E-scooter injuries: Not the average slip and fall
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Use of electric scooters, also known as e-scooters, has increased since its introduction, according to a market research report from 2022 that estimated the North American e-scooter market will reach $15.41 billion by 2029.
This increase can be attributed to several factors, with published literature showing e-scooters are not only sustainable and convenient, but are also enjoyed for speed, being fun and relaxing, being better in hot weather than walking and its ability to replace car trips.
Source: Connor S. Jordan
“I think the potential benefit is there is the sense that [e-scooters] can be a convenient mode of transportation, especially in places where [the scooters are] a great alternative to driving and a great alternative to the use of larger levels of transportation,” Charles J. Jordan, MD, director of the orthopedic trauma service at Baptist Health Orthopedic Care, told Healio/Orthopedics Today. “It can help alleviate traffic and also increase the convenience for people.”
However, with the increase in the use of e-scooters also comes an increase in injuries, sources told Healio/Orthopedics Today.
“I have witnessed an increase not only in the last 2 years, but over the last 10 [years] and the data supports that there are an increased number of people using e-scooters,” William M. Ricci, MD, chief of the orthopedic trauma service at Hospital for Special Surgery, said. “The increased usage is probably the most influential reason for [the rise in injuries]. There are just more people on them and that has increased substantially over the last decade or so, and the last couple of years is just part of that curve.”
High-energy injuries
Although e-scooters may not typically be thought of as a mode of transportation that may cause high-energy injuries, J. Tracy Watson, MD, chief of the orthopedic trauma service at St. Louis University School of Medicine, said e-scooter injuries can be on par with motorcycle injuries.
“[It is] highly underestimated, the magnitude of how fast and how nimble [e-scooters] are,” Watson, who is an Orthopedics Today Editorial Board Member, said. “A lot of times, because they weave in and out of traffic, up and down the sidewalks, it is worse than a motorcycle [and] cars do not see them. So, there are a fair number [of riders] who get clipped by cars because they are invisible," he said.
In a 2022 retrospective review in the Journal of the American Academy of Orthopaedic Surgery, Mia McNulty, MD, and colleagues found a median injury severity score of 4 for patients who presented to the ED with injuries related to e-scooter use.
Injuries sustained from a crash on an e-scooter tend to primarily be to the upper extremity, including wrist fractures, elbow fractures or dislocations, and clavicle fractures, according to Watson.
“The fractures we see from e-scooters, especially bad elbow fractures and dislocations, are significant,” Watson told Healio/Orthopedics Today. “[There is] a lot of comminution, especially in wrist fractures. They will have significant intra-articular comminution compared with your traditional elderly, slip-and-fall distal radius [fractures].”
Additional injuries
Watson said research has shown that less than 5% of e-scooter riders wear helmets, which can lead to orbital fracture or dental injuries in the event of a fall.
“The other major area is foot and ankle injuries. [E-scooters] are so low to the ground and they go so fast. If you start to lose control, the natural tendency is to hop off,” he said. “You are going to put your foot down and you are going so fast that your foot does all kinds of funky things. It may flip you off the scooter.”
Watson said tibial shaft fractures, tibial plateau fractures, femur fractures and spine injuries are not as common as other injuries seen after an e-scooter crash.
Alexander Lauder, MD, of the hand, upper extremity and microvascular surgery section of the department of orthopedic surgery at Denver Health Medical Center and assistant professor at the University of Colorado School of Medicine, said research published by him and colleagues has shown proximal tibia and tibial shaft fractures are the most common fractures next to distal radius fractures.
According to Jordan, he does not encounter as many ligamentous or soft tissue injuries.
Electric bicycles, or e-bicycles, can also be associated with a higher incidence of injury compared with road bicycles due to the speed of e-bicycles, according to Watson. However, these injuries are less frequent compared with injuries among e-scooter riders, he said.
“There is a higher incidence of [injury with e-bikes] because they go faster, but most of those people are wearing protective gear so there is not a lot of data other than they have similar injuries to bicyclists, which can be the same [as e-scooters], although more injuries to the knees [occur] because they fall on their knees,” Watson said. “But they are not breaking their femurs or their hips. Some people do, but it is not routine. There is a higher incidence, but the focus of the huge jump [in injuries] is with e-scooters.”
Causes of e-scooter injuries
While there are no hard data on the exact causes of e-scooter injuries, Ricci said, anecdotally, data “run the gamut from an isolated accident” to an e-scooter hitting a pedestrian or an e-scooter hitting or being hit by a motor vehicle. Ricci said some studies, like the 2019 study by Leslie M. Kobayashi, MD, FACS, and colleagues in Trauma Surgery & Acute Care Open, have shown 25% to 80% of crashes on an e-scooter involved alcohol.
