A population-based study of motorcycle injury and costs

Motorcycle injuries: a systematic review for forensic evaluation

The intricate interplay of exposure and speed leave motorcyclists vulnerable, leading to high mortality rates. During the collision, the driver and the passenger are usually projected away from the motorcycle, with variable trajectories or final positions. Injuries resulting from the crash can exhibit distinct and specific characteristics depending on the circumstances of the occurrence.The aim of this study is to provide a systematic review of the literature on injuries sustained by motorcyclists involved in road accidents describing and analyzing elements that are useful for forensic assessment.The literature search was performed using PubMed, Scopus and Web of Science from January 1970 to June 2023. Eligible studies have investigated issues of interest to forensic medicine about during traffic accidents involving motorcycle. A total of 142 studies met the inclusion criteria and were classified and analyzed based on the anatomical regions of the body affected (head, neck, thoraco-abdominal, pelvis, and limb injuries). Moreover, also the strategies for preventing lesions and assessing injuries in the reconstruction of motorcycle accidents were examined and discussed.This review highlights that, beyond injuries commonly associated with motorcycle accidents, such as head injuries, there are also unique lesions linked to the specific dynamics of accidents. These include factors like the seating position of the passenger or impact with the helmet or motorbike components. The forensic assessment of injury distribution could serve as support in reconstructing the sequence of events leading to the crash and defining the cause of death in trauma fatalities.

Motorcycle crashes and upper extremity trauma

Objectives: Upper extremity injuries following motorcycle crashes (MCC) incur increased healthcare costs and rehabilitation needs. We aim to characterize the epidemiology of MCC upper extremity injuries and identify factors that influence the severity of and cost of care for upper extremity injuries. Methods: We performed a retrospective cohort analysis of 571 patients with upper extremity injuries after MCC at a level 1 trauma center from 2002 to 2013. We collected data pertaining to demographics, helmet use, toxicology, bony injury, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), hospital length of stay (LOS), and cost. Continuous variables were compared using t-test or Wilcoxon rank test, depending on data distribution, and dichotomous variables were compared using Pearson’s chi-squared or Fisher’s exact tests. Regression models were used to evaluate the effect of intoxication or helmets on injury location, severity, cost of care, and LOS. Results: The incidence of MCC upper extremity injury was 47.5%, with hand and forearm fractures the most common injuries (25.5% and 24.7% of total injuries). Intoxicated patients were more likely to have a high cost of care (p = 0.012), extended LOS (p = 0.038), plastic surgery involvement in their care (p = 0.038), but fewer upper extremity bony injuries (p = 0.019). Non-helmeted patients sustained less upper extremity bony injuries (p < 0.001) and upper extremity soft tissue injuries (p = 0.001), yet more severe injuries (ISS ≥ 30, p = 0.006 and GCS < 9, p < 0.01) than helmeted patients. Conclusion: Upper extremity injuries are common in motorcyclists. Despite vital protection for the brain and maxillofacial injury, helmeted MCC patients have an increased incidence of upper extremity injuries compared to non-helmeted patients, but overall have less severe injuries. Intoxicated patients have fewer upper extremity bony injuries, but the higher cost of care, and extended LOS. Therefore, even with the increased risk of injury helmets may expose to the upper extremity, helmets reduced overall morbidity and mortality. In addition to mandatory helmet laws, we advocate for further development of safety equipment focusing specifically on the prevention of upper extremity injuries.

The Orthopedic Injury Burden of Personal Mobility Devices in Singapore - Our Experience in the East Coast

PURPOSE

Personal mobility devices (PMDs) have become increasingly popular as a modality of transport worldwide. Starting out as novelty toys, PMDs are gradually being adopted as the mainstream mode of travel. There is an increasing number of accidents involving both PMD riders and other road users since its introduction, leading to a concomitant increase in demand for healthcare resources to manage the injuries. The main objective of this study was to evaluate the inpatient cost and the orthopedic injury pattern due to PMD accidents.

METHODS

All patients admitted to the Department of Orthopedic Surgery between December 2016 to February 2018 with injuries due to PMD accidents were recruited. Data collection was performed retrospectively on the demographic profiles, injury patterns, admission related outcomes and expenditures of these patients.

RESULTS

43 patients were included in this study. The mean duration of admission was 7.81 days and the median cost of admission was S$7835.01 (approximately US$5620). These were comparable to accidents arising from other modes of transport, such as motorcycles and bicycles. In addition, more than 80% of patients were not wearing protective gear at time of accident. These patients had a slightly higher median cost payable per patient as compared to those who donned protective gear, with a difference of S$1669.78 (approximately US$1221).

CONCLUSION

There is a significant health and financial cost to the individual and society from PMD injuries and admission. This can be reduced with strict regulations on PMD use, advocating protective gear use, and promoting awareness on safety measures and the consequences of PMD accidents. The most common injury mechanism and orthopedic injury type for PMD accidents are different from motorcycle accidents.

Evaluation of the Performance of Helmet Prototypes Fabricated from Acrylonitrile Butadiene Styrene Composites Filled with Natural Resource

The performance of helmet prototypes fabricated from acrylonitrile butadiene styrene composites filled with oil palm empty fruit bunch fibers was evaluated. The fibers were produced using a milling procedure, while the composites were fabricated using a single-screw extrusion. The physical characteristics of the produced fibers, which are water content, size, and density, were investigated. In addition, the mechanical properties of the produced helmets, including shock absorption, yield stress, frequency, and head injury criterion (HIC), were examined. The impact strength of the produced helmets increases with the rise of filler content. In addition, the helmets were also able to withstand a considerable pressure such that the transmitted pressure was far under the maximum value acceptable by the human skull. The present work also found that HICs exhibited by the investigated helmet prototypes fulfill all the practical guidelines as permitted by the Indonesian government. In terms of novelty, such innovation can be considered the first invention in Indonesia since the endorsement of the use of motorcycle helmets.

Safety Analysis of Motorcycle Crashes in Seoul Metropolitan Area, South Korea: An Application of Nonlinear Optimal Scaling Methods

This study identifies the critical factors that affect motorcycle crash severity based on Korean motorcycle crash data in 2009. Motorcyclists, the environment, roadways, other vehicles involved in the crashes, and traffic flow characteristics were used as variables for identifying critical factors. Multivariable statistical methods were used to analyze the data, including categorical principal components analysis (CatPCA) and nonlinear canonical correlation analysis (NLCCA). The results indicate that the following factors are the most critical in increasing motorcycle crash severity: age (motorcyclists in their teens and over fifty years old), motorcycle speed over 30 km/h, speed over 50 km/h for other vehicles involved in the crash, crashes with heavy vehicles such as buses and trucks, crashes on roadways less than six meters wide, crashes at curved sections, crashes at basic roadway segments without any speed control facilities, and head-on crashes. These findings are expected to serve as a valuable reference for formulating remedial policy measures to decrease the severity of motorcycle crashes on roadways in the Seoul metropolitan area of South Korea.

Can Planned Traffic Patterns Improve Survival Among the Injured During Mass Casualty Motorcycle Rallies?

