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Craniofacial Injuries Seen With the Introduction of Bicycle-Share Electric Scooters in an Urban Setting

Published:August 01, 2019DOI:https://doi.org/10.1016/j.joms.2019.07.014

      Purpose

      Standing electric scooters (e-scooters) are rapidly becoming popular modes of transportation in many urban areas across the United States. However, this increase in popularity has resulted in an increase in traumatic injuries associated with these modes of expedient travel. The purpose of the present study was to determine the types of craniofacial trauma directly related to e-scooter use in a major urban center (Dallas, TX).

      Materials and Methods

      We performed a retrospective case series and examined the medical records of the patients who had presented to the emergency department (ED) for trauma related to e-scooter use. Descriptive statistics were calculated for all variables on patient presentation, including incident notes and patient interviews, demographic information, diagnostic tests, trauma (ie, location, type, severity), treatment (ie, type, admission, outpatient referral, follow-up data), and contributing factors (ie, reported or detected alcohol use, use of protective equipment).

      Results

      A total of 90 patients (56 males, 34 females; mean age, 31.8 years) had presented with scooter-related trauma to the ED during the first 7 months of scooters after their introduction to the metropolitan area. A total of 52 admissions (58% of all admissions) involved injuries of the head and face. The patients had presented with a myriad of craniofacial trauma, ranging from abrasions, lacerations, and concussions to intracranial hemorrhage and Le Fort II and III fractures. Of the 52 craniofacial injuries, 30 (58%) were considered severe (ie, fracture, internal hemorrhage, concussion, loss of consciousness), and 22 (42%) were considered minor (ie, lacerations, contusion, abrasion, dental). Alcohol use had been involved in 18% of all scooter-related trauma admissions, and no rider had reported wearing a helmet.