Clifford B. Jones, MD, chief of orthopedic surgery at Dignity Health Medical Group and professor of orthopedic surgery at Creighton Medical School, said injuries to e-scooter riders are commonly related to riding too fast, losing balance and/or trying to stop when riding off of indicated paths, on uneven terrain and/or in high vehicle/pedestrian traffic areas.
The diameter of the wheel, which is smaller than that of a bicycle, may also be the cause of falls after hitting bumps, curbs and potholes, according to Lauder.
Lauder said the laws governing e-scooters may not be clear, leading riders to not follow basic rules of the road while on an e-scooter.
This situation can be deemed the “growing pains associated with” the implementation of e-scooters, Jordan said.
“Riders may not be completely respectful, let’s say, of the potential dangers and making sure to have safety as a number one priority: riding carefully, riding in places where there are not a lot of pedestrians or motor vehicle traffic or even the use of helmets,” Jordan said.
Injuries to pedestrians
In addition to riders sustaining injuries, Jordan said he has “noticed an increase in the incidence of ... people who are not riding a scooter who either get hit by somebody riding a scooter or who trip over the scooters on the street.”
“I know there are rules that are being developed and regulations, maybe even legislation, that might be in the works, but a lot of people seem to think that [e-scooters] are all over the place on the sidewalks and on the street. I have had people trip over them and fall and sustain injuries, as well,” Jordan said.
However, the injuries sustained by pedestrians involved in e-scooter crashes are not followed as closely as those sustained by the riders, according to Watson.
Injuries to pedestrians and bystanders “are not characterized by any specific injury pattern,” Watson said. “It is usually lower extremity, like a broken ankle, or they get bumped down and, similar to riding a scooter, they break their arm or their wrist. But there is not a lot of data other than we do know there is a high incidence of pedestrians and bicyclists, especially, that get hit by [e-scooters].”
Thorough evaluation
Patients who present with e-scooter injuries should be assessed the same as any patient who presents with polytrauma, sources said.
“I do not think that you can ignore the fact that there is always the potential for severe and life-threatening injuries, so I think the evaluation should be no different than any other trauma patient,” Jordan said.
Patients who sustain e-scooter injuries should be thoroughly evaluated using Advanced Trauma Life Support standards, according to Ricci.
“They need to be checked out from head to toe because orthopedic injuries are only part of the story,” Ricci, who is an Orthopedics Today Editorial Board Member, said. “They could have head injuries. They could have injuries to other internal organs, kidney, liver or spleen.”
It may be beneficial to assess these patients through a tertiary or quaternary exam, Jones said.
“The primary exam is their wrist hurts. Their secondary exam is anywhere else that hurts, usually their facial injury or head injury, and then, the third and fourth levels are, ‘Did you miss the elbow injury because they had the wrist that hurt?’” he told Healio/Orthopedics Today. “Once their wrist pain gets less, many times they have an injury up the arm from their initial injury.”
Similarly, physicians should remember to evaluate for bilateral injuries on the primary exam, according to Watson.
“I cannot say for certain, but I am sure there is a little higher incidence of a missed injury on the contralateral extremity,” he said. That often occurs because physicians are so concerned about an obviously injured wrist or elbow that they do not happen to notice right away that the patient has some swelling on the contralateral side, Watson said.
Impact on episode of care
In addition to the possible medical consequences associated with use of an e-scooter, there is a high “cost of care that is incurred from people who have e-scooter-related injuries,” according to Lauder.
“In the 6-month period immediately after [e-scooters] were introduced in Denver, there were $8 million in our hospital costs to treat injuries related to e-scooter use with roughly one-third of patients requiring hospital admission and two-thirds needing surgery,” Lauder told Healio/Orthopedics Today.
Ricci said these increased costs associated with e-scooter injuries are due to the need for multiple episodes of care with more severe crashes.
“For instance, [the patient was] seen in the emergency room is one episode of care. They are diagnosed with an injury or fracture that needs secondary care, whether it is a visit to an orthopedist’s office or whether it needs surgery, and, oftentimes, that leads to additional episodes of care,” Ricci said. “Whereas, if you have a more minor injury, it might be limited to one episode of care in an ER or potentially in a primary care provider’s office.”
In addition to the impact on episodes of care, higher-energy injuries from e-scooter and related crashes can lead to a longer rehabilitation period and, subsequently, a longer recover period for patients, according to Jordan.
