Safety Factors and Patterns of Bicycle Trauma in a Tertiary Level 1 Trauma Center in Boston, Massachusetts: A Retrospective Review and Survey Study

Document Type : RESEARCH PAPER


1 1 Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA 2 Department of Orthopaedics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA

2 Department of Orthopaedics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA

3 Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA


Objectives: Increasing bicycle ridership is accompanied by ongoing bicycle-related accidents in many 
urban cities. There is a need for improved understanding of patterns and risks of urban bicycle usage. 
We describe the injuries and outcomes of bicycle-related trauma in Boston, Massachusetts, and 
determine accident-related factors and behaviors associated with injury severity.
Methods: We conducted a retrospective review via chart review of 313 bicycle-related injuries presenting to a Level 
1 trauma center in Boston, Massachusetts. These patients were also surveyed regarding accident-related factors, 
personal safety practices, and road and environmental conditions during the accident.
Results: Over half of all cyclists biked for commuting and recreational purposes (54%), used a road without a bike 
lane (58%), and a majority wore a helmet (91%). The most common injury pattern involved the extremities (42%) 
followed by head injuries (13%). Bicycling for commuting rather than recreation, cycling on a road with a dedicated 
bicycle lane, the absence of gravel or sand, and use of bicycle lights were all factors associated with decreased 
injury severity (p<0.05). After any bicycle injury, the number of miles cycled decreased significantly regardless of 
cycling purpose.
Conclusion: Our results suggest that physical separation of cyclists from motor vehicles via bicycle lanes, regular 
cleaning of these lanes, and usage of bicycle lights are modifiable factors protective against injury and injury severity.
Safe bicycling practices and understanding of factors involved in bicycle-related trauma can reduce injury severity 
and guide effective public health initiatives and urban planning.
 Level of evidence: IV


