Helmet use and bicycle-related trauma injury outcomes

Factors affecting the intention to wear helmets for e-bike riders: the case of Chinese college students

As the popularity of electric bicycles (e-bikes) continues to surge, the number of accidents involving them has commensurately increased. A significant factor contributing to the high fatality rate in these accidents is the low usage of helmets among e-bike riders. Helmets have been proven to reduce the severity of injuries, yet their usage remains unexpectedly low. This issue is particularly pronounced among college students, the primary buyer group for e-bikes. Regrettably, there is a lack of research exploring their intentions to wear helmets. Understanding determinants of their intentions to wear helmets is crucial in promoting safe e-bike travel. Therefore, the present study aims to develop an integrated theoretical model that combines the Theory of Planned Behavior (TPB) and the Health Belief Model (HBM) to examine the factors influencing e-bike riders' helmet-wearing intentions among college students. Additionally, two variables-descriptive norms and law enforcement-are incorporated. The results indicate that the integrated model accounts for 76% of the variance in helmet-wearing intention, surpassing single-theory models. Specifically, the TPB accounts for 65%, while the HBM explains 53%. Notably, law enforcement emerges as the most influential factor, highlighting the crucial role of enforcing regulations and promoting awareness. Other significant factors include subjective and descriptive norms, attitudes, perceived benefits, perceived susceptibility, perceived barriers, and perceived severity. These findings provide valuable insights for policy development and targeted interventions aimed at improving helmet wear rates among e-bike riders, especially among the college student population.

Cranio-cervical and traumatic brain injury patterns-do they differ between electric bicycle, bicycle, and motorcycle-induced accidents?

PURPOSE

With the growing technical options of power transmission and energy-saving options in electric drives, the number of E-bike-related accidents especially in an elderly population has increased. The aim of the current study was to compare if the increased velocity in comparison to conventional bikes translates into different injury patterns in the cranio-cervical and head region.

METHODS

A retrospective cohort study was performed in patients admitted to our level one trauma center between 2009 and 2019 after being involved in an accident with either an E-bike, bicycle, or motorcycle and suffered cranio-cervical or traumatic brain injury.

OUTCOMES

cranio-cervical/intracranial injury pattern. Data interpretation was conducted in an interdisciplinary approach.

RESULTS

From 3292 patients treated in this period, we included 1068 patients. E-bikers were significantly older than bicyclists (or motorcyclists) and lay between the other two groups in terms of helmet use. Overall injury patterns of E-bikers resembled those found in motorcyclists rather than in bicyclists. E-bikers had a higher incidence of different cerebral bleedings, especially if no helmet was worn. Helmet protection of E-bikers resulted in a comparable frequency of intracranial bleeding to the helmeted bicyclists.

CONCLUSION

The overall pattern of head and cervical injuries in E-bikers resembles more to that of motorcyclists than that of bicyclists. As they are used by a more senior population, multiple risk factors apply in terms of complications and secondary intracranial bleeding. Our study suggests that preventive measures should be reinforced, i.e., use of helmets to prevent from intracranial injury.

Social Disparities in Helmet Usage in Bicycle Accidents Involving Children

Background Bicycle helmet use has a known protective health benefit; yet, pediatric populations have suboptimal helmet rates, which increases the risk of severe injuries. It is imperative to have an updated assessment of behavioral social disparities and for providers to be aware of them to better counsel patients. The study objective was to identify social determinants correlated with helmet use in children involved in bicycle accidents. Based on previous literature, we hypothesized that higher socioeconomic status, female sex, and Caucasian race were associated with increased helmet use. Methods A retrospective case series of 140 pediatric cases of bicycle-related traumas assessing helmet status. Participants presented to the emergency room with injuries due to a bicycle-related trauma and were subsequently admitted to the University of North Carolina (UNC) Hospital System in Chapel Hill, North Carolina (NC), from June 2006 to May 2020. The Institutional Review Board (IRB) approved study comprised a retrospective chart review of 140 cases from the pediatric (<18 years of age) trauma database with coding indicating bicycle-related injury. Zip codes were used to approximate the median household income utilizing the Proximity One government database. The primary exposure was helmet status, which was determined from the electronic record chart review. The hypothesis was formulated before the start of the study. The main outcomes measured in the study included age, sex, race, helmet status, zip code, insurance status, injury types, and mortality. Results There were a total of 140 study participants, of which 35 were female and 105 were male. Males comprised 79.6% of the non-helmeted group, while females were in the minority in both helmet status groups, with 65.7% still being non-helmeted. Additionally, 51.9% of patients who were helmeted used private insurance, and 59.3% of those non-helmeted used public insurance. Of the 71 head injuries, 88.7% were non-helmeted. Principally, this study found that 80.7% of children involved in a bicycle-related accident were not helmeted.  Conclusions Despite NC legislation mandating that children under 16 years of age wear helmets while operating bicycles, many children injured in bicycle-related trauma are not complying with this requirement. This study demonstrates that specific populations have decreased rates of helmet usage and emphasize the continued need to monitor helmet behaviors.

