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Background This study aims to analyze the incidence and outcomes of bicycle-related injuries in hospitalized patients in The Netherlands. Methods Bicycle accidents resulting in hospitalization in a level-I trauma center in The Netherlands between 2007 and 2017 were retrospectively identified. We subcategorized data of patients involved in a regular bicycle, race bike, off-road bike or e-bike accident. The primary outcomes were mortality rate and incidence of multitrauma. Secondary outcomes were differences between bicycle subcategories. Independent risk factors were identified using multivariable logistic regression. All variables with a p value < 0.20 in univariable analysis were entered in multivariable analysis. Results We identified 1986 patients. The mortality rate after emergency room admission was 5.7%, and 41.0% were multitraumas. A higher age, multitrauma and cerebral haemorrhages were independent risk factors for in hospital mortality. Independent risk factors found for multitrauma were a higher age, two-sided trauma, e-bike accidents and cerebral haemorrhage. Conclusion Bicycle accidents resulting in hospitalization have a high mortality rate. Furthermore, a high incidence of multitrauma, fractures and cerebral haemorrhages were found. Considering the increasing incidence of bicycle accident victims needing hospital admission, new and more efficient prevention strategies are essential.
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European Journal of Trauma and Emergency Surgery (2020) 46:413–418
Injuries related tobicycle accidents: anepidemiological study inThe
LiviaE.V.M.deGuerre1· SaidSadiqi2· LoekP.H.Leenen1· CumhurF.Oner2· StevenM.vanGaalen3
Received: 29 May 2018 / Accepted: 8 October 2018 / Published online: 15 October 2018
© The Author(s) 2018
Background This study aims to analyze the incidence and outcomes of bicycle-related injuries in hospitalized patients in
The Netherlands.
Methods Bicycle accidents resulting in hospitalization in a level-I trauma center in The Netherlands between 2007 and 2017
were retrospectively identified. We subcategorized data of patients involved in a regular bicycle, race bike, off-road bike or
e-bike accident. The primary outcomes were mortality rate and incidence of multitrauma. Secondary outcomes were differ-
ences between bicycle subcategories. Independent risk factors were identified using multivariable logistic regression. All
variables with a p value < 0.20 in univariable analysis were entered in multivariable analysis.
Results We identified 1986 patients. The mortality rate after emergency room admission was 5.7%, and 41.0% were multi-
traumas. A higher age, multitrauma and cerebral haemorrhages were independent risk factors for in hospital mortality. Inde-
pendent risk factors found for multitrauma were a higher age, two-sided trauma, e-bike accidents and cerebral haemorrhage.
Conclusion Bicycle accidents resulting in hospitalization have a high mortality rate. Furthermore, a high incidence of mul-
titrauma, fractures and cerebral haemorrhages were found. Considering the increasing incidence of bicycle accident victims
needing hospital admission, new and more efficient prevention strategies are essential.
Keywords Bicycle· Bike· Traffic accident· Traffic injury· E-bike· Epidemiology
Cycling is a popular means of transportation and leisure
activity with many health and environmental advantages.
However, simultaneously with the increasing popularity of
cycling, concerns for road safety have grown. A recent Aus-
tralian study estimated that per 1000km cycled 0.29 crashes
occur [1]. Also, a Dutch study showed that in 2012, 31% of
the lethal traffic accidents and 59% of the traffic accident
victims treated in the emergency room were cyclists [2].
Parallel to the regular city bicycles, other bicycle types have
gained popularity and sales of race bikes, off-road bicycles
and e-bikes have grown [3]. Each subtype is known for its
specific end users and preferred cycling environment but
little is known about the differences in injury risks with spe-
cific morbidity and mortality.
Biking is rooted in Dutch culture and every year approxi-
mately one million bicycles are sold in The Netherlands [3].
Compared to other European countries, The Netherlands has
a higher prevalence of cycling as a mode of transport but
also a higher incidence of severe bicycle crash injuries [4].
Yearly costs of bicycle-related accidents in The Netherlands
are estimated to be 402million euros [2].
Several studies have been conducted to assess bicycle-
related injuries in the general population; however, studies
regarding bicycle-related injuries treated in the emergency
room are lacking. A clear understanding of the epidemiol-
ogy of this group will permit better emergency care and
aid to implement effective injury prevention strategies.
Therefore, the objective of this study is to gain insight in
the epidemiology of bicycle accidents in a level-I trauma
* Said Sadiqi
1 Department ofSurgery, University Medical Center Utrecht,
Utrecht, TheNetherlands
2 Department ofOrthopaedics, University Medical Center
Utrecht, HP G05.228, P.O. Box85500, 3508GAUtrecht,
3 Departement ofOrthopaedics, Diakonessenhuis
Utrecht/Zeist, Utrecht/Zeist, TheNetherlands
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414 L.E.V.M.de Guerre et al.
1 3
center in The Netherlands, as well as the identification of
trauma patterns and factors that may predict the outcomes.
Materials andmethods
All patients who were admitted to the University Medical
Center Utrecht (a large level-I trauma center in The Neth-
erlands) after emergency care following a bicycle accident
between 2007 and 2017 were retrospectively identified in
a well-established trauma care database.
Data were obtained for patients that were involved in
a regular bicycle, race bike, off-road bike or e-bike acci-
dent. The data collected included patient characteristics
(age, gender), trauma mechanism (vehicle, one-sided or
two-sided injury mechanism, helmet protection), injury
characteristics [diagnosis, fractures, haematomas, injury
severity score (ISS)] and mortality. The injuries were clas-
sified as minor or multitrauma according to the ISS score.
