Pattern of maxillofacial and associated injuries in road traffic accidents

Epidemiology of maxillofacial injuries in "Heratsi" No 1 university hospital in Yerevan, Armenia: a retrospective study

Background

The aim of this study was to perform a retrospective analysis of the prevalence, etiologies, types of maxillofacial injuries (MFIs), sites of maxillofacial fractures (MFFs) and their management in Yerevan, Armenia.

Methods

A retrospective cross-sectional study was conducted. The extracted data included age, sex, date of referral, mode of injury, etiology, radiology records and treatment methods. Study outcomes were measured using percentages, means, standard deviations and tests of proportions. P < .05 was considered significant.

Results

A total of 204 patients had a mean age of 36.26 ± 1.08 years (156 males and 48 females), and a total of 259 MFIs were recorded between 2017 and 2020. Interpersonal violence was found to be the most common etiology of MFFs in this study (42.1%), followed by road traffic accidents (RTAs) (27.9%) and falls (18.6%). The nasal bone was the most common injury site (47.5%), followed by the mandible (31.4%) and zygomatic complex (11.7%). The most common fracture site was the mandibular angle (37.9%), followed by the symphysis/parasymphysis (28.1%) and body (12.6%). Isolated soft tissue injuries were reported in 5.9% of the cases. The majority of MFFs were treated by open reduction and internal fixation.

Conclusion

Interpersonal violence, followed by RTAs and falls, was the most common cause of MFIs. Males in the 21–30 years age group had the highest MFI incidence rate. The nasal bone was the most common injury site, followed by the mandible and zygomatic complex. Social education with the objective of reducing aggression and interpersonal conflict should be improved, and appropriate RTA prevention strategies should be strengthened and implemented.

Incidence of maxillofacial fractures in motor vehicle accidents treated in Dubai

Aims

To analyze the incidence of maxillofacial fractures due to motor vehicle accidents in Dubai, as well as age, sex, etiology, patterns, treatment, and complications. To compare the findings with similar studies and provide recommendations for the prevention and management of these fractures.

Materials and methods

A 7-year retrospective study of maxillofacial fractures due to motor vehicle accidents was done.

Results

We found that most of the accidents took place in December, and the majority of the patients were pedestrians (27%). Male to female ratio was 6:1, and patients in their third decade of life were the most affected (39%). The parasymphysis was the most prominently affected region (27.7%), followed by the orbital bone (18.6%). Open reduction surgery was done in 56% of the cases, and postoperative complications were found in 18.4%.

Conclusions

Pedestrians were most commonly involved in the accidents. An increase in awareness, trauma centers, and better facilities would perhaps improve the management of such fractures.

The Patterns and Etiology of Maxillofacial Trauma in South India

Background

Maxillofacial trauma is any physical trauma to the facial region, commonly encountered by maxillofacial surgeons, and is often associated with high morbidity. Maxillofacial injuries can occur as an isolated injury or may be associated with multiple injuries in other parts of the body.

Aim

This study aims to assess the patterns, etiology, and management outcomes of maxillofacial trauma in a teaching hospital in Chennai, South India, over an 8-year period.

Methods

Patients with maxillofacial injury were identified using the department database and clinical records. Nine hundred and forty-four patients were identified with maxillofacial trauma in the Department of Oral and Maxillofacial Surgery between January 2009 and December 2017.

Results

The mean age of the patients was 30 ± 12 years. Of the 944 patients with maxillofacial injuries, 64% had isolated lower face (mandibular) fractures, followed by isolated midface fractures (19%). Road traffic accidents were the most common form of etiology for trauma.

Conclusion

The etiology and pattern of maxillofacial injuries reflect the trauma patterns within the community and can thus provide a guide to help design programs toward prevention and treatment.

Associated Injuries in Maxillofacial Trauma: A Study in a Tertiary Hospital in South India

Aim

Maxillofacial trauma when associated with concomitant injuries has a significant potential for increased morbidity. This study aims to identify the causes of trauma, evaluate the types of associated injuries and to highlight the significance of multi professional collaboration in sequencing of treatment.

Patients and Methods

A total of 300 patients who reported to the casualty of a tertiary Hospital in Karnataka with facial fractures were enrolled.