BACKGROUND

Mass casualty events are infrequent and create an abrupt surge of patients requiring emergency medical services within a brief period. We hypothesize that implementation of a controlled "traffic loop" pattern during a planned high-volume motorcycle rally could improve overall mortality and impact patient outcomes.

MATERIALS AND METHODS

We performed a retrospective analysis of all motorcycle-related injuries during the city's annual motorcycle rally over a 4-y period. Comparative analysis was completed between those injured during "nontraffic loop" hours versus the city's scheduled 23-mile, 3-d "traffic loop" pattern. The two groups were compared for age, gender, injuries, Injury Severity Score, Glasgow Coma Scale, length of stay, ventilator-free days, and mortality. The primary outcome was mortality.

RESULTS

A total of 139 patients were included (120 nonloop and 19 loop). Mean (standard deviation) age was 36.1 (11.2) y and 72.1% were male. Both groups were equivalent in age, gender, Injury Severity Score, and Glasgow Coma Scale. Traffic loop patients required longer intensive care unit length of stay, (median = 9.0, range: 1-49 d), ventilator days (median = 29.5), (range: 1-49 d) and experienced abdominal trauma (P = 0.002). Emergency medical services transport times during loop hours had shorter response times than the nonloop injury group (7.79 ± 5.2 min and 13.22 ± 14.01 min (P = 0.049). No deaths occurred during the city's scheduled traffic loop (0 versus 22, P = 0.0447).

CONCLUSIONS

Controlled traffic patterns during high-volume city gatherings can improve overall mortality and morbidity. Regional trauma system preparedness with field triage guidelines and coordinated trauma care is warranted to effectively care for the injured.

The effect of helmets on motorcycle outcomes in a level I trauma center in Connecticut

OBJECTIVE

The State of Connecticut has a partial motorcycle helmet law, which has been linked to one of the lowest helmet compliance rates in the Northeast. We examine the clinical and financial impact of low motorcycle helmet use in the State of Connecticut.

METHODS

A retrospective cohort study comparing the outcomes between helmeted and nonhelmeted motorcycle crash victims over a 12.5-year period, from July 2, 2002, to December 31, 2013. All patients who were admitted to the hospital after a motorcycle crash were included in the study. Patients were stratified into helmeted and nonhelmeted cohorts. Group differences were compared using t-test or Wilcoxon rank test for continuous variables and chi-square test for dichotomous outcomes. Regression models were created to evaluate predictors of helmet use, alcohol and drugs as confounding variables, and factors that influenced hospital costs.

RESULTS

The registry included 986 eligible patients. Of this group, 335 (34%) were helmeted and 651 (66%) were nonhelmeted. Overall, nonhelmeted patients had a worse clinical presentation, with lower Glasgow Coma Scale (GCS; P <.01), higher Injury Severity Score (ISS; P <.01), higher incidence of loss of consciousness (LOC; P <.01), longer intensive care unit (ICU; P <.01) admissions, and higher incidence of head (P <.01) or face injuries (P <.01). Nonhelmeted patients were also twice as more likely to die from their injuries (P =.04, odds ratio [OR] = 1.89, 95% confidence interval [CI], 1.02-3.45). Financially, nonhelmeted patients incurred mean hospital costs of $18,458, whereas helmeted patients incurred $14,970 (P =.18). ISS, GCS, and ICU length of stay were significantly correlated with increased hospital costs (P <.01). Not using a helmet was a significant predictor of mortality (P =.04) after adjusting for alcohol/drug use and age.

CONCLUSIONS

Helmet use is associated with lower injury severity and increased survival after a motorcycle crash. These outcomes remained consistent even after controlling for age and alcohol and drug use. The medical and financial impact of Connecticut's partial helmet law should be carefully evaluated to petition for increased education and enforcement of helmet use.

Motorcycle injury among secondary school students in the Tiko municipality, Cameroon

Introduction

Injury from motorcycle is a considerable cause of disability and death in the world and especially in low and middle-income countries; it is one of the most serious public health problems. In Cameroon, motorcycle is commonly used for transportation particularly among students. The aim of this paper is to study the risk-factors of the motorcycle-related accidents and injuries among secondary school students’ in the Tiko municipality, Cameroon.

Methods

A cross sectional study was conducted in January 2012 on 391 students age 16-24 from public and private schools in the Tiko Municipality. Logistic regression was used to estimate the association between risk factors and injuries. A closed-ended and few open-ended questionnaire was used to collect data.

Results

The study showed that over 70% of students used motorcycles always or often. Few had undergone any formal training for driving a motorcycle. The vast majority reported not wearing protective gear while driving or riding a motorcycle. Usage of protective gear was particularly low among girls. Over 16% reported using a motorbike always or occasionally under the influence of alcohol or drugs. Over 58% of respondents reported having an accident and over 35% were injured when driving or riding a motorcycle. Those who lived at the Tiko-Douala road have three times higher probability to sustain accidents and injuries than students residing elsewhere (OR 3.19 (1.20-8.46).

Conclusion

It is deeply alarming that every second respondent in the study reported having been in an accident and every third motorcycle user was somehow injured. We therefore call for an immediate attention and a deeper investigation into the highlighted situation, particularly at Tiko-Douala road.

Practical applications of injury surveillance: a brief 25-year history of the Connecticut Injury Prevention Center

BACKGROUND

The mission of the Connecticut Injury Prevention Center (CIPC), jointly housed in Connecticut Children's Medical Center and Hartford Hospital, is to reduce unintentional injury and violence among Connecticut residents, with a special focus on translating research into injury prevention programmes and policy. The CIPC engages in four core activities: research, education and training, community outreach programmes and public policy. As surveillance is an essential element of injury prevention, the CIPC has developed a robust statewide fatal and non-fatal injury surveillance system that has guided our prior work and continues to inform our current projects.

OBJECTIVE

The purpose of this article is to review the projects, programmes, and collaborative relationships that have made the CIPC successful in reducing unintentional injury and violence in Connecticut throughout the course of its 25 years history.

DESIGN, SETTING, PARTICIPANTS

Retrospective review of the application of injury surveillance.

RESULTS/CONCLUSIONS

We believe that the application of our surveillance system can serve as a model for others who wish to engage in collaborative, community-based, data-driven injury prevention programmes in their own communities.

Epidemiology and patterns of musculoskeletal motorcycle injuries in the USA

INTRODUCTION

Motorcycles have become an increasingly popular mode of transportation despite their association with a greater risk for injury compared with automobiles. Whereas the recent incidence of annual passenger vehicle fatalities in the United States of America (USA) has progressively declined, motorcycle fatalities have steadily increased in the past 11 years. Although motorcycle injuries (MIs) have been studied, to the author's knowledge there are no published reports on MIs in the USA during this 11-year period. Methods : Study data were derived from a prospectively collected Level I trauma center database. Data sampling included motorcycle crash injury evaluations for the 10-year period ending on 31 August 2008. This retrospective analysis included patient demographic and medical data, helmet use, Glasgow coma scale (GCS) score, injury severity score (ISS), length of hospital stay (LOS), specific injury diagnosis, and death. Data statistics were analyzed using the Spearman correlation coefficient, Kruskal-Wallis tests, and logistic regression.

