TRINCA AND DOOLEY

MOTOR CYCLE INJURY PATTERN IN VICTORIA

THE PATTERN OF MOTOR CYCLE INJURIES SUSTAINED BY MOTOR CYCLISTS IN VICTORIA IN 1974 AND 1975 G. W. TRINCAAND 6. J. DOOLEY

Melbourne Motor cycle injuries and fatalities (2.4% annually) represent a serious threat to the youth of Australia. This survey outlines the pattern of injuriessustained by motorcyclistsand highlightsof the high percentage(73%) of serious local injuries to the lower extremities. The views of motor cyclist victims on preventive safety measures are also summarized.

THE number of motor cyclist casualties has risen dramatically in the last few years, a trend unmatched by any other category of road user. In 1970, 6,234 motor cyclists (excluding pillion riders) were killed or injured in Australia. I n 1975,365 motor cyclists were killed and 10,584 injured.' Motor cyclists comprised 10% of the persons killed and 12% of the persons injured on Australian roads in 1975. Figure 1 shows that in large part the increase in casualties has been a reflection of the boom in motor cycle popularity.2 Nevertheless, the risk of death or serious injury for every motorcyclistis2.4% annually. It has been estimated that on a distance travel basis, rnotor cycles are involved in about seven times more casualty accidents than the next highest mode of transport, cars and station wagons. Moreover motor cycle crashes tend to cause more severe injuries than other crashes, with the exception of pedestrian injuries. Thevulnerability of the comparatively unprotected motor cyclist compared with the motor vehicle occupant is the obvious reason for the high crash casualty rate. The population of motor cyclists involved i n accidents is relatively homogeneous in terms of age, sex, and to a lesser extent, experience. Ninety-four per cent of the motor cyclists involved in accidents reported to the police are male and 80% are under the age of 25 years3 The purpose of this paper is to analyse the pattern of injuries sustained by motor cyclists. With the help of three fifth-year medical students from St Vincent's Hospital, Melbourne, we have carried out asurvey on motor cycle injuries of patients admitted to four Victorian Hospitals during the years 1974 and 1975. The Hospitals - St Vincent's Hospital, Reprints M i B J Dooley 141 Grey Street. East Melbourne. Victoria

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Melbourne; Preston and Northcote Community Hospital; Geelong and District Hospital; and Mooroopna Base Hospital - were selected to give a spectrum involving a large metropolitan teaching hospital, a large peripheral urban hospital, and two large country base hospitals. The clinical records and radiographs of 212 patients admitted to hospital during these years have been examined and personal interviews were conducted with 90 of the victims. Ten patients who were admitted during 1974 and 1975 to the Victorian Spinal Unit, Austin Hospital, for treatment of spinal injuries with neurological involvement, were studied separately. CLINICALDETAILS The injuries received have been divided intovarious body regions as follows: (1) Head, face and neck, including injuries to the skull and brain, orofacial injuries. cervical and throat; (2) Upper torso (thorax), including fractured ribs. clavicle, crushed chests, intrathoracic injuries such as ruptered aorta, contused and lacerated lung, pneumothorax, etc.; (3) Lower torso, including intraabdominal injuries and fractured pelvis; (4) Lower extremity injuries, including damage to hip articulation, fractured femurs, vascular injuries to the region of the knee joint, lower leg injuries including compound fractures of the tibia and foot, injuries including fracture dislocations of the tarsus and metatarsus; (5) Upper extremity, injuries including the shoulder girdle.

