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World J Surg (2013) 37:136140

DOI 10.1007/s00268-012-1797-4

Effects of Vehicle Size on Pedestrian Injury Pattern and Severity:


Prospective Study
Essa M. AlEassa Hani O. Eid Fikri M. Abu-Zidan

Published online: 27 September 2012


Societe Internationale de Chirurgie 2012

Abstract
Background The type of injuries caused by sport utility
vehicles may be different from those caused by small
passenger cars. We studied prospectively the effects of the
offending vehicle type and design on severity and pattern
of pedestrian injuries.
Methods All injured pedestrians admitted to the two
major trauma centers of Al-Ain city were studied prospectively during the period of April 2006 to October 2007.
Patients were classified into two groups according to the
offending vehicle type: small vehicle and sport utility
vehicle. These two groups were compared regarding the
distribution of injury and its severity.
Results The anatomical distribution of injury in a
descending order were the lower extremities (56.3, 67 %),
head (53.8, 57.1 %), face (37.5, 57.1 %), and upper
extremities (32.5, 28.6 %) in small vehicle and sport utility
vehicle groups, respectively. No significant statistical difference has been found between the two groups regarding
the anatomical distribution and severity.
Conclusions The vehicle size and design did not affect
the anatomical injury distribution and severity in our setting. High-impact speed may overcome the vehicle type
when it comes to injury severity and pattern of distribution.

E. M. AlEassa  H. O. Eid  F. M. Abu-Zidan (&)


Trauma Group, Department of Surgery, Faculty of Medicine and
Health Sciences, UAE University, P.O. Box 17666, Al-Ain,
United Arab Emirates
e-mail: fabuzidan@uaeu.ac.ae
E. M. AlEassa
e-mail: e.aleassa@uaeu.ac.ae
H. O. Eid
e-mail: hani2003@hotmail.com

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Introduction
The United Arab Emirates (UAE) is a rapidly developing
country. Within 40 years, it became a country with
metropolitan cities and well-developed infrastructure. Tolls
came along with these developments; injuries due to road
traffic collisions (RTC) in the UAE are reported to be
among the highest in the world [1]. RTC is the second
leading cause of death in the country [2]. The Statistics
Center of Abu Dhabi Emirate reported more than 5,000
RTC causalities that occurred in 2009 having a mortality of
7.9 %. Twenty percent of these were pedestrian injuries
[3].
Al-Ain city is the largest city in the eastern region of the
Emirate of Abu Dhabi and had a population of 568,221 in
2010; with a male to female ratio of 2:1 and a non-national
to national ratio of 2.2:1. It extends over a large area of
30 9 20 km with an internal length of roads of 1,227 km
[3]. A recent study looking at the driving behavior of road
users in UAE indicated that 5 % of the drivers never
yielded for pedestrians and *11 % occasionally yielded
for them [4]. This puts pedestrians at a high risk of injury
when crossing these lengthy roads. A study from Al-Ain
City showed that 13 % of RTC-injured patients who were
treated at hospitals were pedestrians [5]. Furthermore,
pedestrian injuries accounted for 28.5 % of road traffic
mortality in UAE [6].
Different aspects of pedestrian road traffic injury have
been studied; an important aspect is the biomechanics of
pedestrian injury. During collision, energy is transferred
between objects. Energy is calculated as mass times
velocity squared (E = mv2). It is worth noting that the
velocity is exponential; thus, every kilometer per hour
increase in velocity actually highly increases the energy
that the vehicle possesses and, therefore, the higher the

World J Surg (2013) 37:136140

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energy it transfers to a pedestrian at impact [7]. Accordingly, the injury severity and mortality of pedestrians
increase exponentially with increased impact speed of the
offending vehicle [8, 9]. The number of sports utility
vehicles (SUVs) with a high pumper has been increasing.
The type of injuries caused by SUVs may be different from
those caused by small passenger cars [5, 8, 10].
Roudsari et al. [9] have found that severity of injury and
death is affected by the type and design of the offending
vehicle. Light truck vehicles were associated with triple
higher risk of severe injuries and double the mortality
compared with passenger vehicles [9]. Similarly, Ballesteros et al. [8] have shown that pedestrians hit by SUVs
have an odds ratio of death of 1.7 times compared with
pedestrians hit by small passenger cars. In this study, we
prospectively studied the effects of the offending vehicle
type and design on severity and pattern of pedestrian
injuries.