In line with the available literature, the cut-off point for a
multitrauma patient was settled as > 15 for the abbreviated
injury severity (AIS)-98 classification system, or > 12 for
the AIS-08 system [5].
The primary outcome measures of the study were mortal-
ity between the arrival at the emergency department and
hospital discharge, and the occurrence of multitrauma.
Secondary outcomes were the differences between regular
bicycles, race bikes, off-road bikes and e-bikes.
Statistical analysis
Statistical analyses were performed using SPSS. Normally
distributed and non-normally distributed continuous vari-
ables were expressed as mean (± SD) or median (range).
Categorical data was presented as total counts and per-
centages. The incidence of all accidents was calculated
for each subgroup. The relation between survival and
the baseline variables were evaluated by Chi square test,
Fisher exact test or Mann–Whitney U test. A multivari-
ate logistic regression analysis was performed to identify
independent predictors for survival. All variates with a
p value < 0.2 in the univariate analysis were included in
the multivariate analysis. Associations were considered
significant when the p value was < 0.05.
Patient characteristics
A total of 1986 bicycle-related accidents were identified in
the database, out of which 1655 concerned regular bicycle
accidents (83.3%), 195 race bikes (9.8%), 78 off-road bicy-
cles (3.9%) and 58 e-bikes (2.9%) (Table1). Of all patients
presented in the emergency department, 41.0% were mul-
tiply injured. The recorded mortality was 5.7%. The mean
age at diagnosis was 45 years, 61.1% of the patients were
male and the majority did not wear a helmet (92.5%). The
accidents were one-sided in 49.6% of the cases and 73.0%
had at least one fracture (Table2). As shown in Fig.1,
83.7% of the patients with a multitrauma suffered from
a head or neck injury, 39.4% had thoracic trauma, 10.5%
abdominal injuries, 9.0% pelvic injuries, 10.9% upper
extremities, 14.9% lower extremities and 17.8% spine
injuries. In patients with a minor trauma, significantly
less patients had a head or neck injury (68.3%), thoracic
trauma (18.0%), abdominal injuries (3.8%), pelvic injuries
(5.8%) and spinal injuries (10.4%); however, significantly
more had a lower extremity injury (21.0%) and a similar
percentage had upper extremities injury (11.6%). Table3
shows a stratification of the sustained fractures, with the
most prevalent being facial fractures (28.2%), skull frac-
tures (19.8%) and rib fractures (17.2%). Cerebral haem-
orrhages were common: 16.6% suffered from a subdural
haematoma and 17.0% from a subarachnoid haemorrhage
(SAH). Less common were epidural haematomas (5.4%)
and intracerebral haemorrhage (5.5%).
Risk factors formortality
Age, gender, multitrauma, non-regular bicycle accidents,
one- or two-sided accidents and cerebral haemorrhages
were identified as possible risk factors for mortality. These
risk factors were included in the multivariate logistic
regression model. The analysis identified a higher age,
multitrauma and cerebral haemorrhages as independent
risk factors for mortality.
Table 1 Incidence of bicycle
traumas per subgroup Bicycle subgroup N (%)
Regular bicycle 1655 (83.3)
Race bike 195 (9.8)
Off-road bicycle 78 (3.9)
E-Bike 58 (2.9)
Total 1986
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415Injuries related tobicycle accidents: anepidemiological study inThe Netherlands
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Risk factors formultitrauma
Independent risk factors for multitrauma were higher age,
two-sided trauma, bicycle type and cerebral haemorrhage.
Univariate analysis for multitrauma accidents identified
age, e-bike accidents, one- or two-sided accidents and
occurrence of cerebral haemorrhages as possible risk
An increase in the total number of accidents was seen
between 2009 and 2012. From 2012 onwards, the inci-
dence of bicycle traumas has been relatively stable. The
incidence of minor traumas increased over the years,
Table 2 Baseline characteristics
SD standard deviation, DOA death on arrival, ICU Intensive Care
Unit, MCU Medium Care Unit, OR operating room, Aftermath admis-
sion location after emergency room treatment
N (%)
Male 1213 (61.1)
Female 767 (38.6)
Missing 6 (0.3)
Age Mean 45.0 (SD 24.1)
One-sided 985 (49.6)
Two-sided 1001 (50.4)
ISS Mean 13.6 (SD 10.6)
No 1860 (93.6)
Yes 114 (5.7)
Missing 12 (0.6)
No 1838 (92.5)
Yes 148 (7.5)
None 536 (27.0)
At least 1 1450 (73.0)
Cerebral haemorrhages
Epidural 95 (5.4)
Subdural 295 (16.6)
Subarachnoidal 304 (17.0)
Intracerebral 96 (5.5)
Home 5 (< 1)
Hospital ward 1080 (54.4)
Transferred out 83 (4.1)
MCU 275 (13.8)
ICU 358 (18)
OR 178 (9.0)
Deceased in the emergency room 3 (2.0)
DOA 3(2.0)
Missing 1 (< 1)
Fig. 1 a Anatomical distribution of the injuries in multitrauma
patients. b Anatomical distribution of the injuries in patients with
minor trauma. Since multiple patients had more than one body part
affected the total is > 100%
Table 3 Incidence of fractures Fracture N (%)
Skull 393 (19.8)
Skull base 87 (4.4)
Facial 561 (28.2)
Spine fractures 252 (12.7)
Humerus 58 (2.9)
Lower arm 73 (3.7)
Scapula 48 (2.4)
Sternal 21 (1.1)
Clavicle 168 (8.5)
Rib 342 (17.2)
Pelvis 127 (6.4)
Femur 140 (7.0)
Lower leg 185 (9.5)
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416 L.E.V.M.de Guerre et al.
