MJA

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Volume 193 Number 10

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15 November 2010

619LETTERS

The Medical Journal of Australia ISSN:0025-729X 15 November 2010 193 10668-676©The Medical Journal of Australia2010 www.mja.com.au

Trends in head injuries andhelmet use in cyclists at aninner-city major trauma centre,1991–2010

Michael M Dinh, Susan Roncal, TimothyC Green, Elizabeth Leonard, AmandaStack, Chris Byrne and Jeffrey Petchell

THE

DITOR

The benefits of bicyclehelmet use have been the subject of recentdiscussion, with calls from some experts toreview laws mandating the wearing of hel-mets.

The objective of this brief report is tosummarise long-term trends in cyclist headinjuries seen at an inner-city major traumacentre and determine the odds of any skullfracture or intracranial bleed associated withnot wearing a helmet.This was a retrospective study conductedat the Royal Prince Alfred Hospital (RPAH,Sydney, New South Wales), covering severallocal government areas that have the highestbicycle-use rates in NSW,

where the law formandatory helmet wearing was enacted in1991. Patient data were obtained throughthe hospital trauma registry, which containsdata on all patients admitted to the hospitalwith trauma. These data included informa-tion on helmet use routinely abstracted fromambulance and medical notes. Inclusion cri-teria were cyclists admitted from 1991 to2009, who were over 16 years of age andinvolved in an incident on a public road. Weexcluded patients transferred from otherhospitals. Head Abbreviated Injury Scale(AIS) scores (AIS 1990, 1998 and 2005versions

) were used, with a head AIS score

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3 indicating severe head injury, such assignificant intracranial bleeding or depressedor comminuted skull fracture. Injuries withan AIS score of 2 included isolated concus-sion and simple skull fractures.To investigate the association betweenhelmet use and head injury, we reviewed themedical charts of all cyclists admitted withtrauma from 2008 to June 2010. We com-pared mechanism of injury (fall off bikewithout collision versus collision withanother vehicle or object), anatomical injury(skull fracture or intracranial bleed), helmetuse and the type of road where the incidentoccurred (state or regional roads versus localroads), according to NSW Roads and Traffic Authority classifications. Data were analysedusing Stata software, version 10.1 (Stata-Corp, College Station, Tex, USA). Percent-ages were calculated with 95% confidenceintervals, and categorical data were com-pared using

tests. Mean ages were com-pared using the Student

test, and a logisticregression model was used to obtain oddsratios for any skull fracture or intracranialbleed associated with not using a helmet,after adjusting for mechanism of injury androad type. The study was approved by theSydney South West Area Health ServiceRPAH Ethics Review Committee (RPAHZone).There were 979 patients who met ourinclusion criteria. The long-term trend inthe number of cyclists sustaining severehead injuries remained low (range, 0–3per year) (Box 1). Cyclists as a percentageof total admissions for trauma increasedfrom 1.3% in 2005 (29/2258 [95% CI,0.9%–1.8%]) to 3.9% in 2009 (122/3104[95% CI, 3.3%–4.7%]). Trends in helmetuse and severe head injury are summarisedin Box 2. Severe head injury rates as apercentage of total cyclists admitteddecreased from 10.3% (3/29 [95% CI,3.6%–26.4%]) in 2005 to 2.5% (3/122[95% CI, 0.8%–7.0%]) in 2009, a relativereduction of 76%. Helmet use in admittedcyclists from 1991 to 2009 ranged from85% to 100%.Information was available about the loca-tion of the fall and helmet use for 287 of the313 cyclists identified from 2008–2010 (Box3). Their mean age was 36 years (95% CI,34–37 years) and 81% were men. Non-helmet wearers had five times higher odds of intracranial bleeding or skull fracture com-pared with helmet wearers after adjusting forroad type and mechanism of injury (oddsratio, 5.3 [95% CI, 1.7–17.1];

=0.005).The increase in admissions for bicycleinjury is consistent with recently reportedpopulation trends.

In addition, the numberof cyclists sustaining severe head injurieshas remained consistently low over the longterm, with an apparent decline in the rate of severe head injuries in admitted patientssince 2005. The odds reduction for skullfractures and intracranial bleeds in thosewearing helmets is within the range reportedin a Cochrane review of helmet use.

Thebenefits of helmet use need to be placed inthe context of lifetime costs of severe trau-matic brain injury, estimated to be around$4.8 million per incident case.

It is the opinion of the trauma service atRPAH, based on these findings, that man-datory bicycle helmet laws be maintained,and enforced as part of overall road safetystrategies.

2 Trends in bicycle helmet use andsevere head injury as a percentageof total cyclist trauma admissions,RPAH, Sydney, New South Wales,1991–2009

AIS=Abbreviated Injury Scale.RPAH=Royal Prince Alfred Hospital.

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