The revised trauma score (RTS) was derived from the


GCS, pulse rate, systolic blood pressure, and respiratory
rate obtained on arrival to the emergency department [12].
Offending vehicles were classified as small vehicle
(sedan), sport utility vehicle SUV (4 9 4 wheel drive),
or other vehicles (bus, light trucks, heavy trucks, and
unknown). Patients traumatized by the other vehicles
group were excluded from the study because of their
nonstandardized design or unknown nature. One hundred
nineteen pedestrian injured patients were studied. Eighty
were hit by small vehicles, 21 by SUVs, and 18 were from
the other group (excluded). Statistical Package for Social
Sciences (SPSS version 19.0) software was used for the
statistical analysis. The statistical tests used were Mann
Whitney U test or Fishers exact test as appropriate. The
different continuous, ordinal, or categorical data were
analyzed as two independent groups (small vehicle and
SUVs).

Patients and methods

Results

All injured pedestrians who were admitted to Al-Ain citys


two major trauma centers or who died after arrival to these
hospitals after being involved in a road traffic collision
(RTC) between April 2006 and October 2007 were prospectively studied. Hospitalized trauma patients in our city
are exclusively admitted to these two hospitals. The
patients, or their caregivers, have been interviewed and
followed up by a Research Fellow on a daily basis to
collect relevant information of preidentified variables
regarding the patient, offending vehicle, and the event.
The Local Ethics Committee of Al-Ain Health District
Area has approved this study: RECA/02/44). Patients, who
were admitted to Al-Ain or Tawam Hospitals, or their
caregivers, signed a consent in which they agreed to collect
their data for research purposes. Each patient was given a
case number. Collected data were anonymous when
entered into the database.
All patients were included initially in the database and
analyzed for the following variables: age, gender, nationality, Glasgow coma scale (GCS), vital signs (blood pressure, respiratory rate and heart rate), length of hospital stay
(LOS), intensive care unit (ICU) admission, and outcome
(survival or death). Description of the collision event and
the offending vehicle was noted from the patients medical
charts in case the patients condition limited the interview.
Severity of injury of the affected body region was
recorded according to the Abbreviated Injury Scale (AIS)
of the Association of the Advancement of Automotive
Medicine (version 1998) [11]. The Abbreviated Injury
Score (AIS) and an Injury Severity Score (ISS) were calculated for each affected region and patient, respectively.

There was no statistical difference regarding the age,


nationality, injury severity markers, or mortality between
the small vehicle group and the SUV group (Table 1).
Females were significantly higher in the small vehicle
group (P = 0.04). Thirty-one of 78 (40 %) patients in the
small vehicle versus 3 of 21 (44 %) patients from the SUV
group were taken for surgery (P = 0.79). Fifteen (19 %) of
the small vehicle group were managed in the ICU and only
two (10 %) of the SUV group needed ICU care (P = 0.51).
Table 1 Demographics of hospitalized pedestrian injured patients by
vehicle type (Al-Ain City, 20062007)
Variable

Small
vehicle
(N = 80)

Sport utility
vehicle
(N = 21)

Age (yr)

28.5 (270)

P value

30 (450)

0.7

Gender (male)

60 (75 %)

20 (95.2 %)

0.04

Nationality
(Emirati/non-Emirati)

12 (17.6 %)/
68 (82.4 %)

3 (14.3 %)/
18 (85.7 %)

0.99

Operateda

31 (40 %)

8 (44 %)

0.79

ICU admission

15 (18.8 %)

2 (9.5 %)

0.51

5 (1127)

4 (1116)

0.35

1 (4.8 %)

0.99

Length of hospital
stay (days)
Mortality
GCS

3 (3.8 %)
15 (315)

15 (315)

0.7

TRS

12 (712)

12 (1112)

0.23

ISS

5.5 (145)

5 (134)

0.86

Data presented as numbers (%) or median (range) as appropriate


P = Fishers exact test or MannWhitney U test as appropriate
a

Data were missing for two patients in small vehicle group and three
patients for sport utility vehicle group

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World J Surg (2013) 37:136140

Table 2 Injured body region by offending vehicle type


Body region

Small vehicle
(N = 80)

Sport utility
vehicle (N = 21)

P value

Head

43 (53.8 %)

12 (57.1 %)

0.81

Face

32 (37.5 %)

6 (28.6 %)

0.45

Neck

2 (2.5 %)