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FIGUDE7 Casualties i k i l i P d a n d inlured motor cycle ridcrs) compared wlth motor cycle registrations in Australia 1965-1974 (pillion riders ?xcliided)

We have also studied the pattern of injury received i n . 100 consecutive fatal motor cycle accidents between 1973 and 1974 as reported by the Joint Consultative Committee on road mortality in V i ~ t o r i a .We ~ have attempted to compare these injuries with those sustained by the survivors. The results are shown in Figure 2. It will be noted amongst the 100 consecutive dead motor cyclists, 58 had cerebral injuries, including 47 skull fractures, and eight had fractures or sublu,xations of the cervical vertebrae. No less than 18 of the victims had serious torso injuries, including ruptured aorta in 12, multiple fractured ribs, contused torn lungs in four, and other mediastinal bleeding, ruptured heart, etc. Fourteen had ruptured livers, seven had ruptured spleens, four ruptured kidneys, five ruptured bowel, and nine had multiple fractures. Only 18 of the 100 victims had upper limb fractures and 37 had lower limb fractures. Thus most of the victims died of either serious head injury or serious torso injury. Of the survivors, on the other hand, only 121h0/~ suffered facial or head injuries, and only 9% had upper and lower torso injuries. Seventy-three per cent had serious lower extremity injuries. So whilst few of the survivors had involvement of the head or torso, the majority had serious local fractures, particularly of the lower extremity. I n 204

many ways this pattern of involvement is similar to the injuries sustained by pedestrians. Pedestrians who receive a severe direct blow to the head or trunk usually die of such injuries. Those who receive a glancing blow to the extremities but are thrown clear of the impacting force usually survive, but have serious local injuries.

Findings Examining the 212 victims and taking each region in turn, the details of injuries are: ( 1 ) Head, face arid neck.- Thirty people out of 212 received injuries ot the head, face and neck 27 males and three females. Eleven of these people sustained degrees of brain injury including severe contusions and skull fractures. Six have been left with permanent neurological involvement, including three who have spastic hemiplegia. Seven out of these 11 patients had serious injuries to other regions. Twenty patients sustained serious facial injuries including fractures of the cheek bones and mandible, fractured teeth, extensive deep facial lacerations, and eye injuries. Only one of these patients has serious permanent disability, with partial loss of sight in one eye. Unfortunately, because of insufficient information on the crash reports, we wereunable to comment on the heed helmet performance. There were no AUST N 2 J SURGVOL &-NO

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FIGUHE2 Comparison of body reqions involved in dead and injured motor cyclists

patients admitted with cervical spine injuries. During 1974 and 1975 in the state of Victoria there were 10 motor cyclists admitted to the Austin Hospital with spinal injury and neurological damage. Three had quadriplegia with cervical spine damage, one recovering almost fully, one partially, and one is permanently quadriplegic after 24 months. Five had thoracic spinal fractures or fracture dislocations, four were initially paraplegic, but one recovered almost completely, and two had damage in the thoracolumbar region. (2) Thorax (upper torso).Eleven patients sustained serious chest injuries, seven having serious internal damage including flail chest with contused lung and pneumothorax. There was no case which involved damage to the heart or major blood vessels. Seven of the 11 patients had injuries to other regions including spinal injury, one fracture of the upper limb, two lower limb fractures, and three head injuries. (3) Abdomen and pelvis (lower torso).- There were only eight patients with abdominal and pelvic injury. Three had an injury to the kidney, one requiring nephrectomy. one had a ruptured spleen, AUST N 2 J SURGVOL 49-No

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and four had minor fractures of the pelvis. There was no instance of scrota1 or urethral damage. ( 4 ) Lower extremities- There was a very high incidence (154/212 ( 7 3 % ) ) of severe crush injuries to the lower extremities, particularly the lower leg and foot, usually affecting only one leg. These injuries result from the leg being struck by an impacting force such as car, tree, pole, and so on, or alternatively from the leg being pinned beneath the motor cycle. The lack of protection for the leg resulted in a high percentage of severe compound fractures with abrasive injuries to theskin and many serious intraarticular injuries such as fracture dislocations of the ankle, tarsus, and metatarsus, and fracture dislocations of the femoral and tibia1 condyles involving the knee joint. Tarsometatarsal fracture dislocations probably resulted from the foot being caught o n the foot pedal. These injuries in particular leave serious sequelae, with persistent pain, deformity, and swelling of the foot. Tables 1-4 show the incidence of upper leg and lower leg injuries. (5) Upper extremities.- Forty-seven (22%) of the victims sustained injuries to the upper extremities. There was only one case of severe brachial plexus 205