1 3
whereas the multitrauma incidence remained relatively
stable (Fig.2).
Bicycle subcategories
Compared to patients sustaining trauma with regular bicy-
cles, race bike trauma patients were older, more often male
and the accidents were more often one-sided. Off-road bike
accidents have significantly increased in recent years com-
pared to regular bicycles, these were more often one-sided,
and patients were more often male and younger. A specific
bicycle subgroup concerns e-bikes. Compared to classic
bicycles, e-bike trauma patients are older, mortality is more
common, more accidents include multitrauma, and the num-
ber of accidents has increased significantly in recent years
Helmet protection
In the small subgroup of cyclists wearing a helmet (7.5%),
2.0% of the patients died versus 6.0% of the patients who
did not wear a helmet. However, this difference was not sig-
nificant. When wearing a helmet, significantly less patients
had head and neck injuries, subdural bleedings, intracerebral
bleedings, skull fractures and skull base fractures.
The aim of this study was to gain insight in the incidence and
outcomes of bicycle-related injuries in hospitalized patients
in The Netherlands.
Fig. 2 Incidence of minor and multitrauma bicycle traumas per year
Table 4 Bicycle subgroups
SD standard deviation
Regular bicycle Race bike Off-road E-bike
Male 944 (57.0) 167 (85.6) 74 (94.9) 28 (48.3)
Female 706 (42.7) 27 (13.9) 4 (5.13) 30 (51.7)
Missing 5 (0.3) 1 (0.5)
Age 43.9 (SD 25) 50.8 (SD 15.2) 39.6 (SD 18.3) 64.3 (SD 15.8)
One-sided 762 (46.0) 114 (58.5) 75 (95.2) 34 (58.6)
Two-sided 893 (54.0) 81 (41.5) 3 (3.8) 24 (41.4)
No 1645 (99.4) 93 (47.7) 43 (55.1) 57 (98.3)
Yes 10 (0.6) 102 (52.3) 35 (44.9) 1 (1.7)
Cer. hemorrhage
Epidural 83 (5.0) 6 (3.1) 3 (3.9) 3 (5.2)
Subdural 254 (15.4) 17 (8.7) 9 (11.5) 15 (25.9)
SAB 260 (15.7) 17 (8.7) 6 (7.7) 21 (36.2)
Intracerebral 84 (5.1) 3 (1.5) é (2.6) 7 (12.1)
No 997 (63.3) 111 (61.3) 50 (66.7) 27 (58.7)
Yes 579 (36.7) 70 (38.7) 25 (33.3) 19 (41.3)
No 1544 (93.3) 189 (96.9) 77 (98.7) 50 (86.2)
Yes 102 (6.2) 4 (2.1) 1 (1.3) 7 (12.1)
Missing 9 (0.5) 2 (1.0) 1 (1.7)
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417Injuries related tobicycle accidents: anepidemiological study inThe Netherlands
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Bicycle injuries resulting in hospitalization were charac-
terized by a high mortality of 5.7%, and a considerably high
multitrauma incidence of 41.0%. In a Dutch study investi-
gating bicycle-related traumatic brain injuries, 4% of the
cyclists treated at the emergency department deceased in
the hospital due to their multiple injuries [6]. The somewhat
higher incidence found in our study could be explained by
the more severely injured patient population as we only took
into account patients who were admitted to the hospital ward
after their treatment at the emergency department. In the
present study, 73.0% of the patients presented with at least
one fracture, while 16.6% and 17.0% suffered from subdural
and subarachnoid haemorrhages, respectively. Injuries to the
head and thorax were the most common.
Increased age, multitrauma and cerebral haemorrhages
were found to be independent risk factors for mortality. For
multitrauma, additionally two-sided trauma and e-bike acci-
dents were found as independent risk factors. Previous stud-
ies reported not wearing a helmet, increased age and alcohol
consumption as risk factors for bicycle crash mortality [2, 7].
A systematic review showed the association between bicycle
helmet use and reduced odds of head injury, serious head
injury, facial injury and fatal head injury [8]. Our results
indicate that the prevalence of helmet wearing in The Neth-
erlands for cyclists remains low. When wearing a helmet this
is associated with less head and neck injuries. Furthermore,
cerebral haemorrhages are a risk factor for both multitrauma
and mortality. These results support that promoting to wear
bicycle helmets is an important safety strategy opportunity
for Dutch legislators.
Recent research concerning the increasingly popular
e-bikes has raised many concerns [9]. In The Netherlands,
27.6% of the total number of fatal bicycle accidents in 2017
were e-bike accidents [10]. In the present study, we found a
high mortality and morbidity rate in an older patient group.