      Conclusions

      Injuries to the head and face were commonly found with e-scooter admissions in this sample, and the high prevalence of extremity injuries suggested that patients were breaking their fall during the crash. Craniofacial trauma related to e-scooter use could be significantly reduced by the wearing of a protective helmet.
      Standing electric rental scooters (e-scooters), a mode of bicycle-share travel applications common in major urban areas, have become a common form of modern transport. Customers of bicycle-share applications use mobile devices to locate and rent transport methods, including bicycles, standing scooters, and semimotorized bicycles. Since their introduction in 2017, bicycle-share services have become available in more than 80 urban municipalities in the United States. In Dallas, Texas, standing rental scooters have been available for public use since July 1, 2018, with the 4 major e-scooter companies in the metropolitan area (ie, Bird, Lime, Uber, Lyft) recording ∼7000 scooters actively in use. From July 1, 2018 to September 20, 2018, the recorded data showed 450,514 trips, with an aggregate distance traveled of 595,437 miles. Although these data do not reflect the total ridership data to the present, extrapolating this information can estimate the heavy burden of usage within the metroplex, with additional e-scooter introductions planned by other companies. A study by Trivedi et al
      • Trivedi T.K.
      • Liu C.
      • Antonio A.L.M.
      • et al.
      Injuries associated with standing electric scooter use.
      brought attention to the incidence of trauma related to e-scooters. Although e-scooters are easily available for public use and arguably provide a convenient and economical method of transport for “last mile” urban transport, local media have reported concerns regarding the public health effects of bicycle-share programs. Specifically, the burden of traumatic injuries caused by unregulated and unsafe use of these services has not been studied, especially given the variability of the urban settings using bicycle-share applications. Given the convenience of mobile application-based e-scooter use, users are especially vulnerable to falls and associated extremity and craniofacial trauma owing to a variety of factors ranging from the ergonomics of e-scooter riding to bicycle lane availability, and the civic infrastructure. The present study considered the incidence and nature of craniofacial trauma reported at a large, urban Level I trauma center in the southwestern United States (Dallas, TX).
      Currently, 4 e-scooter companies are functioning in Dallas, renting similar models of e-scooters that travel ∼15 miles/hr.
      • Popovich N.
      • Gordon E.
      • Shao Z.
      • et al.
      Experiences of electric bicycle users in the Sacramento, California area.
      The user stands on a small platform and uses an ∼3.5-ft handlebar to navigate the vehicle (Fig 1). Given the ergonomics of riding standing scooters, the expedient nature of e-scooter use, and the lack of the use of protective gear, users are especially susceptible to trauma from falls. In addition, the users' hands are engaged in navigation and holding stance; thus, on impact, the users will be unable to break their fall, making them especially susceptible to craniofacial trauma.
      • Langford B.
      • Chen J.
      • Cherry C.
      Risky riding: Naturalistic methods comparing safety behavior from conventional bicycle riders and electric bike riders.
      • Papoutsi S.
      • Martinolli L.
      • Braun C.
      • Exadaktylos A.
      E-bike injuries: Experience from an urban emergency department—A retrospective study from Switzerland.
      • Graves J.M.
      • Pless B.
      • Moore L.
      • et al.
      Public bicycle share programs and head injuries.
      The easy access and mass usage of e-scooters through mobile applications have exposed thousands of users to a potential public health risk.
      • Allem J.
      • Majmunder A.
      Are electric scooters promoted on social media with safety in mind? A case study on Bird’s Instagram.
      Furthermore, because of the differences in city guidelines for dedicated bicycle/scooter lanes, helmet laws, and the enforcement of laws related to bicycle-share travel, it has been difficult to assess the effect of available infrastructure and other factors on injuries associated with bicycle-share e-scooters.
      • Fishman E.
      • Schepers P.
      Global bike share: What the data tells us about road safety.
      • Griffin R.
      • Parks C.
      • Rue III, L.
      • McGwin G.
      Comparison of severe injuries between powered and nonpowered scooters among children aged 2 to 12 in the United States.
      • Haileyesus T.
      • Annest J.
      • Dellinger A.
      Cyclists injured while sharing the road with motor vehicles.
      • Friedman S.M.
      • Adamson M.
      • Cleiman P.
      • et al.
      Helmet-wearing practices and barriers in Toronto bike-share users: A case-control study.
      Notable cases have included recent legislation in California removing helmet laws for adult riders of e-scooters,
      • Allem J.
      • Majmunder A.
      Are electric scooters promoted on social media with safety in mind? A case study on Bird’s Instagram.
      although cursory observations have shown the lack of helmet use, the frequent use by large groups, sidewalk travel on e-scooters, and the almost ubiquitous location of scooters at or near areas of alcohol sales.
      • Allem J.
      • Majmunder A.
      Are electric scooters promoted on social media with safety in mind? A case study on Bird’s Instagram.
      • Fishman E.
      • Schepers P.
      Global bike share: What the data tells us about road safety.
      • Siman-Tov M.
      • Radomisiensky I.
      • Peleg K.
      • et al.
      A look at electric bike casualties: Do they differ from the mechanical bicycle?.
      • Yao L.
      • Wu Q.
      Traffic safety for electric bike riders in China.
      Figure thumbnail gr1
      Figure 1Photographs showing riding position for electric scooters.
      Our trauma center is located in downtown Dallas and is next to major tourist and urban attractions, providing a unique setting in which to examine the frequency of e-scooter injuries in the first months subsequent to their introduction. The purpose of the present study was to evaluate the emergency department (ED) admissions linked to injuries associated with e-scooter use to measure the incident and types of craniofacial trauma immediately after the introduction of e-scooter rentals.

