Severe bicycling injury risk factors in children and adolescents: A case–control study
Introduction
Bicycling improves mental and physical health, reduces the risk of diabetes and obesity and reduces air pollution (Andersen et al., 2000, Reynolds et al., 2009, de Hartog et al., 2011). Conversely, bicycling is the most common cause of sport and recreation injury in those under 19 years old (Rivara and Grossman, 2004), the fourth-leading cause of hospitalizations and sixth leading cause of unintentional injury deaths in Canada for those under age 15 (Public Health Agency Of Canada, 2006). Children and adolescents have the highest rates of hospitalization for bicycle injuries (Jacobsen et al., 2009, Boufous et al., 2011). Given the popularity of cycling as an alternative mode of transportation, understanding risk factors for injury, especially severe injury, is important.
A number of studies have identified factors associated with severe injuries among bicyclists, though few have focused on children and adolescents and simultaneously examined a comprehensive list of potentially modifiable characteristics. Acton et al. (1995) noted that among children less than 15 years old, males had greater fatality rates than females and rates were highest between 12 and 14 years of age. Linn et al. (1998) found that motor vehicle involvement increased the odds of hospital admission 5-fold in their series of emergency department reported injuries among those under 19 years old. For those under 21 years old, Shah et al. (2007) noted the greatest rates of bicycle-related hospitalization for those 10–13 years old and that boys had higher rates than girls. Adolescents 15–18 years old had bicycling fatality rates over 4 times greater than those under 15 years old and those who sustained an injury on the street had an increased risk of hospitalization and death in the study by Mehan et al. (2009). Finally, Siman-Tov et al. (2012) identified strong relationships between motor vehicle involvement and a number of severe injury indicators (intensive care unit admission, length of hospital stay, rehabilitation and mortality) in those under 18 years of age.
Other studies have not restricted their analyses to children and adolescents in the search for severe bicycle related injuries. Rivara et al. (1997) noted an increased risk of serious injury in those under 13 and those 40 and older compared with 20–39 year olds. They also found an increase in the likelihood of severe injury with greater self-reported speed and with motor vehicle collisions (Rivara et al., 1997). Fatalities were associated with being male, motor vehicle collisions, and greater self-reported speed while helmet use reduced risk (Rivara et al., 1997). The likelihood of a severe injury due to a single bicycle crash was lower in municipalities with more bicycling and higher among those 25 and older in the study by Schepers (2012). Based on police traffic collision reports, Kim et al. (2007) noted a relationship between bicyclist fatalities and greater vehicle speed, inclement weather, truck involvement, motor vehicle and bicyclist intoxication and being 55 and older. Boufous et al. (2012), however, again using police traffic collision reports, found that severe injuries and fatalities were associated with adult age groups, dark conditions, greater location speed limits, rural locations, curved roads, certain crash types (e.g., vehicles collided from opposite directions) and no helmet use.
The most common mechanism of injury is a fall or loss of control (Rivara et al., 1997, Jacobsen et al., 2009); although, as noted above, a collision with a MV is associated with more severe injury and death (Cushman et al., 1990, Acton et al., 1995, Rivara et al., 1997, Linn et al., 1998, Kim et al., 2007, Jacobsen et al., 2009). Helmets reduce head, brain and severe brain injuries for all types of crashes (Finvers et al., 1996, Rivara et al., 1997, Attewell et al., 2001, Thompson et al., 2004, Amoros et al., 2012) and incorrect bicycle helmet fit increases head or facial injury risk (Rivara et al., 1999, Romanow et al., 2014).
To summarize, sex (males), age (adolescents), and motor vehicle involvement have been found to increase the risk of a severe bicycling injury in studies on children and youth. In those investigations examining risk factors for severe injuries among all age groups, these same factors, along with helmet use, the number of bicyclists, vehicle speed, weather conditions, bicyclist intoxication, time of the day, location speed limit, road type and rural location influenced severe bicyclist injury risk. Given the lack of comprehensive analytic studies focused on children and adolescents, the objective of this investigation was to simultaneously examine a wide range of potential risk factors for severe bicycling injuries in youth.
Section snippets
Study population
Study participants were bicyclists under the age of 18 who presented to one of seven EDs in Calgary (Alberta Children’s Hospital, Foothills Medical Centre, Peter Lougheed Centre, Rockyview General Hospital) and Edmonton (Stollery Children’s Hospital, University of Alberta Hospital, North East Community Health Centre) between May 2008 and October 2010. These individuals were originally part of a larger study of risk factors for motor vehicle related and severe injuries in relation to visibility
Cyclist characteristics
Data from 1470 participants were included in this study (Fig. 1). There were 119 cases (8.1%), and 1351 controls (91.9%). There were 403 females and 1067 males. Most (n = 844) were 6–12 years old, 479 were 13–17, and 147 were 5 and under.
Body region distribution
There were 1817 separate injuries (Table 1). Cases incurred 177 injuries while controls sustained 1640 injuries. Among cases, the upper extremities accounted for approximately a third of the injuries. Head injuries represented 27% of the injuries among cases,
Discussion
We found that the risk of severe injury was significantly greater among those who collided with a moving MV, if the bicyclist was not wearing a helmet, if they were male, or if they were injured on an unpaved surface. Previous studies have not assessed such a wide array of risk factors simultaneously in such a large sample of children and adolescents.
The post-secondary education status of parents was a predictor of severe injury, which is consistent with findings from other studies (Pless et
Conclusions
This study has identified several modifiable factors associated with severe cycling injuries that could be used to reduce the public health burden of these crashes. Bicycle–MV collisions are a significant risk factor for severe bicycle injuries in children and adolescents. Helmet use significantly reduced the odds of severe injury and is strongly recommended for bicyclists. Separating bicyclists from motor vehicles and reducing speed limits would likely increase safety, which may lead to more
Conflict of interest
None.
Financial disclosure
None.
Acknowledgements
The authors would like to thank the clinical and research staff at the participating hospitals. A special acknowledgment is to the study research staff and students in Edmonton and Calgary, the Paediatric Emergency Research Team (PERT), the volunteers from the Paediatric Emergency Medicine Research Associates Program (PEMRAP) at the Alberta Children’s Hospital, and the emergency medicine research assistants at the Foothills Medical Centre. The authors would also like to thank Jamie McEwen for
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