Predictors of Mortality in Bicycle-Related Trauma: An Eight-Year Experience in a Level One Trauma Center

Background: Bicycle-related trauma has increased during the last decades, mainly due to the antipollution environmental policies. This study investigates the outcome of bicycle-related trauma in our level-one trauma center over a period of eight years. Methods: Data from 446 consecutive bicycle-related trauma patients admitted to our trauma center from 2011 to 2019 were selected and retrospectively analyzed. The sample was divided into three age groups: <18 years, 18−54 years, and ≥55 years. Mortality rates were obtained for the overall population and patients with an Injury Severity Score (ISS) ≥ 25. Month and seasonal patients’ distribution was described to provide an epidemiological overview of bike-related trauma over the years. Results: Patients ≥ 55 years showed a lower pre-hospital and in-hospital GCS (p ≤ 0.001), higher levels of lactates (p < 0.019) and higher ISS (p ≤ 0.001), probability of death (p ≤ 0.001), and overall mortality (p ≤ 0.001). The head and chest Abbreviated Injury Scale (AIS) ≥ 3 injuries were predictors of mortality, especially in patients over 55 years (p < 0.010). Bicycle-related trauma was more frequent during the summer (34%), particularly in July and August. Conclusions: Age over 55 years old, head and chest injuries, and an ISS > 25 were independent predictors of mortality.

Bicyclists injured by automobiles: helmet use and the burden of injury

Background

Given the widespread use of bicycles on public roadways, bicyclists injured in automobile collisions present a familiar problem to trauma centers worldwide. The aims of this study are to characterize the current injury patterns and to quantify independent risk factors for preventable injury and death, with a focus on helmet utilization and traumatic brain injuries.

Methods

This is a retrospective study using the American College of Surgeons Trauma Quality Improvement Program database for the period 2010 to 2016. Data were abstracted for bicyclists ≥16 years of age injured by an automobile. The primary outcome of interest was mortality. The secondary outcomes included intracranial, facial, and cervical spine injuries, as well as polytrauma. We used multivariate logistic regression to identify risk factors associated with outcomes.

Results

Of the 980 955 cases in the database, 7159 (0.73%) were bicyclists involved in a collision with an automobile. The median age was 45 years and 85% of patients were male. Polytraumatic occurrences accounted for 58% of injuries. Helmet use was reported in 25.4% of cases, a rate that did not change significantly during the study period. Helmet utilization was higher in those aged >65 years and in patients located in the West and Northeast regions of the USA. Helmet use was associated with an overall lower incidence of all reported forms of intracranial injuries. Overall mortality was 7.4%. Independent risk factors associated with mortality included age >65, lack of helmet use, head injury, and abdominal injury.

Discussion

Bicyclists injured in collisions with an automobile are at high risk of severe injury and mortality. Preventive strategies should target older bicyclists, helmet utilization, and increasing helmet accessibility for all bicyclists using roadways.

Level of evidence

Level IV.

Bike Helmet Usage in the Most Disadvantaged Neighborhoods: A Focused Area for Trauma Prevention

INTRODUCTION

There is a paucity of data to describe how neighborhood socioeconomic disadvantage (NSD) correlates with childhood injuries and outcomes. This study assesses the relationship of NSD to bicycle safety and trauma outcomes among pediatric bicycle versus automobile injuries.

