Injuries related to bicycle accidents: an epidemiological study in The Netherlands

Abstract

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.

Full text

Vol.:(0123456789)
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European Journal of Trauma and Emergency Surgery (2020) 46:413–418
https://doi.org/10.1007/s00068-018-1033-5
ORIGINAL ARTICLE
Injuries related tobicycle accidents: anepidemiological study inThe
Netherlands
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
Abstract
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
Introduction
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
s.sadiqi-3@umcutrecht.nl
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,
TheNetherlands
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
Patients
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].
Outcomes
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.
Results
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
1 3
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
factors.
Trends
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 (%)
Gender
Male 1213 (61.1)
Female 767 (38.6)
Missing 6 (0.3)
Age Mean 45.0 (SD 24.1)
Accident
One-sided 985 (49.6)
Two-sided 1001 (50.4)
ISS Mean 13.6 (SD 10.6)
Deceased
No 1860 (93.6)
Yes 114 (5.7)
Missing 12 (0.6)
Helmet
No 1838 (92.5)
Yes 148 (7.5)
Fracture
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)
Aftermath
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
(Table4).
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.
Discussion
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
Gender
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)
Accident
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)
Helmet
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)
Multitrauma
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)
Deceased
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
1 3
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
study.
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.
1 3
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
population.
Compliance with ethical standards
Conflict of interest All authors declare that they have no conflict of
interest.
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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