PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 31 no. 2 July – december 2016
ORIGINAL ARTICLES
PhiliPPine Journal of otolaryngology-head and neck Surgery 27
ABSTRACT
Objective: To describe the type and determine the number of motorcycle related cranio-
maxillofacial injuries that were seen by the ORL service in the emergency room of a tertiary
hospital from January 2013 to December 2013.
Methods:
Design: Cross sectional retrospective chart review
Setting: Tertiary National University Hospital
Participants: One hundred nine (109) charts of patients seen at the emergency
room from January 2013 to December 2013 were reviewed
Results: Of the 109 charts of patients involved in vehicular accidents, there were 76 documented
cases of motorcycle related accidents. Of these, 91% involved males and 9% involved females.
Seventy one percent (71%) did not wear helmets, of whom 36% were young adult males between
the ages of 18-30 years. Those that wore helmets had a total of 27 different facial fracture sites:
19% zygomatic tripod fractures, 15% temporal bone fractures and 11% with no fractures noted.
Among those who did not wear helmets 75 fractures were noted. Twenty four percent (24%) were
tripod fractures, 15% temporal bone fractures and 12% maxillary fractures. Only one did not incur
any fractures.
Conclusion: Most cranio-maxillofacial fractures seen at the emergency room were from
motorcycle related injuries (70%). Despite implementation of Republic Act 10054 (The Motorcycle
Helmet Act of 2009) majority of motorcycle-related accidents are still incurred by riders without
helmets.
Keywords: cranio-maxillofacial fractures, motorcycle accidents, helmet, tripod fracture, temporal
bone fracture
Motorcycles have become an increasingly popular form of transportation due to their
low cost in fuel consumption and flexibility in avoiding traffic conditions in the metropolitan
area. However, this type of transport is the top cause of fatal and nonfatal injuries in vehicular
accidents.1
Several studies have shown that the use of helmets decreased the incidence of fatal and
nonfatal injuries.2-5 The enactment of the universal helmet law also decreased hospital admissions
for motorcycle related injuries.2-5 In the Philippines, the Motorcycle Helmet Act was signed into
Motorcycle Related Cranio-Maxillofacial Injuries
at a Tertiary Hospital in the Philippines
Rhodieleen Anne R. de la Cruz, MD1
Rene S. Tuazon, MD2
1Department of Otorhinolaryngology
Philippine General Hospital
University of the Philippines Manila
2Department of Otorhinolaryngology
College of Medicine - Philippine General Hospital
University of the Philippines Manila
Correspondence: Dr. Rene S. Tuazon
Department of Otorhinolaryngology
Ward 10, Philippine General Hospital
University of the Philippines Manila
Taft Avenue, Ermita, Manila 1000
Philippines
Phone (632) 554 8467
Email: rstuazonmd@gmail.com
Reprints will not be available from the author.
The authors declared that this represents original material
that is not being considered for publication or has not been
published or accepted for publication elsewhere in full or in
part, in print or electronic media; that the manuscript has been
read and approved by the authors, that the requirements for
authorship have been met by each author, and that the authors
believe that the manuscript represents honest work.
The authors signed disclosures that there are no financial or
other (including personal) relationships, intellectual passion,
political or religious beliefs, and institutional affiliations that
might lead to a conflict of interest.
Presented at the Philippine Society of Otolaryngology Head
and Neck Surgery Descriptive Research Contest. September 18,
2014. Natrapharm, The Patriot Building, Parañaque City.
Philipp J Otolaryngol Head Neck Surg 2016; 31 (2): 27-30 c Philippine Society of Otolaryngology – Head and Neck Surgery, Inc.
Creative Commons (CC BY-NC-ND 4.0)
Attribution - NonCommercial - NoDerivatives 4.0 International
PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 31 no. 2 July – december 2016
28 PhiliPPine Journal of otolaryngology-head and neck Surgery
ORIGINAL ARTICLES
law in March 2010.6 Despite the enactment of this law there have
still been numerous cases of motorcycle related accidents without
helmet use.7 As, such there is a need to collect epidemiological data
on the frequency of helmet use among motorcyclists. Determining the
number of motorcycle accidents, demographics, frequency of helmet
use and type of injuries may assist in formulating a program to increase
awareness of the law and its provisions, and lessen injuries from road
accidents.