Thorax

20 (25 %)

0.99

5 (23.8 %)

0.99

Abdomen

7 (8.6 %)

4 (19 %)

0.23

Spine

5 (6.3 %)

2 (9.5 %)

0.63

26 (32.5 %)
45 (56.3 %)

6 (28.6 %)
14 (66.7 %)

0.8
0.46

Upper extremity
Lower extremity

P = Fishers exact test

Table 3 Abbreviated injury score in pedestrian injured body region


by offending vehicle
Body region

Small vehicle
(N = 80)

Sport utility
vehicle (N = 21)

P value

Head

2 (15)

2 (14)

0.56

Face

1 (12)

1 (12)

0.21

Neck
Thorax

2 (22)
3 (15)

0
1 (15)

0.19

Abdomen

1 (14)

1 (11)

0.26

Spine

2 (22)

2 (22)

0.99

Upper extremity

2 (13)

1 (12)

0.29

Lower extremity

2 (14)

2 (13)

0.7

Data represented as median (range)


P = MannWhitney U test

There was no statistical significance in the distribution of


the injured regions between the two groups (Table 2). The
most common injured region was the lower extremity
followed by the head, face, and upper extremity. Furthermore, there was no statistical difference of the AIS of
different regions between the two groups (Table 3). There
also was no statistical difference of injury pattern to the
lower extremities between the two groups (Table 4).

Excluding pedestrians, our Road Traffic Injury Registry


indicates that there were 775 hospitalized trauma patients
who were occupants of 635 car vehicles during the same
study period. Of these 635 vehicles, 176 (27.7 %) were
SUVs and 385 (60.6 %) were small vehicles. In the present
study, significantly less SUVs hit pedestrians than SUVs of
the injured vehicle occupants (21/119 [17.6 %]) compared
with 176/635 [27.7 %]; P = 0.023, Fishers exact test).

Discussion
Our study has shown that there was no significant difference in anatomical distribution of pedestrian injuries and
their injury severity between small vehicle and SUV
groups. This may be explained by different reasons. The
sample size of the study may have been small. This
explanation is unlikely, because the data do not show
trends of difference between the two groups. In fact, our
study sample included all admitted pedestrians in our city
of a half million population during a period of 18 months.
Patients who died at the scene were not included in the
study. The traffic police records of Al-Ain City indicate
that the average annual RTC pedestrian deaths during the
years 20062008 was 21 deaths (personal communication,
Al-Shajrawi WS, Road Traffic Engineer, Al-Ain City
Traffic police, UAE). This indicates that, during the study
period, *85 % of pedestrian mortality in Al-Ain City
occurred in the prehospital setting and *15 % occurred in
the hospital. We do not know exactly which type of
vehicles caused these prehospital pedestrian deaths.
Assuming that the ratio of the SUV that hit pedestrians are
the same as other road traffic collisions indicates that SUVs
caused more mortality in the prehospital setting compared
with small cars. This suggestion is supported by others [8].
During 2009, 176,587 motor vehicles were licensed in
Al-Ain City; 90 % of these were categorized as light
vehicles, including small cars and SUVs. The exact percentage of SUVs licensed in Al-Ain City was not reported
[3]. During 2007 in UAE, 86 % of vehicles involved in
road traffic crashes were light vehicles [6]. Interestingly
88 % (95 % confidence interval (CI), 8690) of vehicles
involved in crashes in our Road Traffic Collision Registry

Table 4 Lower limb pedestrian injuries and their AIS in relation to the knee joint in offending vehicle groups
Region

Small vehicle
(N = 45)

Sport utility vehicle


(N = 14)

P value

Small vehicle
AIS

Sport utility vehicle

P value

Above knee

n = 15 (33.3 %)

n = 5 (35.7 %)

0.76

3 (14)

2 (13)

0.22

Below knee

n = 26 (57.8 %)

n = 8 (57.1 %)

0.62

2 (13)

2 (13)

0.66

n = 4 (8.9 %)

n = 1 (7.1 %)

0.99

1 (11)

1 (N/A)