METHODS

Between 2008 and 2018, patients ≤18 y old with bicycle versus automobile injuries from a Level I pediatric trauma center were evaluated. Area Deprivation Index (ADI) was used to measure NSD. Patient demographics, injury, clinical data characteristics, and bike safety were analyzed. Traffic scene data from the Statewide Integrated Traffic Records System were matched to clinical records. Multivariate logistic regression was used to assess demographic characteristics related to helmet usage.

RESULTS

Among 321 patients, 84% were male with a median age of 12 y [interquartile range 9-13], and 44% were of Hispanic ethnicity. Hispanic ethnicity was greater in the most disadvantaged ADI groups (P < 0.001). Mortality occurred in two patients, and most (96%) were discharged home. Of Statewide Integrated Traffic Records System matched traffic records, 81% were at locations without a bike lane. No differences were found in GCS, intensive care unit admission, or length of stay by ADI. Hispanic ethnicity and the highest deprivation group were independently associated with lower odds of wearing a helmet (AOR 0.35, 95% confidence interval 0.1-0.9, P = 0.03; AOR 0.33 95% confidence interval 0.17-0.62; P = 0.001), while patient age and sex were unrelated to helmet usage.

CONCLUSIONS

Outcomes for bike versus auto trauma remains similar across ADI groups. However, bike helmet usage is significantly lower among Hispanic children and those from neighborhoods with greater socioeconomic disadvantage.

Evaluation of two rotational helmet technologies to decrease peak rotational acceleration in cycling helmets

The risk of brain trauma has been associated with the rotational kinematics leading to the development of helmets with a variety rotational management technologies. The purpose of this paper was to employ a rotation specific test protocol to evaluate the effectiveness of two of these technologies. Dynamic response of the head was measured to assess the performance of each technology. Three cycling helmets with identical construction were included in this study. One helmet with no rotational technology, an established, commercial technology and a novel helmet rotational technology designed and assembled by the authors were tested. A drop test onto a 45° anvil was used to measure the ability of each helmet to manage the dynamic response of the head form during a series of impacts. The results revealed both rotational helmet technologies resulted in lower peak rotational acceleration and brain strain, however each technology demonstrated unique performance characteristics depending on the impact condition.

Analyzing pediatric bicycle injuries using geo-demographic data

PURPOSE

Bicycle accidents are potentially preventable, and helmets can mitigate the severity of injuries. The purpose of the study it to investigate geo-demographic areas to establish prevention policies and targeted programs.

METHODS

From October 2013 to March 2020 all bicycle injuries at a Level 1 trauma center were collected for ages ≤18 years. Demographics, injuries, and outcomes were analyzed. Incidents were aggregated to zip codes and the Local Indicators of Spatial Association (LISA) statistic was used to test for spatial clustering of injury rates per 10,000 children.

RESULTS

Over the 8-year time period, 77 cases were identified with an average age of 13±4 years, 83% male and 48% non-Hispanic white. The majority of patients (98%) were not wearing a helmet. Loss of consciousness was reported in 44% and 21% sustained a traumatic brain injury. Twenty-eight percent required ICU care and 36% required operative interventions. There was only 1 mortality in the cohort (<1%).Injuries were more common in lower household income zip codes (Figure 1). Six zip codes encompassing several interstate exits and the connected heavy-traffic roadways comprise a statistically significant cluster of pediatric bicycle accidents (Figure 1).

CONCLUSION

Low-income neighborhoods and those near major roadways held the highest risk for pediatric bicycle accidents. Use of helmets was extremely low in the patient population, with high rates of traumatic brain injury. With this information, targeted programs to address high-risk intersections, helmet access, and safety education can be implemented locally.

Cycling-Related Injuries During COVID-19 Lockdown: A North London Experience

Objectives

There has been a notable surge in cycling injuries during the COVID-19(SARS-CoV-2 virus) pandemic. Cycling in general increased during lockdown as a leisure & fitness activity along with reduction in the use of public transport for commuting. We investigated the bicycle-related maxillofacial injuries & associations presenting through our emergency department(ED) which covers more than 1.6 million of London population.

