Type of injury and trauma severity in children involved in two-wheeler accidents: a retrospective study

1. Introduction

In urban areas with dense traffic, two-wheeled vehicles are widely used as practical and economical means of transportation, particularly in narrow or congested spaces. However, their use exposes riders to significant risks due to the absence of protective features typically found in larger vehicles. Thus, understanding these vulnerabilities is essential to addressing the safety challenges faced by motorcyclists and cyclists.

In Turkey, traffic regulations allow children as young as 11 years to ride bicycles and 15 years to ride electric bicycles, neither of which requires a license [1], which has contributed to the increased popularity of bicycles among children. Recently, the use of electric bicycles has increased, and it has been found that they can reach speeds of up to 25 km/h [1], making them more attractive than manual bicycles. Despite recommendations to use protective equipment and adhere to traffic rules, such as riding in designated bicycle lanes or staying on the rightmost side of the road, compliance with these guidelines remains low, particularly in large cities where dedicated bicycle lanes are often absent.

Moreover, the lack of regulation surrounding bicycle use significantly exacerbates the risks of severe accidents for both riders and passengers. A notable concern is the insufficient use of helmets and protective gear for the trunk and extremities, which also significantly increases the likelihood of severe injuries [2]. In addition, the extent of trauma in two-wheeler accidents varies depending on whether the affected individuals are drivers, passengers, or pedestrians. Passengers often sustain more severe injuries due to the absence of safety features, while the dynamics of accidents frequently increase their exposure to high-impact forces. Furthermore, pedestrians are similarly vulnerable, as accidents involving two-wheelers often result in extensive trauma that can affect vital organs.

In Turkey, motorcycle-related accidents account for 23.8% of all traffic fatalities, while bicycle-related accidents contribute to 2.3%. Among these fatalities, 10.1% involve children, highlighting the urgent need for targeted preventive measures [3].

This study aimed to analyze data from three major hospitals in a developed province on Turkey’s European border, focusing on pediatric patients treated for injuries related to bicycle and motorcycle accidents [4]. By examining the patterns of trauma, emergency department (ED) findings and prognostic outcomes, this study seeks to inform strategies for injury prevention. Emphasis is placed on the importance of protective equipment and stricter safety regulations to reduce the burden of injuries among children in similar urban settings.

2. Materials and methods

3. Results

A total of 220 pediatric patient records were retrospectively analyzed. Children aged 0–6 years were found to be more likely involved in accidents as pedestrians, while those older than 11 years were mainly involved as riders (Table 1). Of the patients, 179 (81.3%) were male, and 41 (18.7%) were female. The majority of accident-related admissions were to the second trauma center (140 cases, 63.7%), followed by the third trauma center (49 cases, 22.3%) and the academic hospital (31 cases, 14.0%). Annual admissions were distributed as follows: 35 cases (15.9%) in 2019, 36 (16.4%) in 2020, 82 (37.3%) in 2021 and 67 (30.4%) in 2022. Rider injuries were the most common (71.8%), with electric bicycle-related injuries accounting for 50% of cases. The lower extremities were the most frequently affected anatomical region (59.1%). Hospitalization was required for 11.4% of patients, and all patients were ultimately discharged (Table 2).

A comparison was conducted between groups injured in bicycle and motorcycle accidents, and significant demographic and clinical differences were observed between the study groups. Those in the bicycle injury group were found to be significantly older than those in the motorcycle injury group (p < 0.05). The mean ages for different groups were as follows: pedestrians (10.5 years), riders (14.8 years) and passengers (12.5 years). Patients injured in motorcycle accidents were more likely to receive treatment at the academic hospital (p ≤ 0.05), while those injured in bicycle accidents were predominantly treated at the third trauma center (p < 0.05). However, most cases in both groups were treated at the second trauma center. Cyclists had a significantly higher rate of injuries compared to motorcyclists (p < 0.05). Pedestrian and passenger injuries were more prevalent in the motorcycle injury group (p ≤ 0.05). Lower extremity injuries were the most common in both groups, but no statistically significant differences were observed between them (p > 0.05). Discharge rates from the ED were high across both groups. However, the surgery rate was higher in patients injured in motorcycle accidents, while the duration of hospitalization was longer in the bicycle injury group (Table 3).

