengers were unrestrained. Type of impact was generally similar for front-seat as for back-seat occupants, except for rollover impacts, which were commoner among rear-seat passengers. Injury severity distribution was similar for front-seat as for rear-seat occupants. Except for minor-to-moderate neck injuries, which were the result of deceleration, most injuries to rear-seat passengers were due to contact with the front seat, with glazing materials, or with other parts of the car. The use of car restraints by rear-seat passengers should reduce the incidence and severity of injuries.

'Whiplash injuries' of the neck: a retrospective study

This is a retrospective study of 102 patients with whiplash injuries of the neck followed up at approximately 2 years. The results show that 67 patients were asymptomatic by this time and the remaining 35 patients still exhibited symptoms. Prognostic indicators were found to be age, occipital headaches, referred symptoms, interscapular pain, abnormal neurological signs, positive radiological findings and osteoarthritic changes of the cervical spine. Symptoms that persisted for more than 2 months indicated prolonged disability.

The incidence and prognostic significance of radiological abnormalities in soft tissue injuries to the cervical spine

The radiographs and initial clinical findings of 73 patients who had sustained trauma to the cervical spine without bony injury in vehicle collisions were reviewed. The patients were also re-examined clinically two years after the injury. Forty eight (65.8%) had abnormal radiographs at presentation--prevertebral soft tissue swelling in 15 (20.6%), degenerative changes in 15 (20.6%), and an angular deformity between two adjacent vertebral bodies in 27 (37.0%). Prevertebral soft tissue swelling was found to have no significance with respect to clinical outcome and showed no association with the presence of an angular deformity. Degenerative changes are associated with a poor prognosis. The presence of an angular deformity was found to carry a good prognosis in this group of patients. The exact mode of injury is not associated with any specific radiographic appearance except that "roll overs" and side collisions are more likely to cause angulation in the cervical spine.

The unrestrained coach passenger--an injury complex

Details are given of the injuries sustained by 16 occupants of a coach that overturned. An injury of the forequarter common to 10 patients is described. An explanation for this injury complex is proposed and its prevention is discussed.

Traumatic rupture of the stomach due to a seat belt

A case of gastric rupture is described in a patient who was wearing a lap and diagonal inertia reel seat belt at the time of a head-on collision. The literature is reviewed and the mechanism of injury is discussed.