J Indian Acad Forensic Med, 30(4)

Review Article

Motorized two-wheeler crash injuries and the role of helmet-use in their prevention:
an overview

B. R. Sharma

Abstract
Road-traffic accidents are a major cause of premature death and disability all over the world and
motorized two wheelers (motorcycles/scooters/ mopeds) account for the majority of such cases,
particularly, in the developing countries like India where they are one of the most important means of
transportation, unlike the developed countries where they are used for recreation. Head injuries are a
leading cause of death from motorcycle crashes, with many deaths occurring despite optimal use of the
available treatment facilities. On the other hand, there is substantial evidence that safety helmets are
effective in reducing the incidence and severity of head injuries due to motorcycle crashes. In recent
years, mandatory helmet use for motorcyclists has received a considerable attention all over India.
Strict implementation of the helmet laws, presently limited to bigger cities only, if extended to smaller
cities, and towns may help restrict the ever-increasing workload of emergency management services
engaged in trauma care.

Keywords : Motorized two wheelers, crash, head injury, chest injury, abdominal injury, mandatory
helmet-use, law.

Introduction focusing on elementary school-age children,

Nonuse of safety helmets has been shown Another study demonstrated that injury
to result in a shift in the spectrum of injuries, not prevention strategies targeting helmet use could
only to more fatalities but also to more severe increase utilization of this safety device and thus
nonfatal injuries1. It has also been documented decrease the occurrence of severe head injuries
that disability related to the nonfatal injuries is in victims of bicycle crash and motorcycle crash
extensive, and much of the cost is borne by the admitted to a level I trauma center".
society", Although there have been recent It has been reported that helmets reduce
advances in access to sophisticated trauma the probability of the occurrence of head injuries,
systems and in the treatment of head injuries, the severity of head injuries when they occur, and
much of the morbidity and mortality of head the probability of death in both bicycle and
injuries persists despite optimal use of such motorcycle crashes'". Statistics have shown an
treatment", Injury prevention efforts are, thus, vital 8% decrease in bicycle crash-related mortality
to decrease the impact of such injuries. and a 21 % decrease in motorcycle crash-related
The Seattle bicycle helmet carnpalqn" has mortality". States introducing mandatory helmet
been considered a model program in health use laws have experienced a decrease in the
promotion and injury prevention. It utilized a number of both fatal and nonfatal motorcycle
multidimensional approach, emphasizing broad- crashes, and States repealing helmet laws have
based community coalition building and experienced subsequent increases in motorcycle
traurnav'? Proponents of the law have pointed out
Professor, Dept. of Forensic Medicine and that the costs of head injuries to motorcyclists are
Toxicology, Govt. Medical College & Hospital, in fact, a societal issue, because the tremendous
Chandigarh - 160030 . costs of treating and caring for severely head.;.
e-mail: [email protected] injured patients are usually borne by the society"

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Sharma: Two wheeler & helmet - use

A study by Chiu et al 11, demonstrated the and sever head injuries from motorcycle crashes
effectiveness of the motorcycle helmet use law, will decline as a result, but the fatalities and
as shown by several trends: a 33% decrease in severe injuries that will continue to occur will
motorcycle-related injuries; decreases in severity involve other anatomic regions.
of injury, associated injuries, and length of Motorcyclists constitute a large segment
hospital stay; and better outcome. According to of the patient population with head injury
this study, data provided by the Taiwan associated with other multiple organ injuries
Department of Health showed that after treated at Trauma centers / tertiary care centers
implementation of the helmet law, the number of all over the world 19. However, certain aspects of
motorcycle-related injuries decreased by 14%, motorized two wheeler driving are peculiar to
length of hospital stay decreased by 14.5%, and Indian conditions and need to be mentioned: 1)
costs of hospitalizations from motorcycle-related Roads and driving conditions are such that a
injuries decreased by an average of US $3.93 large number of accidents occur without actual
million per month. collision. 2) Motorized two-wheeler in India is a
The medical and public health literature on family vehicle and the number of pillion riders may
motorcycle crash injuries of the past two decades be more than one. 3) At some places, helmet is
has focused predominantly on head trauma and compulsory for the driver as well as the pillion
the role of helmets in reducing fatal and non-fatal rider, whereas at some, it is compulsory for
brain injuries":". Although this emphasis is well drivers only and still not mandatory at many
justified, since head injuries are the leading places. Some riders wear turbans (a substitute for
anatomic site involved in fatalities, a substantial the helmet) whose efficacy in protecting against
proportion of those injured in motorized two head injury is not known. 4) Nearly all female
wheeler crashes have severe, life-threatening or pillion riders sit sideways with both legs to the left
fatal injuries to the chest and abdominal r~gions. of the vehicle because the common mode of
Studies have reported that 7% to 23% of all fatal dress, the sari, prevents them from sitting astride
injuries sustained in motorcycle crashes were to and they do not wear safety helmets. Majority of
the trunk region15.16. It has also been reported !that the female motorcycle drivers also does not wear
anpbngfatally injured helmeted riders, 36% died helmets.
from severe trunk injuries whereas among I the Head injury is a common outcome among
non-helmeted riders 19% died from trunk motorcyclists who crash, and the helmet has
injuries". This finding might suggest that non-use been the principal countermeasure for decreasing
of helmets will substantially reduce the head injury in crashes 1. 11, 20. Many studies of
occurrence of fatal injuries to the trunk. However, helmet effectiveness have concluded that helmets
this interpretation is incorrect, since there is only decrease the severity of injury, the likelihood of
a proportional shift from one anatomic region to death, and the overall cost of medical care 21.
another with the change from unhelmeted to Data from the United States as a whole, from
helmet use. In other words, as the percentage of various states, from other countries, and from
fatal or severe head injuries decreases with individual cities and hospitals have demonstrated
helmet use, the proportion of fatal or severe that motorcycle helmets provide protection during
injuries in other anatomic regions must increase. motorcycle crashes 22,
This anomaly was observed in a finding Arguments by the organizations that
from California18 where, in the year before object to motorcycle helmet legislation include: 1)
mandatory helmet law, 61 % of the most severe Reduction of the peripheral vision, 2) restricted
fatal injuries were to the head; whereas in the year hearing, 3) production of neck injuries by the extra
after the implementation of the helmet law the weight of helmet and 4) religious grounds for
percentage declined to 43%. Likewise the shift in wearing turban in a particular Indian community.
fatal trunk injuries was from 34% to 46% Howeyer, it has been shown that even the full
respectively. As more states and countries adopt facialihelmet coverage allows almost complete
mandatory helmet use laws the number of fatal perip ral vision of 180°.This may be slightly