Possible contributing factors making e-bikes more prone
to severe traffic accidents are the speed difference between
cyclists and e-bikers using the same traffic lanes, increased
risk taking behaviour and misperception of the e-biker’s
approaching speed [11]. In this group, especially the older
patients show increased use of anticoagulation drugs
which makes (more than in the other bicycle categories)
wearing helmets essential in the prevention of specifically
head related injuries. A first step to decrease severe e-bike
accidents was recently made when a new traffic law in The
Netherlands made wearing a helmet compulsory in e-bikes
surpassing the speed of 25km/h (speed pedelecs). This fol-
lowed EU legislation as defined in the white Paper “Rules
and Regulations on electric cycles in the EU” categorizing
this subcategory of e-bikes as a similar mode of transpor-
tation as a L1e-B moped [12]. For this category, compul-
sory helmet wear for moped was applied. Unfortunately the
white paper stated that none of the EU member states have
imposed helmet usage on adult users of conventional bicy-
cles consequently exempting the 25km/h–250kW pedelecs
from compulsory helmet wear. However, increased road user
awareness, increased distinctiveness from other bicycles and
compulsory helmet wear for all e-bike categories would be
needed to reverse the alarming increase in both morbidity
and mortality related to e-bike accidents as found in this
Hartog etal. estimated that the beneficial effect of cycling
due to increased physical activity results in 9 times more
gain in life years than the loss from inhaled air pollution
and traffic accidents [13]. However, bicycle crashes are still
significant contributor to traffic accident-related mortality
and morbidity, while often being considered as prevent-
able. Therefore, stronger injury prevention strategies are
needed such as education by promoting safety measures
and to increase awareness concerning upcoming new (often
faster) bicycle subtypes. Secondly, stricter traffic laws may
be needed in The Netherlands to stop the current negative
trend of increased accidents.
This study has several limitations. The patient group only
represents a percentage of all bicycle-related injuries, as
only the patients admitted after emergency room care were
included. The minor injuries not requiring hospital admis-
sion and on site fatal bicycle accidents are not represented
in this study creating somewhat a selection bias. It is also
conceivable that the incidence of accidents with race bikes,
off-road bicycles and e-bike might be much higher, since
not all of these accidents will be registered as such but as
regular bicycle accidents instead at the emergency room.
Furthermore, this is a regional study and our results might,
therefore, not apply to other regions with different bicycle-
related infrastructure, traffic laws and cycling popularity.
However, since the investigated trauma center is one of the
largest in The Netherlands, we expect the results to be rep-
resentative for other Dutch trauma regions. A previous study
showed that bicycle crash prevalence and severity in The
Netherlands is among the highest in Europe [4]. Therefore,
the results of this study might not be comparable to countries
with different cycling cultures. Historically, the Dutch adult
cyclists seems to be rather reluctant in voluntary use of hel-
mets on regular bicycles but the data from this study should
emphasize that the class L1e-A 25km/h–250kW pedelec
is not a regular bicycle. Further data collection would be
required to better understand influencing factors leading to
bicycle accidents such as the crash mechanism, speed, infra-
structure, alcohol or smartphone use, and more complete
data regarding protective gear and the type of bicycle [7].
In conclusion, this study investigated the epidemiology of
bicycle accidents in a large level-I trauma center and found
a high mortality rate, many multitrauma cases, a high inci-
dence of fractures and cerebral haemorrhages. Considering
the increasing incidence of bicycle crash victims needing
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418 L.E.V.M.de Guerre et al.
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hospital admission, prevention strategies such as protective
gear, better infrastructure and more strict traffic laws are
essential. Furthermore, more extensive national databases
should be implemented to enable more specific research
and gain new insights. The authors make a strong recom-
mendation for stronger legislation on the use of protective
helmets especially when e-bikes are involved in the elderly
Compliance with ethical standards
Conflict of interest All authors declare that they have no conflict of
Open Access This article is distributed under the terms of the Crea-
tive Commons Attribution 4.0 International License (http://creat iveco
mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribu-
tion, and reproduction in any medium, provided you give appropriate
credit to the original author(s) and the source, provide a link to the
Creative Commons license, and indicate if changes were made.
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... Only 7.5-14% of the cyclists in the Netherlands wear a bicycle helmet. 4,13 Prior reviews in this field have not aimed to research e-bikes and e-scooters. The increasing popularity of these motorized vehicles and the ease of accessibility due to ride-sharing platforms has led to increasing numbers of traffic accidents involving e-bikes and e-scooters. ...
... 2,34 The rates of mortality and cerebral haemorrhage are also substantially higher for e-bike accidents than for accidents involving other vehicles. 13 The use of helmets by cyclists, users of e-bikes, and users of e-scooters is rare. 2,13 Perhaps the users of these vehicles are not aware of the significant risk of injury in the absence of a helmet, or have others reasons for not wearing one. ...
... 13 The use of helmets by cyclists, users of e-bikes, and users of e-scooters is rare. 2,13 Perhaps the users of these vehicles are not aware of the significant risk of injury in the absence of a helmet, or have others reasons for not wearing one. 13 In the Netherlands only 7.5-14% of cyclists wear a helmet. ...