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CYCLE INJURY P A T T E RN IN VICTORIA

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TABLE 1

Lower Extremity Injuries. 154/212=75% ~

~~~

..

~

Upper leg - Fractured femur, hip dislocation. extensive laceration Lower leg - Knee, tibia and fibula. ankle, foot Combined injuries - eg femur and tibia Associated trunk and head injuries

59 109 14 5

-

~~~

TABLE2 Upper Leg Injuries, 59’212=28% ~

~~~-

Hip dislocations

7

Deep lacerations groin Fractured shafls femur

2 41

( w i t h 9 fractured tibia ad fibula)

Fat enihoilsm

9 4

Deep vein thrombosis

4

Fractured femoral condyle

damage involving all roots of the brachial plexus, ending in intractable pain and resulting in arthrodesis of the shoulder with above-elbow amputation Twenty-seven (12%) patients had fractures of the forearm bones involving either the elbow joint, the forearm bones themselves, or the wrist joint Eleven (5%) had injuries confined to the carpal bones and hands Fourteen had fractures to the upper arm including three with fractures of the scapula and clavicle and four with dislocations of the shoulder Only five have been left with serious permanent disability, apart from the patient with the brachial plexus injury, one has a partial radial and ulnar nerve palsy, one is left with a stiff elbow, and three with malunion of either single or double fracture of the forearm Safety Aspects With the aim of ascertaining motor cyclists feelings about safety, interviews were obtained with 90 victims Their ideas are summarized as follows 1 Visibility is important The majority thought that riding with headlights on during the day was a good TABLE3 Lower Leg I r ~ i i i r f e s 109 212 51 Fool rnfiiries fractures dislocations d e r p lacerations e f c 12 Symer amputations1 F r a c r i i r r d t i h i d a n d fibuld Knee iiifiiries fracliircd pateiae tibia1 coridyles krire Irqdmenls A S S O Ct~l c d h e a d lorso mjiirres

-

23 61 13

3

TAB( E 4 F i a c i i i r c d Tibiae a n d Fibiriae w i t h indicalrori o f Severity Fractured t h a e a n d fihuldc Compound fractiircs Nnn-oninn

Averaqe healing time to union Combined with fractured femur Patients needinq more t h a n one operation Mean hospital stay

206

61

23 10 20 weeks 14

19 ($4000) 41 days

idea. Clothing seemed to bea matter concerning the individual. The majority believed, however, that light-coloured clothing, including a white helmet, made them more obvious. Protective boots and leather clothing gave increased protection. 2. They unanimously agreed on the value of wearing a crash helmet. (Stack Hat!) 3. The majority of cyclists favoured stricter licencing and rider training, somewhat similar to police riding instruction programme. 4. Views on the value of crash bars were equally divided. Half felt that they were of some protection, but approximately the other half felt that crash bars allowed the bike to skid when “put down”, or might catch on passing traffic, etc. 5. Most of the motor cyclists felt that motor cars drivers were often unaware of, or did not care about, the motor cyclist.

DISCUSSION Pattern of Injury Sustained b y Motor Cyc//sts The pattern of injuries received by thedead motor cyclists is different from the pattern of injury received by the survivors. Virtually all the dead victims died of either serious head or trunk injuries. In the survivors, on the other hand, these injuries were far less common, the injuries being confined mainly to severe local injuries to the extremities, particularly the leg. There is no doubt that the wearing of a crash helmet saved many from death and serious injury, but unfortunately there appears to be no accurate record of helmet performance. We are unable to explain why there were no cervical spine injuries in the patients admitted to the four hospitals mentioned. For the whole of Victoria, during 1974 and 1975, therewereonlythreequadriplegicsdueto cervical spine injuries. In some way the crash helmet gives protection to the neck. This is not seen in motor car accident victims, where head and cervical spine injuries are frequently associated. The motor cyclist is usually thrown off his vehicleat the time of the crash, and deceleration is probably slower than for the entrapped, but at the same time protected, motor car occupant. There is a surprising absence of damage to the uretha and bladder, yet the motor cyclist is astride the vehicle involved in the crash. There is a psrticularly low incidence of fractured pelvis. The rnost striking feature of the survey was the confirmation of a very high percentage of severe crush injuries to the lower extremities, particularly the lower area of the leg, including a high percentage of compound fractures of the tibia and fibula and serious intraarticular injuries such as AUST N Z J SURLVOL 49-No