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 J Indian Acad Forensic Med, 30(4)
reduced from the normal 200°, but is not the medical cost of motorcycle repeal and found
functionally significant impairment. The question that $61 million could have been saved in 1979
of hearing is a bit different. The sound of an had the helmet law not been repealed. Converted
approaching vehicle from the side or rear must to 2005, this figure might cross $250 million per
compete with the sound of the motorcycle engine year on account of increased cost of medical care
and wind across the biker's ears in a non- and rehabilitation. Increase in medical costs may
helmeted mode. Both the wind and motorcycle be attributed to the severity of a greater number
engine, however, are louder than that of an of head injuries, which increased hospital days,
approaching car. Use of the helmet reduces all Intensive Care Unit days, and days of disability.
sound levels equally. It does not differentially According to yet another study 26, the medical
reduce the sound of approaching vehicles, and cost for non-helmeted riders was 189.3% higher
therefore, the ability to detect the approaching than for the helmeted riders. The hospital cost
vehicles is not impaired. The question of injuries difference in 1977, for helmeted vs. non-helmeted
induced by the extra weight of the helmet to the riders, was 199.2% while in 1978 the increase
cervical spine has been answered by the studies was 201 %. The portion of injured motorcyclists
that demonstrated decreased cervical spine injury who required hospitalization with and without
on account of energy attenuation from the mandatory helmet use legislation was 25.5 per
absorbing capabilities of the helmet that reduces 100 accidents vs. 41.6 per 100 accidents
cervical vertebral loading 22. respectively. The days of disability for helmeted
Motorcycle crashes are associated with a riders was 26.7 vs. 51.1 for non-helmeted.
wide spectrum of injuries, which are often in The follow-up question, then, is how to
multiple anatomic regions 23.24. Therefore, when a increase safety helmet use. The two most obvious
severe injury is present in one anatomic region, methods are education and mandatory helmet
there is a high likelihood that severe injuries also legislation. To improve voluntary helmet use in the
are present In other anatomic regions. absence of mandatory helmet-use laws,
Furthermore, there is a strong association motorcyellsts need an increased awareness of
between severe injuries in one anatomic region their vulnerability. According to a study, most
and severe injury both within the same anatomic injured motorcyclists who do not wear helmets
region and in other anatomic regions in fatally arid report that they did not expect to be injured; yet
non-fatally injured motorcyclists. This finding has 40% of the head injury-associated deaths have
obvious important implications for the clinical been ascribed to the motorcyclist's loss of
evaluation and management of the injured control, not, apparently, to some action of the
motorcyclist and the future design. of injury driver of another motor vehicle 27. Thus
prevention strategies for the motorized two comprehensive motorcycle helmet-use legislation
wheeler drivers. Clearly, it is not enough to design appears to be a viable and scientifically sound
a better helmet to decrease brain injury severity component of those efforts. Strategies to design
without also providing better protection for vital protective gears for the trunk, spine, limbs etc
organs in the chest, abdomen and spine. In should be our next priority. But then, in the
addition, extremity injuries although, usually non- absence of strict implementation of the rules, can
fatal, but they are most common and may result .we expect the motorcyclists who avoid wearing
in tremendous long-term morbidity. even the safety helmets.to wear the trunk guard,
The financial burden of helmet non-use spine guard, limb guard etc.
has been reported to t,p tremendous. Rivara et al. Yet another alternative is to impose speed
2 studied 105' motorcycle patients from Seattle restrictions (limits) for the two-wheeler motorized
admitted to a level - I trauma center and reported vehicles associated with their classification into
that the average cost per patient was $25.764. different categories depending upon their use as
Only 60% of the costs were for the initial for example for sporting events -. high speed, and
hospitalization and 63.4% of the medical costs personal/family vehicle - low speed. It has been
were borne by the public. Muller 25 reported on reported that the risks of fatal injuries in

246
Sharma: Two wheeler & helmet - use

motorcycle crashes are related to the engine 3. LaHaye PA, Gade GF and Becker DP. Injury
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Helmets reduce head injuries and
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