Maxillofacial injury is a common injury resulting from bicycle (including e-bike) and scooter accidents. With 80,000 admissions to emergency departments in 2019, bicycle accidents account for more than half of all traffic-related emergency department visits in the Netherlands. The United States reports approximately 130,000 injuries and 1000 fatalities related to cycling annually. This systematic review and meta-analysis was performed to examine the protective effect of helmets against maxillofacial injuries resulting from bicycle and scooter (including e-bike and e-scooter) accidents. After a systematic literature search, 14 studies were found to be eligible for this systematic review. Of these, 11 were included in the meta-analysis. None of the included studies focused on vehicles with motors (e-bikes and e-scooters); all focused only on non-motorized vehicles. All included studies were non-randomized, which could have led to bias in the pooled results. Data from the included studies were tested for heterogeneity using the binary random-effects model (DerSimonian-Laird method), and the odds ratio for the occurrence of maxillofacial injury in cyclists wearing a helmet versus those not wearing a helmet was calculated by random-effects meta-analysis. Patients who had worn a helmet suffered significantly fewer maxillofacial injuries than patients who had not, in bicycle accidents (odds ratio 0.682). In conclusion, wearing a helmet has a significant protective effect against maxillofacial injury, indicating the need for strict helmet legislation.
... At a high level, the literature identifies skull fracture, subdural haematoma and subarachnoid haemorrhage as being the most common severe TBI pathologies for cyclists. 4,16,26,29,34,36,22,61,72,77,94 Mild injuries such as soft tissue injuries and short periods of loss of consciousness are prevalent in less severely injured cohorts. The data sources with sufficient data available for analysis frequently come from settings which treat and capture a high proportion of severe TBI. ...
... intensive care or neurosurgery settings common head injuries tend to be more severe. 26,29,22,88,101 Figure 2 shows the proportion of studies separated by data source, which shows that the largest number of reported cycle head injuries are based on general hospital admissions, followed by all-severity hospital settings and road traffic collision databases. This figure highlights the potential bias of the severity of injuries captured in previous studies. ...
... A study of around 2000 cyclists admitted to Netherlands major trauma centres from 2007 to 2017 found that subarachnoid haemorrhage and subdural haematoma were common. 22 A large, particularly valuable study comprising over 11,000 cyclists from the UK's Trauma Audit Research Network (TARN) database found differences in head injury between helmeted and non-helmeted cyclists. 29 Skull fracture was the most prevalent head injury in non-helmeted cyclists (27% vault and 26% base) followed by subarachnoid haemorrhage (24%), subdural haematoma and cerebral contusions (both 22%). ...
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Head injuries are common for cyclists involved in collisions. Such collision scenarios result in a range of injuries, with different head impact speeds, angles, locations, or surfaces. A clear understanding of these collision characteristics is vital to design high fidelity test methods for evaluating the performance of helmets. We review literature detailing real-world cyclist collision scenarios and report on these key characteristics. Our review shows that helmeted cyclists have a considerable reduction in skull fracture and focal brain pathologies compared to non-helmeted cyclists, as well as a reduction in all brain pathologies. The considerable reduction in focal head pathologies is likely to be due to helmet standards mandating thresholds of linear acceleration. The less considerable reduction in diffuse brain injuries is likely to be due to the lack of monitoring head rotation in test methods. We performed a novel meta-analysis of the location of 1809 head impacts from ten studies. Most studies showed that the side and front regions are frequently impacted, with one large, contemporary study highlighting a high proportion of occipital impacts. Helmets frequently had impact locations low down near the rim line. The face is not well protected by most conventional bicycle helmets. Several papers determine head impact speed and angle from in-depth reconstructions and computer simulations. They report head impact speeds from 5 to 16 m/s, with a concentration around 5 to 8 m/s and higher speeds when there was another vehicle involved in the collision. Reported angles range from 10° to 80° to the normal, and are concentrated around 30°–50°. Our review also shows that in nearly 80% of the cases, the head impact is reported to be against a flat surface. This review highlights current gaps in data, and calls for more research and data to better inform improvements in testing methods of standards and rating schemes and raise helmet safety.
... In our own series of 14 traumatic cases, we also observed the types of injury that are most frequently reported in the literature, including the anterior approach for hip surgery (4 cases), inguinal hernia repair (2 cases) and seat-belt injury (2 cases). Interestingly, we also operated two cases of injury after bicycle accidents, which can be explained by the frequent use of bicycles for transportation in the Netherlands [74]. Overall, outcome after surgery in our small series was variable. ...
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Meralgia paresthetica is often idiopathic, but sometimes symptoms may be caused by traumatic injury to the lateral femoral cutaneous nerve (LFCN) or compression of this nerve by a mass lesion. In this article the literature is reviewed on unusual causes for meralgia paresthetica, including different types of traumatic injury and compression of the LFCN by mass lesions. In addition, the experience from our center with the surgical treatment of unusual causes of meralgia paresthetica is presented. A PubMed search was performed on unusual causes for meralgia paresthetica. Specific attention was paid to factors that may have predisposed to LFCN injury and clues that may have pointed at a mass lesion. Moreover, our own database on all surgically treated cases of meralgia paresthetica between April 2014 and September 2022 was reviewed to identify unusual causes for meralgia paresthetica. A total of 66 articles was identified that reported results on unusual causes for meralgia paresthetica: 37 on traumatic injuries of the LFCN and 29 on compression of the LFCN by mass lesions. Most frequent cause of traumatic injury in the literature was iatrogenic, including different procedures around the anterior superior iliac spine, intra-abdominal procedures and positioning for surgery. In our own surgical database of 187 cases, there were 14 cases of traumatic LFCN injury and 4 cases in which symptoms were related to a mass lesion. It is important to consider traumatic causes or compression by a mass lesion in patients that present with meralgia paresthetica.
... In recent years, cycling has become more popular than in the past for transport and for sports purposes [1]. Bicycle-related trauma is widespread in urban areas, representing a consistent percentage of road traffic victims worldwide (2) [2]. ...
