The authors have declared that no competing interests exist.
The objective of the study was to establish the role of helmet use on severity and pattern of maxillofacial injuries among motorcycle crash victims attending Mulago Hospital. This was descriptive cross sectional case series study using a questionnaire in form of an oral interview, clinical examination and review of medical records of the patients. The pattern of injuries was assessed based on the demarcated regions of the face. The severities of the injuries were scored using the Facial Injury Severity Scale. The data were analysed using SPSS version 17.0. There were 105 participants (male/female: 97/8) aged 15 to 63 years. Most participants (n= 74, 70.5%) were riders and the rest were passengers. There were no female riders. Most participants were from Kampala and surrounding districts. Overall, 35.2% of the participants had helmets: 50% of the riders and 0% of the passengers. About 73% o the participants used Three Quarter Shell helmet design. There was no significant difference in the pattern of injuries between the passengers and non helmeted riders (p=0.076). There was a higher frequency helmeted riders (n = 15, 40.5%) with pan-facial fractures compared to other participants. Non helmeted riders and passengers had significantly more injuries to the lower two thirds of the face compared to the helmeted riders. Passengers had less severe facial injuries compared to riders. We conclude that about a third of the participants who were riders used helmets, being particularly the Three Quarter Shell design. The helmeted riders had more severe maxillofacial injuries and of panfacial category as compared to other participants. The passengers had least severe injuries compared to riders. It is recommended to carry out further studies to elucidate on motorcycle related maxillofacial injuries especially in regard to the quality of helmets and their adequate use.
Motorcycles are a common means of transportation in low and middle income countries. Their use is associated with high prevalence of injuries; a major public health concern
In Nigeria, maxillo-facial injuries due to motorcycle riding constituted 50.5% to 57% of the road traffic accidents
Kampala metropolitan is congested with public service vehicles; estimated at 15,000 minibuses and 30,000 motorcycles
This was case series descriptive cross sectional study.
The study was carried out in Oral and Maxillofacial Surgery, Neurosurgery and Orthopaedics units of Mulago Hospital. Mulago Hospital is a national referral and teaching health facility located in Kampala, the capital city of Uganda. The hospital has a capacity of 1500 beds. The units are specialized in managing patients, particularly with trauma who are mainly referred from other health facilities in the country.
The study participants (n=105) were patients aged 15 – 63 years with maxillofacial injuries following motorcycle crashes either as riders or passengers and attending Oral and Maxillofacial Surgery (n=77), Neurosurgery (n=22) and Orthopaedic unit (n=6) of Mulago Hospital. They were requested for consent/assent before recruitment into the study. Participants who were too ill to answer the questionnaire (n=3) and too young to wear a helmet (n=4) were excluded from the study.
A structured questionnaire was administered to the participants or their guardians in form of an oral interview by the Principal Investigator (JOK) to get background information. Information on the design of helmet into a computer and again double checked for errors and completeness. The injury severity scores based on FISSwere categorized: 1 = score 1-6 and 2 = score > 6. The data were analyzed using Statistical Package for Social Sciences Inc., (SPSS version 17.0 for windows, Chicago, Illinois, USA). Frequency distribution was used to summarize the data. Chi-square statistics was used to assess any significant differences in participants based on quantitative variables. Paired t test was used to assess the intra-examiner reliability in recording observations. The level of significance was set at p value <5%.
Blind duplicate examination of mandibular fractures was conducted on 20 patients 4 days after the main survey. The agreement was substantial (Cohen’s κ = 0.70). Similarly, blind duplicate viewing of 50 radiographs, a week later gave an almost perfect agreement (Cohen’s κ = 0.84). There was neither evidence of systematic error in clinical examination nor in viewing of radiographs (paired t test, p>0.05).
The study complied with a protocol approved by Makerere University School of Medicine Research and Ethics Committee (No. REC REF 2011-173). Permission to carry out the study was obtained from Mulago Hospital administration. Informed consent was obtained from the study participants /guardians of children below 18 years of age. In addition to the consent, the children were requested to assent to the study. The consent/assent form was translated from English into the local language (Luganda) for participants who did not understand English. The nature and purpose of the study were explained to the participants in accordance with Helsinki Declaration
The study sample constituted 105 participants (male/female: 97/8). Most participants (n= 74; 70.5%) were riders and none of them a female. They all rode the saddle motor cycles. Overall, the participants were aged 15 to 63 (mean, 29.01 ± 9.5) years with majority 62.9%, n=66) aged 21 to 30 years. The riders were aged 18 to 59 (mean, 28 ± 8.7) years while the passengers were 15 to 63 (mean, 29 ± 11.4) years. The helmeted riders were aged 18 to 59 years (mean, 30.4 ± 9.3) years and the non helmeted counterparts were 18 to 50 (mean, 27.1 ± 7.8) years. Based on the units of study, the helmeted riders were 22, 11 and 4 in Oral and maxillofacial, Neurosurgery and Orthopaedic Surgery unit, respectively.
The subjects with maxillofacial injuries came from 21 districts of Uganda. Kampala district had the majority of cases (46.7%, n = 49) followed by Wakiso district with 21.0% (n=22) and Mokono district had worn during crash was obtained from the participants with the help of pictures of helmets (
Clinical examination for maxillofacial injuries was carried out while the patient was lying supine in the dental chair/couch with the help of artificial light by JOK. The pattern of maxillofacial bone fracture was assessed clinically and confirmed with radiological imaging.. The severity of the injuries was scored on Facial Injury Severity Scale (FISS) and recorded in a data recording form.