Results

Associated injuries were sustained by 162 patients. The predominant aetiology was the Road Traffic Accident with maximum number of patients in the age group of 20-29 and a male to female ratio of 10.1:1. The mandible was the most frequently fractured bone. Head injury was the most common associated injury. The mortality rate was 0.66%. The mean ISS and GCS values among the patients who sustained associated injuries along with maxillofacial trauma were higher and lower respectively, as compared to those without associated injuries with a statistically significant difference (p < 0.001).

Conclusion

Implementation of strict road safety measures in the rural and interior regions of South India, to prevent morbidity and mortality due to road traffic accidents is essential. Injuries to the facial skeleton must be approached with the knowledge of probable associated injuries that could have been incurred.

Surgical Anatomy of the Cervical Part of the Hypoglossal Nerve

Iatrogenic injuries to cranial nerves, half of which affect the hypoglossal nerve, occur in up to 20% of surgical procedures involving the neck. The risk of injury could be minimized by in-depth knowledge of its positional and relational anatomy. Forty-one hypoglossal nerves were dissected from cadaveric specimens and positions described in relation to the internal carotid artery (ICA), external carotid artery (ECA), carotid bifurcation, mandible, hyoid bone, mastoid process, and the digastric tendon. The distance of the nerve from where it crossed the ICA and ECA to the carotid bifurcation was 29.93 (±5.99) mm and 15.19 (±6.68) mm, respectively. The point where it crossed the ICA was 12.24 (±3.71) mm superior to the greater horn of hyoid, 17.16 (±4.40) mm inferior to the angle of the mandible, and 39.08 (±5.69) mm from tip of the mastoid. The hypoglossal nerve loop was inferior to the digastric tendon in 73% of the cases. The hypoglossal nerves formed high loops in this study population. Caution should be exercised during surgical procedures in the neck. The study also revealed that the mastoid process is a reliable fixed landmark to locate the hypoglossal nerve.

Orofacial trauma in rural India: A clinical study

PURPOSE

Orofacial trauma is becoming a leading medical problem worldwide. Most of the studies pertaining to orofacial trauma have been done in urban areas but very little scientific literature is available for rural areas.

METHODS

A prospective medical institute-based study of orofacial injury patients was carried out from May 2013 to April 2016 (36 Months). Data regarding incidence, age and sex distribution, causes, types and site of injury, treatment modalities and trauma associated complications were collected and analysed.

RESULTS

A total of 784 patients were studied. Males outnumbered females by a ratio of 2.9:1. Age range was 9 months-75 years with the peak incidence in the age-group of 18-34 years. Most injuries were caused by road-side accidents (72.7%), followed by assault and falls in 11.6% and 8% respectively. Soft tissue injuries and mandibular fractures were the most common type of injuries. Head/neck (50.29%) and limb injuries (27.2%) were the most prevalent associated injuries. Surgical debridement and soft tissue suturing was the most common emergency procedure. Closed reduction was performed in 61% of patients and open reduction and internal fixation in 30% of cases and 9% were managed conservatively. Complications occurred in 6.88% of patients, mainly due to infection and malocclusion. The mean duration of hospital stay was (10.12 ± 6.24) days.

CONCLUSION

This study highlights the importance of department of dental surgery along with other disciplinaries in the management of orofacial injuries. Road-side accident remains the major etiological factor of orofacial injuries in our setting.

Cost analysis of facial injury treatment in two university hospitals in Malaysia: a prospective study

Objective

Facial injury (FI) may occur in isolation or in association with injuries to other parts of the body (facial and other injury [FOI]). The objective of this study was to determine the direct treatment costs incurred during the management of facial trauma.

Materials and methods

A prospective cohort study on treatment cost for FIs and FOIs due to road-traffic crashes in two university hospitals in Malaysia was conducted from July 2010 to June 2011. The patients were recruited from emergency departments and reviewed after 6 months from the date of initial treatment. Direct cost analysis, comparison of cost and length of hospital stay, and Injury Severity Score (ISS) were performed.

Results

A total of 190 patients were enrolled in the study, of whom 83 (43.7%) had FI only, and 107 (56.3%) had FOI. The mean ISS was 5.4. The mean length of stay and costs for patients with FI only were 5.8 days with a total cost of US$1,261.96, whereas patients with FOI were admitted for 7.8 days with a total cost of US$1,716.47. Costs doubled if the treatment was performed under general anesthesia compared to local anesthesia.