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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.
... As the popularity of two-wheeled vehicles grows, concerns about road safety are growing as well [12,13]. Cyclists have a high level of vulnerability: bicycle fatalities account for 8% of the total road fatalities recorded in 2016 in EU countries [6]. ...
Tyre characteristics can strongly affect bicycle dynamics. In light of this, proper test-rigs are required to accurately measure tyre parameters. The paper presents a review of the methods and devices developed for the experimental characterisation of bicycle tyres in the lateral direction. The main aspects of the known test devices are described, highlighting the respective features. The technology of test-rigs for bicycle tyre parameter measurement seems to be just beginning. ARTICLE HISTORY
... These differences might be owing to differences between adults and children regarding the circumstances of collisions and the features and mechanisms of injuries. First, although the head is the most commonly injured body region in adult and child bicyclists 19,[23][24][25][26][27] , children survive head injuries more often than adults. The adult brain is considered to be less amenable to physiological and neuroanatomical reorganization following injury 28,29 . ...
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Bicyclists still account for the majority of child deaths in traffic accidents, despite a gradual decrease in incidence. Therefore, we investigated factors associated with child and adult bicyclist fatalities. In this retrospective study, we used data from a national hospital-based database, the Japan Trauma Data Bank. Data from 2004 to 2019 were obtained for child cyclists (5–18 years; n = 4832) and adult cyclists (26–45 years; n = 3449). In each age group, physiological variables, outcomes, and injury severity were compared between fatal and non-fatal cases. Multivariate logistic regression was performed to determine factors associated with fatality. In adults, fatality was associated with lower values for body temperature, Glasgow Coma Scale score, and Abbreviated Injury Scale (AIS) score for the neck and upper extremities, and with higher values for respiratory rate, heart rate, focused assessment with sonography for trauma positivity rate, and AIS scores for the head, chest, and abdomen. In children, fatality was associated with lower values for body temperature and the Glasgow Coma Scale score, and with higher values for the AIS chest score. These findings point to factors associated with bicyclist fatalities and may help in the development of effective strategies to reduce these fatalities.
... Unsere Ergebnisse haben gezeigt, [24]. Nie derländische Studien bestätigen, dass unabhängig, ob es sich um einen schweren oder leichteren Radunfall han delt, vor allem Kopf/Gesicht und Extremitäten verletzt werden [25]. ...
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Dooring Bicycle Accidents with Severe Injury Patterns: 10-Year Study of a Level 1 Trauma Center Abstract. Studies in Switzerland, Germany and Austria have shown that, contrary to popular belief, dooring accidents are among the most common bicycle accidents. The resulting injuries are often serious and often lead to hospital admission. All dooring accidents of the Inselspital Emergency Department in Bern between 2012 and 2021 were identified and evaluated retrospectively. The data were generated from the database of the management system (Ecare) of the University Hospital Bern by means of a search query with the German keywords: "Autotüre", "Autotuere", "Dooring" and were anonymised. Most patients were female and on average 34 years old; most injuries occurred to the head and the extremities. Treatment was mostly done on an outpatient basis. The ISS (Injury Severity Score) was an average of 3.5. One of the patients needed emergency surgery. This is the first Swiss study to systematically record and evaluate dooring accidents. Since cycling is a trend, especially in urban areas, and consequently the number of cyclists is constantly increasing, it can be assumed that the number of dooring injuries will also increase and corresponding prevention measures will have to be taken. The current COVID-19 pandemic tends to aggravate the problem, as in the context of infection control the number of cyclists and, consequently, accidents is increasing, especially in urban areas, in the context of infection control. This said, it is crucial to gain more information about the time slots of the accidents and the casualties through appropriate studies in order to take adequate preventive and protective measures.
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In this paper, the twisting torque of bicycle tyres is studied. The twisting torque is just the self-aligning torque for null lateral slip and non-null camber. The relationship between twisting torque and contact patch area has been analyzed. As the latter increases, twisting torque increases as well. A theoretical model to evaluate twisting torque has been implemented. Since twisting torque is mainly due to longitudinal slip in cambered wheel, increasing the contact patch area the stresses are located at a larger distance from the median plane of the contact patch. The resulting torque will be higher in magnitude. Finally, the model has been validated comparing the outcomes with the experimental data, with a mean error less than 3% for camber angles less than 10 deg.
This study aims to compare the accident injury severity of e-bikes with that of other types of two-wheelers based on accident data and to analyze the factors influencing them. Using 1015 police accident records from Zhangjiakou City in 2020 and 2021, the accident injury severity of e-bikes was firstly compared with that of other two-wheelers based on five levels of accident injury severity classified according to the records. Two ordered Probit regression models were secondly used to compare the factors influencing the accident injury severity of e-bikes with that of other two-wheelers and the magnitude of their effects. At the same time, the contributions of each influential factor to the degree of accident injury of two-wheelers were estimated with the assistance of classification trees. Results show that e-bikes are closer to bicycles than motorcycles in terms of injury severities and the factors influencing them, in which the factors "accident configuration," "division of responsibility for the accident," and "collision with a heavy vehicle or four-wheeled vehicle" are significant. Based on the findings, potential measures are suggested to reduce e-bike accident casualties, such as improving rider education, ensuring speed limit enforcement, promoting safety equipment wearing, and making road design friendly to non-motorized and elderly riders. The results of this study can provide an essential reference for traffic management and rider education measures on e-bikes.