The aim of this study was to determine the following: 1) frequency
of helmet use in drivers or riders involved in motorcycle accidents; 2)
the number of motorcycle-related cranio-maxillofacial injuries; 3) type
of cranio-maxillofacial fracture incurred by patients who were helmets
users versus non-users; and 4) mechanisms of injury.
METHODS
With institutional ethical review board approval, a retrospective
cross sectional chart review of cases involving vehicular accidents
between January 1 and December 31, 2013 was conducted. Charts were
retrieved from the hospital medical records section using the patient’s
case number and name obtained from the emergency room census.
Included were records of those 1) referred to the
otorhinolaryngology Emergency Room (ORL ER) service from January
2013 to December 2013; 2) who were drivers and passengers involved
in motorcycle accidents; and 3) who underwent radiographic tests.
Excluded were records of patients 1) who absconded or went home
against advice before they underwent radiographic tests; 2) who
were involved in other types of vehicular accidents; and 3) involved
in motorcycle accidents but not referred to the ORL service. A data
abstraction sheet was used to encode data from the charts.
Data regarding qualitative variables were summarized using
frequencies and percentages. Quantitative data were summarized using
mean, standard deviation and these were analyzed using Microsoft
Excel 2010 Version 14.0.7015.1000 SP2 (Microsoft Corp., Redmond, WA,
USA).
RESULTS
Of the 121 charts of patients incurring cranio-maxillofacial injuries
initially retrieved from the medical records section, 109 charts of
patients meeting inclusion and exclusion criteria were involved in
vehicular accidents. Seventy-six (70%) of these were motorcycle related.
There were 69 males and 7 females, with ages ranging 14-60 years old.
Demographic data of the patients are summarized in Table 1.
Only 29% of the patients in the charts reviewed wore a helmet
during the time of the accident. Most of the patients who did not wear
Table 1. Distribution of age according to sex of patients involved in motorcycle accidents
(n=76)
Frequency Mean age +/- Standard
Deviation
Range
Males
Females
TOTAL
69
7
76
30 +/- 11 years old
29 +/-11 years old
30 +/- 11 years old
14-60 years old
17-47 years old
14-60 years old
FrequencyType Percent
Motorcycle vs pavement
Motorcycle vs post
Motorcycle vs tricycle
Motorcycle vs bus
Motorcycle vs truck
Motorcycle vs motorcycle
Motorcycle vs gutter
Motorcycle vs car
Motorcycle vs jeep
Unknown mechanism
Motorcycle vs building
Motorcycle vs canal
Motorcycle vs wire
Motorcycle vs pedestrian
Motorcycle vs wall
Motorcycle vs truck
Motorcycle vs van
Motorcycle vs taxi
Motorcycle vs plant box
Motorcycle vs dog
Motorcycle vs tree
Motorcycle vs rock
TOTAL
39
5
4
3
3
3
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
76
51.32
6.58
5.26
3.95
3.95
3.95
2.63
2.63
2.63
1.32
1.32
1.32
1.32
1.32
1.32
1.32
1.32
1.32
1.32
1.32
1.32
1.32
100.00
Table 2. Distribution of Mechanism of injury (n=76)
helmets were between the ages of 18-30 years old and those that did
wear helmets were mostly between the ages of 31-50 years old. Males
and females showed the same trend of helmet use.
Cranio-maxillofacial fractures were noted for all the charts reviewed.
Most patients had multiple fracture sites resulting in 102 fractures
documented for the 76 patients. Seventy-five (75) fracture sites were
noted for 54 patients not wearing helmets. Approximately 1.22 fractures
PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 31 no. 2 July – december 2016
ORIGINAL ARTICLES
PhiliPPine Journal of otolaryngology-head and neck Surgery 29
accidents regardless of helmet use however more cranio-maxillofacial
fractures were seen for patients not wearing helmets. Motorcycle users
most commonly hit the pavement, which caused their injuries.
In other developed countries such as Italy there was decrease
in hospital admissions for traumatic brain injuries after stricter
implementation of the motorcycle helmet law.5 A meta-analysis in the
United States showed that a universal helmet act does decrease the
number of hospital admissions.8
The data from our study showed that less than 25% used helmets
during the time of the accident which is well below the values of other
developing countries with a universal helmet law. In a similar study in
Brazil, 76% of patients wore helmets during the time of the accident.4
Our values were much closer to a study in Jamaica where only 34% wore
helmets.3 Even though these three countries had a universal helmet
law, its effectiveness was not the same.