Conclusion

Treatment of FI and FOI imposes a financial burden on the health care system in Malaysia.

Prevalence, pattern, etiology, and management of maxillofacial trauma in a developing country: a retrospective study

OBJECTIVES

This retrospective study aims to evaluate the prevalence of maxillofacial trauma in a developing country, along with its pattern, etiology and management. Data for the present study were collected from the Department of Dentistry, ESIC Medical College and Post Graduate Institute of Medical Sciences and Research, Chennai in India.

MATERIALS AND METHODS

The medical records of patients treated for maxillofacial injuries between May 2014 and November 2015 were retrospectively retrieved and analyzed for prevalence, pattern, etiology, and management of maxillofacial trauma. SPSS software version 16.0 was used for the data analysis.

RESULTS

Maxillofacial fractures accounts for 93.3% of total injuries. The mean and standard deviation for the age of the patients were 35.0±11.8 years and with a minimum age of 5 years and maximum age of 75 years. Adults from 20 to 40 years age groups were more commonly involved, with a male to female ratio of 3:1. There was a statistically significantly higher proportion of males more commonly involved in accident and injuries (P <0.001).

CONCLUSION

The most common etiology of maxillofacial injury was road traffic accidents (RTA) followed by falls and assaults, the sports injuries seem to be very less. In RTA, motorized two-wheelers (MTW) were the most common cause of incidents. The majority of victims of RTA were young adult males between the ages of 20 to 40 years. The malar bone and maxilla were the most common sites of fracture, followed by the mandible. The right side of the zygomatic complex was the predominant side of MTW injury. The majority of the zygomatic complex fractures were treated by conservative management. Open reduction and internal fixation were performed for indicated fracture patients.

Trends of maxillofacial fractures in the Garhwal Himalayas at Government Medical College, Srinagar, Uttarakhand

CONTEXT

Evaluation of Maxillofacial fractures in hilly region of Garhwal Himalyas and its relation with age, gender, anatomical location, seasonal variation and treatment provided.

AIMS

The aim of the present study is to analyze the pattern of maxillofacial fractures in the Garhwal Himalayan region of India and to compare the results with similar studies in India and the rest of the world.

SETTINGS AND DESIGN

This was a prospective study conducted on 102 patients with 128 facial fractures.

MATERIALS AND METHODS

This study was conducted on 102 patients who were admitted for the treatment of maxillofacial fractures in the Department of Dentistry at Government Medical College, Srinagar, Uttarakhand, India.

STATISTICAL ANALYSIS USED

All analyses were performed using Chi-square test and level of significance.

RESULTS

Peak incidence was noted in the second to fourth decades of life. Male: female ratio was 4:1. Road traffic accident was the main etiology (42.2%), followed by fall (37.2%) and assault (11.8%). Among other etiology of injury, distinguishing feature was bear bite, which was only seen in winters causing 5.9% of total injury. Fall was reported high in females whereas road traffic accident in males. Mandible was fractured in 73.5% of patients while mid-face in 26.5% of patients. Open reduction with internal fixation was the choice of treatment in 60.8% of cases. Nearly 79.4% of patients were treated under local anesthesia. The mean duration of hospitalization was (standard deviation 5.2 days) 5.3 days.

CONCLUSIONS

Road traffic accidents still remain the main cause of maxillofacial fractures in developing countries such as India. In hilly area, road traffic accident can be minimized by better wide roads with guide walls/parapet, strict law enforcement for overspeed, overload, and to use seat belts while driving, and use of helmet while riding two-wheeler. Open reduction internal fixation remains the first choice of treatment in facial fractures due to early return of function with minimal morbidity and better nutritional status in patients compared to closed reduction.

Injury characteristics and outcome of road traffic accident among victims at Adult Emergency Department of Tikur Anbessa specialized hospital, Addis Ababa, Ethiopia: a prospective hospital based study

BACKGROUND

Road traffic injuries are the eighth leading cause of death globally, and the leading cause of death for young people. More than a million people die each year on the world's roads, and the risk of dying as a result of a road traffic injury is highest in Africa.

METHODS

A prospective hospital based study was undertaken to assess injury characteristics and outcome of road traffic accident among victims at Adult Emergency Department of Tikur Anbessa specialized hospital, Addis Ababa, Ethiopia. A structured pre-tested questionnaire was used to gather the required data. The collected data were analyzed using SPSS version 20.0. Hierarchical multiple regression analysis was used to identify predictors of fatalities among the road traffic crash victims.