Study Design/Methods

A retrospective observational study was undertaken in the Barnet General Hospital ("hub") which receives all maxillofacial referrals from 6 "spoke" hospitals & other urgent primary/community care practices in North London area between 16 March 2020 & 16 July 2020. All data corresponding to cycling injuries during the lockdown period was analyzed with the aid of trauma database/trust-wide electronic patient records.

Results

Twenty-two patients (6.7%) with cycling-related injuries out of a total of 322 patients who attended during the 4 months study period with maxillofacial emergencies were identified. Average age of patient cohort was 35.4 years, mainly consisting of adult males (77%). Seven patients had minor head injury and 1 patient suffered traumatic brain injury. About 59% patients did not wear a protective helmet & 3 patients had heavy alcohol/recreational drug intoxication during the accidents. Four patients needed inpatient admission and treatment under general anesthesia.

Conclusions

Based on our humble study, we advocate the need for robust road & personal safety measures with mandatory government legislations, policing of drug intoxication & encouragement of physical & mental health improvement measures during these unprecedented times & beyond.

Helmets Protect Pediatric Bicyclists From Head Injury and Do Not Increase Risk of Cervical Spine Injury

OBJECTIVES

Only 21 states have mandatory helmet laws for pediatric bicyclists. This study sought to determine the incidence of helmeted riders among pediatric bicyclists involved in a collision and hypothesized the risk of a serious head and cervical spine injuries to be higher in nonhelmeted bicyclists (NHBs) compared with helmeted bicyclists (HBs).

METHODS

The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for pediatric (age <16 years) bicyclists involved in a collision. Helmeted bicyclists were compared with NHBs. A serious injury was defined by an abbreviated injury scale grade of greater than 2.

RESULTS

From 3693 bicyclists, 3039 (82.3%) were NHBs. Compared with HBs, NHBs were more often Black (21.6% vs 3.8%, P < 0.001), Hispanic (17.5% vs 9.3%, P < 0.001), without insurance (4.6% vs 2.4%, P = 0.012), and had a higher rate of a serious head injury (24.6% vs 9.3%, P < 0.001). Both groups had similar rates of complications and mortality (P > 0.05). The associated risk of a serious head (odds ratio = 3.17, P < 0.001) and spine injury (odds ratio = 0.41, P = 0.012) were higher and lower respectively in NHBs. Associated risks for cervical spine fracture or cord injury were similar (P > 0.05).

CONCLUSIONS

Pediatric bicyclists involved in a collision infrequently wear helmets, and NHBs was associated with higher risks of serious head injury. However, the associated risk of serious spine injury among NHBs was lower. The associated risks for cervical spine fracture or cervical cord injuries were similar. Nonhelmeted bicyclists were more likely to lack insurance and to be Black or Hispanic. Targeted outreach programs may help decrease the risk of injury, especially in at-risk demographics.

Head protection in electric micromobility: A critical review, recommendations, and future trends

Traffic jams are a burden in urban areas, being time-consuming and contributing to stressful driving and CO₂ emissions. To implement the United Nations' 2030 agenda for sustainable development, governmental strategies aim to accelerate the shift to sustainable and smart mobility. Consequently, e-micromobility (EMM) appeared as a practical solution for short-distance commuters, and it is growing at upsetting rates thanks to the introduction of sharing services. In fact, urban mobility has drastically changed over the last decade, and electric mobility and micromobility changed the panorama in larger metropolises, given their accessibility, large availability, and the potential to be a time saver in short trips and a potentially sustainable alternative in particular scenarios. The downside of portable e-transportation is the rapid increase in injuries and fatalities. Focusing on standing e-scooters, head injuries are becoming one of the most common as shown by research conducted in different urban emergency departments, alongside bone fractures, skin abrasions, and lacerations. In this work, a comprehensive review is carried out focusing on head protection for EMM, mostly for e-scooters, and the respective target markets, safety measures, and existing regulations. In the end, a critical assessment is given with recommendations for legislators and future research. Users are mostly males from 18 to 40 years old, upper-to-middle income, with elevated levels of educational attainment. Their motivation to use e-scooters is mainly to replace short walking trips. EMM, in particular e-scooters, will continue to grow thanks to its potential to substitute other micromobility alternatives. The evolution of safety measures and regulations did not keep pace with such a drastic change in mobility trends. This is evident considering how some countries are struggling with vehicle categories and regulations for helmet use and testing. The lack of legal obligation to wear a helmet and the absence of an adequate and feasible concept of protective equipment for sharing services are the main barriers to helmet use among riders. Mitigation measures have been implemented by the EMM sharing companies to improve the safety of its users by checking if they wear helmets and by offering vehicle-integrated solutions.