RESULTS

The study identified 1252 motorcycle crash injuries. Helmets were worn by 40.7% of patients for which helmet data were available. The rates of the most common orthopedic injuries were tibia/fibula (19.01%), spine (16.21%), and forearm (10.14%) fractures. The most common non-orthopedic motorcycle crash injuries were concussions (21.09%), skull fractures (8.23%), face fractures (13.66%), and hemo- and pneumothorax (8.79%). There was a significant correlation between greater age and higher ISS (r=0.21, P<0.0001) and longer LOS (r=0.22, P<0.0001). Older patients were also less likely to wear a helmet (OR=0.99, 95% CI: 0.98, 0.997), associated with a significantly higher risk for death (after adjustment for helmet use OR=1.03, 95% CI: 1.00, 1.05). All patients without helmets had a significantly lower GCS score (P=0.0001) and a higher mortality rate (after adjustment for patient demographic data OR=2.28, 95% CI: 1.13, 4.58).  Conclusion : Compared with historical reports, the prevalence of skull, face, spine, and pelvis fractures have increased in American motorcycle crashes. Compared to recent European studies, the incidence of USA skull and face fractures is much higher, while the incidence of USA spine and pelvis fractures is more comparable; however, this is not associated with increased in-hospital mortality.

Modeling offenses among motorcyclists involved in crashes in Spain

In relative terms, Spanish motorcyclists are more likely to be involved in crashes than other drivers and this tendency is constantly increasing. The objective of this study is to identify the factors that are related to being an offender in motorcycle accidents. A binary logit model is used to differentiate between offender and non-offender motorcyclists. A motorcyclist was considered to be offender when s/he had committed at least one traffic offense at the moment previous to the crash. The analysis is based on the official accident database of the Spanish general directorate of traffic (DGT) for the 2003-2008 time period. A number of explanatory variables including motorcyclist characteristics and environmental factors have been evaluated. The results suggest that inexperienced, older females, not using helmets, absent-minded and non-fatigued riders are more likely to be offenders. Moreover, riding during the night, on weekends, for leisure purposes and along roads in perfect condition, mainly on curves, predict offenses among motorcyclists. The findings of this study are expected to be useful in developing traffic policy decisions in order to improve motorcyclist safety.

Motorcycle-related spinal injury: crash characteristics

This study presents an analysis of crash characteristics of motorcyclists who sustained spinal injuries in motorcycle crashes. The aim of the study is to identify the salient crash characteristics that would help explain spinal injury risks for motorcyclists. Data were retrospectively collected from police case reports that were archived at MIROS from year 2005 to 2007. The data were categorized into two subcategories; the first group was motorcycle crashes with spinal injury (case) and the second group was motorcycle crashes without spinal injury (control). A total of 363 motorcyclists with spinal injury and 873 motorcyclists without spinal injury were identified and analyzed. Descriptive analysis and multivariate analysis were performed in order to determine the odds of each characteristic in contributing to spinal injury. Single vehicle crash, collision with fixed objects and crash configuration were found to have significant influence on motorcyclists in sustaining spinal injury (p<0.05). Although relatively few than other impact configurations, the rear-end impacted motorcyclist shows the highest risk of spinal injury. Helmets have helped to reduce head injury but they did not seem to offer corresponding protection for the spine in the study. With a growing number of young motorcyclists, further efforts are needed to find effective measures to help reduce the crash incidents and severity of spinal injury. In sum, the study provides some insights on some vital crash characteristics associated with spinal injury that can be further investigated to determine the appropriate counter-measures and prevention strategies to reduce spinal injury.

Fatal accident distribution by age, gender and head injury, and death probability at accident scene in Mashhad, Iran, 2006-2009

Several studies have investigated road traffic deaths, but few have compared by road user type. Iran, with an estimated 44 road traffic deaths per 100,000 population in 2002 had higher road traffic deaths than any other country for which reliable estimates can be made. So, the present study was conducted on road death data and identified fatal accident distribution by age, gender and head injury as well as the influences of age and gender on deaths at accident scenes for all road user groups. Data used in this study are on fatal road accidents recorded by forensic medicine experts of the Khorasan Razavi province in Mashhad, the capital of the province, the second largest city and the largest place of pilgrimage, immigration and tourism in Iran. Chi-square test and odds ratio were used to identify the relation of death place with age and gender in 2495 fatal road accidents from 2006 to 2009. The t-test and analysis of variance were employed for continues variable, age, to compare males' and females' mean age for all road user categories. For two genders, all three groups of fatalities (pedestrian, motorcyclist and motor vehicle occupant) had a peak at the ages of 21-30. The youngest were male motorcyclists (mean age = 28). Old pedestrians were included in road deaths very much, too. Male/female overall ratio was 3.41 and the highest male/female ratio was related to motorcyclists (14). The overall ratio of head injury to other organ injuries (torso and underbody) was 2.51 and pedestrians had the largest amount of head injury (38.2%). Regarding death at accident scene, for all road users, gender did not have any significant relation with death at the scene (P-value > 0.1); on the contrary, age had significant relation (P-value < 0.05). Females were more vulnerable at accident scenes (male/female ratio at accident sense < 1). Pedestrians aged 21-30, motorcyclists 41-50 and motor vehicle occupants 31-40 died the most at accident scenes. Identifying the most endangered groups of road accident fatalities, which was conducted in this study, is invaluable for the appropriate design of prevention strategies and allocation of financial resources for each group of road user fatalities - since in developing nations, there are insufficient financial resources to traffic safety and we should consider superiorities, i.e. the most risky groups. Steps which may contribute to safety promotion for local conditions include suitable facilities for old pedestrians, a training course before obtaining motorcycle license for motorcyclists, informing young road users by provincial media about death risk of road users and improving management of the head-injured patients. Finally, suggestions for future researches were made.

Incidence of orthopedic surgery intervention in a level I urban trauma center with motorcycle trauma

BACKGROUND

This study summarizes orthopedic injuries sustained in motorcycle collisions in patients presenting to a Level I trauma center.

METHODS

We performed a retrospective review of orthopedic injuries in motorcycle trauma victims brought into the emergency department. Of 2,634 presenting cases, 151 were identified as involving motorcycle collisions. Variables included age, gender, mechanism of injury, type and location of injury, concomitant injuries, length of hospitalization, number of orthopedic procedures during primary admission, and subsequent readmission.

RESULTS

A total of 71.5% of patients required orthopedic consultation. Average age was 35.0 years, with men injured at a ratio of 8:1. The most common mechanism of injury was motorcycle versus automobile (n=48). A total of 206 fractures in 108 patients were discovered. The most common site of fracture involved the lower extremities. Open reduction with internal fixation was performed on 110 fractures (69 patients) during primary admission. Fifty-seven patients (52.8%) sustained open fractures requiring emergent orthopedic intervention. Fifty-three patients had various concomitant complications. Two patients died during initial hospitalization. Average hospitalization for patients without orthopedic consultation was 11.9 days versus 13.8 days with orthopedic consultation. The average number of orthopedic procedures performed on patients was 1.6.

