Traumatic injury associated with motorcycle incidents in Latin America: a systematic literature review

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Abstract

Purpose:

In recent decades, Latin America has experienced a notable increase in trauma due to motorcycle traffic incidents. Improvements to road safety and the care of motorcycle incident victims have been adversely affected by infrastructural and socioeconomical challenges throughout the region. This systematic review aims to investigate the existing literature on traumatic injuries from motorcycle collisions in Latin American countries to better understand and address the impact of these incidents on the region.

Methods:

This study was conducted in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Article searches were performed using the Pubmed, EMBASE, and Web of Science databases with a predetermined search strategy. Gray literature was identified through several simple searches of the SCIELO database. Articles in English, Spanish, and Portuguese were included. Using Covidence, seven independent reviewers separately completed 2 rounds of article screening. Each of the final included articles was reviewed for extraction and consensus by 3 reviewers.

Results:

Of the 675 initially identified, a total of 37 articles met the criteria for inclusion and were selected for final data extraction after full-text screen. The regional representation was limited to 4 Latin American countries [Argentina (n = 1), Brazil (n = 33), Guatemala (n = 1), and Mexico (n = 2)]. Predominantly, the studies focused on the prevalence of motorcycle incidents (n = 34), with limited studies reporting on the treatment (n = 13) or outcomes (n = 8) of motorcycle incident victims. Surgical intervention was the most commonly noted treatment (n = 9) with reporting on fixation methods (n = 4), wound management (n = 2), flap coverage procedures (n = 1), fasciotomy (n = 1), and implant use (n = 1). Complications were the most commonly reported outcome (n = 4), of which injury sequelae/residual pain, mortality, infection, vascular damage, mental health effects, amputation, and hospital readmission were discussed.

Conclusion:

Despite the overwhelming perception among surgeons on the burden of motorcycle incidents in Latin America, this systematic review demonstrates a paucity of research evaluating the consequences of musculoskeletal trauma from these incidents in the region. In identifying these gaps, additional research initiatives can be directed toward better understanding the ramifications of these injuries, ranging from direct patient care to regional policy development.

1. Introduction

Worldwide, traffic incidents account for the loss of approximately 1.3 million lives annually. An additional 20 to 50 million people sustain nonfatal injuries each year, with a proportion of these cases resulting in some form of disability.¹ Throughout Latin America, deaths from road traffic incidents are the second leading cause of mortality among young adults aged 15 to 29. Among this population, motorcyclists are most greatly afflicted, accounting for 23% of all traffic incident fatalities.² Latin America has experienced a significant increase in motorcycle use in recent decades, due to their relative affordability and versatility for navigating precarious road infrastructure. This trend, combined with the poor infrastructure and socio-economic challenges throughout the region, has contributed to a substantial rise in the rate of traffic collisions associated with this mode of transportation.² In turn, this has imposed various challenges in the management of road safety and motorcycle incident injuries throughout Latin America.

Through the United Nations Decade of Action for Road Safety (2021–2030), the World Health Organization (WHO) aims to reduce deaths and injuries from traffic incidents by at least 50% by 2030.³ A critical early initiative toward this objective is to understand the regional impact of motorcycle collisions through research. Empirical data on this topic are particularly limited throughout Latin America. Existing scientific literature lacks consensus on the epidemiology, use of personal protective equipment, victim demographics, presence of alcohol or drugs, treatments, and the economic costs associated with motorcycle incidents in Latin America.

This systematic review of the literature aims to provide epidemiological data on the characteristics of motorcycle collisions in Latin American countries in response to the urgent need to understand and address their impact. A comprehensive analysis of this literature can help determine the magnitude of the problem while identifying gaps and areas for future research. This information is imperative to the implementation of preventive measures and effective treatments for motorcyclist injuries throughout Latin America.

2. Materials and Methods

2.1. Search Strategy

A systematic review was conducted following Preferred Reporting Items for Systematic review and Meta-Analysis Protocols.⁴ This project was exempt from IRB review. Study inclusion criteria were established a priori to include the following: original, full-text, peer-reviewed articles (case reports and case series were excluded); articles containing data from >20 subjects; articles published in English, Spanish, or Portuguese; and articles describing musculoskeletal injuries resulting from incidents involving motorcycles (or any type of 2-wheeled motorized vehicle used for transportation or recreation) in patients of any age.