An Overview of the Effectiveness of Bicycle Helmet Designs in Impact Testing

Cycling accidents are the leading cause of sports-related head injuries in the US. Conventional bicycle helmets typically consist of polycarbonate shell over Expanded Polystyrene (EPS) foam and are tested with drop tests to evaluate a helmet’s ability to reduce head kinematics. Within the last decade, novel helmet technologies have been proposed to mitigate brain injuries during bicycle accidents, which necessitates the evaluation of their effectiveness in impact testing as compared to conventional helmets. In this paper, we reviewed the literature to collect and analyze the kinematic data of drop test experiments carried out on helmets with different technologies. In order to provide a fair comparison across different types of tests, we clustered the datasets with respect to their normal impact velocities, impact angular momentum, and the type of neck apparatus. When we analyzed the data based on impact velocity and angular momentum clusters, we found that the bicycle helmets that used rotation damping based technology, namely MIPS, had significantly lower peak rotational acceleration (PRA) and Generalized Acceleration Model for Brain Injury Threshold (GAMBIT) as compared to the conventional EPS liner helmets (p < 0.01). SPIN helmets had a superior performance in PRA compared to conventional helmets (p < 0.05) in the impact angular momentum clustered group, but not in the impact-velocity clustered comparisons. We also analyzed other recently developed helmets that primarily use collapsible structures in their liners, such as WaveCel and Koroyd. In both of the impact velocity and angular momentum groups, helmets based on the WaveCel technology had significantly lower peak linear acceleration (PLA), PRA, and GAMBIT at low impact velocities as compared to the conventional helmets, respectively (p < 0.05). The protective gear with the airbag technology, namely Hövding, also performed significantly better compared to the conventional helmets in the analyzed kinematic-based injury metrics (p < 0.001), possibly due to its advantage in helmet size and stiffness. We also observed that the differences in the kinematic datasets strongly depend on the type of neck apparatus. Our findings highlight the importance and benefits of developing new technologies and impact testing standards for bicycle helmet designs for better prevention of traumatic brain injury (TBI).

Analysis of Bicycle-Motor Vehicle Crashes in San Antonio, Texas

Bicycling is inexpensive, environmentally friendly, and healthful; however, bicyclist safety is a rising concern. This study investigates bicycle crash-related key variables that might substantially differ in terms of the party at fault and bicycle facility presence. Employing 5 year (2014-2018) data from the Texas Crash Record and Information System database, the effect of these variables on bicyclist injury severity was assessed for San Antonio, Texas, using bivariate analysis and binary logistic regression. Severe injury risk based on the party at fault and bicycle facility presence varied significantly for different crash-related variables. The strongest predictors of severe bicycle injury include bicyclist age and ethnicity, lighting condition, road class, time of occurrence, and period of week. Driver inattention and disregard of stop sign/light were the primary contributing factors to bicycle-vehicle crashes. Crash density heatmap and hotspot analyses were used to identify high-risk locations. The downtown area experienced the highest crash density, while severity hotspots were located at intersections outside of the downtown area. This study recommends the introduction of more dedicated/protected bicycle lanes, separation of bicycle lanes from the roadway, mandatory helmet use ordinance, reduction in speed limit, prioritization of resources at high-risk locations, and implementation of bike-activated signal detection at signalized intersections.