When injuries were analyzed based on bicycle type, patients injured in e-bike accidents were significantly older than those in manual bicycle accidents (p < 0.05). A higher proportion of e-bike-related injuries were treated at the third trauma center (p < 0.05), whereas manual bicycle injuries were more frequently treated at the second trauma center (p < 0.05). Severe injuries (p < 0.05) and chest-abdomen-lumbar injuries (p < 0.05) were more common in the e-bike group. While discharge and hospitalization rates did not differ significantly between the groups (p > 0.05), the surgery rate was higher in the manual bicycle group, and the duration of hospitalization was longer for e-bike-related injuries (Table 4).

Among patients classified as having severe injuries, head trauma and lower extremity injuries were the most common (Table 5).

Lower extremity injuries were the most frequently observed type of injury in bicycle riders involved in e-bike accidents (Fig. 1).

Fig. 1.Injury sites according to bicycle types.

The review of patient records revealed that none of the children, whether riders or passengers, were wearing protective equipment at the time of their accidents. Importantly, there were no fatalities reported among the children included in this study.

4. Discussion

This study revealed that children involved in two-wheeled vehicle accidents were most frequently injured as riders, with bicycles being the predominant vehicle type. Among bicycle-related accidents, e-bikes were associated with a higher frequency of injuries, particularly in the lower extremities. Although many injuries were severe, the full recovery and discharge of all patients highlight the remarkable resilience and recovery potential of children in the context of trauma [6].

Our findings indicate that male children were significantly more likely to sustain injuries, a trend consistent with previous studies, and research suggests that males are often more exposed to risk-taking behaviors or engage in activities that elevate their likelihood of trauma [7]. These findings underscore the importance of developing targeted prevention strategies that account for this demographic disparity.

Trauma accounts for a significant proportion of ED visits across all age groups [8]. Previous studies demonstrate that adult pedestrians have a significantly higher risk of severe injuries and fatalities compared to children, with outcomes influenced by factors such as the speed and size of the striking vehicle and the severity of injuries caused by skidding [9]. In this study, the lower severity of injuries among pedestrians may be explained by the inclusion of motorcycle accidents, which are smaller vehicles compared to passenger cars. The youngest average age among injured individuals was observed in pedestrians, emphasizing the particular vulnerability of young children and their tendency toward carelessness in hazardous situations, highlighting the importance of increased parental supervision to protect children from external trauma. Additionally, a significantly higher proportion of patients in the motorcycle injury group received treatment at the academic hospital, reflecting the facility’s critical role in providing emergency medical care.

A study by Karacasu et al. [10] reported that traffic accidents predominantly occur during the summer months. Similarly, the findings of this study suggest that accidents are more frequent during hot, sunny days when children are more likely to engage in outdoor activities such as exploration and adventure.

Research indicates that children are particularly vulnerable to bicycle accidents, which often lead to serious extremity injuries [11]. Consistent with this, our current study identified lower extremity injuries as the most frequent type of injury across all vehicles. Thus, implementing targeted safety measures is essential to protect young riders from such injuries. An evaluation of the types of vehicles involved revealed that trunk injuries, specifically affecting the chest, abdomen and lumbar regions, occurred at similar rates in e-bike and motorcycle accidents. However, e-bike accidents were associated with more significant trauma compared to traditional bicycle accidents. The high incidence of severe injuries linked to e-bike accidents observed in this study highlights the increased risks associated with their use.

In our province, the population density in the largest district is approximately twice that of the city center [5], which explains the higher number of trauma admissions in this region. Despite the generally calm traffic, adherence to traffic rules and a high level of education contributing to a safe environment [12, 13], parents often allow their children to cycle without restriction. The notable number of accidents involving children, even in a city where compliance with traffic regulations is high, highlights the ongoing risks associated with cycling. However, it is commendable that no child fatalities were recorded, likely reflecting the region’s overall commitment to safety. It has been suggested that individuals tend to underestimate the importance of protective equipment in environments perceived as safe [14], which is concerning, as head trauma remains the leading cause of mortality among children after accidents [15]. In this study, head injuries were prominently observed, yet none of the children involved were wearing protective gear or helmets, highlighting a critical gap in safety measures that warrants immediate attention. Mandatory helmet use has been shown to significantly enhance safety. For instance, in Florida, USA, the introduction of mandatory helmet laws for bicycle riders, coupled with helmet distribution programs, demonstrates a strong commitment to reducing head injuries [16]. Adopting similar measures globally could substantially reduce the risk of life-threatening head trauma in children, and encouraging helmet use should extend beyond only rule enforcement to foster a culture for better safety measures. By promoting helmet use and other protective measures as habitual practices, we can help children develop a sense of responsibility and self-awareness as riders. This nurturing approach not only safeguards children in the present but also instills lifelong habits of safety and conscientious behavior, even in settings where rules are not strictly enforced.