2.2. Data Sources

The article search was conducted on April 2023 in 3 databases: PubMed, Web of Science, and EMBASE. To review the gray literature, simple searches were conducted in the SciELO database to identify relevant articles. A search strategy unique to each database was developed with a research librarian using English search terms (Appendix A, http://links.lww.com/OTAI/A122).

2.3. Study Selection

Study selection and duplicate detection was performed using Covidence systematic review software (https://www.covidence.org/). Two rounds of screening were done for inclusion: 1) title and abstract screening and 2) full-text screening. Seven researchers (C.M.M., L.A., J.M., A.C., G.G., M.C.M., and V.O.) independently reviewed all articles (N = 534). Each article was reviewed twice for consensus, and any discrepancies were reviewed by the entire group of authors. The included articles underwent 3 rounds of full-text screening (N = 106) to ensure accuracy of collected data (Table 1). Conflicts were resolved by consensus among the researchers. Thirty-seven publications were included in the final review (Appendix B, http://links.lww.com/OTAI/A123).

Table 1.

Overview of data extraction characteristics.

Country

Study demographics

Number of participants

Age

Sex

Study design

Hospital or clinic-based convenience sampling or population-based sampling

Period of data collection

Anatomical location of injury

Focus of study

Prediction

Quantitative assessment

Management

Outcomes

Risk factors

Cost evaluation

Mortality rate

Use of helmet or protective equipment

Use of alcohol of substances

Characterization of accidents

Time of day

Day of week

Location of accident

Use of quality of life metrics

Patient follow-up

Outcomes provided

Mobility

Radiographic time to healing

Return to work

Complications

Complications reported

Mortality

Thromboembolic event

Infection

Impact on mobility

Impact on activities of daily living

Secondary fractures

Injury severity using ISS or other metric

Timing

Presentation to treatment

Hospitalization period

ICU admission period

Accident cause

Vehicular collision

Collision with fixed object

Roadway hazard

Intersection

Distracted/impaired driving

Speeding

Inclement weather

Reckless driving

Association of injury type and injury mechanism

Impact of public policy

ISS, Injury Severity Score.

3. Results

A total of 1031 citations (234 from PubMed, 258 from EMBASE, 183 from Web of Science, 356 from SciELO) were identified in the initial search. After duplicate detection, a total of 534 unique citations were included. After title and abstract review, there were 106 articles included in the full-text screen. A total of 37 articles (n = 37) were selected for final data extraction after full-text review (Fig. 1).

Figure 1.

PRISMA flow diagram outlining the study selection process.⁴

3.1. Study Design

Convenience sampling, defined as a nonprobability sampling method where subjects are selected based on their accessibility to the researcher,⁵ was the predominant sampling strategy utilized in the evaluated studies. Data from hospital or clinic-based subjects were evaluated in 73% of the articles (n = 27), whereas registry (n = 7) and survey-based data (n = 3) were evaluated in the remaining articles. The data collection period ranged from 1 to 84 months and averaged 18 months across the studies evaluated. Injury incidence and/or prevalence was reported in 32 of the studies, with limited publications reporting on the risk factors (n = 9), treatments (n = 13), outcomes (n = 2), and cost evaluations (n = 2) of traumatic musculoskeletal injuries resulting from motorcycle collisions (Table 2).

Table 2.

Overview of the 37 included articles.