Bicycle utilization continues to increase annually, and this trend was recently accelerated by the coronavirus disease of 2019 pandemic. There is limited epidemiologic data, however, regarding the prevalence and nature of bicycle‐related injuries. Therefore, the purpose of this study is to characterize trends in bicycle‐related injuries. The National Electronic Injury Surveillance System was queried for bicycle‐related injuries from 2012 to 2021. Patient demographic and injury data were collected and analyzed to describe trends in incidence, patient demographics, and injury patterns associated with an emergency department encounter for a bicycle‐related injury. There were an estimated 4,666,491 (95% confidence interval: 4,661,472–4,671,510) bicycle‐related injuries from 2012 to 2021. The incidence of these injuries has significantly decreased over time (R = −0.983, R2 = 0.967, p < 0.001). However, the rate of injury in elderly patients increased over time. Injuries occurred most often during summer months (36%) and on weekend days (31.9%). Males and younger patients were more commonly injured. Head injuries were the most commonly affected body part among all age groups. Fractures were the most common injury type overall. Upper extremity injuries were more common than the lower extremity. Despite increased public bicycle utilization, there is a significant downtrend in bicycle‐related injuries over the last decade. Injuries among elderly patients are becoming more common, who demonstrate a high rate of fracture and head injury. Fractures and head injuries were the most common injuries among all age groups, highlighting the importance of bicycle safety initiatives and helmet‐wearing regardless of age.
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Background The research literature was systematically reviewed and results were summarized from studies assessing bicycle helmet effectiveness to mitigate head, serious head, face, neck and fatal head injury in a crash or fall. Methods Four electronic databases (MEDLINE, EMBASE, COMPENDEX and SCOPUS) were searched for relevant, peer-reviewed articles in English. Included studies reported medically diagnosed head, face and neck injuries where helmet use was known. Non-approved helmets were excluded where possible. Summary odds ratios (OR) were obtained using multivariate meta-regression models stratified by injury type and severity. Time trends and publication bias were assessed. Results A total of 43 studies met inclusion criteria and 40 studies were included in the meta-analysis with data from over 64 000 injured cyclists. For cyclists involved in a crash or fall, helmet use was associated with odds reductions for head [OR = 0.49, 95% confidence interval (CI): 0.42–0.57), serious head (OR = 0.31, 95% CI: 0.25–0.37), face (OR = 0.67, 95% CI: 0.56–0.81) and fatal head injury (OR = 0.35, 95% CI: 0.14–0.88). No clear evidence of an association between helmet use and neck injury was found (OR = 0.96, 95% CI: 0.74–1.25). There was no evidence of time trends or publication bias. Conclusions Bicycle helmet use was associated with reduced odds of head injury, serious head injury, facial injury and fatal head injury. The reduction was greater for serious or fatal head injury. Neck injury was rare and not associated with helmet use. These results support the use of strategies to increase the uptake of bicycle helmets as part of a comprehensive cycling safety plan.
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Although from a societal point of view a modal shift from car to bicycle may have beneficial health effects due to decreased air pollution emissions, decreased greenhouse gas emissions, and increased levels of physical activity, shifts in individual adverse health effects such as higher exposure to air pollution and risk of a traffic accident may prevail.Objective: We describe whether the health benefits from the increased physical activity of a modal shift for urban commutes outweigh the health risks. We have summarized the literature for air pollution, traffic accidents, and physical activity using systematic reviews supplemented with recent key studies. We quantified the impact on all-cause mortality when 500,000 people would make a transition from car to bicycle for short trips on a daily basis in the Netherlands. We have expressed mortality impacts in life-years gained or lost, using life table calculations. For individuals who shift from car to bicycle, we estimated that beneficial effects of increased physical activity are substantially larger (3-14 months gained) than the potential mortality effect of increased inhaled air pollution doses (0.8-40 days lost) and the increase in traffic accidents (5-9 days lost). Societal benefits are even larger because of a modest reduction in air pollution and greenhouse gas emissions and traffic accidents. On average, the estimated health benefits of cycling were substantially larger than the risks relative to car driving for individuals shifting their mode of transport.
Objectives: In 2014, 726 bicyclists were killed and an additional 50,000 were injured in crashes with motor vehicles. The number of cyclists in the United States is increasing, and as a result there has been a call for more bike lanes. We examined the difference in the severity of injury of bicyclists involved in motor vehicle crashes when riding in the traffic lane compared with riding in a bike lane or on a paved shoulder. We also controlled for other safety factors, including alcohol use, travel speed, posted speed, helmet usage, and lighting conditions to determine their impact on bicyclist safety. Methods: Single-year National Automotive Sampling System-General Estimates System files were used to analyze data regarding the bike lanes, and multiyear data were used to analyze the additional factors. Univariate and multiple regression analyses controlling for confounders were performed on the data. Results: When adjusting for speed limit, alcohol use by driver, weather conditions, time of day, and helmet use, the cyclist's position had no significant effect on the severity of injury (P = 0.57). The severity of injury was significantly greater when the driver or bicyclist had been drinking alcohol (P < 0.0001 and P < 0.003, respectively). Bicyclists were more severely injured when vehicles moved at greater speeds and the posted speed limit was higher (P < 0.0001 for both). Also, injury severity was found to be significantly higher when lighting conditions were "dark" (P < 0.0001). Conclusions: Our findings suggest that simply having a dedicated space for bicyclists, such as a bike lane or a paved shoulder, does not reduce the severity of injuries sustained when a crash with a motor vehicle takes place. Cyclist safety could be improved by implementing changes that affect vehicle speed, alcohol use by drivers, and lighting conditions. Moreover, emergency physicians should be aware that when they receive a report of a cyclist being struck by a car in a bike lane, they should prepare to treat injuries of severity similar to those received by a bicyclist hit by a vehicle in traffic.
