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CONTEXT: Child and adolescent bicycling is beneficial, but injuries occur and can be severe and costly. OBJECTIVE: To systematically review the individual and environmental factors associated with bicycling injury risk in children and adolescents. DATA SOURCES: Fourteen electronic databases were searched. STUDY SELECTION: Two authors independently assessed potentially relevant articles for eligibility. The inclusion criteria were as follows: bicyclists younger than 20 years old; examined individual and environmental characteristics of bicycling crashes; compared injured and uninjured bicyclists or bicyclists with different types or severity of injury; study designs with a predetermined comparison group; and published in English from January 1990 to May 2015. The exclusion criteria were outcomes related to helmet use, helmet legislation, or mountain biking, and comparisons of census-based injury rates. DATA EXTRACTION: Data on study design, setting, population, injury definitions, injury risk factors, and results were extracted. Risk of bias was assessed by using the Newcastle-Ottawa Scales. RESULTS: Fourteen articles were included. Lower socioeconomic status, riding on the road, riding in rural compared with urban areas, and riding on the sidewalk were associated with bicycling injury. Bicycling safety education did not protect children against future injury. Injuries related to a motor vehicle collision were more severe than other bicycling injuries. LIMITATIONS: Study heterogeneity prevented meta-analyses. Study quality was affected by inadequate definitions of study groups and self-reported data. CONCLUSIONS: Lower socioeconomic status and riding location were associated with bicycling injury and severity increased with motor vehicle collisions. The bicycling environment is a promising avenue for prevention.

Each year, an estimated 20,000 to 30,000 children in Canada are treated in hospital emergency departments for playground-related injuries (1). In Canada, approximately 2500 children 14 years of age and younger are admitted to hospital for serious injuries resulting from a playground fall every year (2). Studies show that 67% of playground injuries are caused by falls from equipment to the ground, and that the height of fall is a risk factor for injury (3,4) and severe injury (5). These falls usually occur from equipment such as monkey bars, track rides and jungle gyms that require upper body strength (6,7). In Canada, 36% of playground injuries occur on school playgrounds and 57% of playground injuries are sustained by children five to nine years of age (3). Since the introduction of playground safety standards, severe head injuries have become increasingly rare (8,9). Fracture of the upper extremities is the most common playground injury (10,11). The Canadian Standards Association, an organization that develops product standards to promote public safety and health, recognizes playground surfacing as one of the main risk factors for playground injury (12). The literature also shows an increased risk of injury when falling on to a non-impact-absorbing surface (4,13). To comply with the Canadian Standards Association, surfacing under playground equipment must be able to attenuate impact to a specific standard as measured by the Head Injury Criterion (HIC) and, therefore, reduce the risk of serious injury from a fall. Studies investigating surface-specific injury rates show an increased risk of injury when falling onto a non-impact-absorbing surface. Sosin et al (14) found the injury rate for asphalt to be six times that of sand, with rubber mats and gravel having rates twice that of sand. Mott et al (6) confirmed the protective effect of impact-absorbing surfaces, finding concrete to have an injury rate five times that of rubber. Chalmers et al (4) obtained similar results, finding the likelihood of being injured in a fall on a non-impact-absorbing surface was 2.28 times that of a fall onto an impact-absorbing surface. Howard et al (15) compared upper extremity fracture rates in schools with wood fibre surfacing with those with granite sand surfacing. With the wood fibre surfacing, the risk of an arm fracture was 4.9 times higher than the granite sand surfacing. Playground surfaces are dynamic in that extreme temperatures and weather conditions influence their ability to attenuate impact, which potentially has serious implications for injury risk. In a laboratory-based study, Mack et al (16) found pea gravel to have low impact attenuation under all tested conditions and recommended that playground providers abstain from installing it. Lewis et al (17) tested wood chips, sand, grass, rubber matting and gravel under four environmental conditions simulated in a laboratory: dry and warm, dry and frozen, wet and warm, and wet and frozen. Wood chip surfacing had the best impact attenuation in all of the environmental conditions except for wet and frozen, in which gravel had the lowest HIC score. These differences illustrate the need for a playground study to be conducted in situ. Studies that have examined the effect of environmental conditions on the impact attenuation properties of playground surfacing, under conditions of actual use, have also reported mixed findings. Vidair et al (18) tested HIC values of poured-in-place surfaces at various temperatures as part of a larger study conducted to evaluate the risk of serious head injury due to falls on California (USA) playground surfaces made of recycled tires. High temperatures were found to increase the HIC score of poured-in-place surfacing, which reduces the ability of the surface to attenuate impact. Sherker et al (19) monitored the in situ performance of tanbark, a wood chip surfacing, by placing two samples in three school playgrounds. The school playground samples were compared with two control samples. One control sample was kept inside a laboratory and the other was kept outdoors and exposed to similar weather conditions as the playground samples. Significant changes in surface depth and impact attenuation were detected in all samples after a period of eight weeks. The playground surfacing in ‘low use’ areas deteriorated slower than playground surfacing in ‘high use’ areas. Little difference between the surface changes to the indoor and outdoor control samples were found. This suggests that the performance of tanbark deteriorates regardless of weather. No study has related injury rates on playground surfaces to season; therefore, the objective of the present study was to determine whether season affects the injury rate and injury profile of playground surfacing used in elementary schools from the school districts in Calgary (Alberta) and the surrounding area under conditions of actual use.