Source (first author, year)	Country	Study focus
Anjos, 2007	Brazil	Incidence/prevalence risk factors
Batista, 2015	Brazil	Incidence/prevalence
Dantas, 2019	Brazil	Incidence/prevalence risk factors
daSilva, 2016	Brazil	Incidence/prevalence outcomes
Debieux, 2010	Brazil	Incidence/prevalence
DosAnjos, 2017	Brazil	Cost evaluation
dosSantos, 2008	Brazil	Incidence/prevalence risk factors
Jáuregui-González, 2019	Mexico	Incidence/prevalence
Leite, 2018	Brazil	Incidence/prevalence
Macedo, 2017	Brazil	Treatment
Matos, 2014	Brazil	Incidence/prevalence risk factors
Paiva, 2015	Brazil	Incidence/prevalence treatment
Parreira, 2012	Brazil	Incidence/prevalence
Pereira, 2009	Brazil	Incidence/prevalence
Ramos-Villalón, 2020	Mexico	Incidence/prevalence
Rodrigues, 2014	Brazil	Incidence/prevalence
Silva, 2020	Brazil	Incidence/prevalence risk factors
Valente, 2022	Brazil	Incidence/prevalence
Vasconcelos, 2019	Brazil	Risk factors
Freitas, 2018	Brazil	Incidence/prevalence
Besse, 2018	Argentina	Incidence/prevalence cost evaluation
GonzálezLemus, 2021	Guatemala	Incidence/prevalence
Batista, 2006	Brazil	Incidence/prevalence risk factors
Gorios, 2015	Brazil	Incidence/prevalence treatment
JañaNeto, 2016	Brazil	Incidence/prevalence
Koizumi, 1985	Brazil	Incidence/prevalence
Koizumi, 1992	Brazil	Incidence/prevalence
Miki, 2014	Brazil	Incidence/prevalence
PintoAde, 2008	Brazil	Incidence/prevalence
Pires, 2022	Brazil	Incidence/prevalence
Rocha, 2022	Brazil	Incidence/prevalence
Silva, 2018	Brazil	Incidence/prevalence
deOliveira, 2003	Brazil	Incidence/prevalence outcomes
Lucas-Neto, 2016	Brazil	Incidence/prevalence risk factors
Mascarenhas, 2016	Brazil	Incidence/prevalence risk factors
Monteiro, 2020	Brazil	Incidence/prevalence
Cavalcanti, 2013	Brazil	Incidence/prevalence

3.2. Study Demographics

Most eligible articles (n) were published in Brazil (n = 33, 89%), with limited representation from other Latin American countries including Mexico (n = 2, 5%), Argentina (n = 1, 3%), and Guatemala (n = 1, 3%). The number of participants collectively evaluated in the eligible studies ranged from 37 to 11,366, with an average of 84.9 participants. The mean age of participants was 32.2 years (range: 10.7‒59). On average, most motorcycle injured victims evaluated were male (84.9%), composing between 32.1% and 100% of the study populations assessed (Table 3). Patients were characterized based on their age and sex (n = 35, 95%), education level (n = 9, 24%), marital status (n = 8, 22%), profession/employment (n = 7, 19%), socioeconomic status (n = 5, 14%), nationality/residence (n = 4, 11%), race/ethnicity (n = 5, 14%), and health demographics (n = 5, 14%) (Table 4).

Table 3.

Patient demographics and mortality rate.

	Average age	Male patients	Mortality rate
# Of articles reporting variable (n)	23	34	12
Mean	32.2 y	84.9%	3.6%
Range	10.7–59 y	32.1%–100%	0%–6.4%

Table 4.

Characterization of patients and accidents as reported by number of articles (n).

Patient Characteristics	n
Education level	9
Socioeconomic status	5
Profession/employment status	7
Marital status	8
Nationality/place of residence	4
Race/ethnicity	5
Health demographics (comorbidities, insurance, disability, smoking status)	5
Accident characteristics	n
Time of day	15
Day of week	13
Geographic region	6
Incidence by month	1
Work-related	1

3.3. Incident Characterization

Motorcycle incident occurrence was characterized by time of day (n = 15), day of week (n = 13), incidence by month (n = 1), geographic region (n = 6), transport of >2 passengers (n = 2), and work-related incidents (n = 1) (Table 4). The use of helmet/safety equipment was reported in 18 articles, whereas the use of alcohol or substances was reported in 16 articles. Commonly reported causes of motorcycle incidents included vehicular collision (n = 12), collision with a fixed object (n = 6), driver limitations (including distracted/reckless driving, disregard for traffic laws/speeding or driver ability) (n = 11), and falls from motorcycles (n = 4). In 8 of the studies, the type of injury was correlated with the mechanism of injury (eg, lateral collision vs. frontal collision). Emergency response time was discussed in 2 studies, although an average time could not be readily discerned as one study provided only the percentage of patients receiving emergency care within a given response time.