Data on completed forms were double checked for errors and completeness while the participant was still present in the clinic or ward. The data were inputted
((n=10, 9.5%;
Three different types of helmet design were used by the riders: the TQS (n=27, 73.0%), FF (n=8, 21.6%) and HS (n=2, 5.4%). Overall, 35.2% of the participants had helmets: 50% of the riders and 0% of the passengers (
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< 21 years | Passenger | 0 (0.0) | 4 (100) | 4 (100) |
Rider | 2 (16.7) | 10 (83.3) | 12 (100) | |
≥21 years | Passenger | 0 (0.0) | 27 (100) | 27 (100) |
Rider | 35 (56.5) | 27 (43.5) | 62 (100) |
Use of helmet significantly increased with age of the motorcycle riders (p=0.004). Pattern of maxillofacial injuries
There was no significant difference in the pattern of injuries between the passengers and non helmeted riders (p=0.076). There was a higher frequency of helmeted riders (n = 15, 40.5%) with pan-facial fractures compared to 4 non helmeted riders and 1 passenger (
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Non helmeted | Passenger (n=31) | 0 (0.0) | 3 (9.7) | 14 (45.2) | 3 (9.7) | 0 (0.0) | 10 (32.3) | 1 (3.2) |
Rider (n=37) | 0 (0.0) | 2 (5.4) | 17 (45.9) | 3 (8.1) | 3 (8.1) | 8 (21.6) | 4 (10.4) | |
Helmeted | Rider (n=37) | 1 (2.7) | 4 (10.8) | 3 (8.1) | 4 (10.8) | 1 (2.7) | 9 (24.3) | 15 (40.5) |
UT = Upper Third; MT = Middle Third; LT = Lower Third; UTT = Upper Two Thirds; ULT = Upper and Lower Thirds; LTT = Lower Two Thirds; PF = Pan Facial
The influence of gender on FISS score could not be assessed because the data were skewed towards males. The overall mean FISS was 7.0 (SD 5.3). Helmeted riders had more severe maxillofacial injuries, range 1 to 19 (mean, 10.1 ± 5.4) FISS as compared to their non helmeted counterparts (mean FISS, 6.59 ± 4.9). Passengers had the least severity of maxillofacial injuries (mean FISS, 4.0 ± 1.6;
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Non helmeted | Passenger (n=31) | 30 (96.8%) | 1 (3.2%) |
Rider (n=37) | 24 (64.9%) | 13 (35.1%) | |
Helmeted | Rider (n=37) | 12 (32.4%) | 25 (67.6%) |
Helmeted riders had significantly more severe maxillofacial injuries as compared to the non helmeted counterparts (p=0.004) and overall, the riders sustained significantly more severe maxillofacial injuries as compared to the passengers (p=0.001). Three of the participants lost an eye each: 2 helmeted riders (5.4%) and a female passenger (3.2%,
There are several scoring systems, but with challenges related to their use as previously discussed
We observed most of the participants were from Kampala and the neighboring districts probably because the study site (Mulago Hospital) is within Kampala and in proximity of the surrounding districts. Furthermore, Kampala metropolitan has more motorcycles compared to other regions
In the present study, the motorcycle riders were aged 18 to 59 (mean, 28 ± 8.7) years, which is consistent with other studies elsewhere
We observed all the riders were males, who coincidentally, are the ones mostly involved in riding motorcycles for public transport in Uganda. This finding is similar to previous studies
The absence of female motorcycle riders in the present study and elsewhere in Africa may probably be due to the type of motorcycles on the market, the straddle type which do not favor mounting by female and child riders unlike the scooters, which are more appealing and commonly used in recreational and sporting activities
In the present study, 50% of the riders used helmet (
Other reasons for not willing to wear helmet include: discomfort, obscuring of vision, disturbance of hearing, ruffling up hair style, cost or thefts of helmets while others said helmets are responsible for crashes
In the present study, about three quarters (27/37) of the riders wore helmets of Three Quarter Shell design and because of the limited variability, the relationship between helmet design and type of maxillofacial injuries could not be assessed. However, amongst the non helmeted participants, the injuries were predominantly mandibular fractures and the associated soft tissue injuries while the helmeted group had panfacial fractures in addition to mandibular fractures. Overall, most participants had injuries of the lower two thirds of the face irrespective of helmet use (
We found significantly more helmeted riders had severe maxillofacial injuries (with 2 of them losing an eye each) as compared to the non helmeted counterparts (
Overall, we found the riders had sustained significantly more severe maxillofacial injuries as compared to the passengers contrary to previous workers
One previous study
About a third of the participants and only riders used helmets particularly of the Three Quarter Shell design at the time of injury. None of the passengers had a helmet. Generally, helmeted riders had severe maxillofacial injuries and of panfacial category as compared to other participants.
Although the present study generated baseline data, it was daunted with various limitations indicative of further studies to elucidate on factors such as the quality of helmets and their adequate use as well as mechanism of maxillofacial injuries during motorcycle crashes.
The authors are grateful to the participants for their cooperation during the study. The staff members in the study units of Mulago Hospital were instrumental in mobilizing the study participants.