Main Subjects

1. Rissel CE. Active travel: a climate change mitigation strategy
with co-benefits for health. N S W Public Health Bull. 2009;
20(1-2):10-3. doi: 10.1071/nb08043.
2. Hamer M, Chida Y. Active commuting and cardiovascular risk:
a meta-analytic review. Prev Med. 2008; 46(1):9-13. doi:
3. Oja P, Titze S, Bauman A, et al. Health benefits of cycling: a
systematic review. Scand J Med Sci Sports. 2011; 21(4):496-
509. doi: 10.1111/j.1600-0838.2011.01299.x.
4. Liu L, Núṅez AE, An Y, et al. Burden of Cardiovascular Disease
among Multi-Racial and Ethnic Populations in the United
States: an Update from the National Health Interview
Surveys. Front Cardiovasc Med. 2014; 1:8. doi:
10.3389/fcvm.2014.00008. eCollection 2014.
5. CDC Wonder. Underlying Cause of Death 1999-2013. 2015.
Available at:
6. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and
stroke statistics--2015 update: a report from the American
Heart Association. Circulation. 2015; 131(4):e29-322. doi:
7. Lindsay G, Macmillan A, Woodward A. Moving urban trips
from cars to bicycles: impact on health and emissions. Aust N
Z J Public Health. 2011; 35(1):54-60. doi: 10.1111/j.1753-
8. Rojas-Rueda D, de Nazelle A, Tainio M, Nieuwenhuijsen MJ.
The health risks and benefits of cycling in urban
environments compared with car use: health impact
assessment study. BMJ. 2011; 343:d4521. doi:
9. Derriks HM, Mak PM. IRTAD special report. Underreporting
of Road Traffic. 2007.
10. Beck LF, Dellinger AM, O’Neil ME. Motor vehicle crash injury rates by mode of travel, United States: using exposure-based
methods to quantify differences. Am J Epidemiol. 2007;
166(2):212-8. doi: 10.1093/aje/kwm064.
11. Wegman F, Zhang F, Dijkstra A. How to make more cycling
good for road safety? Accid Anal Prev. 2012; 44(1):19-29. doi:
12. Liu H-T, Rau C-S, Liang C-C, et al. Bicycle-related
hospitalizations at a Taiwanese level I Trauma Center. BMC
Public Health. 2015;15:722. doi: 10.1186/s12889-015-2075-
13. Gaudet L, Romanow NTR, Nettel-Aguirre A, Voaklander D,
Hagel BE, Rowe BH. The epidemiology of fatal cyclist crashes
over a 14-year period in Alberta, Canada. BMC Public Health.
2015; 15:1142. doi: 10.1186/s12889-015-2476-9.
14. Rowe BH, Rowe AM, Bota GW. Bicyclist and environmental
factors associated with fatal bicycle-related trauma in
Ontario. CMAJ. 1995; 152(1):45-53.
15. Noakes TD. Fatal cycling injuries. Sports Med. 1995;
20(5):348-62. doi: 10.2165/00007256-199520050-00006.
16. Bike Network Plan.
17. Ramos NC. Death toll mounts for bicyclists on Boston’s
streets-The Boston Globe. Available at: Accessed
August 11, 2015.
18. Pedroso FE, Angriman F, Bellows AL, Taylor K. Bicycle Use
and Cyclist Safety Following Boston’s Bicycle Infrastructure
Expansion, 2009-2012. Am J Public Health. 2016;
106(12):2171-2177. doi: 10.2105/AJPH.2016.303454.
19. McLeod K. Where We Ride 2014: Analysis of Bike
Commuting. Available at:
analysis-bike-commuting. Accessed October 1, 2015.
20. Copes WS, Champion HR, Sacco WJ, Lawnick MM, Keast SL,
Bain LW. The Injury Severity Score revisited. J Trauma. 1988;
28(1):69-77. doi: 10.1097/00005373-198801000-00010.
21. Baker SP, O’Neill B, Haddon W, Long WB. The injury severity
score: a method for describing patients with multiple injuries
and evaluating emergency care. J Trauma. 1974; 14(3):187-
22. Dennis J, Ramsay T, Turgeon AF, Zarychanski R. Helmet
legislation and admissions to hospital for cycling related head
injuries in Canadian provinces and territories: interrupted
time series analysis. BMJ. 2013; 346:f2674. doi:
23 Teschke K, Brubacher JR, Friedman SM, et al. Personal and
trip characteristics associated with safety equipment use by
injured adult bicyclists: a cross-sectional study. BMC Public
Health. 2012; 12:765. doi: 10.1186/1471-2458-12-765.
24. Lusk AC, Morency P, Miranda-Moreno LF, Willett WC,
Dennerlein JT. Bicycle guidelines and crash rates on cycle
tracks in the United States. Am J Public Health. 2013;
103(7):1240–8. doi: 10.2105/AJPH.2012.301043.
25. Chen L, Chen C, Srinivasan R, McKnight CE, Ewing R, Roe M.
Evaluating the safety effects of bicycle lanes in New York City.
Am J Public Health. 2012; 102(6):1120–7. doi:
26. Lusk AC, Furth PG, Morency P, Miranda-Moreno LF, Willett
WC, Dennerlein JT. Risk of injury for bicycling on cycle tracks
versus in the street. Inj Prev. 2011; 17(2):131–5. doi:
27. Kiburz D, Jacobs R, Reckling F, Mason J. Bicycle accidents and
injuries among adult cyclists. Am J Sports Med. 14(5):416–9.
doi: 10.1177/036354658601400516.
28. Cripton PA, Shen H, Brubacher JR, et al. Severity of urban
cycling injuries and the relationship with personal, trip, route
and crash characteristics: analyses using four severity
metrics. BMJ Open. 2015; 5(1):e006654. doi:
29. Morgan AS, Dale HB, Lee WE, Edwards PJ. Deaths of cyclists in
London: trends from 1992 to 2006. BMC Public Health. 2010;
10:699. doi: 10.1186/1471-2458-10-699.
30. Jamil O, Al Shdefat S, Arshad Z, et al. Cycling-related
orthopaedic fractures admitted to the Major Trauma Centre
in the cycling capital of the UK. Arch Orthop Trauma Surg.
2022; 142(10):2747-2753. doi: 10.1007/s00402-021-04097-
31. Jonsson A, Larusson SH, Mogensen A, Bjornsson HM,
Mogensen BA. [Incidence of Bicycle injuries presenting to the
Emergency Department in Reykjavik 2005-2010].
Laeknabladid. 2016; 102(2):77-82. doi:
32. McGrath, Kevin; Tranter M. Investigating Road Traffic
Accident Statistics – Matching Hospital and Police data.
London, UK;
33. Rogers SC, Campbell BT, Saleheen H, Borrup K, Lapidus G.
Using trauma registry data to guide injury prevention
program activities. J Trauma. 2010; 69(4 Suppl):S209-13. doi:
34. Nelson TA, Denouden T, Jestico B, Laberee K, Winters M. A Global Tool for Collision and Near Miss
Mapping. Front Public Health. 2015; 3:53. doi: