J Indian Acad Forensic Med. October - December 2016, Vol. 38, No.

4 ISSN 0971-0973

Original Research Paper

An Epidemiological Study of Fracture Related Deaths in a

Tertiary Care Hospital in West Bengal
1 2 3 4
Alakesh Halder, Kaushik Mukhopadhyay, Shailesh V Parate, Ashok Kumar Samanta

Abstract
Fractures due to Road Traffic Accidents or fall, are an extremely common occurrence and often
lead to death. Aim of this study was to find out the epidemiology of fracture related deaths in a medical
college mortuary in eastern India. For this, an autopsy-based cross-sectional study was conducted from
1st April, 2013 to 31st March, 2014 in the department of Forensic and State Medicine, Nil Ratan Sircar
Medical College, Kolkata. During this period a total of 2813 autopsies were carried out. Of these, 613
cases were associated with fractures, of which 100 cases of fracture were selected randomly and
analyzed. RTA and fall were the commonest cause of fracture related deaths. Fractures among RTA
victims were common in male (78.9%), in middle age persons (38.6%) and during rainy season. Greater
number of victims died within first 24 hours of the event, both in case of RTA (43.8%) and fall (57.6%).
Skull (48%) and spine (11%) fractures were present in most of the cases. This study can help concerned
authorities to plan and implement safety measures to avoid preventable death

Key Words: Fracture, Road Traffic Accident, Fall from height

Introduction: Majority of fractures occur in children or

Fracture of a bone is defined as a breach in
the continuity of a bone or a complete or
incomplete discontinuity of bone caused by
direct or indirect violence.[1]. Fractures or
breaking of bones usually happens when too
much force is applied to a bone, usually during a
fall from height or a Road Traffic accident. The
global status report on road safety 2015, by
WHO, reflecting information from 180 countries,
indicates that worldwide the total number of road
traffic deaths has reached 1.25 million per year,
with the highest road traffic fatality rates in low-
economic countries.[2] Over 1,37,000 people
were died in India in road traffic accidents in
2013 alone; which is more than the number of
people killed in all our wars put together.[3]. But
fractures may also occur due to fall in the
bathroom or stair case, gunshot injury etc.
Corresponding Author:
1
Tutor,
Department of Forensic Medicine,
NRS Medical College, Kolkata
2
Asst. Prof.,
Department of Pharmacology,
3
Asst. Prof.,
4
Prof. & Head,
Department of Forensic Medicine, ESIC Medical
College, Kolkata
Email: dralakeshhalder@gmail.com
DOR: 26/09/2016 DOA: 25/12/2016
DOI: 10.5958/0974-0848.2016.00102.0
in elderly people, as young and middle-aged
adults generally have very strong bones. An
autopsy surgeon encounters different types of
mechanical injuries during autopsy examination
like abrasion, laceration, contusion etc. Fracture
of bone is a common form of mechanical injury
which may sometimes be the only cause or a
contributory factor in causation of death. Usually,
fractures occur accidentally, though they may
also be present in suicidal or homicidal deaths.
They are important medicolegally for manner of
production of fracture, the type of weapon used,
the gravity of the trauma, the direction of
infliction, etc.
The aim of this study was to study the
fractures in different parts of the body, their
seasonal variation, survivability and to determine
the relation between the fractures and their
manner of production.
Materials and Methods:
We conducted a cross-sectional
autopsy-based study in association with the
clinical records available from investigating
agencies. This hospital and mortuary based
study was conducted from 1st April, 2013 to 31st
March, 2014. During this period a total of 2813
autopsies were carried out in the department of
Forensic and State Medicine, Nil Ratan Sircar
Medical College, Kolkata. Of these, 613 cases
were associated with fractures, among which
100 cases of fractures were selected randomly