RESULTS

A total of 230 road traffic accident victims were studied. The majority of the study subjects were men 165 (71.7%) and the male/female ratio was 2.6:1. The victims' ages ranged from 14 to 80 years with the mean and standard deviations of 32.15 and ± 14.38 years respectively. Daily laborers (95 (41.3%)) and students (28 (12.2%)) were the majority of road traffic accident victims. Head (50.4%) and musculoskeletal (extremities) (47.0%) were the most common body region injured. Fractures (78.0%) and open wounds (56.5%) were the most common type of injuries sustained. The overall length of hospital stay (LOS) ranged from 1 day to 61 days with mean (± standard deviation) of 7.12 ± 10.5 days and the mortality rate was 7.4%. Hierarchical multiple regression analysis showed that age of the victims (ß = 0.16, p < 0.05), systolic blood pressure on admission (ß = -0.35, p < 0.001) and Glasgow coma scale (ß = -0.44, p < 0.001) were statistically significant predictors of fatalities among the victims.

CONCLUSIONS

This study showed diverse injury characteristics and high morbidity and mortality among the victims attending Adult Emergency Department of Tikur Anbessa specialized hospital, Addis Ababa, Ethiopia. The findings reflect that road traffic accident is a major public health problem. Urgent road traffic accident preventive measures and prompt treatment of the victims are warranted in order to reduce morbidity and mortality among the victims.

Magnitude and outcomes of road traffic accidents at Hospitals in Wolaita Zone, SNNPR, Ethiopia

BACKGROUND

A Road traffic accident is an incident on a way or street open to public traffic, resulting in one or more persons being killed or injured, and involving at least one moving vehicle.

METHODS

The aim of this study is to assess magnitude and outcome of road traffic accidents among trauma victims at hospitals in Wolaita zone. A cross sectional hospital based study design using retrospective chart review was conducted from March 5th to March 25th, 2014. Simple random sampling technique was applied to identify sample population. The data was entered in to Epi info version 3.5.1 and transferred to SPSS version 16 for further analysis.

RESULTS

A total of 384 trauma victims were incorporated in the study of which 240 (62.5%) were due to road traffic accidents. The majority of patients were male 298 (77.6%) and most commonly aged between 20-29 (35.42%). The principal outcome of injury was more commonly lower extremity (182 patients, 47.4%), compared to upper extremity (126 patients, 32.8%).

CONCLUSION

Of all trauma patient presenting to hospitals (62.5%) are the result of road traffic accident. Hence, the provision of tailored messages to all members of the community regarding knowledge and practices of road safety measures like appropriate use of pavements by pedestrians and avoiding risky driving behaviors. Besides this make use of compulsory motorcycle helmets would appear to be a very important intervention.

Head and maxillofacial injuries in child and adolescent victims of automotive accidents

Background. Victims of motor vehicle accidents may suffer multiple lesions, including maxillofacial injuries. The aim of this study was to evaluate the prevalence and factors associated with head, facial, and maxillofacial injuries in child and adolescent victims of automobile accidents. A cross-sectional study was carried out with analysis of forensic medical reports from the Legal Medical Institute of Campina Grande, Brazil, between January 2008 and December 2011. Descriptive and inferential statistical analysis was conducted using the chi-square test (α = 0.05). From 1613 medical reports analyzed, the sample is composed 232 (14.4%) reports referring to child and adolescent victims of automobile accidents aged 0–19 years of both sexes. Victims were mostly adolescents aged from 15 to 19 years (64.2%), males (73.7%), and motorcyclists (51.3%). More than half of the victims had single lesions (54.3%) located in the head (20.7%) and face (21.6%). Head injuries occurred more frequently in children aged 0–4 years (53.8%, PR = 5.065, 95% CI = 1.617–5.870) and pedestrians (30.4%, PR = 2.039, 95% CI = 1.024–4.061), while facial and maxillofacial injuries occurred in higher proportion among females (31.1%, PR = 0.489, 95% CI = 0.251–0.954). Our findings suggest that accidents involving motorcyclists are the most prevalent, affecting male adolescents aged from 15 to 19 years, resulting in a high frequency of injuries in the head and face regions.