This case-control study describes the profile of bicyclists injured in mountain bike terrain parks (MBTPs) and examines risk factors for severe injury among MBTP riders. Cases were hospitalised bicyclists injured in MBTPs. Controls were bicyclists injured in MBTPs who were discharged from the emergency department. No significant differences were observed in the distribution of age and sex between cases and controls. A higher proportion of cases compared with controls suffered a head injury (22%), fracture (41%) or internal organ injury (32%). Controls suffered a higher proportion of superficial injuries (26%), sprains (10%) or wounds (16%). Upper extremity protective equipment (e.g. elbow or shoulder pads) was used more by cases than controls (23% vs. 11%, p = 0.03). Riders who self-reported cycling faster than usual had significantly higher risk of severe injury compared with others. The risk of severe injury may be reduced by encouraging bicyclists to control their speed or by modifying MBTP design to limit the opportunity to gain speed.

Background The standard response time benchmark for Emergency Medical Services (EMS) has been set at eight minutes or less for ground ambulances in many parts of the world. It has not been extensively studied, especially in paediatric patients who suffered a traumatic injury. As injury is the leading cause of death for those under the age of 18 it is important to determine if this benchmark for EMS response time may be a factor in paediatric mortality and morbidity outcomes. Methods All paediatric calls made to EMS between April 2010 to September 2013 in the cities of Calgary and Edmonton, Alberta, Canada were examined to select patients who had suffered a traumatic injury. These records were then linked to emergency department records and hospitalisation records using a deterministic linkage strategy using personal healthcare number, sex, and receiving facility. Patients were excluded if they were ≥18 years old, attended to outside of Calgary or Edmonton areas or suffered a medical complaint not related to an injury. Response time, the exposure, was defined as time of call to 9–1–1 to arrival of ambulance on scene. Response time was dichotomized into Results 42 620 patients were attended to between April 2010 and September 2013. Overall, 6778 patients were included in the study. 52 patients died and 628 patients were admitted to hospital. The adjusted mortality risk ratio given a response time of ≥8 minutes was 0.635 (95% CI: 0.346–1.166; p = 0.143). The adjusted hospital admission risk ratio given a response time of ≥8 minutes was 1.165 (95% CI: 0.985–1.379; p = 0.075). Conclusions A response time of ≥8 minutes was not associated with a difference in all cause mortality or hospital admission for paediatric patients suffering from a traumatic injury.