CONCLUSIONS

Motorcycle collisions frequently involve patients in their working prime, thus placing substantial burden on the individual and society. Although these patients must continue to receive Level I trauma care, strengthened prevention and improved education efforts are warranted.

[Biometeorological influence on motorcyclists and bicyclists trauma]

INTRODUCTION

Biometeorological circumstances have great influence on all traffic participants, especially on reflexes, movement coordination and perception ability, increasing the number of accidents. Motocyclists and bicyclists are specific participants in traffic, so their traumatism has its own special characteristics.

OBJECTIVE

The aim of this study was to establish biometeorological influence on motorcyclists and bicyclists accidents.

METHODS

Comparative analysis of everyday biometeorological phases for the city of Kragujevac determinated by the Republic Hydrometeorological Service of Serbia and motorcyclists and bicyclists accident evidence received from Kragujevac traffic police for the period 2004-2008.

RESULTS

There were 5,180 traffic accidents in this period, with 180 accidents in which 77 motorcyclists and 116 bicyclists were knocked down. Most of the accidents were in 2008 (53) and the least in 2005 (28). Most accidents occurred during August (28) and between 19.00 and 20.00 hours (18). There were no accidents during January, between 04.00 and 06.00 hours. There were 85% accidents in the urban area. Most of 169 males were aged 16-20 and 21-25 years (20 and 21). Most of 24 females (6) were aged 11-15 years. Those who caused the accident mostly sustained injuries due to improper speed limit (31), while the victims due to the disrespect of street-crossing priorities (32). Forty-one motorcyclists and 85 bicyclists suffered mild body injuries. Thirty-one motorcyclists and 27 bicyclist suffered severe injuries. Five motorcyclists and four bicyclists ended lethally. Most accidents happened in biometeorological phases 9 (63), 4 (32) and 1 (31).

CONCLUSION

Statistical analysis showed a significant correlation between accidents and biometeorological phases, with most accidents occurring during stabile warm weather and rapid penetrations of cold fronts, and with a sudden switch of weather conditions.

Motorcycle-related injuries: effect of age on type and severity of injuries and mortality

BACKGROUND

The aim of this study was to evaluate the relationship of age to the injury types, distribution, and severity in motorcycle crash (MCC) victims admitted to Los Angeles County emergency hospitals in California.

METHODS

This Los Angeles countywide trauma registry study included all MCC victims admitted to the 13 trauma centers of the Los Angeles County between January 1995 and December 2007. Besides demographical data collected, the Injury Severity Score, body area (head, chest, abdomen, and extremities), Abbreviated Injury Scale score >or=3, specific organ injuries, and mortality were calculated according to age groups (<or=18 years, 19-55 years, and >55 years). A stepwise logistic regression model was used to identify independent risk factors for death.

RESULTS

Among 6,530 admissions due to MCCs, there were 493 patients (7.5%) aged 18 years or younger, 5,627 patients (86%) aged 19 years to 55 years, and 398 patients (6.5%) older than 55 years. The incidences of severe injury (Injury Severity Score >15) in the three ascending age groups were 23.5%, 30.3%, and 36.2%, respectively (p < 0.05), and critical injuries (Injury Severity Score >25) occurred in 6.5%, 12.3%, and 13.8%, respectively (p < 0.05). Severe head injuries were significantly more likely in the population older than 55 year (odds ratio [OR] {95% confidence interval [CI] } = 1.45 {1.03-2.03}, p = 0.04). The risk of sustaining a severe chest injury (Abbreviated Injury Scale Chest Score >or=3) increased in a stepwise fashion with increasing age, with an OR (95% CI) = 1.86 (1.44-2.39) in the age group 19 years to 55 years and 2.81 (2.03-3.88) in the older than 55 years group, p < 0.001. Mortality was twofold higher in the 19-year- to 55-year-old group [OR (95% CI) = 2.30 (1.08-4.93), p = 0.03] and threefold higher in the older than 55 years group [OR (95% CI) = 3.28 (1.36-7.93), p = 0.05] compared with the <or=18-year-old group.

CONCLUSIONS

Injuries related to MCCs show age-related injury distribution, severity, and mortality rates. Older patients are significantly more likely to suffer severe trauma, severe head and chest injuries, and spinal fractures. Adaptation of trauma team activation criteria and more aggressive triage of older victims of motorcycle trauma should be considered.

A review of risk factors and patterns of motorcycle injuries

Per vehicle mile traveled, motorcycle riders have a 34-fold higher risk of death in a crash than people driving other types of motor vehicles. While lower-extremity injuries most commonly occur in all motorcycle crashes, head injuries are most frequent in fatal crashes. Helmets and helmet use laws have been shown to be effective in reducing head injuries and deaths from motorcycle crashes. Alcohol is the major contributing factor to fatal crashes. Enforcement of legal limits on the blood alcohol concentration is effective in reducing motorcycle deaths, while some alcohol-related interventions such as a minimal legal drinking age, increased alcohol excise taxes, and responsible beverage service specifically for motorcycle riders have not been examined. Other modifiable protective or risk factors comprise inexperience and driver training, conspicuity and daytime headlight laws, motorcycle licensure and ownership, riding speed, and risk-taking behaviors. Features of motorcycle use and potentially effective prevention programs for motorcycle crash injuries in developing countries are discussed. Finally, recommendations for future motorcycle-injury research are made.

Methodological issues in motorcycle injury epidemiology

Motorcycle riders are over 30 times more likely than car occupants to die in a traffic crash. While this fact is well known, specific issues of methodology in epidemiological motorcycle-injury research have been rarely researched. To facilitate more-valid research on motorcycle injuries, this article evaluates the current state of our knowledge on how we measure the population at risk of injury, completeness of case finding and identification, validity of crash/injury data sources, and completeness of information on important exposures such as alcohol consumption, helmet status, crash severity, and crash speeds, as well as problems of existing injury severity scales and statistical analyses for correlated injury data.

Helmets for preventing injury in motorcycle riders

BACKGROUND

Motorcycle crash victims form a high proportion of those killed or injured in road traffic crashes. Injuries to the head, following motorcycle crashes, are a common cause of severe morbidity and mortality. It seems intuitive that helmets should protect against head injuries but it has been argued that motorcycle helmet use decreases rider vision and increases neck injuries. This review will collate the current available evidence on helmets and their impact on mortality, and head, face and neck injuries following motorcycle crashes.

OBJECTIVES

To assess the effects of wearing a motorcycle helmet in reducing mortality and head and neck injury following motorcycle crashes.

SEARCH STRATEGY

We searched the Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials (The Cochrane Library issue 2, 2007), MEDLINE (up to April 2007), EMBASE (up to April week 16, 2007), CINAHL (January 1982 to February 2003), TRANSPORT (up to issue 12, 2006) (TRANSPORT combines the following databases: Transportation Research Information Services (TRIS) International Transport Research Documentation (ITRD) formerly International Road Research Documentation (IRRD), ATRI (Australian Transport Index) (1976 to Feb 2003), Science Citation Index were searched for relevant articles. Websites of traffic and road safety research bodies including government agencies were also searched. Reference lists from topic reviews, identified studies and bibliographies were examined for relevant articles.