An assessment of etiological spectrum and injury characteristics among maxillofacial trauma patients of Government dental college and Research Institute, Bangalore

BACKGROUND

Maxillofacial injuries pose a therapeutic challenge to trauma, maxillofacial and plastic surgeons practicing in developing countries. This was a retrospective study carried out to determine the incidence, etiology, injury characteristics of maxillofacial injuries reported at our centre.

PATIENTS AND METHODS

The data for this study were obtained from the medical records of 689 cases reported to our centre during the period from 2006-2009. Records of patients who were either treated in the emergency room as outpatients or the Department of Oral and Maxillofacial Surgery as inpatients were analyzed and were subjected to statistical analysis using statistical package for social sciences (SPSS) for Windows version 17.0. Data was summarized in form of proportions and frequency tables for categorical variables and was subjected to Chi-Square test.

RESULTS

Out of 689 patients, 75.9% were male and 24.1% were female. 42.5% of the patients were in the age group of 21 to 30 years. Road traffic accidents accounted for the majority (74.3%) of cases of maxillofacial trauma. Mandible was seen as the most commonly fractured bone (50.3%) and 53.8% head and neck injuries were most common among the associated injuries.

CONCLUSION

Road traffic accidents were clearly the most prevalent etiological factor for maxillofacial trauma. Measures on prevention of road traffic crashes should be strongly emphasized in order to reduce the occurrence of these injuries.

Pattern, severity, and management of cranio-maxillofacial soft-tissue injuries in Port Harcourt, Nigeria

Background:

The pattern of craniofacial soft-tissue injuries occurring either in isolation or in association with fractures vary in different societies and is multiply influenced. The effects are enormous because of the prominence of the face; therefore, the purpose of this study was to document any changing pattern, severity and management of these craniofacial injuries in our center.

Patients and Method:

Cranio-maxillofacial region was classified into upper, middle and lower face. The cause, type, and site of the injuries were documented. Gunshot injuries were further categorized as penetrating, perforating or avulsions. Further, classification of injuries into mild, moderate, and severe was carried out based on multiple factors.

Result:

A total of 126 patients with soft-tissue injuries presented to our hospital out of which 85 (67.5%) were males and 41 (32.5) were females. The age range of the patients was between 10 months and 90 years with a mean ± SD of 26.4 ± 15.5 years. Road traffic accident was the most common etiology of which vehicular accidents constituted 50 (54.9%) and the motorcycle was 2 (2.2%). Assault contributed 16 (17.6%) while cases due to gun shots were 13 (14.3%). A total of 19 (15.1%) patients had associated head injuries, 11 (8.7%) patients had craniofacial fractures involving any of the bones while 3 (2.4%) patients had limb fractures and 2 (1.6%) patients had rib fractures. There were 51 (41.8%) cases classified as mild injuries, 37 (30.3%) cases as moderate injuries and 24 (19.7%) cases as severe injuries. Total of 126 cases managed, 121 (96.0%) received primary closure of the wounds while 5 (4.0%) received delayed closure under general anesthesia.

Injury characteristics and outcome of road traffic crash victims at Bugando Medical Centre in Northwestern Tanzania

Background

Road traffic crash is of growing public health importance worldwide contributing significantly to the global disease burden. There is paucity of published data on road traffic crashes in our local environment. This study was carried out to describe the injury characteristics and outcome of road traffic crash victims in our local setting and provide baseline data for establishment of prevention strategies as well as treatment protocols.

Methods

This was a prospective hospital based study of road traffic crash victims carried out at Bugando Medical Centre in Northwestern Tanzania between March 2010 and February 2011. After informed consent to participate in the study, all patients were consecutively enrolled into the study. Data were collected using a pre-tested questionnaire and analyzed using SPSS computer software version 15.0.