For this study, motorcycle accidents with or without helmets were
more common in 30-year-old males (30 +/- 11 years old) and 29-year-old
females (29 +/-11 years old). This data is comparable to similar studies in
developing countries such as Brazil and Jamaica, except for a younger
peak age incidence of 10 to19 years among female motorcyclists in the
former.3,4
Motorcycle riders were at a disadvantage when collision occured
due to the lack of safety devices like seat belts and air bags. A helmet was
the most important safety gear. A prospective cross-sectional study in a
trauma center in Jamaica showed a 70% reduction in injury severity and
40% reduction in mortality of helmet users as compared to non-helmet
users.3 A Cochrane review of 53 observational studies concluded that
motorcycle helmets reduce the risk of mortality with an Odds Ratio (OR)
of 0.58, 95% Confidence Interval (CI) 0.50 to 0.68 among the 4 cross-
sectional studies provided. The same review also found that helmets
decrease the risk of head injury with an OR of 0.23 to 0.35.9
Although insufficient to generate a hypothesis on the impact of
helmets on head injuries, our data suggests that when a ratio of the
number of fractures per patient is obtained, more fractures were seen
per person for the non-helmet group compared to the helmet group.
The data also suggests that there were more instances where no
fractures were seen for the group who used helmets compared to those
who did not use helmets. Although our results were not concurred with
by the Brazil study, where more fractures were seen for the groups who
wore helmets, this may be because those that did not wear helmets
in that study sustained encephalic trauma and treatment for the facial
fractures were not prioritized. 4
Helmets may not always protect riders from facial fractures but have
been proven to prevent significant traumatic brain injuries.3 In the
study in Jamaica, those who did not wear helmets had more intracranial
lesions (44.7%) and had more severe traumatic brain injuries (46.8%).7
Figure 1. Most common fractures of patients with helmets during motorcycle accidents (n=27)
Figure 2. Most common fractures of patients without helmets during motorcycle accidents. (n=75)
per patient with helmets were observed while 1.37 fractures per patient
were sustained by those who did not wear helmets. Only 1 out of the 54
patients without helmets had no fractures.
The most common fractures incurred by patients with and without
helmets are described in Figures 1 and 2.
There were several mechanisms of injury noted for the charts
reviewed. Motorcycle riders hit the pavement causing cranio-
maxillofacial fractures more than 50% of the time. (Table 2)
DISCUSSION
Our study showed that 70% of vehicle related accidents are due to
motorcycle use and the frequency of helmet use was low. Tripod and
temporal bone fractures were commonly seen for patients in motorcycle
PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 31 no. 2 July – december 2016
30 PhiliPPine Journal of otolaryngology-head and neck Surgery
ORIGINAL ARTICLES
REFERENCES
1. AAPhilippines.org [homepage on the Internet]. Philippines: Metro Manila Development
Authority. Road Safety Unit Traffic Operations Center. Metro Manila Accident Reporting and
Analysis System: Traffic Accident Report January to December Accident Report January to
December 2009; [updated 2011 cited 2014 Aug 3]. Available from: http://www.aaphilippines.
org/roadsafety/.../MMARAS%20Annual%20Report%202009.pdf.
2. Tsai MC, Hemenway D. Effect of the mandatory helmet law in Taiwan. Inj Prev. 1999 Dec [cited
2014 Aug 3]; 5(4): [290-1]. Available from: http://injuryprevention.bmj.com/content/5/4/290.
full . DOI: 10.1136/ip.5.4.290; PubMed PMID: 10628919; PubMed Central PMCID: PMC1730540.
3. Crandon IW, Harding HE, Cawich SO, Frankson MA, Gordon-Strachan G, McLennon N, et al. The
impact of helmets on motorcycle head trauma at a tertiary hospital in Jamaica. BMC Res Notes.
2009 Aug. [Cited 2014 Aug 3]; 2(1):[About 5p]. Available from: http://www.biomedcentral.
com/1756-0500/2/172. DOI: 10.1186/1756-0500-2-172; PubMed PMID: 19715612; PubMed
Central PMCID: PMC2746805.
4. Maliska MC, Borba M, Asprino L, Moraes MD, Moreira RW. Oral and maxillofacial surgery-Helmet
and maxillofacial trauma: a 10-year retrospective study. Brazilian Journal of Oral Sciences.
