Orthopaedic injuries due to electric scooter trauma presenting to a level 1 trauma centre before and after introduction of a scooter-sharing scheme

Abstract

Background

Epidemiological data from various jurisdictions has shown that electric scooters are associated with significant trauma. The Victorian state government introduced a trial scooter sharing scheme on February 1, 2022 in inner city Melbourne. This is a descriptive study from the largest trauma centre in Victoria, geographically at the heart of the government sharing scheme, investigating the “scope of the problem” before and after introduction of the ride sharing scheme.

Methods

Retrospective case series. Insitutional orthopaedic department database was searched from 1 Jan 2021 to 30 June 2022 to identify all admissions, requiring orthopaedic management, associated with e-scooter trauma. Data collected included, alcohol/drug involvement, hospital LOS, injury severity score, ICU admission, injuries sustained, surgical procedures, discharge destination, and death.

Results

In the 12 months prior to, and five months since introduction of the ride share scheme, 43 patients sustaining e-scooter related injuries were identified. Eighteen patients (42%) presented in the five months since ride sharing was introduced and 25 patients in the preceding 12 months. 58% of patients were found to be intoxicated. Fourteen percent required an ICU admission. Forty-four percent of patients were polytrauma admissions. The median length of stay was two days, longest individual hospital stay was 69 days. There were 49 surgical procedures in 35 patients including neurosurgical, plastics and maxillofacial operations. The mean Injury Severity Score was 17.28.

Conclusion

Electric scooters are associated with a significant trauma burden. This data may be combined with other clinical services and could be used to inform policy makers.

1. Introduction

Electric scooter use is rapidly increasing around the world. They are seen as a rapid, efficient and environmentally friendly mode of transportation,¹ with the potential advantage of reducing traffic congestion. However, they have been associated with reports of a significant incidence of injuries, in multiple cities worldwide.2, 3, 4 There has been limited analysis of the burden of e-scooter injuries in an Australian context.^5,6 Studies from Europe and North America suggest that the behaviours and regulations are different between jurisdictions, and this may influence patterns of injury.⁷

In February of 2022, the City of Melbourne, City of South Yarra, and City of Port Phillip (council jurisdictions in the Melbourne metropolitan area) partnered with the Victorian State Government to approve an e-scooter ride-sharing scheme.⁸ This involved government purchase of 500 scooters which were made available for hire. The e-scooters were speed limited to 20 km per hour and were permitted for use on footpaths, shared pathways, and roads where there is a speed limit of 50 km/h or below. A helmet is mandatory and passengers not permitted.⁹ Our anecdotal experience is that these e-scooters are responsible for a significant number of injuries. This study aims to characterise and quantify the orthopaedic trauma burden within our institution, arising from e-scooter accidents.

2. Methods

This is a retrospective, observational, chart review study. All patients who were admitted under, or consulted by, the orthopaedic team following an injury associated with an e-scooter device between 1 January 2021 and 30 June 2022 were included in the study. Patients were identified from the Alfred Hospital orthopaedic unit database by screening for mechanism of injury.

E-scooter is defined as a personal device of no more than three wheels with handlebars, which is designed to be stood on by the operator and is powered by an electric motor that is capable of propelling the device with or without human assistance. Other types of scooters (i.e, non motorised, or mobility scooters) were excluded.

A medical chart review was undertaken to extract the following data: demographics, circumstance (rider or pedestrian), alcohol or substance involvement (defined as positive blood alcohol >0.05% or positive urine toxicology on sample taken in the emergency department), timing of presentation, type and severity of injury, injury severity score (ISS), mode of presentation (walk-in, road ambulance or helicopter), discharge destination, any surgical procedures undertaken, intensive care (ICU) admission, and length of stay (LOS).

Institutional ethics committee approval was granted for this study. There was no external funding provided.

3. Results

3.1. Demographics

Forty-three patients were identified from our database that were admitted as a result of e-scooter accidents, from 1 Jan 2021 until 30 June 2022. The mean patient age was 42 years, seven of 43 were over the age of 50 years, and 79% of patients were male. Twenty-nine of 43 patients were brought in by ambulance including helicopter transfer, (as opposed to walk-in, or via private car). The median hospital length of stay was 2.0 days, with nine patients staying in hospital more than ten days, the longest individual stay was 69 days. Six patients were admitted to intensive care, there were no deaths in this series. Forty patients were discharged directly home after the acute hospital stay, three patients were discharged to an acquired brain injury rehabilitation centre. The length of stay for these patients were 53, 33 and 69 days respectively. Twenty five of 43 patients (58%) presented intoxicated with alcohol or illicit drugs.

3.2. Injury chronology

We were particularly interested in the injury rate in relationship to the 1 February 2022 introduction of the government e-scooter ride-sharing scheme.⁸ Eighteen of our 43 patients (42%) presented as a result of an e-scooter accident after introduction of the ride-sharing scheme. This equates to two admissions per month prior to the rideshare scheme and 3.6 admissions per month after.

3.3. Injury characteristics

There were 107 distinct injuries in 43 patients. The mean ISS was 17.28, with 19 of 43 (44%) patients classified as a polytrauma admission (defined as ISS >15). Patients who were intoxicated at presentation had an ISS of 20.48 compared with 12.83 for those not intoxicated (p = 0.05). All six patients requiring intensive care admission were intoxicated on arrival to the emergency department.