SELECTION CRITERIA

We considered studies that investigated a population of motorcycle riders who had crashed, examining helmet use as an intervention and with outcomes that included one or more of the following: death, head, neck or facial injury. We included any studies that compared an intervention and control group. Therefore the following study designs were included: randomised controlled trials, non-randomised controlled trials, cohort, case-control and cross-sectional studies. Ecological and case series studies were excluded.

DATA COLLECTION AND ANALYSIS

Two authors independently screened reference lists for eligible articles. Two authors independently assessed articles for inclusion criteria. Data were abstracted by two independent authors using a standard abstraction form.

MAIN RESULTS

Sixty-one observational studies were selected of varying quality. Despite methodological differences there was a remarkable consistency in results, particularly for death and head injury outcomes. Motorcycle helmets were found to reduce the risk of death and head injury in motorcyclists who crashed. From four higher quality studies helmets were estimated to reduce the risk of death by 42% (OR 0.58, 95% CI 0.50 to 0.68) and from six higher quality studies helmets were estimated to reduce the risk of head injury by 69% (OR 0.31, 95% CI 0.25 to 0.38). Insufficient evidence was found to estimate the effect of motorcycle helmets compared with no helmet on facial or neck injuries. However, studies of poorer quality suggest that helmets have no effect on the risk of neck injuries and are protective for facial injury. There was insufficient evidence to demonstrate whether differences in helmet type confer more or less advantage in injury reduction.

AUTHORS' CONCLUSIONS

Motorcycle helmets reduce the risk of death and head injury in motorcycle riders who crash. Further well-conducted research is required to determine the effects of helmets and different helmet types on mortality, head, neck and facial injuries. However, the findings suggest that global efforts to reduce road traffic injuries may be facilitated by increasing helmet use by motorcyclists.

Economic Impact of Motorcycle Helmets: From Impact to Discharge

BACKGROUND

The economic impact of helmet use remains controversial. Previous studies of injured motorcyclists suggest a marginal inpatient hospital cost difference between helmeted and unhelmeted riders. The purpose of this study was to expand the economic analysis of motorcycle helmet utilization to the point of injury by including motorcycle crash patients who do not require hospital admission.

METHODS

Prehospital motorcycle crash data were collected from the National Highway Transportation Safety Administration (NHTSA) General Estimates System (GES) database from 1994 to 2002 with respect to helmet use, injury severity, and transport to a hospital. A focused literature search yielded the hospital admission rates of helmeted and unhelmeted motorcyclists evaluated in the emergency department. The National Trauma Data Bank (NTDB) was queried from 1994 to 2002 to collect data including helmet use and hospital charges for injured motorcyclists. Cost analysis was performed by linkage of the queried databases and data from the literature. Statistical comparisons between groups were performed using an independent samples t test and chi analysis.

RESULTS

The NHTSA GES database yielded 5,328 sample patients. 1,854 patients (34.8%) were unhelmeted and 3,474 (65.2%) were helmeted. Transport to a hospital was required of 78.6% of unhelmeted and 73.3% of helmeted patients (p < 0.01). Of motorcyclists evaluated in the emergency department, 39.9% of unhelmeted and 32.8% of helmeted patients required hospital admission. NTDB analysis of injured motorcyclists from the concomitant interval yielded 9,033 patients in whom helmet use data were available and 5,343 patients for whom associated hospital cost data were available. Unhelmeted motorcyclists incurred charges of 39,390 dollars + 1,436 dollars per injury, whereas helmeted motorcyclists incurred charges of 36,334 dollars + 1,232 dollars per injury. Mathematical extrapolation derived a charge of 12,353 dollars per unhelmeted and 8,735 dollars per helmeted motorcyclist for every crash with a difference of 3,618 dollars between helmeted and unhelmeted riders involved in a motorcycle crash.

CONCLUSIONS

With a current estimate of 197,608 motorcycle crashes/year in which 69,163 riders were unhelmeted, the differential healthcare economic burden between unhelmeted and helmeted motorcyclists is approximately $250,231,734 per year and underscores the need for improved legislation to improve motorcycle helmet utilization.

Trends in Arkansas Motorcycle Trauma After Helmet Law Repeal

OBJECTIVES

This study aimed to assess the impact of the 1997 Arkansas helmet law repeal on motorcycle registrations, crash and fatality risks, and alcohol involvement in motorcycle crashes.

METHODS

Annual motorcycle registration data for the years 1990 through 2001 were obtained from the Arkansas Department of Finance and Administration. These motorcycle registration data were complemented by the motorcycle crash data from the Arkansas State Police Highway Safety Office and motorcycle fatality data for the state of Arkansas from the Fatality Analysis Reporting System. The impact of the repeal on crash rates, helmet usage, and alcohol involvement was assessed through comparisons of data from before (1993 to 1996) and after (1998 to 2001) the repeal.

RESULTS

After the repeal, an increase in motorcycle registrations correlated with a marked rise in the total number of crashes and fatalities; however, fatalities per crash remained virtually the same. The proportion of motorcycle fatalities that were not wearing a helmet increased from 47.0% (47/100) before the repeal to 78.2% (104/133) after the repeal (P = 0.001). The overall percentage of fatal motorcycle crashes involving alcohol use remained unchanged after the repeal (37.6% [29/77] to 38.5% [40/104], P = 0.91), but the percentage of fatal crashes involving drinking nonhelmeted drivers increased from 14.2% (11/77) to 33.6% (35/104) (P = 0.003). Inebriated motorcyclists killed in crashes were overwhelmingly non-helmeted (87.5%, 35/40) after the repeal, up from 37.9% (11/29) before the repeal (P < 0.001).

CONCLUSIONS

These findings suggest that the repeal of the mandatory helmet law in Arkansas has had a significant adverse effect on road safety.

No license required: severe pediatric motorbike-related injuries in Ohio

OBJECTIVE

Motorbikes (MBs), including motorcycles and dirt bikes, are becoming increasingly popular among children and adolescents. MBs are intended for off-road use. Although children who are younger than 16 years cannot be licensed to drive cars, they can drive MBs off-road without licenses. The objective of this study was to determine the epidemiology of severe MB injuries to children who are younger than 16 years in Ohio.

METHODS

Eight hospitals that admit the majority of pediatric trauma patients in Ohio were approached to participate. Cases were identified using hospital trauma registries and were defined as any hospitalized child who was younger than 16 years and sustained MB injuries between January 1, 1995, and December 31, 2001.