“That also contributes to lost work time, lost time where they are contributing in one way or another to their community,” Jordan said. “I do think this is not an insignificant issue. Just like any other major craze that happens that secondarily, unfortunately, has the side effect of causing injuries, there is a lot of lost productivity that happens, in addition to the fact that these are not just 1- or 2-week recovery type injuries. These can be 6 weeks, 3 months or more.”
E-scooter injury prevention
To reduce and prevent e-scooter injuries, sources who spoke with Healio/Orthopedics Today stressed the importance of wearing protective gear, such as helmets with a facial component and wrist guards.
However, protection does not stop at wearing the appropriate gear. Lauder said legislation related to e-scooter use varies between states, with no formal guidelines in some states, including registration of the e-scooter, whether a drive license is needed for operation and a minimum age for operation.
“The legislation is not clear to the public who operates these scooters,” he said.
Similar to the creation of bicycle lanes, communities need to identify where e-scooters should be used, whether that is with bicycles in a bicycle lane, on the sidewalk or in a place of their own that needs to be created, according to Jordan.
“A lot of major cities have done a good job of creating bicycling lanes, for example, which have helped mitigate the issue of where bikes belong. On the street with cars or do they belong on sidewalks with people?” he said. “[Cities have] decided that [bicycles are] something that is more in the middle. We should not be mingling pedestrians with bikes, but we might not want to intermingle bicycles with motor vehicles.”
Focus on safety
E-scooters need to be used by riders in the same way as other types of motor vehicles or modes of transportation, including avoiding mood altering drugs, such as alcohol or narcotics, prior to riding, Jones said.
“I do not think people understand how fast they are going, number one. I do not think they are able to process uneven surfaces, changing lanes, abiding by the rules of the road, and then the third thing is being able to stop,” he said. “Since they have problems with that, they use their arms and their reaction times are slower, so they get facial injuries also on top of that.”
Paying attention to the surrounding area when riding an e-scooter may also help avoid crashes from occurring, according to Ricci. Riders should not listen to music, look at their phone or try to multitask in other ways while riding an e-scooter, he said.
“People should focus on safety, be attentive to their surroundings and, certainly, avoid alcohol when you are on an e-scooter,” Ricci told Healio/Orthopedics Today.
Pedestrians should be just as aware of their surroundings as e-scooter riders, so they know when someone riding an e-scooter is trying to pass them, Jordan said.
“The awareness that this is a technology that has caught on quickly, especially in highly populated centers, is something that is huge,” he said. “Just awareness in itself can be a huge contributor toward decreasing the incidence of injuries.”
- Reference:
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- Hayward H. National trends in pediatric e-scooter injury. Presented at: American Academy of Pediatrics National Conference & Exhibition; Oct. 7-11, 2022; Anaheim, California.
- Injuries using e-scooters, e-bikes and hoverboards jump 70% during the past four years. www.cpsc.gov/Newsroom/News-Releases/2021/Injuries-Using-E-Scooters-E-Bikes-and-Hoverboards-Jump-70-During-the-Past-Four-Years#:~:text=Much%20of%20the%20increase%20between,the%20head%20and%20the%20neck. Published Sept. 30, 2021. Accessed Oct. 12, 2022.
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- Namiri NK, et al. JAMA Surg. 2020;doi:10.1001/jamasurg.2019.5423.
- North America electric scooter market worth $15.41 billion and 3,182.6 thousand units by 2029 – Exclusive report by Meticulous Research. www.globenewswire.com/en/news-release/2022/05/18/2446159/0/en/North-America-Electric-Scooter-Market-Worth-15-41-Billion-and-3-182-6-Thousand-Units-by-2029-Exclusive-Report-by-Meticulous-Research.html. Published May 18, 2022. Accessed Oct. 12, 2022.
- Ptak M, et al. PLoS One. 2022;doi:10.1371/journal.pone.0262682.
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- For more information:
- Clifford B. Jones, MD, can be reached at 485 S. Dobson Road, Suite 110, Chandler, AZ 85224; email: cbjones230@gmail.com.
- Charles J. Jordan, MD, can be reached at 15955 SW 96th St., Suite 401, Miami, FL 33196; email: charlesjordanmd@gmail.com.
- Alexander Lauder, MD, can be reached at 777 Bannock St., Denver, CO, 80204; email: lauder.alexander@gmail.com.
- William M. Ricci, MD, can be reached at 525 East 71st St., 2nd Fl., New York, NY 10021; email: carnevalen@hss.edu.
- J. Tracy Watson, MD, can be reached at 1008 Spring Ave., St. Louis, MO 63110; email: tracy.watson.1@health.slu.edu.
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