Results

A total of 1678 road traffic crash victims were studied. Their male to female ratio was of 2.1:1. The patients ages ranged from 3 to 78 years with the mean and median of 29.45 (± 24.22) and 26.12 years respectively. The modal age group was 21-30 years, accounting for 52.1% patients. Students (58.8%) and businessmen (35.9%) were the majority of road traffic crash victims. Motorcycle (58.8%) was responsible for the majority of road traffic crashes. Musculoskeletal (60.5%) and the head (52.1%) were the most common body region injured. Open wounds (65.9%) and fractures (26.3%) were the most common type of injuries sustained. The majority of patients (80.3%) were treated surgically. Wound debridement was the most common procedure performed in 81.2% of the patients. The complication rate was 23.7%. The overall average length of hospital stay (LOS) was 23.5 ± 12.3 days. Mortality rate was 17.5%. According to multivariate logistic regression analysis, patients who had severe trauma (Kampala Trauma Score II ≤ 6) and those with long bone fractures stayed longer in the hospital and this was significant (P < 0.001) whereas the age of the patient, severe trauma (Kampala Trauma Score II ≤ 6), admission Systolic Blood Pressure < 90 mmHg and severe head injury (Glasgow Coma Score = 3-8) significantly influenced mortality (P < 0.001).

Conclusion

Road traffic crashes constitute a major public health problem in our setting and contribute significantly to unacceptably high morbidity and mortality. Urgent preventive measures targeting at reducing the occurrence of road traffic crashes is necessary to reduce the morbidity and mortality resulting from these injuries. Early recognition and prompt treatment of road traffic injuries is essential for optimal patient outcome.

Etiological spectrum, injury characteristics and treatment outcome of maxillofacial injuries in a Tanzanian teaching hospital

BACKGROUND

Maxillofacial injuries pose a therapeutic challenges to trauma, maxillofacial and plastic surgeons practicing in developing countries. This study was carried out to determine the etiology, injury characteristics and management outcome of maxillofacial injuries at our teaching hospital.

PATIENTS AND METHODS

A prospective hospital based study of maxillofacial injury patients was carried out at Bugando Medical Centre from November 2008 to October 2009. Data was collected using a structured questionnaire and analyzed using SPPS computer software version 11.5.

RESULTS

A total of 154 patients were studied. Males outnumbered females by a ratio of 2.7:1. Their mean age was 28.32 ± 16.48 years and the modal age group was 21-30 years. Most injuries were caused by road traffic crushes (57.1%), followed by assault and falls in 16.2% and 14.3% respectively. Soft tissue injuries and mandibular fractures were the most common type of injuries. Head/neck (53.1%) and limb injuries (28.1%) were the most prevalent associated injuries. Surgical debridement (95.1%) was the most common surgical procedures. Closed reduction of maxillofacial fractures was employed in 81.5% of patients. Open reduction and internal fixation was performed in 6.8% of cases. Complications occurred in 24% of patients, mainly due to infection and malocclusion. The mean duration of hospital stay was 18.12 ± 12.24 days. Mortality rate was 11.7%.

CONCLUSION

Road traffic crashes remain the major etiological factor of maxillofacial injuries in our setting. Measures on prevention of road traffic crashes should be strongly emphasized in order to reduce the occurrence of these injuries.

Factors associated with severity of road traffic injuries, Thika, Kenya

Background: Road traffic injuries continue to exert a huge burden on the health care system in Kenya. Few studies on the severity of road traffic injuries have been conducted in Kenya. We carried out a cross-sectional study to determine factors associated with severity of road traffic injuries in a public hospital in Thika district, Kenya. Methods: Road crash victims attending the Thika district hospital, a 265-bed public hospital, emergency room were recruited consecutively between 10th August 2009 and 15th November 2009. Epidemiologic and clinical information was collected from medical charts and through interview with the victims or surrogates using a semi-structured questionnaire. Injuries were graded as severe or non-severe based on the Injury Severity Score (ISS). Independent factors associated with injury severity were assessed using multivariate logistic regression. Results: The mean age of participants was 32.4 years, three quarters were between 20-49 years-old and 73% (219) were male. Nineteen percent (56/300) of the victims had severe injury. Five percent (15) had head injury while 38% (115) had fractures. Vulnerable road users (pedestrians and two-wheel users) comprised 33% (99/300) of the victims. Vulnerable road users (OR=2.0, 95%CI=1.0-3.9), road crashes in rainy weather (OR=2.9, 95%CI=1.3-6.5) and night time crashes (OR=2.0, 95%CI=-1.1-3.9) were independent risk factors for sustaining severe injury. Conclusion: Severe injury was associated with vulnerable road users, rainy weather and night time crashes. Interventions and measures such as use of reflective jackets and helmets by two wheel users and enhanced road visibility could help reduce the severity of road traffic injuries.