What to expect? Injury patterns of Electric-Scooter accidents over a period of one year - A prospective monocentric study at a Level 1 Trauma Center

Purpose

E-scooters are a new type of urban transportation utilized in Germany since June 2019, primarily in larger cities in the context of sharing offers. Such electrically operated standing scooters can be driven at a maximum speed of 20 km/h. A helmet is not mandatory. The aim of this prospective study is to document the injury patterns over the period of 1 year and compare our findings with already available data.

Methods

Over a period of 1 year (July 2019–July 2020), data on E-scooter-related accidents treated at a level 1 trauma center of a major German city were prospectively documented. Injury patterns were analyzed, and epidemiological data evaluated.

Results

Fifty-nine (35 female, 24 male) accidents were included in the observation period. Mean age of accident victims was 30.03 years (± 9.32). Alcohol influence at the time of accident was detected in 9 cases (15.25%). Many of the accident victims suffered multiple injuries. Most of the injuries were upper (50.84%) and lower extremity (47.45%) as well as craniofacial injuries (62.71%). A helmet was not worn in any of the cases.

Conclusion

In the year following their introduction, E-scooter-related accidents have led to an additional burden on the emergency capacities of the involved University Hospital, especially in the summer months of 2019. Protective equipment is de facto not worn. Injuries to the extremities, head, and face were most common. None of the accident victims died. This coincides with results from other major cities in national and international comparison. A more intensive education about injury consequences of unprotected E-scooter use and the discussion of a possible obligation to wear a helmet and further protection equipment for the extremities should take place.

Sex-based differences in helmet performance in bicycle trauma

OBJECTIVES

To determine the existence of sex-based differences in the protective effects of helmets against common injuries in bicycle trauma.

METHODS

In a retrospective cohort study, we identified patients 18 years or older in the 2017 National Trauma Database presenting after bicycle crash. Sex-disaggregated and sex-combined multivariable logistic regression models were calculated for short-term outcomes that included age, involvement with motor vehicle collision, anticoagulant use, bleeding disorder and helmet use. The sex-combined model included an interaction term for sex and helmet use. The resulting exponentiated model parameter yields an adjusted OR ratio of the effects of helmet use for females compared with males.

RESULTS

In total, 18 604 patients of average age 48.1 were identified, and 18% were female. Helmet use was greater in females than males (48.0% vs 34.2%, p<0.001). Compared with helmeted males, helmeted females had greater rates of serious head injury (37.7% vs 29.9%, p<0.001) despite less injury overall. In sex-disaggregated models, helmet use reduced odds of intracranial haemorrhage and death in males (p<0.001) but not females. In sex-combined models, helmets conferred to females significantly less odds reduction for severe head injury (p=0.002), intracranial bleeding (p<0.001), skull fractures (p=0.001), cranial surgery (p=0.006) and death (p=0.017). There was no difference for cervical spine fracture.

CONCLUSIONS

Bicycle helmets may offer less protection to females compared with males. The cause of this sex or gender-based difference is uncertain, but there may be intrinsic incompatibility between available helmets and female anatomy and/or sex disparity in helmet testing standards.

Characteristics and Injury Patterns in Electric-Scooter Related Accidents-A Prospective Two-Center Report from Germany

Since the introduction of rental E-scooters in Germany in mid-June 2019, the safety of this new means of transport has been the subject of extensive public debate. However, valid data on injuries and usage habits are not yet available. This retrospective two-center study included a total of 76 patients who presented to the emergency department following E-scooter-related accidents. The mean age was 34.3 ± 12.4 years and 69.7% of the patients were male. About half of the patients were admitted by ambulance (42.1%). Fractures were found in 48.6% of patients, and 27.6% required surgical treatment due to a fracture. The upper extremities were the most commonly affected body region, followed by injuries to the lower extremity and to the head and face. Only one patient had worn a helmet. In-hospital treatment was necessary for 26.3% of the cases. Patients presented to the emergency department mainly during the weekend and on-call times. This is the first report on E-scooter-related injuries in Germany. Accidents with E-scooters can cause serious injuries and, therefore, represent a further burden to emergency departments. The use of E-scooters appears to be mostly recreational, and the rate of use of protective gear is low.