Cycling-Related Injuries During COVID-19 Lockdown: A North London Experience

Abstract

Objectives: There has been a notable surge in cycling injuries during the COVID-19(SARS-CoV-2 virus) pandemic. Cycling in general increased during lockdown as a leisure & fitness activity along with reduction in the use of public transport for commuting. We investigated the bicycle-related maxillofacial injuries & associations presenting through our emergency department(ED) which covers more than 1.6 million of London population. Study Design/Methods: A retrospective observational study was undertaken in the Barnet General Hospital (“hub”) which receives all maxillofacial referrals from 6 “spoke” hospitals & other urgent primary/community care practices in North London area between 16 March 2020 & 16 July 2020. All data corresponding to cycling injuries during the lockdown period was analyzed with the aid of trauma database/trust-wide electronic patient records. Results: Twenty-two patients (6.7%) with cycling-related injuries out of a total of 322 patients who attended during the 4 months study period with maxillofacial emergencies were identified. Average age of patient cohort was 35.4 years, mainly consisting of adult males (77%). Seven patients had minor head injury and 1 patient suffered traumatic brain injury. About 59% patients did not wear a protective helmet & 3 patients had heavy alcohol/recreational drug intoxication during the accidents. Four patients needed inpatient admission and treatment under general anesthesia. Conclusions: Based on our humble study, we advocate the need for robust road & personal safety measures with mandatory government legislations, policing of drug intoxication & encouragement of physical & mental health improvement measures during these unprecedented times & beyond.

Introduction

COVID-19 pandemic has posed wide-ranging ramifications to the people & community. Since the first reporting of SARS-CoV-2 virus in Wuhan, China at the end of Decem- ber 2019, countries have had to introduce & re-adjust extraordinary & radical reforms to control the spread. Needless to say, it also brought in restrictions on movement of people, work, schools & physical activities causing a tremendous impact on general as well as mental health. There was notable & worrying increase in domestic violence & self-harm during this period.[1] Many people adopted lifestyle changes to cope with the imposed lock- down taking up new activities & hobbies to improve their physical & mental health.

Cycling is a beneficial physical activity with positive health outcomes. It has been proven to reduce risk of mul- tiple co-morbidities including mental health disorders & mortality apart from easing traffic congestion, protecting the environment & providing economic benefits.[2,3] We noted an increase in cycling injuries presenting to our unit during the recent COVID-19 pandemic lockdown period compared to previous years (

Table 1. Cycling Injuries Data 2018-2020 (March to July).

). We investigated this sudden increase in cycling injuries presenting to our unit during this challenging period.

Methods

The data was derived from our robust maxillofacial trauma database & electronic patient record (Cerner^®). The results were collected & analyzed by a single clinician. All bicycle-related injuries starting from 16th March 2020 (beginning of lockdown period in the UK) extending for a total period of 4 months (coincidental with easing of lockdown) were retrospectively interrogated in this study. Statistical analyses were conducted using Chi-square and Fisher’s Exact tests to ascertain relationships between dif- ferent variables (IBM SPSS^® software).

Results

All 22 patients who suffered maxillofacial injuries cycling (CI) during the lockdown period were included in this study (

Table 2. Data Analysis—Cycling Injuries.

). The incidence was 6.7% (Total maxillofacial emergencies in this period: n ¼ 332). COVID-19 status testing was restricted to patients undergoing general anes- thetic procedures (18%) in our trust and were all reported as negative. All patients were assessed and treated using stan- dard personal protective equipment (PPE) provided as per local trust protocol and in conjunction with the national guidelines.

Majority of the patient cohort were Adult males (77%) with children constituting only 14% of cases comparable to data related to previous years (Average age: 35.41 years). This was mainly due to reduction in pediatric services in our trust leading to temporary restriction of pediatric emer- gencies needing admission from the end of March 2020 due to flurry of COVID-19 cases. Fall injuries related to loss of balance, hitting obstacles and intoxication made up 17/22 cases (77%) cases with the remaining cases related to Road traffic accidents/collision (RTA/RTC).

Seven patients suffered with minor head injury (HI) and 1 patient had traumatic brain injury (subarachnoid/subdural hemorrhage). Transient loss of consciousness, confusion/ disorientation, vomiting, retrograde amnesia, headaches were some of the symptoms noted in these patients with 3 patients presenting to Emergency Department(ED) with GCS of 14/15. Only 41% of these patients confessed to wearing a helmet during their journey. Three patients pre- sented with alcohol/recreational drug intoxication. Seven patients (32%) also presented with other bodily injuries (BI) including upper & lower limb abrasions, soft tissue swelling, shoulder dislocation, distal radius, and ulna sty- loid & scaphoid fractures.

Soft tissue facial trauma (73%), Facial fractures (23%) and Dental Trauma (5%) were the primary maxillofacial injuries (MI) suffered by this cohort. Majority of the lacera- tions were related to the lips (44%) followed by chin (25%) and forehead (19%) regions showing a predilection to mid face injuries.

Sixteen patients (73%) also had secondary injuries including Soft tissue trauma (62.5%), Dental trauma (25%) & other fractures (6.25%). Local anesthetic treatment was required in the majority (64%) and 4 patients needed general anesthetic procedures (18%). Two complications/ re-attendances (9%) were noted with 1 patient attending due to loose intermaxillary fixation screw & another complain- ing of residual foreign body in the upper lip.