A study by Habelt et al. [17] explored the prevalence of sports injuries among children and found that those who ride bicycles most frequently experience soft tissue and knee injuries. It is concerning that children often sustain lower extremity injuries during falls, as they instinctively attempt to protect themselves. These injuries may result from factors such as poor motor coordination, improper bicycle adjustments or other physical characteristics of the child, such as their height and weight. Recognizing these risks is essential to ensure that children are equipped with the appropriate bicycles and safety gear to minimize the likelihood of injury while cycling.

Research shows that protective equipment, much like seat belts in motor vehicles, can significantly reduce the risk of serious injuries during cycling [18]. However, relying exclusively on protective gear is not sufficient to ensure safety. Many accidents arise from human factors such as reckless driving and inexperience, which must be addressed to reduce accident rates effectively. In addition to promoting the use of safety features, such as bells and lights on bicycles, to improve visibility, a comprehensive approach to road safety is needed. Such measures should focus not only on equipment but also on addressing behavioral and systemic factors that contribute to accidents.

Expanding bicycle lanes, enforcing stricter traffic inspections and incorporating traffic education into school curricula are potential strategies to increase safety awareness among children and reduce the risk of accidents involving larger vehicles. Additionally, integrating cycling safety training into driver’s license education for adults could encourage greater caution when navigating side streets and improve adherence to yielding protocols. This approach would also promote heightened awareness of cyclists’ presence on the road. Together, these measures could significantly contribute to the prevention of accidents involving two-wheeled vehicles.

5. Limitations of the study

This study had several limitations inherent to its retrospective design, primarily related to the availability of data. Information on the proportion of motorcycle riders under 18 who may have avoided hospital care due to concerns about legal penalties was not available. Similarly, data on patients with minor injuries who did not seek hospital treatment were not included. Additionally, the absence of precise information regarding the timing of accidents limited the assessment of essential factors such as lighting conditions, the presence of obstacles, the type of vehicle involved, and whether the rider was under the influence of alcohol or other substances. These limitations might have occurred due to the study’s reliance on hospital records, and incorporating both police and hospital data in future studies could provide a more comprehensive understanding of the circumstances surrounding these accidents and improve the robustness of the findings.

6. Conclusions

The increasing use of e-bikes among children raises significant safety concerns. Our study suggests that developing protective equipment specifically designed to prevent or reduce injuries to the lower extremities (i.e., the knees) and to the trunk (chest, abdomen and lumbar regions) is essential. Additionally, the use of reflective materials to enhance visibility and draw attention from others could further improve safety and substantially reduce the risk of injury among child e-bike riders.

Availability of data and materials

Data is available from the corresponding author upon reasonable request.

Author contributions

OG, TÖ, HS, SÖB—Conception. OG, TÖ, BŞ—Design-Supervision; Analysis. MD, NBÇ, HS, SÖB—Material; Data Collection. OG, TÖ, MD, BŞ—Literature Review. OG, TÖ, MD, NBÇ, HS, SÖB—Writer. TÖ, BŞ—Critical Review.

Ethics approval and consent to participate

The study was conducted in accordance with the Declaration of Helsinki. Due to its retrospective nature, consent to participate was not obtained from patients. The Scientific Research Ethics Committee of Kırklareli University Faculty of Medicine approved this study (P202300040-06/17.07.2023). The ethics committee waived informed consent to participate. However, we ensured the privacy and confidentiality of the patient’s data.

Acknowledgment

Thanks to all the peer reviewers for their opinions and suggestions.

Funding

This research received no external funding.

Conflict of interest

The authors declare no conflict of interest.