RESULTS

Six hospitals participated. A total of 182 children were hospitalized with a mean age of 11.4 years (range: <1-15 years). A total of 89.6% were male, 89.0% were white, 68.7% had commercial medical insurance, and 71.4% were from urban areas. From 1995 to 1997, there were an average of 20 annual admissions; however, from 1998 to 2001, there were an average of 30 per year. Of the 85% of patients with injury events documented, 35.5% were riding in streets and 53.3% were unhelmeted. One patient died; 8 required rehabilitation. The mean injury severity score was 9.9 (median: 9), and mean length of hospitalization was 4.6 days (median: 3). Unhelmeted riders had significantly higher injury severity scores than helmeted ones (11.5 vs 8.4). The difference in mean length of hospitalization of unhelmeted compared with helmeted riders approached statistical significance (6.1 vs 3.7 days). Of the 163 patients with documented diagnoses, there were 510 injuries; 68.7% of patients sustained multiple injuries. Of all injuries, the most commonly injured body parts were lower extremity (23.4%), head (22.2%), abdomen/pelvis (13.4%), upper extremity (12.4%), and face (11.8%). The most common injuries were fractures (37.1%), abrasions/contusions (24.4%), lacerations (13.4%), intracranial injuries (7.5%), and solid abdominal organ injuries (7.5%). Central and Southwest Ohio had higher numbers of hospitalized injuries than other areas.

CONCLUSION

Urban, white boys with commercial medical insurance predominated among children with MB-related injuries in Ohio. Most injured children did not wear a helmet and sustained multiple injuries. Not wearing a helmet resulted in significantly increased injury severity and a trend toward increased lengths of stay in the hospital. MB-related injuries increased by approximately 50% during the study period. Children should not operate MBs until they are old enough to obtain a motor vehicle driver's license, which occurs at a minimum of 16 years of age. High-risk populations need to be targeted to reduce these injuries, and requiring helmet use while operating MBs should be pursued.

Motorcycle-related hospitalizations in the United States, 2001

OBJECTIVES

To estimate the prevalence of motorcycle-related hospitalization in the United States in 2001 and to describe the demographic, clinical, hospital, and financial characteristics associated with these injuries.

METHODS

Cross-sectional analysis of the 2001 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project was conducted in 2003.

RESULTS

There were an estimated 30,505 (confidence interval=26,566-34,445) motorcycle-related hospital discharges in 2001. Approximately 62% of cases were aged > or =30 years, and males accounted for 89% of cases. The most common principal diagnoses were fractures of the lower limb (29.4%), fractures of the upper limb (13.1%), and intracranial injuries (12.3%). The mean length of stay was 5 days, the median hospital charge was $15,404, and the total estimated hospital charges were >$841 million. The majority of patients (56.5%) were admitted to large urban teaching hospitals, and these hospitals accounted for nearly 70% of all hospital charges. Approximately 26% of cases were self-pay or listed public insurance as the expected payer.

CONCLUSIONS

These findings shed light on the substantial morbidity and financial impact of motorcycle-related injuries. Renewed and strengthened prevention efforts are warranted.

Helmets for preventing injury in motorcycle riders

BACKGROUND

Motorcycle crash victims form a high proportion of those killed or injured in road traffic accidents. Injuries to the head, following motorcycle crashes, are a common cause of severe morbidity and mortality. It seems intuitive that helmets should protect against head injuries but it has been argued that motorcycle helmet use decreases rider vision and increases neck injuries. This review will collate the current available evidence on helmets and their impact on mortality, and head, face and neck injuries following motorcycle crashes.

OBJECTIVES

To quantify the effectiveness of wearing a motorcycle helmet in reducing mortality and head and neck injury following motorcycle crashes.

SEARCH STRATEGY

Databases including the Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials (The Cochrane Library issue 1, 2003), MEDLINE (January 1966 to February 2003), EMBASE (January 1985 to February 2003), CINAHL (January 1982 to February 2003), IRRD (International Road Research Documentation), TRANSDOC, TRIS (Transport Research Information Service), ATRI (Australian Transport Index) (1976 to Feb 2003), Science Citation Index were searched for relevant articles. Web sites of traffic and road accident research bodies including government agencies were also searched. Reference lists from topic reviews, identified studies and bibliographies were examined for relevant articles.

SELECTION CRITERIA

We considered for inclusion studies that investigated a population of motorcycle riders who had crashed, examining helmet use as an intervention and with outcomes that included one or more of the following: death, head, neck or facial injury. Studies included any that compared an intervention and control group and, therefore, included any randomised controlled trials, non-randomised controlled trials, cohort, case-control and cross-sectional studies. Ecological and case series studies were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently screened reference lists for eligible articles. Two reviewers independently assessed articles for inclusion criteria. Data were abstracted by two independent reviewers using a standard abstraction form.

MAIN RESULTS

Fifty-three observational studies were identified of varying quality. Despite methodological differences there was a remarkable consistency in results, particularly for mortality and head injury outcomes. Motorcycle helmets appear to reduce the risk of mortality although, due to heterogeneity in study design, an overall estimate of effect was not calculated. There was some evidence that the effect of helmets on mortality is modified by speed. Motorcycle helmets were found to reduce the risk of head injury and from five well-conducted studies the risk reduction is estimated to be 72% (OR 0.28, 95%CI 0.23, 0.35). Insufficient evidence was found to estimate the effect of motorcycle helmets compared with no helmet on facial or neck injuries. However, studies of poorer quality suggest that helmets have no effect on the risk of neck injuries and are protective for facial injury. There was insufficient evidence to demonstrate whether differences in helmet type confer more or less advantage in injury reduction.

REVIEWERS' CONCLUSIONS

Motorcycle helmets reduce the risk of mortality and head injury in motorcycle riders who crash, although the former effect may be modified by other crash factors such as speed. Further well-conducted research is required to determine the effects of helmets and different helmet types on mortality, head, neck and facial injuries. However, the findings suggest that global efforts to reduce road traffic injuries may be facilitated by increasing helmet use by motorcyclists.

A longitudinal study of risk factors for motorcycle crashes among junior college students in Taiwan

A cohort of 4729 junior college students in an urban and a rural area in Taiwan was followed up for a period of 20 months. Students' characteristics, including riding exposures, as well as human, vehicular, and environmental factors were collected using one initial and three follow-up questionnaires. The Anderson-Gill (AG) multiplicative intensity model was used to determine the risk of a motorcycle crash over time while also allowing for the modeling of multiple events. The average response rate for the four assessments was 92%. The adjusted relative hazard (RH) for students living in the rural as opposed to the urban area for crashes was 1.67 at the beginning of the study but decreased to 0.66 by the end. Past motorcycle crash history, number of riding days, average riding distance, risk-taking level, alcohol consumption, and traffic violations were all significantly associated with an increased risk of being involved in a crash. Conversely, increasing age, riding experience, and automobile licensure were related to a decreased risk of crashing. Furthermore, helmet use was not independently related to the risk of crashing. In conclusion, a high-risk group predisposed to involvement in a motorcycle crash, including both non-injury and injury-related crashes, can be identified using selected risk factors for crash prevention among young riders.

The negative impact of the repeal of the Arkansas motorcycle helmet law

BACKGROUND

On July 1, 1997, Arkansas became the first state in 14 years to repeal their adult helmet law. We examined the clinical and financial impact of this repeal.

METHODS

A 6-year retrospective review was conducted of the University of Arkansas for Medical Sciences trauma registry including the 3 years before and the 3 years after the repeal of the helmet law. A head and neck Abbreviated Injury Scale (AIS) score >or= 3 was considered severe. All patients admitted to the hospital or who died in the emergency department were included in the study. The database of the Arkansas Highway and Transportation Department was also used to determine the number of crashes and fatalities occurring statewide (1995-1999).