No statistical significance was noted to establish any rela- tionship between alcoholwith falls (p ¼ 0.5584) & RTA/RTC (p ¼ 1); helmet use with head injury (p ¼ 0.8058); RTA/RTC with head injury (p ¼ 0.8475) & bodily injuries (p ¼ 0.5186) (

Table 3. Statistical Analysis of Variables.

).

Discussion

About 3% of the population in England & Wales are depen- dent on bicycles for commuting.[3] They are included in the “vulnerable road users” along with pedestrians & motorcy- clists. A recent large population survey of cycling commu- ters from 22 sites in UK noted significantly increased risk of traffic related incidents & hospital admissions in this cohort adding to UK Government statistics showing increase in number of fatalities/serious injuries among cyclists (by 29% compared to 2008).[4,5] A recent retrospec- tive review of orthopedic injuries in pediatric population related to cycling during the COVID-19 period noted >100% increase in bicycle-related injuries.[6]

The City of London in particular is known to have increased bicycle traffic & considered widely as “bike friendly.”[7] It has developed effective sustainable transport facilities including provision of “Cycleways” (previously London Cycle Superhighway’) to assist commuters to reach different areas of the city.[8] The London cycle hire scheme (LCHS) was started in 2010 providing easy access to shared bicycles round the year connecting different parts of the city. Woodcock et al noted improved overall health benefits in a large health outcome study for cyclists using the bike hire scheme in London.[9] A number of “cycling friendly” initiatives including ultra-low emission zones, segregated cycle paths & congestion charges have been implemented to curtail motor vehicle traffic in many parts of the city. Unfortunately, the cyclists also constituted 8% of all road traffic fatalities in London in 2017 which increased to 11% in 2018.[10]

Our cohort consisted of patients between the ages of 4 to 67 years (Mean 35.41 years (with 82% (n ¼ 18) being males & majority of these patients did not wear protective ing helmets.[13,15] A retrospective cohort study of about 7000 patients in Germany showed no reduction in facial injuries in helmet wearers and this is attributed to the design of the helmets which did not afford facial protection. 16 Recently, lightweight full face helmets have entered the market pro-mising protection from facial trauma along with head injury (Figure 1). There is no law in the UK making helmet use mandatory, although the Highway Code specifies wear- ing a correct sized & securely fastened helmet for all cyclists.[17] Additionally, the LCHS does not provide a pro- tective helmet & current evidence suggests that cyclists using this scheme are also less likely to use helmets.[18] There is market availability of a range of protective portable/ foldable helmets that can be stored and carried easily, albeit they are on the expensive side [100€–400€] (Figure 2). At least, 29 countries have some form of legislation toward use of helmets for cyclists [19] (

Table 4. Countries With Helmet Legislations for Cyclists.

). A political discussion has ensued regarding mandatory helmet requirement in spite of concrete evidence that they reduce head/facial injuries in cyclists. Many argue that legislations discourage people from taking up sustainable transport. A number of studies especially in countries like Sweden & Australia have noted reduction of cycling injuries & associated fatalities due to compulsory helmet use.[20,21] A Cochrane study in children noted similar findings suggesting that helmet use decreased head injuries.[22] Recent meta-analyses of 21 studies observed significant reductions of minor & major head injuries as well as debunking the generalized notion that helmet use dissuades people from cycling.[23]

Majority of cyclists who attended the emergency depart- ment were due to “single cycling accidents” i.e. without involvement/collision with other vehicles (77%). This is also one of the reasons for underreporting of cycling inju- ries as the injuries are less likely to be “serious” in nature compared to road traffic collisions. Due to the retrospective nature of study, specific data with regards to type of bicycles (conventional or electric or modified) was not available. Early studies of electric bicycle injuries have been noted to be more serious in nature & comparable to motorcycle related injuries.[24] Cyclists are also at a higher risk of spinal injuries and increased incidences of these life-changing injuries during recent times are concerning.[25]

In our study, only 3 patients confessed to have been cycling under the influence of alcohol. However, there is growing evidence to associate cycling injuries with alcohol intake. In the UK, there are no laws to measure the legal limit of alcohol for a cyclist as observed in some European countries.[26]

Limitations of This Study

Our study was limited by a small cohort and retrospective nature of the study and the sample may not be representa- tive of all bicycle injuries of North London as it is depen- dent on patients reporting these injuries as well presence of other ED in the vicinity which are not part of our trust. Small facial injuries seen by ED may still be discharged without any maxillofacial review. No information was gathered regarding type of bicycle, speed, experience of the rider & location of the injury. Major inferences are there- fore not possible from this humble review. A prospective multi-center investigation may provide a realistic sample & data for accurate analysis.

Conclusion

In general, providing cyclists a safe environment (cycle paths/bicycle lanes; decreasing speed limit in built up areas to 20 mph) is essential & the “safety in numbers” (more cyclists on the road decreases risk of cycling injuries) concept seems to get a boost from current research.[27,28] We recommend sweeping changes to the current laws to improve road safety, legislation of personal safety mea- sures & active policing of drug intoxication among cyclists just as other road users. The pandemic of COVID-19 will lead to long term changes to the lifestyle & health of our population especially in major cities of the world. Prospec- tive studies are needed to derive robust data related to cycling injuries & its associations to prevent debilitating injuries.