408
J Indian Acad Forensic Med. October - December 2016, Vol. 38, No. 4
and analyzed. Demographic data was collected,
including the age, sex, religion, place of
incidence, seasonal variation, body parts
involvement, manner of production, duration of
survival etc.
Results:
A total 100 cases of fracture related
deaths were analyzed in this study. Table 1
shows that fractures due to RTA was common in
males (78.9%), as compared to females (21.1%)
but the percentage of fractures due to fall was
almost the same in both genders - males, 51.5%
and females, 49.5%, respectively. Fractures due
to both fall and RTA was more prevalent in the
age group 21 to 60 years. Most of the deaths
occurred within the first 6 hours of the incident
while very few victims survived more than one
month. Time of the day and duration of the
survival has been detailed in Table 1.
Figure 1 shows the percentage of
fracture related deaths due to different causes.
Majority of fractures were due to RTA (57%) and
fall (33%). Hanging (3%) and gunshot injuries
(4%) were the cause in certain cases. Among
fall category, fall from height (31%) and fall in
bathroom (27%) were the important contributors.
Figure 2 shows seasonal variation
among the deaths due to fracture. Higher
number of incidents occurred in rainy season,
especially July and August.
Most of the victims died due to fracture
in the axial skeleton - skull (48%), vertebra
(11%) and Thoracic fracture (13%). A few cases
showed multiple fractures, which is detailed in
Table 2.
Discussion:
Age wise distribution:
Fractures due to both fall and RTA were
more prevalent in the age group 21 to 60 years.
The findings of this study were consistent with
the study from New Delhi, which revealed that
the incidence of traffic injury per 1000 population
was high in the age group of 15 to 55 years.[4]
Sinha S.N., et al retrospectively studied road
traffic accident fatalities in Port Moresby for a
period of 10 years spanning from 1976 to 1985
and observed that the highest fatality rates were
in the age group between 15-54 years.[5] Kumar
A, et al, found that most of the victims were
adults; age group involved being 41-50 years
(29.5%) and 31-40 years (27.9%).[6] Chandra J,
et al found that the most common group involved
in road traffic accidents was the 21-60 years.
Findings of these studies were similar to our
study.[7]
409
ISSN 0971-0973
Sex distribution:
Fractures due to RTA were more
common in males (78.9%) but there was no
difference in the gender in fractures due to fall -
males, 51.5% and females, 49.5%. Reddy, et al
found that 92% of the victims were males.[8]
Adeyemo A.O, et al found 85.8% male victims
among the 148 cases that he studied.[9]
Santhiyasekaran observed that 82.5% of the
victims were male.[10] Similar male prevalence
was found in several studies conducted in
different parts of India.[11,12]. The findings of
our study are consistent with these observations.
Causes of fracture related death:
In 2006, Pathak, et al found that RTA
(66%), followed by fall (23%) were the main
external factors causing fracture related
deaths.[13] Igho, et al. reported that RTA (58%)
and domestic/sport related fall (27%) cause
most of the fracture related incidents.[14] In our
study also, majority of fractures were due to RTA
(57%) and fall (33%). Fall from height (31%) and
fall in bathroom (27%) were the two common
mechanisms for fractures in the fall category.
The time of the day when incidence of
fracture occurred
The peak time of the day, contributing
highest number of RTA vary greatly in different
studies. Pillay VV, in his study, encountered the
maximum number of traffic fatalities in the late
evening hours of 8 PM to 12 AM (31%) and the
second highest peak from 12 PM to 4 PM, while
the least number was recorded for the period
from 12 AM to 4 AM.[15] Sinha SN, et al found
that in 40.2% of all the fatalities, the accidents
occurred between 6 PM to 6 AM and in 35.3%,
between 6 AM to 6 PM.[5]. Kumar A, et al,
observed that the time of occurrence and
mortality was maximum, between 12-6 PM while
mortality rate was highest during 6 PM -12 AM.
In this study, majority of RTA took place
between 6 AM to 12pPM but fall was frequent
from 12 – 6 PM.[6]
Duration of survival after fracture
As per Table IV, most of the victims
survived less than 6 hours, both in RTA (24.6%)
and in fall from height (33.3%) and very few
survived for more than a month 3.4% and 6.6%,
respectively. Patil, et al reported that 63% of the
victims died within first 24 hours of the injury.[16]
In the present study, 62.3% of the victims died
within the first 24 hours. Reddy, et al found that
59% of the victims died within first 24 hours and
only 23% victims survived more than 3 weeks.[8]
Seasonal variation
We found that higher number of
incidents occurred in the rainy season,
especially, July (26%) and August (23%). Similar
J Indian Acad Forensic Med. October - December 2016, Vol. 38, No. 4
pattern ws found in other studies also. Mazurek
A J made an epidemiological study of pediatric
injury following road traffic accidents and found
that most of the injuries occurred in July and
Summer.[17] Kumar A, et al found that the
number of cases and mortality were maximum in
the rainy season while mortality rate was highest