Background: Detailed information on health care costs and productivity costs for the whole spectrum of injuries is lacking. We measured the total costs of injuries by external-cause, injury groupings, age and sex. Method: Injury patients visiting an Emergency Department in the Netherlands were included. Health service use and work absenteeism were estimated with national database data and a prospective follow-up study. Health care costs (direct costs) and productivity costs (indirect costs) were determined using the incidence-based Dutch Cost of Injury Model. Results: Total costs of injuries were €3.5 billion annually (€210/capita and €4300/patient); €2.0 billion healthcare costs and €1.5 billion productivity costs. Home and leisure injury subcategory falls caused 41% of total costs. Traffic injury was prominent in the 15-54 age group, mainly due to bicycle injuries. Sports injuries, in special football/soccer injuries, resulted in high costs in the 15-24 age group. Although costs per patient were comparable between males and females, health care costs were higher in females, whereas males have more than twice as high productivity costs. Health care costs were highest for hip fractures (€20,000/patient). Extremity fractures had high costs due to high incidences and high productivity costs per patient. Conclusion: Our detailed cost model identified known risk groups, such as elderly females with hip fractures resulting from falls, as well as less obvious important high risk groups, such as young children falling from furniture, young males who sustained football/soccer injuries and bicycle injuries among all ages. This information is essential to assess additional priority areas for prevention.
The Injury Severity Score (ISS) is the most ubiquitous summary score derived from Abbreviated Injury Scale (AIS) data. It is frequently used to classify patients as 'major trauma' using a threshold of ISS >15. However, it is not known whether this is still appropriate, given the changes which have been made to the AIS codeset since this threshold was first used. This study aimed to identify appropriate ISS and New Injury Severity Score (NISS) thresholds for use with the 2008 AIS (AIS08) which predict mortality and in-hospital resource use comparably to ISS >15 using AIS98. Data from 37,760 patients in a state trauma registry were retrieved and reviewed. AIS data coded using the 1998 AIS (AIS98) were mapped to AIS08. ISS and NISS were calculated, and their effects on patient classification compared. The ability of selected ISS and NISS thresholds to predict mortality or high-level in-hospital resource use (the need for ICU or urgent surgery) was assessed. An ISS >12 using AIS08 was similar to an ISS >15 using AIS98 in terms of both the number of patients classified major trauma, and overall major trauma mortality. A 10% mortality level was only seen for ISS 25 or greater. A NISS >15 performed similarly to both of these ISS thresholds. However, the AIS08-based ISS >12 threshold correctly classified significantly more patients than a NISS >15 threshold for all three severity measures assessed. When coding injuries using AIS08, an ISS >12 appears to function similarly to an ISS >15 in AIS98 for the purposes of identifying a population with an elevated risk of death after injury. Where mortality is a primary outcome of trauma monitoring, an ISS >12 threshold could be adopted to identify major trauma patients. Level II evidence-diagnostic tests and criteria. Copyright © 2015 Elsevier Ltd. All rights reserved.
Use of electrically assisted bicycles with a maximum speed of 25 km/h is rapidly increasing. This growth has been particularly rapid in the Netherlands, yet very little research has been conducted to assess the road safety implications. This case–control study compares the likelihood of crashes for which treatment at an emergency department is needed and injury consequences for electric bicycles to classic bicycles in the Netherlands among users of 16 years and older. Data were gathered through a survey of victims treated at emergency departments. Additionally, a survey of cyclists without any known crash experience, drawn from a panel of the Dutch population acted as a control sample. Logistic regression analysis is used to compare the risk of crashes with electric and classical bicycles requiring treatment at an emergency department. Among the victims treated at an emergency department we compared those being hospitalized to those being send home after the treatment at the emergency department to compare the injury consequences between electric and classical bicycle victims. The results suggest that, after controlling for age, gender and amount of bicycle use, electric bicycle users are more likely to be involved in a crash that requires treatment at an emergency department due to a crash. Crashes with electric bicycles are about equally severe as crashes with classic bicycles. We advise further research to develop policies to minimize the risk and maximize the health benefits for users of electric bicycles.
The paper compares the risk-taking behavior of the riders of electric-bikes and bicycles and their effects on safety at signalized intersections. Data were collected at signalized intersections in the city of Kunming in China. Traffic conflicts techniques are used to estimate the safety effects of electric-bikes and bicycles, with the incidents observed divided into sixteen types. About 77.7% of conflicts were caused by the risky behavior of the automobiles drivers that in particular did not yield right-of-way to electric-bikes/bicycles, 13.4% by the risky behavior of e-bikers, and the rest by cyclists. Red-light running was the leading cause for the conflicts in which the electric-bikes were at-fault.
White papers: rules & regulations on electric cycles in the EU
  • E Bike
Bike E. White papers: rules & regulations on electric cycles in the EU; 2017. al-1.amazo app/uploa ds/2015/09/rules -regul ation -on-elect ric-cycle s-in-theeurop ean-union -may-2017.pdf.