Safety on Bicycles, Skateboards, Scooters, and Skates

Helmets for Preventing Head and Facial Injuries in Bicyclists. Thompson DC, Rivara FP, Thompson R. Cochrane Database Syst Rev.1999;4:CD001855Injury-control Recommendations: Bicycle Helmets. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep.1995;44(RR-1)Bicycle Helmet Legislation for the Uptake of Helmet Use and Prevention of Head Injuries. Macpherson A, Spinks A. Cochrane Database Syst Rev.2007;2:CD005401In-line Skating Injuries in Children and Adolescents. American Academy of Pediatrics, Committee on Injury and Poison Prevention and Committee on Sports Medicine and Fitness. Pediatrics.1998;101:720–722Skateboard and Scooter Injuries. American Academy of Pediatrics, Committee on Injury and Poison Prevention. Pediatrics.2002;109:542–543Pediatricians should counsel families on ways their children can avoid injury on bikes, scooters, skateboards, and skates. Although some recommendations are based more on common sense than on evidence, the protective effects of helmet use for bicycle riders are uncontested. Each year in the United States, approximately 500,000 people of all ages are treated in emergency departments (EDs) for injuries related to bicycle riding. About 6% of these visits, 30,000 per year, lead to hospitalization, and close to 1,000 of the injuries are fatal. Facial injury, bony fractures, blunt abdominal trauma, abrasions, and lacerations account for most of the injuries. Although head injuries are involved in only one third of these ED visits, they lead to two thirds of hospital admissions and cause three quarters of the deaths related to biking. Children younger than age 15 years are disproportionately affected, accounting for three quarters of ED visits for bicycle-related head injuries and up to one half of the deaths.Fewer ED visits, approximately 125,000 per year, are made for injuries related to the use of scooters, skateboards, and skates. Most of these injuries involve fractures of the wrist, hand, or ankle and trauma to the face. One third of those injured on skateboards experience their trauma in the first week of skateboarding. These data on morbidity and mortality derive from hospital inpatient and ED records, which represent the severe end of the spectrum of injuries.Helmets have been shown to provide as much as an 88% reduction in the risk of head and brain injury and a 65% reduction in injuries to the upper extremities and mid-face related to bicycle riding. For inline skaters, wearing wrist guards and elbow pads can reduce the risk of upper extremity injuries by 90%. Few data have been reported on the protective effects of safety gear for riders of scooters and skateboards. One study supports the belief that when cyclists wear bright or reflective clothing and limit riding in the dark, they are more likely to be noticed by drivers.Pediatricians are urged to counsel children and families to use properly fitting, approved helmets for all of these activities and to wear these helmets low on the forehead for maximal protective effect. People on scooters, skateboards, and skates should wear knee and elbow pads. Skateboarders and skaters also should wear wrist guards. Novice skaters are encouraged to learn in rinks. For those on skateboards, specifically designed parks are favored over courses that have home-constructed ramps and jumps because they provide environments that are likely to be safer and better supervised. Children and adolescents should not ride scooters or skateboards in traffic. Skaters and skateboarders never should hitch a ride on motor vehicles, a dangerous practice known as “skitching” or “truck-surfing.”The past 30 years of literature on office-based safety counseling by pediatricians has failed to demonstrate much impact on behavior outside of improvements in household safety and the use of infant car seats. The most important advances in bicycle safety have come from the increased use of helmets resulting from community-based advocacy and legislation. Public campaigns have employed widespread educational efforts and subsidies for helmets. These interventions have been most effective when they have been community-based and the helmets are provided free, rather than leaving users to buy low-cost helmets. The first major campaign in the United States was carried out in Seattle, Washington, between 1987 and 1992, leading to a rise in helmet use in the community from less than 6% to 40% and a reduction by two thirds in the rate of bicycle-related head injury among children ages 5 to 14 years belonging to one health maintenance organization. Helmet use rose from 8% to 19% from 1990 to 1992 in Montgomery County, Maryland, during a similar initiative.Legislative interventions have had powerful effects in the United States and abroad. Two- to fivefold increases in observed helmet use by children have been documented in Austin, Texas; Jacksonville/Duval County, Florida; San Diego, California; a rural community in Georgia; and across the states of Oregon and California. In Victoria, Australia, helmet use by children rose from 6% to 36% over the course of a 7-year educational campaign between 1983 and 1990. One year after legislation was enacted there, helmet use by children doubled again, to 73%. Between 1990 and 1996 in Houston, Texas, helmet use rose from 4% to 67% after legislation was passed, and the rate of bicycle-related head injuries at one major medical center was cut in half. In four provinces in Canada, where mandatory bicycle helmet laws were enacted between 1994 and 1998, hospitalizations for bicycle-related head injury dropped by 45% compared with 27% in provinces having no such legislation. Bicycle-related traumatic brain injuries among minors fell by 18% in California, and associated fatalities were reduced by 30% in Oregon following statewide legislation.Bicycle helmet laws are now in effect in 22 states and 129 counties and municipalities in the United States. To date, no credible evidence has documented that riders who wear helmets counteract the protection by riding faster or under more dangerous conditions. This concept of “risk homeostasis” has been the principal argument waged against campaigns and legislation in favor of helmet use. Other barriers to more widespread use of helmets and protective gear, particularly among children and adolescents, include a perceived low risk of personal injury, lack of comfort, poor ventilation, and concerns about appearance. These important obstacles need to be addressed creatively.The “SAFE KIDS Campaign” of the National Highway Safety Traffic Administration offers sample legislative wording for those interested in advocating for mandatory use of bicycle helmets. Health professionals should realize that work to promote bicycle helmet use through community campaigns and legislative advocacy has the potential to do the greatest good.Comment. Don't we, as a nation, ever learn? After all the years it took to get automobile seat belt legislation passed, why, with so much compelling data, do only 22 states have bicycle helmet laws in place today?

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