RESULTS

Although total and fatal crashes in Arkansas were not significantly different (1995-1996 vs. 1998-1999), nonhelmeted deaths at the scene of a crash significantly increased from 19 of 48 (39.6%) (1995-1996) to 40 of 53 (75.5%) (1998-1999) (p < 0.0001). Before repeal, 25% of nonfatal crash admissions were nonhelmeted (18 of 73). This significantly increased to 54% (52 of 96, p< 0.001) after repeal. Overall, patients who were nonhelmeted had significantly higher AIS scores for head and neck, significantly more severe head injuries (AIS score >or= 3), 47% (33 of 70) versus 20% (20 of 99), and significantly longer length of intensive care unit stay. Financially, patients without helmets had significantly higher unreimbursed charges compared with their helmeted counterparts, resulting in a total of 982,560 dollars of additional potentially lost revenue over the length of the study.

CONCLUSION

Repeal of the mandatory helmet law was associated with an increase in the nonhelmeted crash scene fatality rate. After the repeal, there was a disproportionately higher admission rate for nonhelmeted motorcycle crash survivors. These patients had an increased use of hospital resources and poorer reimbursement of charges compared with their helmeted counterparts. This resulted in significantly higher unreimbursed charges. States considering repeal of their mandatory adult helmet laws should consider the potential negative financial impact on their health care system and the increased morbidity associated with nonhelmeted motorcycle riders involved in a crash.

Hospital cost is reduced by motorcycle helmet use

BACKGROUND

The purpose of this study was to identify the impact of motorcycle helmet use on patient outcomes and cost of hospitalization, in a state with a mandatory helmet law.

METHODS

Patients admitted after motorcycle crashes from July 1996 to October 2000 were reviewed, including demographics, Injury Severity Score, length of stay, injuries, outcome, helmet use, hospital cost data, and insurance information. Statistical analysis was performed comparing helmeted to unhelmeted patients using analysis of variance, Student's test, and regression analysis.

RESULTS

We admitted 216 patients: 174 wore helmets and 42 did not. Injury Severity Score correlated with both length of stay and cost of hospitalization. Mortality was not significantly different in either group. Failure to wear a helmet significantly increased incidence of head injuries (Student's test, p < 0.02), but not other injuries. Helmet use decreased mean cost of hospitalization by more than $6,000 per patient.

CONCLUSION

Failure to wear a helmet adds to the financial burden created by motorcycle-related injuries. Therefore, individuals who do not wear helmets should pay higher insurance premiums.

Spinal injuries in motorcycle crashes: patterns and outcomes

BACKGROUND

The purpose of this study was to determine patterns of spinal injury and clinical outcomes resulting from motorcycle crashes.

METHODS

We analyzed data collected on 1,121 motorcyclists involved in road traffic accidents (from 1993-2000) and identified those who had sustained a spinal injury.

RESULTS

Spinal injury occurred in 126 (11.2%) riders (112 male riders [88.9%] and 14 female riders [11.1%]), with a mean age of 30.2 years (range, 16-61 years) and Injury Severity Score of 18.8 (range, 4-66). Isolated injuries to the spine occurred in 30 (23.8%) riders. The thoracic spine was injured in 69 (54.8%), the lumbar spine in 37 (29.4%), and the cervical spine in 34 (27.0%) cases. Multiple vertebral levels were affected in 54 (42.9%). Neurologic injury occurred in 25 riders (19.8%), with complete distal neurologic injury in 14 (4 cervical, 9 thoracic, and 1 lumbar). Eleven (8.7%) patients required spinal surgery. There were 13 (10.3%) deaths.

CONCLUSION

The thoracic spine is the most commonly injured spinal region in motorcycle crashes. Multiple level injuries are common. Protocols concentrating on the radiographic clearance of the cervical region may miss a significant number of spinal injuries. Vigilance is required in assessing these patients, who often have multiple injuries.

Evaluating Blunt Abdominal Trauma with Sonography: A Cost Analysis

Ultrasonography (US) is becoming increasingly utilized in the United States for the evaluation of blunt abdominal trauma (BAT). The objective of this study was to assess the cost impact of utilizing US in the evaluation of patients with BAT in a major trauma center. All patients sustaining BAT during a 6-month period before US was used at our institution (Jan–Jun 1993) were compared to BAT patients from a recent period in which US has been utilized (Jan–Jun 1995). The numbers of US, computed tomography (CT), and diagnostic peritoneal lavage (DPL) were tabulated for each group. Financial cost for each of these procedures as determined by our finance department were as follows: US $96, CT $494, DPL $137. These numbers are representative of actual hospital expenditures exclusive of physician fees as calculated in 1994 U.S. dollars. Cost analysis was performed with t test and chi squared test, and significance was defined as P < 0.05. There were 890 BAT admissions in the 1993 study period and 1033 admissions in the 1995 study period. During the 1993 period, 642 procedures were performed on the 890 patients to evaluate the

abdomen: 0 US, 466 CT, and 176 DPL (see table). This compares to 801 procedures on the 1033 patients in 1995: 552 US, 228 CT, and 21 DPL. Total cost was $254,316 for the 1993 group and $168,501 for the 1995 group. Extrapolated to a 1-year period, a significant ( P < 0.05) cost savings of $171,630 would be realized. Cost per patient evaluated was significantly reduced from $285.75 in 1993 to $163.12 in 1995 ( P < 0.05). This represents a 43 per cent reduction in per patient expenditure for evaluating the abdomen. By effectively utilizing ultrasonography in the evaluation of patients with blunt abdominal trauma, a significant cost savings can be realized. This effect results chiefly from an eight-fold reduction in the use of DPL, and a two-fold reduction in the use of CT.

Impact of a helmet law on two wheel motor vehicle crash mortality in a southern European urban area

BACKGROUND

In Spain, a federal road safety law went into effect in the fall of 1992 extending to urban areas the unrestricted use of safety helmets by all two wheel motor vehicle occupants.

OBJECTIVES

To assess the effect of the law in reducing fatal motorcycle crash injuries; to estimate the number of lives saved; and to determine changes in the distribution of severity and anatomical location of injuries.

METHODS

Pre-test/post-test design of all deaths of two wheel motor vehicle occupants from 1990-92 (pre-law period) and from 1993-95 (post-law period) detected by the Barcelona Forensic Institute and the city police department. Injuries were coded using the 1990 version of the abbreviated injury scale. Poisson regression methods were used to model trends in mortality ratios and to provide estimates of the number of lives saved.

RESULTS

Between 1993 and 1995, 35 lives of two wheel motor vehicle occupants were spared, representing a decrease of 25% in the observed motorcycle crash mortality in the post-law period when compared with what would be expected if no such law had gone into effect. The proportion of deaths with severe head injuries was also reduced from 76% to 67% in the post-law period.

CONCLUSIONS

This study offers the first evaluation of a helmet law using combined forensic and police data in a large south European urban area where there is widespread use of motorcycles. Our results confirm the effectiveness of the helmet law, as measured by the reduction in the number of deaths and mortality ratios after the law implementation. The findings reinforce the public health benefits of mandatory non-restricted motorcycle and moped helmet use, even in urban areas with lower traffic speeds.