Background Bicycling injuries in young people represent a substantial cost to health care systems. The objective of this review was to examine the individual and environmental factors associated with bicycling-related injury risk in children and youth. Methods Fourteen electronic databases were searched using exploded subject headings and keywords. Two authors independently screened article titles and abstracts for inclusion. The full-text of the potential articles was assessed to determine eligibility. The inclusion criteria were bicyclists less than 18 years old; individual and environmental characteristics of bicycling outcomes; comparisons between injured and uninjured bicyclists, injury type or severity level; study designs with a pre-determined comparison group; and publications in English from 1990 to May 2015. The exclusion criteria were injury outcomes related to helmet use, helmet legislation or mountain biking; comparisons of census-based injury rates; cross-sectional studies; and letters to the editor. A modified version of the Newcastle-Ottawa Scale was used to assess study quality. Results Fifteen articles met the inclusion and exclusion criteria. Overall, 46 different risk factors were examined. The most commonly reported risk factors were age (N = 10 studies), sex (N = 7), equipment related factors (N = 6), bicycling exposure (N = 5), bicycling purpose (N = 5), and motor vehicle (MV) collision (N = 4). The reviewed studies varied in quality; the main weaknesses were inadequate definitions of study groups, lack of control for potential confounders, and the use of self-reported data. Conclusions While many of the studies had significant limitations, one recurring theme was that young bicyclists received more severe injuries when exposed to MV collisions. To reduce injuries in children and adolescents, we recommend separating bicyclists from MVs on the road and implementing strategies to reduce traffic speed and volume.

Background There is limited literature regarding the effectiveness of visibility aids (eg, reflectors, lights, fluorescent clothing) in reducing the risk of a bicyclist- motor-vehicle (MV) collision. Objectives To determine if visibility aids reduce the risk of a bicyclist-MV collision. Methods Cases were bicyclists who were struck by a MV and assessed at emergency departments (EDs) from May 2008-October 2010 in Calgary and Edmonton, Alberta, Canada. Controls were bicyclists with non-MV injuries from the same EDs over the same time period. Participants were interviewed about their personal and injury characteristics, including use of visibility aids (clothing colour or reflective clothing, bike reflectors, etc). Injury information was collected from charts. ORs and 95% CIs were estimated for visibility aids after adjustment for confounders using logistic regression. Results There were 2403 injured bicyclists with 278 MV cases. The risk of a bicyclist-MV collision increased with age. Commuting also increased the odds of MV collision (OR 5.8; 95% CI 4.5 to 7.5). After accounting for location speed limit, bicyclist speed, and previous injury, white (OR 0.25; 95% CI 0.07 to 0.9) or other coloured (OR 0.45; 95% CI 0.2 to 0.9) compared with black clothing on the upper body reduced the odds of collision. Fluorescent clothing was associated with MV collisions (OR 1.7; 95% CI 1.0 to 2.8), even after adjusting for commuting and bicycling location. Significance Clothing choice may be important in reducing the risk of MV collision; however, factors beyond the individual also need to be examined.

Background The popularity of mountain biking (MB) has led to the development of commercial MB parks. Little is known about the injury profile and risk factors in these areas. Objective To determine the injury profile and risk factors for severe injury among cyclists in MB parks. Design Prospective case-control study. Cases were hospitalised cyclists injured in MB parks. Controls were cyclists injured in MB parks seen and discharged from the emergency department (ED). Setting Four EDs in Calgary, Alberta, Canada. Participants Recreational cyclists injured in a MB park who presented to one of the study EDs from May 2008 to August 2010. 351 patients were interviewed. Assessment of risk factors Crash circumstances were captured through interviews and injury data through medical chart review. Main outcome measurements Severe injury as defined by hospitalisation; levels within factors were compared using OR and 95% CI. Results 23 participants were hospitalised (cases).The most common body region injured was the head/neck/face among cases, and the upper extremities among controls. 21% of cases and 9% of controls were female. A greater proportion of cases than controls were older than 25 years (22% vs 15%, respectively). Full-face helmets were used less among cases than controls (21% vs 41%, respectively). Arm and elbow protection was used more among cases than controls (arm: 13% vs 2%; elbow: 22% vs 8%). On univariate analyses, we found an indication of increased odds of severe injury among females (OR=2.8; 95% CI 0.96 to 8.06). Riding a new bicycle (OR=2.74; 95% CI 1.16 to 6.45) and cycling on grass compared with dirt (OR=7.06; 95% CI 1.21 to 41.33) increased the odds of severe injury. Conclusion Preliminary analysis suggests surface and experience-related characteristics may increase the risk of severe injury. Case-control differences were noted in protective equipment use.