in the Summer.[5]
Distribution of fracture Cases according to
body parts involvement
Most of the victims died due to fracture
in the axial skeleton - skull (48%), vertebra
(11%) and thoracic fracture (13%). A few cases
showed multiple fractures. Skull fractures were
also found as the major contributor (69%) of
death among RTA victims by Kumar, et al.[6]
Murthy, et al found that head injury is the most
common cause of death among victims of
fall,[18] Whereas fractures of extremities was
common in non-fatal RTA, as reported by Singh,
et al, Igho, et al, Meena, et al and Ganveer, et
al.[14, 19-21]
Limitations of our study was the
relatively small sample size due to logistic
concerns. This study was based only on
macroscopical findings, radiological examination
would help to identify further information.
Conclusion:
From the present study, it has been
revealed that within the jurisdiction of the
department of the Nil Ratan Sircar Medical
College, male deaths due to fracture were much
more than that of the females. Virtually, death of
most of the victims were accidental in nature.
Middle to old aged people within the age group
41-60 years were prone to fracture related
deaths. First six hours is the most important
period following development of fracture, which
needs proper medical attention to avoid the
preventable deaths. This study may help the
concerned authorities to take appropriate steps
to implement traffic rules and plan better
availability of health care for accident victims.
References:
1. Kruger G.O. Textbook of Oral and Maxillofacial Surgery. 6th edition.
Jaypee Brothers; 1990 http://www.oalib.com/references/14219385
2. WHO | Global status report on road safety 2015 [Internet]. WHO.
World Health Organization; 2016 [cited 2016 Sep 21]. Available from:
http://www.who.int/violence_injury_prevention/road_safety_status/201
5/en/ [Cited 2016 Sep 22]
3. Road Accident Statistics in India - Road Safety [Internet]. [cited 2016
Sep 21]. Available from: http://sites.ndtv.com/roadsafety/important-
feature-to-you-in-your-car/[Cited 2016 Sep 21]
4. Verma P, KN T. Epidemiology of road traffic injuries in delhi: result of
a survey. Reg Heal Forum WHO South-East Asia Reg. 2004;8.
5. Sinha S, SK S. RTA fatalities in Port Moresby: a ten year survey.
Accid Anal prev. 1989;21:297–301.
410
ISSN 0971-0973
6. Kumar A, G.U. Q, Aggarwal A, Pandey DN. Profile of thoracic
injuries with special reference to road traffic accidents in Agra.
Journal of Indian Academy of Forensic Medicine. 1999;21(4):104–9.
7. Chandra J, Dogra TD, Dikshit PC. Pattern of cranio-intracranial
injuries in fatal vehicular accidents in Delhi, 1966-76. Med Sci Law.
1979;19(3):186–94.
8. Reddy NB, Hanumantha, Madithati P, Reddy NN, Reddy CS. An
epidemiological study on pattern of thoraco-abdominal injuries
sustained in fatal road traffic accidents of Bangalore: Autopsy-based
study. J Emerg Trauma Shock. 2014;7(2):116–20.
9. Adeyemo AO, Arigbabu AO, Adejuyigbe O. Thoracic injuries in
road traffic accidents: analysis of 148 cases. Injury. 1984;16(1):30–4.
10. Sathiyasekaran B. Study of the injured and the injury pattern in road
traffic accident. Indian Journal of Forensic Sci. 1991;5:63–8.
11. Singh H, Dhattarwal SK, Pattern and Distribution of injuries in fatal
road traffic accidents in Rohtak (Haryana) Journal of Indian Academy
of Forensic Medicine 2004; 26(1): 20-23.
12. Choudhary BL, Singh Deepak, Tirpude BH, Sharma RK, Meel
Veena, profile of road traffic accidents cases in kesturba Hospital of
MGIMS, Sevagram, Wardha, Maharashtra, Ind medica medico legal
update 20,5; 5(4): 1-12.
13. Pathak A, Desania N. L , Verma R. Profile of road traffic accidents
and head injury in jaipur (rajasthan). Journal of Indian Academy of
Forensic Medicine. 2008;1:6–9.
14. Emmanuel Igho O, Akpoghene Isaac O, Onyemaechi Eronimeh
O. Road traffic accidents and bone fractures in ughelli, nigeria. IOSR
J Dent Med Sci. 2015;14(4):2279–861.
15. Pillay VV. Scientific article of IJV Annual Conference. In: Indian
Academy of Forensic Medicine.
http://medind.nic.in/jal/t05/i3/jalt05i3p166.pdf
16. Patil AM, Vaz WF. Pattern of fatal blunt head injury: a two year
retrospective / prospective medico legal autopsy study. Journal of
Indian Academy of Forensic Medicine. 2010;32(2):144–9.
17. Mazurek AJ. Epidemiology of paediatric injury. J Accid Emerg Med.
1994;11(1):9–16.
18. Vasudeva Murthy C, Harish S, Girish Chandra Y. The study of
pattern of injuries in fatal cases of fall from height. 5(1):4–5. Al Ameen
J Med Sci; Volume 5, No.1, 2012
19. Ganveer GB, Tiwari RR. Injury pattern among non-fatal road traffic
accident cases: a cross-sectional study in Central India. Indian
Journal of Medical Science. 2005;59(1):9–12.
20. Meena RK, Singh AM, Singh CAK, Chishti S., Kumar AGC,
Langshong R. Pattern of fractures and dislocations in a tertiary
hospital in north – east india. Internet J Epidemiol. 2013;11(1).
http://ispub.com/IJE/11/1/1444#
21. Singh R, Singh HK, Gupta SC, Kumar Y. Pattern, severity and
circumtances of injuries sustained in road traffic accidents: a tertiary
care hospital-based study. Indian Journal Community Medicine.
2014;39(1):30–4.
Figure:1. Causes of fracture related death
J Indian Acad Forensic Med. October - December 2016, Vol. 38, No. 4 ISSN 0971-0973