      Materials and Methods

       Study Design and Sample

      We conducted a retrospective controlled-interval study to evaluate the incidence of craniofacial trauma associated with e-scooter use using the hospital's database of de-identified patients admitted since the introduction of motorized e-scooter rentals at a large, urban Level I trauma center (Dallas, TX). Summary statistics were calculated from the ED medical records for all traumas linked to motorized scooter use. All necessary institutional and ethical approvals were obtained from the institutional review boards.
      The study population included patients admitted (emergent or self-admitted) for treatment at the Baylor University Medical Center at Dallas ED from July 1, 2018 to January 31, 2019. The patients were identified using injury etiology keywords, and the medical records were reviewed to assess the clinical treatment variables associated with scooter-related injuries, including patient demographic data, diagnostic testing results, treatment, and admission details. Injuries were scored for location (eg, head, face, intracranial, neck, chest, abdomen, spine, skin, extremity), type (eg, fracture, dislocation, laceration, abrasion, contusion, concussion, loss of consciousness), and treatment (eg, radiography/computed tomography, reduction, surgery, intubation, outpatient referral/surgery, immobilization, trauma activation). All admissions were then screened for any physician notes or comments associating any trauma with e-scooter use, the specifics of each trauma, patient complaints, and minor traumas not typically coded in patient files (eg, dental trauma, minor abrasions, minor contusions). Reported data such as helmet use, pedestrian involvement, and automobile involvement were also included. Patients were excluded if scooter-related injuries could not be readily identified, if the injury etiology was multifactorial or tangentially related to e-scooter use (eg, pedestrian hit by a scooter), or if patient-reported information was not able to verify the involvement of an e-scooter.

       Data Collection

      We further stratified the facial injuries according to the craniofacial regions: upper face (from the most cephalic point of the head to the orbital floor laterally and nasal bridge medially), midface (bound superiorly by the orbital floor, laterally by the zygomatic arches, and inferior at the tip of the maxillary central incisor), and lower face (bound superiorly by the mandibular dentition, inferiorly by the soft tissue menton, and laterally by the mandibular condyles). The medical records from the ED admissions were reviewed and scored by the region of craniofacial trauma to better estimate the prevalence of head and facial trauma due to e-scooter use. Patients with unspecified trauma were excluded from the analysis by region.

       Statistical Analysis

      Descriptive statistics were calculated for all normally distributed variables, including the proportions and percentages of the total ED encounters for e-scooter–related trauma. Because of the smaller sample sizes, the median and interquartile range were used to better represent non-normally distributed variables.