Factors affecting motorcycle helmet use in the population of Greater Athens, Greece

OBJECTIVES

Helmet use is the best preventive measure available against two wheel motorized vehicle (TWMV) related head injuries. In some countries, however, helmets are used only by a minority of TWMV riders. In collaboration with the Road Traffic Police Department, an inspection survey was undertaken to assess the prevalence and to determine predictors of helmet use.

SETTING

The Greater Athens area, Greece, during July and August 1998.

METHODS

A total of 982 TWMVs were stopped, 349 of which had two riders (36%). All riders were interviewed by staff members of the Centre for Research and Prevention of Injuries among the Young.

RESULTS

The average prevalence of helmet use was 20.2%. It ranged from 9.7% on small suburban roads to 50.8% on highways. Prevalence of use was significantly lower during the weekend days and at night. Women were significantly more likely to wear a helmet and, controlling for gender, drivers were significantly more likely to be helmet users. Riders of more powerful TWMVs and passengers, who themselves had a TWMV driving license, were helmet users more frequently. Among non-users, the majority (46%) indicated that "the helmet made them feel uncomfortable", particularly in warm weather, whereas 18% claimed that there was little need for a helmet in low speed riding.

CONCLUSIONS

A multipronged campaign is urgently needed in Greece to increase the prevalence of helmet use by TWMV riders. The campaign should include not only police enforcement but also initiatives to make helmets more convenient to wear and less expensive.

Helmets, injuries and cultural definitions: motorcycle injury in urban Indonesia

This paper examines motorcycle helmet use and injuries in a developing country with a helmet law. Data were collected by systematic street observations and interviews with motorcyclists and supplemented with motorcycle injury data from a 1 month study of all patients coming to emergency departments in Yogyakarta, Indonesia. Observations show that 89% of motorcycle drivers (N = 9242) wore helmets; only 20% of the passengers (N = 3541) did. However, only 55% of the drivers wore helmets correctly (e.g. with chin strap buckled). Differences in time and place were noted in interviews when motorcyclists reported wearing helmets least at night and when no police were around; various reasons for not wearing helmets included physical discomfort and absence of police surveillance. Data from emergency departments found that motorcycles were involved in 64% of all traffic accident injuries, comprising 33% of total trauma patients presenting to emergency departments. Injury Severity Scores were calculated for the 26% of motorcycle injuries which were admitted to the hospital, with 60% having scores of 1-8, 27% 9-15, and 9% > 15. We conclude that although motorcycle drivers appear to comply with the motorcycle helmet law, it is a "token compliance." Less than 50% of riders were maximally protected by helmets and very little safety consciousness was found among drivers. Suggestions for improving helmet use that take cultural definitions of wearing helmets into account are presented for future research.

Motorcycle trauma in the state of Illinois: analysis of the Illinois Department of Public Health Trauma Registry

STUDY OBJECTIVE

To assess the current morbidity and mortality of motorcycle trauma in the state of Illinois and, specifically, to assess the incidence and cost of head injury to motorcycle crash patients according to their helmet use.

DESIGN

Retrospective, cross-sectional examination of the Illinois Department of Public Health Trauma Registry, for which data are available from July 1, 1991, through December 31, 1992. Data are collected from all hospitals designated as Level I or Level II trauma centers in Illinois.

PARTICIPANTS

All patients involved in motorcycle crashes and subsequently taken to a Level I or Level II trauma center in Illinois and entered into the trauma registry during the period studied.

RESULTS

Head injury, spinal injury, helmet use, demographic data, hospital charges, days in ICU, and source of payment were selected as outcome measures. During the 18-month study period, 1,231 motorcycle trauma patients were entered into the trauma registry. Eighteen percent were helmeted and 56.0% were nonhelmeted. In 26.0% the helmet status at the time of the crash was unknown. Thirty percent of the helmeted patients sustained head injury and 4% sustained spinal or vertebral injury, compared with 51% and 8%, respectively, for nonhelmeted patients. Nonhelmeted patients were significantly more likely to sustain severe (Abbreviated Injury Score [AIS], 3 or more) or critical (AIS, 5 or more) head injury. Patients with these serious head injuries incurred almost three times the hospital charges and used a disproportionately larger share of ICU days than those with mild or no head injuries. There was a trend toward greater use of public funds or self-pay status (no insurance) for payment of hospital charges in nonhelmeted patients.

CONCLUSION

Motorcycle helmet nonuse was associated with an increased incidence of serious head injury. Motorcycle trauma patients with severe or critical head injuries used a significantly greater proportion of ICU days and hospital charges than those with mild or no head injuries.

Relationship of helmet use and head injuries among motorcycle crash victims in El Paso County, Colorado, 1989-1990

A case-control study was conducted in El Paso County, Colorado to estimate differences in risk of head injury among persons in motorcycle crashes who were or were not wearing helmets. There were 71 cases, motorcyclists with head injuries from crashes, and 417 controls, motorcyclists in crashes without head injuries. Motorcyclists not wearing helmets were 2.4 times as likely to sustain head injuries (95% confidence limits: 1.23, 4.70) than motorcyclists wearing helmets. This odds ratio was adjusted for age and crash characteristics, using logistic regression. Alcohol intoxication and severity of motorcycle damage were also associated with significantly elevated odds ratios related to sustaining a head injury.

Accuracy of fatal motorcycle-injury reporting on death certificates

This study identifies differences in motorcycle injury fatality statistics gathered from different sources. Police Accidents Reports (PARs), identifying fatal motorcycle injuries occurring in Connecticut during 1987 were matched with state death certificates. Matched death certificates were analyzed in three major areas: content, coding, and motorcycle fatality reporting. Death certificates underreported motorcycle fatalities by 38% compared to PARs. Forty percent of death certificates were missing some or all of the required information: 7 did not include the word motorcycle, 18 did not contain acceptable ICD-9 terminology for a motorcyclist, and 17 did not describe how the injury occurred. Forty-one percent of death certificates contained external cause of injury code (E-code) errors. Incomplete information on death certificates was responsible for 52% of inaccurate reporting and E-code errors for 48%. The accuracy of fatal motorcycle injury cause of death reporting on death certificates could be improved by better physician training and rapid implementation of both the computerized death certificate coding systems and upcoming ICD-10 classification system.

A cost-benefit analysis of legislation for bicycle safety helmets in Israel

Legislation requiring bicyclists to wear helmets in Israel will, over a helmet's 5-year duration (assuming 85% compliancy, 83.2% helmet efficiency for morbidity, and 70% helmet efficiency for mortality), save approximately 57 lives and result in approximately 2544 fewer hospitalizations; 13,355 and 26,634 fewer emergency room and ambulatory visits, respectively; and 832 and 115 fewer short-term and long-term rehabilitation cases, respectively. Total benefits ($60.7 million) from reductions in health service use ($44.2 million), work absences ($7.5 million), and mortality ($8.9 million) would exceed program costs ($20.1 million), resulting in a benefit-cost ratio of 3.01:1.