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Association Between Conventional Bicycle Helmet Use and Facial Injuries After Bicycle Crashes

Educational Objective
To review the conventional bicicle helmet's effectiveness in preventing facial trauma.
1 Credit CME
Key Points

Question  Do bicycle helmets provide sufficient protection to the face during bicycle crashes, and, if so, how much protection do they offer?

Findings  In this cohort study of 85 187 bicycle crashes from records in the US National Trauma Database, helmets were found to not sufficiently protect the face in bicycle crashes. Helmet protective capacity for the face lessens for the mid face and lower face.

Meaning  Bicyclists are at risk for experiencing facial fractures and soft-tissue injuries during crashes, particularly to the mid and lower face; public education regarding potential facial injury despite helmet use may be warranted.


Importance  Bicycling is an increasingly common activity in the United States that is often associated with fall injuries to the head and face. Although helmets lessen head injury, their role in reducing facial injuries is less clear; therefore, it is important to understand the protective capacity for the face in current helmet design.

Objective  To estimate the conventional bicycle helmet’s association with the rate of facial injury after bicycle crashes.

Design, Setting, and Participants  This retrospective cohort study accessed records from January 1, 2010, to December 31, 2014, from the National Trauma Databank, which collects data from emergency departments in US hospitals. Each record pertained to 1 emergency department admission for a bicycle crash. The National Trauma Databank registry data are collected and recorded by incident, which is equivalent to an injury-related hospital admission. All injuries involving patients aged 18 to 65 years for whom data on helmet use and injury were available were included. Statistical analysis was conducted from July 19 to October 17, 2016.

Exposures  Helmeted and nonhelmeted bicycle crashes.

Main Outcomes and Measures  Head and facial injuries among helmeted and nonhelmeted bicycle crashes.

Results  A total of 85 187 facial injuries met inclusion criteria (patient age 18-65 years, availability of helmet use status, and type of injury). Demographic information on bicycle riders was frequently unavailable. Among all injuries, fractures to the head (11.6% [9854]) and face (11.3% [9589]) occurred at similar rates. Helmets reduced head fractures by 52% (from 14.0% [7623] to 7.3% [2231]) and head soft-tissue injuries by 30% (from 15.0% [8151] to 10.9% [3358]), but had lower rates in protecting against facial injuries. While reducing facial injuries overall, the amount of protection with helmet use varied with facial location of the injury. Reduction in facial fractures was 35% (95% CI, 31%-39%) for upper face, 28% (95% CI, 23%-32%) for mid face, and 21% (95% CI, 15%-26%) for the lower face. Helmets were less protective against facial soft-tissue injuries, with a reduction of 33% (95% CI, 30%-36%) in the upper face, 21% (95% CI, 16%-26%) in the mid face, and 2% (95% CI, 0%-6%) in the lower face.

Conclusions and Relevance  Although bicycle helmets provide some protection against facial injuries after bicycle crashes, the level of protection depends on the proximity of the injury to the helmeted head. The lower face is particularly vulnerable to injury despite helmet use.

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Article Information

Accepted for Publication: October 2, 2018.

Corresponding Author: Rahul Seth, MD, Department of Otolaryngology–Head and Neck Surgery, University of California, 2233 Post Street, Third Floor, San Francisco, CA 94115 (rahul.seth@ucsf.edu).

Published Online: December 13, 2018. doi:10.1001/jamaoto.2018.3351

Author Contributions: Ms Benjamin and Dr Seth had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Knott, Seth.

Study concept and design: Benjamin.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Benjamin, Hills, Seth.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Benjamin, Hills, Seth.

Obtained funding: Seth.

Administrative, technical, or material support: Knott, Murr, Seth.

Supervision: Benjamin, Knott, Seth.

Conflict of Interest Disclosures: None reported.

Funding/Support: Funding for this project was provided through a monetary gift from a trauma patient and the University of California, San Francisco (UCSF) Department of Otolaryngology–Head and Neck Surgery. This project was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through UCSF-Clinical and Translational Science Institute (CTSI) grant UL1 TR000004.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: Contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health.

Meeting Presentation: The study was presented at the Triological Society; April 29, 2017; San Diego, California.

Additional Contributions: Jennifer Creasman, MSPH (UCSF CTSI), assisted with data extraction. Compensation was received.

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