      Results

      A total of 90 patients (56 males, 34 females) had been admitted to the ED because of e-scooter–related injuries from July 1, 2018 to January 31, 2019 (Table 1). The age of those admitted ranged from 13 to 60 years (mean age, 31.8 years). Most (64.4%) admissions had involved extremity injuries, with 18 fractures, 4 dislocations, and 10 laceration repairs (Table 1). Eight patients (8.8%) had required transfer to the intensive care unit, 13 patients (14.4%) had been admitted to the floor, and 10 patients (11.1%) had undergone surgery. The male patients had experienced trauma at a greater rate (62.2%) of e-scooter–related injuries, and 7 of the patients admitted (7.7%) were younger than 18 years (Fig 2). Alcohol consumption was reported in 16 of all e-scooter–related ED visits (17.8%) at the single site during the first 7 months of their introduction, and none of the admitted patients had reported the use of protective headwear. Of the 90 ED visits, 60 (66.6%) had occurred between 6 pm and 6 am and 52 (57.7%) had occurred during a weekend.
      Table 1Summary Statistics and Frequencies of Trauma
      DemographicAll PatientsGender
      MaleFemale
      Age (yr)
       <187 (7.8)3 (3.3)4 (4.4)
       18-2418 (20.0)11 (12.2)6 (6.7)
       25-3132 (35.6)20 (22.2)12 (13.3)
       32-3810 (11.1)7 (7.9)3 (3.3)
       39-4510 (11.1)7 (7.8)3 (3.3)
       46-527 (7.8)5 (5.6)2 (2.2)
       53-595 (5.6)3 (3.3)2 (2.2)
       >591 (1.1)01 (1.1)
       Total90 (100)56 (62.2)33 (36.7)
      Trauma
      Percentages computed from all patients (n = 90) who had presented with an injury.
       Extremity58 (64.4)3523
       Head33 (36.7)2112
       Face40 (44.4)2614
       Intracranial6 (6.7)51
       Skin6 (6.7)33
       Abdomen3 (3.3)12
       Spine2 (2.2)20
       Chest2 (2.2)20
       Total1509555
      Alcohol consumption16 (17.8)11 (12.2)5 (5.5)
      Data presented as n (%).
      Percentages computed from all patients (n = 90) who had presented with an injury.
      Figure thumbnail gr2
      Figure 2Age and sex distribution of emergency room (ER) admissions for motorized scooter-related traumas during the 6-month period immediately after their introduction.
      Of the 90 patients, 52 (57.7%) had presented with craniofacial trauma related to e-scooter use. When evaluated by region, 15 patients had presented with trauma in multiple facial regions. Of the 52 patients, 28 had trauma to the upper face, 28 to the midface, and 9 to the lower face. This total likely underrepresents the incidence of trauma stratified by region, because 4 patients had had craniofacial trauma to unspecified location (ie, concussion, abrasion, nonspecific facial lacerations). Soft tissue facial injuries were noted in 44 patients (80.8%) who had sustained craniofacial trauma, 28 (53.8%) of whom had required laceration closure. Extensive craniofacial injuries included subarachnoid/subdural hemorrhage in 6 patients (11.5% of craniofacial patients), 1 of whom required emergency craniotomy. Le Fort II and III fractures and 2 Le Fort I fractures had occurred in 3 patients, 1 of whom had sustained a bilateral Le Fort II/III and left-sided Le Fort I fracture. Surgical intervention in the form of open reduction and internal fixation was performed for these patients. One zygomaticomaxillary complex fracture was observed and required open reduction and internal fixation. Only 1 patient had experienced a mandibular fracture, including a right nondisplaced condylar head fracture treated nonsurgically. Dentoalveolar injuries had occurred in 6 patients (11.7% of craniofacial trauma cases). The injuries were confined to the anterior maxillary segment and had ranged from concussion to avulsion of associated teeth.