Table:1. Distribution of fracture victims based on

Epidemiology Table.2: Distribution of fracture Cases according to body
Parameter Prevalence Prevalence Prevalence Prevalence parts involvement (n=100)
among among among fall among fall
RTA RTA (%) (Number of (%)
Body parts involvement Number of cases Percentage
(Number of cases)
Skull fracture 48 48
cases)
Vertebrae fracture 11 11
Sex
Thoracic fracture 13 13
Male 45 78.94 17 51.51
Upper limbs fracture 1 1
Female 12 21.06 16 49.49
Lower limbs fracture 4 4
Total 57 100 33 100
Skull + thorax fracture 7 7
Age in years
Pelvis + thorax fracture 5 7
1--20 6 10.53 5 15.15
Thorax+ upper limb fracture 3 8
21-40 19 33.33 10 30.30
Hyoid bone fracture 3 3
41- 60 22 38.60 8 24.24
Pelvis + lower limb fracture 5 5
61 - 80 8 14.04 9 27.27
Total 100 100
81- 100 2 3.51 1 3.03
Total 57 100 33 100
Time of day when incidence of fracture occurred
00.01— 2 6.06 Figure.2: Month wise distribution of fracture related deaths
6.00 8 14.1
6.01— 11 33.33
12.00 21 36.8
12.01— 14 42.42
18.00 16 28
18.01— 6 18.18
24.00 12 21.1
Total 57 100 33 100
Duration of survival after fracture
< 6 hours 14 24.6 10 30.30
6—24 9
hours 11 19.2 27.27
1 -- 3 days 7 12.3 4 12.12
3 --7 days 13 22.8 2 6.06
1 -- 2 3
weeks 8 14.3 9.09
2 -- 3 1
weeks 1 1.7 3.03
3-- 4 week 1 1.7 2 6.06
>1 month 2 3.4 2 6.06
Total 57 100 33 100

411