3.4. Injury Characterization

Anatomically, injuries to the lower extremities were the most commonly reported (n = 30). Injury severity was reported in 11 studies, with the most commonly cited metrics being the Condensed Abbreviated Injury Scale (n = 5) and the Injury Severity Score (n = 4).

3.5. Treatment

The treatment of musculoskeletal injuries was discussed in 13 of the reviewed articles, with surgical intervention being the most commonly evaluated treatment (n = 9). Table 5 provides a summary of the specific surgical interventions reviewed, which include fixation (n = 4), wound management (n = 2), flap coverage (n = 1), fasciotomy (n = 1), and implant use (n = 1). The average time to treatment was 107.6 hours or 4.5 days, ranging from 6 hours to 3 weeks according to 3 studies evaluating this time point (Table 6).

Table 5.

Number of articles reporting on type of treatment.

Total articles	9
Internal fixation	3
External fixation	1
Wound management/debridement	2
Implant use	1
Fasciotomy	1
Flap coverage	1
Surgical timing	1

Table 6.

Time points reported.

	Period of data collection	Duration of follow-up	Time to treatment	Duration of hospitalization
# Of articles reporting variable (n)	37	9	3	9
Time range	1–84 mo	2 wk–48 mo	6 h–3 wk	15.3 d
Mean time	18 mo	12 mo	107.55 h/4.5 d	0–161 d

3.6. Follow-Up and Outcomes

Patient follow-up was discussed in 9 of the studies, with follow-up periods ranging from 2 weeks to 48 months and averaging 11.8 months. Hospital duration averaged 15.3 days (range: 0–161) as conveyed in the 9 studies describing this time point. Two studies reported on the duration of ICU admission, which averaged 10.2 days (range: 1–87) (Table 6). Eight of the included articles reported on patient outcomes. Complications were the most prevalently assessed outcomes (n = 4), of which mortality, infection, injury sequelae, vascular damage, mental health effects, amputation, and hospital readmission were discussed (Table 7). The mortality rate was reported in 12 articles, with a cumulative average mortality rate of 3.6% and ranging from 0% to 6.4%. Other reported outcomes included mobility (n = 2), return to work (n = 1), and impact to family/social routine (n = 1).

Table 7.

Outcomes reported.

Outcomes reported		Number of articles
	Total articles	8
Outcome type	Mobility	2
	Return to work	1
	Complications	4
	Impact on family/social routine	1
Complication type	Sequelae/residual pain	2
	Infection	1
	Mortality	1
	Vascular damage	1
	Mental health effects	1
	Amputation	1
	Hospital readmission	1

4. Discussion

Age and sex were the most consistently reported demographics, reaffirming the WHO statistics that young males are the prevailing demographic afflicted by motorcyclist injuries.³ Further characterization of motorcycle injured victims, including nationality, education, socioeconomic, marital, and employment status, was varied and largely incomplete. Similarly, the characterization of motorcycle incidents was inconsistently reported, with fewer than half the articles providing details on the time of day or month in which the incident occurred. There has been increased interest in Latin America in publishing on motorcycle incidents in the context of road policies and social cost of motorcyclists.^6,7 However, these variables are generally not correlated with injuries or patient outcomes.