There were 49 operations in 35 different patients (81% of our cohort), 36 of these procedures were orthopaedic and 13 non-orthopaedic (neurosurgical, faciomaxillary, cardiothoracic, and plastics) procedures. There were nine head injured patients, 14 spine fractures, and eight pelvic fractures included in this cohort.

3.4. Long length of stay patients

There were 26 patients who had a hospital LOS of four or more days. This separate cohort had an average length of stay of 11.73 days and the average ISS was 22.35. Twenty two of these 26 patients were male (85%). Three of 26 had intracranial injuries and were discharged to specialised inpatient rehabilitation, the remainder were discharged home. Seventeen of 26 patients (63%) were admitted under the trauma service, with multi-system injuries. The number of patients in this cohort that were intoxicated or drug affected was 58%, the same proportion as in the overall cohort.

4. Discussion

The public enthusiasm for shared e-scooters as a convenient mode of transportation in urban areas is understandable. There is a low barrier to entry, they are available, affordable, and environmentally friendly. Their use is on the rise. There was an estimated 84 million shared micromobility trips taken in the US in 2018, 38.5 million of which were shared e-scooter rides,¹⁰ a rate of use that is exponentially increasing from the meagre 321,000 trips taken in 2010. However their increasing use, unsurprisingly, is associated with increasing numbers of injuries requiring both inpatient and outpatient treatment,11, 12, 13 with reports of devastating injuries and mortality.⁷ To date, a number of studies have described the potential harm caused by these devices, but there have not been any reports published in our jurisdiction. Given that we are the largest trauma centre in our city, and geographically located in the centre of the local government areas of the approved ride-share scheme,⁸ we are in an excellent position to evaluate the injury characteristics arising from e-scooter injury.

We report our experience treating these patients, over a 12 month period prior to, and a five month period after introduction of the scheme. Our data demonstrates that there is a significant trauma burden associated with these readily available devices with the rate of hospital admissions increasing after the introduction of the ride-share scheme. Eighteen of 43 patients (42%) presented after introduction of the ride-sharing scheme, despite this timeframe being only 29% of the data collection period. We cannot be certain that the ride share scheme was responsible for this increase as it may simply reflect a general acceptance and increasing popularity of such devices. Whilst the majority of patients were admitted for a short time period, and often only one or two days, there were a subset (19 patients or 38%) of patients who sustained catastrophic polytrauma injuries and required intensive care stay, multiple operations, and life-changing procedures. The average patient presenting after an e-scooter injury is a young adult, but we did see a significant proportion of patients over the age of 50 years. Orthopaedic fracture surgery was the most common type of procedure these patients were likely to undergo as a result of their injuries.

We observed a significant number of injuries that were consistent with a high energy mechanism, despite the devices having a limited maximum speed of 20kph. These included head injuries, spine fractures, and pelvic fractures. The prevalence and range of injuries in this study provide additional evidence demonstrating that these devices have risk of substantial injury, and thus can have significant impact on the health care burden as has been reported in other countries.¹⁴

Intoxication whilst using an e-scooter was seen as a factor resulting in more serious injury. The 58% of our cohort who were intoxicated on arrival after e-scooter trauma presented with a higher ISS (p = 0.05) and were more likely to undergo multiple long bone fixation, cranial procedures, and be admitted to the intensive care unit.

Designed spaces for scooter riders are currently lacking. In our city, they ride on the footpath, in designated bicycle lanes on the road or on the road itself. Riding on the footpath with pedestrians is a concerning observation, which puts pedestrians at risk. Despite the government provided devices that form part of the ride-sharing scheme having a theoretical maximum speed of 20 km/h as per local legislation,⁹ however they can be modified to travel much faster, consistent with other reported cases.¹⁵

Our study is limited in its retrospective nature. It does not record long term outcomes of these patients after these injuries and only captures patients admitted to hospital. Nevertheless, the present series reports a valuable demographic and clinical snapshot of the e-scooter injuries in our city, and clearly demonstrates an increased rate of injury after the introduction of an e-scooter sharing scheme.

5. Conclusion

As e-scooter use continues to exponentially increase, the prevalence of both minor and major orthopaedic, and other injuries, will likely continue to rise. Despite the lure of a cheap, easy ride, that is more “environment-friendly”, the consequences of injuries from e-scooters in the medium to long term remains unclear. Further research is necessary to characterise the full burden of presentations to our health service, including all emergency and outpatient presentations and long term follow up of these patients to fully characterise the health and economic burden of these devices.

Funding/sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Informed consent

Not applicable for this article type.

Institutional ethical committee approval (for all human studies)

Institutional ethics approval was sought and approved by Alfred Health under project number 351/22 on 20 June 2022.

Authors contribution

AJT: Conceptualization, Data curation, formal analysis, investigation, methodology, project administration, Writing original draft, Writing review and editing.

SC: data curation, formal analysis, investigation.

SML: supervision, writing review and editing, project administration.

ERE: conceptualization, investigation, methodology, project administration, writing review and editing.

Declaration of competing interest

The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.