0.99

Knee

P = Fishers exact test or MannWhitney U test as appropriate

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were light vehicles. These included SUVs (27.7 %) and


small vehicles (60.6 %).
It is important to note that the offending vehicle design
and type has no effect on the severity of pedestrian injury if
the pedestrian was hit by an impact speed of more than
30 miles/hour (48.3 km/hour) [8]. Nevertheless, being hit by
a SUV or van at speeds less than that was associated with
more injuries to the brain, thorax, and abdomen compared
with small cars [8]. Front bumpers, which were designed to
reduce pedestrian injuries, give measurable benefits only
with vehicle speeds of less than 50 km/hour [13].
We did not study the effect of the impact speed of the
offending vehicles on the pedestrian injuries in our study,
because the information was gathered from either the patient
or the caregiver. It is important to note that the speed limit in
most of the streets within Al-Ain City during the study period
ranged from 80 to 100 km/hour. Based on the study conducted by Matsui, the details of the lower limb injury (site
and presence of fracture) might be used to roughly point out
the impact speed and the type of the offending vehicle. Fortythree of the 59 (73 %) patients who had lower injury in our
study had fractures of the lower limb. Those, according to
Matsuis study, had a high-speed impactat least more than
40 km/hour [10]. This indicates that *75 % of our patients
were hit by high-impact speed, which may explain why there
was no difference in the anatomical distribution between the
two groups. Although there is no direct evidence in our data,
the cited studies may indicate indirectly that injuries of our
patients might have occurred at speeds higher than 50 km/
hour [8, 10, 13].
The severity of pedestrian injuries depends on the design
and height of the offending vehicles bumper, the impact
speed, and the ground contact effect [10, 13]. In a typical
pedestrian crash, the bumper first strikes the leg; the thigh,
pelvis, or chest then hit the bonnet leading edge, followed by
the upper body hitting the bonnet, and finally the head hits the
windscreen [13]. DiMaggio et al. [14] found that the odds
ratio of mortality of children hit by light trucks or vans
(including SUVs) will double compared with children hit by
small cars. Furthermore, children aged 59 years who were
hit by light trucks or vans were four times more likely to die
than when struck by a small car because their low height
made them susceptible to severe head injury [14].
It has been reported that *80 % of adult pedestrians
involved in a RTC had lower-limb injury [15]. Lower
extremities are more commonly injured followed by the
head, face, and upper extremities [16, 17]; these findings
are similar to our study. Roudsari et al. [9] reported that
light trucks or vans had significantly higher percentage of
lower extremity injuries compared with passenger vehicles
when they hit children. Ballesteros et al. [8] reported that
injuries above the knee were more frequent with SUVs,
whereas the small vehicles caused more below-knee

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injuries. Our present study has shown that there was no


difference in lower extremity and head injury between
SUVs and small vehicles.
It would be necessary to test vehicle designs for safety of
pedestrians who are at high risk for severe disability and
death [18]. The Vehicle Safety Working Party in the European Transport Safety Council has proposed a vehicle
pedestrian-friendly test to approve vehicle body designs
[19]. The test, European Enhanced Vehicle-Safety Committee Work Group 17 (EEVC WG 17), examined the safety
of the body design to the lower extremities and head in
pediatric and adult population. In 2003, this workgroup
tested some vehicles in the market accredited by the European New Car Assessment Program (EURO NCAP); none of
them have passed the pedestrian safety measures in regards
to lower extremities safety [20]. The Euro NCAP has adapted
a pedestrian-safety program and has accredited the first
pedestrian-friendly vehicle model in 2005 [21]. More
research is needed to understand the association between the
vehicle design and the pattern and severity of pedestrian
injuries. Vehicle manufacturers need to test their designs
from pedestrian injurys perspective, which may reduce the
severity of the resulting injuries. The combined effect of
friendly car fronts and impact speed reduction by using
autonomous braking has large potential to decrease pedestrian injuries [13].

Conclusions
The vehicle size and design did not affect the anatomical
distribution and severity of pedestrian injuries in our setting. Lower extremity was the most frequent injured region
followed by the head, face, and upper extremity. Impact
speed may be more important than the vehicle type when it
comes to pattern and severity of pedestrian injuries in our
setting. Our study highlights the importance of monitoring
the vehicle speed and enforcing the law to keep the speed
below the legal limit.
Acknowledgments The authors thank Road Traffic Engineer,
Wajih Al-Shajrawi, Head of Traffic Engineering and Statistics
Branch, Al-Ain police Department, Al-Ain, UAE, for supplying
the data on pedestrian prehospital mortality of Al-Ain city (years
20062008). This study was supported by an interdisciplinary UAE
University Grant No. 02-078-1/4.
Conflict of interest

No conflict of interest is declared by all authors.

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