      Discussion

      With the advent of technological advancements and improvements in data infrastructure, ride-share e-scooters provided by companies such as Lime, Bird, and Razor have become a mainstay for point-to-point transportation for people across many large metropolitan centers in the United States. The present study evaluated craniofacial traumas that had occurred in association with e-scooter use. We reviewed all ED admissions for the first 7 months after the introduction of e-scooter rentals in a large, urban setting to evaluate the incidence of craniofacial trauma specifically linked to e-scooter use. To the best of our knowledge, the present study is the first to attempt to examine the incidence and prevalence of craniomaxillofacial injuries as they correlate with standing e-scooter injuries. Facial injuries of all spectrums were found in our study, with injuries spanning fatal intracranial hemorrhage to simple facial abrasions requiring minimal medical attention. The results from the present study have demonstrated that the introduction of e-scooter usage is linked to a greater incidence of craniofacial trauma at a Level I trauma ED.
      When evaluated by craniofacial region, most injuries had occurred within the upper face and midface (Table 2). Injury to the lower facial region was seen in 12 patients. Based on the mechanics of a forward momentum fall, we anticipated greater high-energy injuries to the lower face; however, this was not the case. This might be explained by the 58 concomitant appendicular extremity injuries (64.4%), the most prevalent injury type recorded in the present sample. The larger prevalence of injuries to the upper face and lower face were also likely because of the lack of helmet use. Of the 90 patients included in our analysis, none had reported wearing a helmet during their incident. This was further confounded by riders attempting to break their fall with their upper extremity before landing. Furthermore, a gross underrepresentation of extremity and dentoalveolar injuries was noted in our sample resulting from the underreporting of individual extremity injuries and dental trauma in the ED medical records.
      Table 2Summary of Craniofacial Trauma and Treatment
      RegionPatients (n)Laceration RepairSurgerySurgical Procedure
      Upper face2871Le Fort III
      Midface2861Open reduction Le Fort I
      Lower face950Not applicable
      Multiple regions15123Emergency craniotomy; open Le Fort III; comminuted zygomaticomaxillary fracture
      The advent of application-based transportation offers an innovative and convenient method of short distance transportation. However, cities with very few dedicated bicycle lanes force riders to share the lane with motor vehicles or pedestrians on the sidewalk. Nearly 2% of all traffic fatalities in Texas have involved cyclists, with fatalities peaking in the evening hours and in urban areas.
      Bicyclists and other cyclists: 2016 data. National Center for Statistics and Analysis, 2018.
      The present study found that most trauma admissions (66.6%) had occurred in the evening. Furthermore, the prevalence of extremity injuries in the present study mirrored those reported in the limited existing e-scooter studies in California,
      • Trivedi T.K.
      • Liu C.
      • Antonio A.L.M.
      • et al.
      Injuries associated with standing electric scooter use.
      likely from riders attempting to break their fall.
      All 4 application-based e-scooter companies currently operating in the study area require a valid driver's license and notified disclaimer that all riders must wear a helmet when operating the e-scooter. However, none of the patients in the present study had been wearing a helmet. The lack of helmet use, in conjunction with the high number of extremity injuries, has demonstrated the need for better communication of the risks associated with e-scooter use. The noncompliance with the posted safety rules was also a significant factor in trauma related to e-scooter use. Our analysis identified no helmet use among the ED admissions, pointing to the lack of compliance, which could significantly reduce the number of e-scooter injuries.
      The limitations of the present study included that we had studied only ED visits associated with e-scooter use at a single trauma center in a metropolitan area with 4 Level I trauma centers. The trauma reported in the present study was likely an underrepresentation of overall injuries associated with e-scooter rentals, limited to those presenting to our ED in need of medical attention. Furthermore, many injuries, including minor injuries and injuries prevented by helmets, were likely underrepresented. Also, these bicycle-share services are available near a major tourist destination with multiple nearby businesses offering alcoholic beverages. Although the bicycle-share companies such as Lime, Bird, and so forth require users to sign an agreement to use helmets and to not consume alcohol while using their e-scooters, nearly 18% of all reported traumas within 7 months of e-scooter introduction had involved alcohol. In addition, the reported proportion was limited only to those individuals with readily apparent or self-reported alcohol intoxication. Future studies should investigate the trauma prevalence across various urbans settings, including the presence of city infrastructure meant to mitigate dangerous automobile and pedestrian measures (eg, bicycle lanes, restricted use neighborhood).
      In conclusion, although providing an innovative and economical method of urban “last mile” transport, e-scooters have also been shown to be significantly associated with craniofacial injuries. The present study found that more than one half of all trauma patients presenting to a Level I trauma ED in Dallas, Texas, for e-scooter injuries had had injuries to the head and face. Craniofacial injuries require specialist intervention ranging from dentoalveolar splinting to extensive facial reconstruction, highlighting the implications of craniofacial trauma risk associated with e-scooter use. Craniofacial trauma associated with e-scooter use could be significantly reduced by the use of proper protective equipment and access to well-regulated bicycle lanes and cyclist/pedestrian safety policies. Special focus on the factors contributing to traumatic events involving e-scooters, such as helmet use, pedestrian interaction, alcohol use, and policies regarding scooter use will help establish the best practices for the mitigation and treatment of such injuries.

      Acknowledgments

      We thank J. K. Fritz (Orthopedic Surgery, Baylor University Medical Center); Jordin K. Shelley, BS, Nakia Rapier, MSN, RN, and Michael L. Foreman, MD, FACS (Division of Trauma, Critical Care, and Acute Care Surgery, Baylor University Medical Center); Joseph Young, DO (Emergency Department, Baylor University Medical Center); and Amin Heravi (Texas A&M College of Dentistry).

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