[serial on internet] 2012 Jun. [cited 2014 Aug 3];11(2):[125-9]. Available from: http://revodonto.
bvsalud.org/scielo.php?script=sci_arttext&pid=S1677-32252012000200010&lng=en.
5. Servadei F, Begliomini C, Gardini E, Giustini M, Taggi F, Kraus J. Effect of Italy’s motorcycle
helmet law on traumatic brain injuries. Inj Prev. 2003 Sep. [cited 2014 Aug 3]; 9(3):[257-60].
Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1731012/pdf/v009p00257.
pdf. DOI:10.1136/ip.9.3.257; PubMed PMID: 12966016; PubMed Central PMCID: PMC1731012.
6. Senate.gov [homepage on the Internet]. Philippines: Republic of Philippines Congress of the
Philippines [Updated 2009 cited 2013 September 2]. Available from: https://www.senate.gov.
ph/republic_acts/ra%2010054.pdf.
7. Official Gazette [homepage on the Internet]. Philippines: Republic of the Philippines
Department of health. [updated 2013 cited 2014 August 15]. Available from: http://www.gov.
ph/2013/04/29/9-out-of-10-doa-motorcycle-riders-found-not-wearing-helmet/.
8. MacLeod JB, DiGiacomo JC, Tinkoff G. An evidence-based review: helmet efficacy to reduce
head injury and mortality in motorcycle crashes: EAST practice management guidelines. J
Trauma. 2010 Nov. [cited 2014 Aug 3]; 69(5): [1101-11]. Available from: http://journals.lww.com/
jtrauma/Citation/2010/11000/An_Evidence_Based_Review__Helmet_Efficacy_to.12.aspx. DOI:
10.1097/TA.0b013e3181f8a9cc; PubMed PMID: 21068615.
9. Liu BC, Ivers R, Norton R, Boufous S, Blows S, Lo SK. Helmets for preventing injury in motorcycle
riders. Cochrane Database Syst Rev. 2008 Jan 23 [cited 2014 Aug 3]. 1(CD004333): [about 44p].
Available from: http:// http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004333.pub3/
pdf. DOI: 10.1002/14651858.CD004333.pub3; PubMed PMID: 18254047.
The previously cited study in Brazil noted that mandibular fractures
and fractures of the midface were common.4 They associated it with the
fact that even with helmets there is still a prominence of the mandible
and dissipation of forces to the midface.4 In contrast, the most common
fractures seen for both helmet and non-helmet users in our study were
tripod fractures followed by temporal bone fractures. Mandibular
fractures were not as common. Temporal bone fractures were also noted
in our study but not mentioned in the Brazil study,4 perhaps because
they did not consider these part of maxillofacial injuries. Temporal bone
fractures were common in both helmet and nonhelmet groups in our
study may suggest that helmets do not offer significant protection from
this type of fracture.
The study had several limitations. The charts reviewed were
limited to those referred to the ORL service at a tertiary hospital in the
Philippines from January 2013-December 2013. Records of persons
with motorcycle-related injuries that were not referred to our service
were not included. Charts not retrieved by the records section were also
excluded from data analysis. Radiographic images were not reviewed
for confirmation of injuries listed in the charts. The study did not also
account for those patients with fatal injuries or those who had traumatic
brain injuries that could have been a significant addition to the data
gathered.
It is recommended that a prospective study will yield a more valid
estimate of the cases referred to our service since we will no longer
be dependent on the medical records being complete. It may also be
important to note the frequency of use of Department of Trade and
Industry (DTI) - approved helmets specifically and to determine the
efficacy of these helmets in preventing head injuries. It will also be
interesting to determine the efficacy of the different types of helmets
in preventing certain facial fractures.
Traffic road accidents are a major public health problem because
of the consequences of injuries to riders and destruction of property.
Thus, several countries have already passed laws to prevent this, one of
which is the universal helmet law. However, compliance to this law has
still been low. As evidenced by our study, motorcycle related accidents
continue to be a common reason for hospital admission. Most cranio-
maxillofacial injuries are incurred by those who did not use helmets
during the time of the accident. Data from this study can be used for
further public health researches to improve health policies on road
traffic accident prevention. There is still room for improvement in the
implementation of the Motorcycle Helmet Act of 2009.