Although the acquisition of motorcycles in Latin America has increased in recent years due to their affordability and versatility, less than a third of the articles included in this review were published in the last 5 years. As a result, the current magnitude of motorcycle incidents throughout the region is likely drastically underrepresented. In addition, the increased use of motorcycles to generate income, particularly in low and lower-middle sectors of Latin American society,^3,8 is similarly inadequately reflected in these literature sources. Only a single article reported on incident occurrence during work activity, providing insufficient data for determining any association between the proportion of motorcycle injured victims who were working at the time of injury.⁹

Despite the immense burden of motorcyclist injuries on Latin American communities and health systems,⁸ there remains a paucity of critical information pertaining to these injuries, treatments, and outcomes of motorcycle injured patients. Variables including injury type, clinical follow-up, time to receive treatment, total treatment time, hospitalization, interventions performed, results, complications, and patient evaluation using quality of life metrics are considered in less than a third of the articles in this review. Most included articles report on the incidence and prevalence of motorcycle collisions, most commonly characterizing collision or patient type. Limited data are reported on the injuries, treatments, or clinical outcomes, including quality of life and physical or psychological sequelae. Articles correlating the risk of death with motorcyclist injury or patient age have been published by other regions globally within the last 5 years^10,11; however, within the general literature, there is a lack of detailed information pertaining to motorcycle collision injuries.

Given the prevailing focus on characterizing motorcycle incidents and or patient populations, these data are limited on specific injury type or classification. Mortality was most consistently reported as an acute outcome at the time of the incident, with only one article evaluating mortality as a patient outcome measure.¹² The limited mortality data evaluated after treatment or hospitalization signify that the overall mortality of motorcycle collisions throughout Latin America is likely considerably underrepresented.

This study had various limitations, primarily pertaining to the quantity and diversity of included sources. Given the paucity of literature on the topic, this study can provide only a relatively limited understanding of the impact of motorcycle incidents throughout Latin America. Furthermore, the literary sources are not a diverse representation of Latin American countries, as the included publications represent only 4 Latin American countries, with 89% of the data originating from a single country, Brazil. Although gray literature searches were conducted beyond the most commonly used databases, the search may have missed articles that were unindexed or indexed only in smaller, regionally based databases.

The findings of this systematic review provide an opportunity to prioritize future areas of research and determine standardized variables for characterizing the incidents, patients, injuries, sequelae, and outcomes associated with motorcyclist injuries throughout Latin America. A potential mechanism to capture these data is through the implementation of a standardized registry. Capturing data from motorcycle collision patients treated at trauma centers in Latin America can better characterize the patient populations, injuries, management, outcomes, and complications. An evaluation of the current treatment guidelines and trends throughout the region are an initial step toward addressing a resource-consumptive contributor to the current health care crisis and inform policy in the region. Registry data could also be applied to determine the correlation between protection measures and motorcyclist injury severity, ultimately informing and standardizing the discrepant regulations on helmets and personal safety equipment among Latin American countries.⁸ Despite the highly variable and inconsistent data reported on helmet use, it is considered a proven intervention for reducing motorcycle-related fatalities and injuries.^1,13 Head traumas, brain injuries, and deaths have increased in countries that have overturned helmet use laws. The individual states in the United States that repealed their helmet enforcement laws have been shown to have a 12%–23% increase in mortality rates relative to states that have retained their laws.¹ This evidence supports the implementation of universal helmet laws and other potential considerations, such as graduated licensing system, compulsory training to obtain a motorcycle permit, and setting maximum penalties for traffic offenses and speeding. Beyond these proven interventions, additional legislative, occupational, and infrastructural characteristics should be considered. Further, data should be extended to all stakeholders affected by this health problem, including motorcycle manufacturers and vendors, mechanics, insurance companies, users of road infrastructure, media, health system, educational system, and regulatory entities.⁸ Through this approach, resources can be enhanced to develop strategies for improving the treatments and outcomes of motorcycle collision victims, while simultaneously reducing the occurrence of these incidents in Latin America.

In summary, a notable disparity exists between the availability of high-quality research studies on motorcyclist injuries in Latin America and the tremendous burden these injuries have on regional health care systems. Although the prevalence and incidence of motorcycle collisions is well represented in the current literature, an evaluation of the treatments and outcomes of motorcycle injured patients remains largely unaddressed. A deepened understanding of the morbidity and mortality related to motorcycle incidents can aid in the development of enhanced safety and interventional standards and policies to reduce the rates of death, injury, and disability due to this mode of transportation.

Data sharing is not applicable to this article as no new datasets were generated or analyzed during the current study. Researchers with questions about the study or data extraction process are welcome to contact the corresponding author.