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fracture dislocations of the ankle joint, tarsus, and metatarsus, and fracture dislocations of the femoral and tibia1 condyles involving the knee joint. lntraarticular injuries often left severe sequelae with painful, stiff and later, arthritic joints. The majority of the motor cyclists interviewed favoured: ( a ) increased visibility with bright clothing, white helmet, and headlights on during the day; ( b ) stricter licencing, adequate rider instruction, and compulsory restriction of bike capacity (below 250 ccs) for learners; and (c) the wearing of crash helmets. ACKNOWLEDGEMENTS We should like to thank Dr Ian Johnston, of the Commonwealth Department of Transport, and Dr

TRINCA AND DOOLEY

Peter Vulcan, Director of the Road Safety and Traffic Authority in Victoria, for their invaluable help in the preparation of this paper; also thethree medical students of St Vincent's Hospital, Melbourne Margaret Tobin, Mr P. Lane and Mr A. Sprigyins. who conducted the interviews, aided by a grant from the Road Trauma Trust of the Royal Australasian College of Surgeons. REFERENCES 'Expert Group o n Road Safety - T h e Road Accident Situation in Australia in 1975. Report to the Australian Minister for Transport, October, 1975. 2JOHNSTON, I. R., MILNE, P. W., and CAMERSON, M . H I Age, Experience and Motor Cycle Engine Capacity in Motor Cycle Accidents. Motor Cycles and Safety Symposium. A.R.R.B.. Melbourne, 1976. %eport by the Joint Consultative Committee on Road Mortality Victoria, 1975.

THE PATTERN OF INJURY IN MOTOR CYCLE ACCIDENTS IN A COUNTRY AREA PETERKING

Shepparton, Victoria MOTOR cycle accidents are common, and the death rate amongst motor cyclists is high. The Australian Bureau of Statistics shows that thedeath rate amongst motor cyclists per unit kilometre travelled is eight times as high as it is for other vehicle users. For those of us who treat survivors of motor cycle crashes, rates of death seem irrelevant, when compared with the far greater proportion of survivors with disabling injuries. These patients most frequently require costly, long-term inpatient management, and settlements for residual disabilities are often large. Goulburn Valley Base Hospital serves a population of approximately 90,000. Several major Victorian highways, including the Hume, Goulburn Valley, Midland, and Murray Valley, provide a setting for accidents, and other accidents occur in the built-up area o f cities throughout the Goulburn Valley - in particular, Shepparton. Some 40% of accidents, however, occur on surrounding farms, or riverside trails. Of 341 motor vehicle accidents reReprints M i Peter King F R A C S St Shepparton Vlctoria 3630

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ported to the Shepparton police in 1976, 38 involved motor cycles. The represents a ratio of one in nine motor vehicle accidents involving motor cycles. The police estimate that only one in ten accidents involving motor cycles are actually reported. The Goulburn Valley Base Hospital figures show that in 1974, motor cycle accidents accounted for only 20% of individuals sustaining motor vehicle injuries admitted to the hospital. In 1975 and 1976 however, 102 patients were treated for injuries sustained from motor cycle accidents, representing 31 Ohof all motor vehicle injuries treated. In 1975, the average period of inpatient admission for motor cycle accidents was 20 days, and in 1976 12.5 days. The longest length of stay in 1975 was 150 days, and in 1976, 114 days. Patients suffering severe leg injuries frequently remain in hospital for three months. Combining the 1975 and 1976 figures to show the it is apparent that 70% of age incidence (Figure l), the patients arewithin theagegroupoffrom 17to23 years. It can be seen that the youngest patient was 11 years of age, and there were eight 14-year-olds. In regard to sex incidence, there were 10 females 207