Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery 52 (2014) 789–792
Influence of type of helmet on facial trauma in motorcycle accidents Marcelo Augusto Cini a , Bárbara Grassi Prado b,∗ , Patricia de Fragas Hinnig c , Walter Yoshinori Fukushima c , Fernando Adami d a
Health Science at ABC School of Medicine - São Paulo, Brazil School of Public Health at University of São Paulo - São Paulo, Brazil c ABC School of Medicine – São Paulo, Brazil d Health Science Program at ABC School of Medicine - São Paulo, Brazil b
Accepted 13 May 2014 Available online 23 June 2014
Abstract The mandatory use of helmets by motorcyclists has lowered the incidence of facial trauma, but we know little about the effects of different models of helmet on such injuries. We aimed to find out how different types of helmet affect facial injuries. We collected retrospective data from the medical records of 157 patients treated in a trauma centre in metropolitan São Paulo between January and December 2011. Patients wearing open-face helmets were twice as likely to require an operation as those wearing full-face helmets. The type of helmet is strongly associated with the treatment required. © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Motorcycle; facial trauma; traffic accidents; head protection devices
Introduction In Brazil, accidents are responsible for about 16 000 deaths each day, and thousands of other injuries result in disabling or permanent sequelae.1 In 2007, nearly 30% of all deaths from external causes were traffic-related, and the proportion of motorcyclists killed out of the total killed in traffic-related accidents rose from 4% in 1996 to 28% in 2007. The large increase in the number of motorcycles sold in recent years has been an important contributing factor.2
∗
Corresponding author. E-mail addresses: [email protected] (M.A. Cini), [email protected], [email protected] (B.G. Prado), [email protected] (P.d.F. Hinnig), [email protected] (W.Y. Fukushima), [email protected] (F. Adami).
Facial injuries, including fractures, have serious implications for the management of patients with multiple injuries.3 The implementation of laws that require seat belts to be worn in cars and helmets to be worn by motorcyclists is likely to have an impact on the incidence of facial trauma,4 and in developed countries this has been the case.5 Facial injuries can have emotional and functional consequences, and can result in permanent deformity.6 In 2010, the Brazilian Federal Government spent about R$ 44,303,497,000 on health, of which 52% was invested in outpatient and inpatient hospital care. Spending was US$ 771.56 per capita, and R$ 3,198,391,200 was spent on admissions for operations.7 Facial trauma accounts for 7.4% - 8.7% of admissions to accident and emergency (A&E) departments.8,9 The vulnerability of the face and the lack of protection provided by
http://dx.doi.org/10.1016/j.bjoms.2014.05.006 0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
790
M.A. Cini et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 789–792
Fig. 1. Types of helmet approved by Brazilian law.
open-face helmets may explain the high incidence of injury including severe injury in this area. Head injuries, which may account for half of all trauma-related deaths,10 often require treatment by a multidisciplinary team including specialists from ophthalmology, general surgery, plastic, oral and maxillofacial surgery, and neurosurgery.11 In Brazil, the number of motorcyclists injured in traffic accidents is gradually overtaking that of other road users. Motorcycles are increasingly being used to transport passengers (“mototaxis”) and for commercial purposes (“motoboys”),12 and riders are more vulnerable to injury than occupants of other motor vehicles.13,14 Resolution 203 of the Brazilian Traffic Code (September 2006) made the wearing of helmets by motorcyclists mandatory on public roads. The regulations state that helmets must display a safety stamp from the National Institute of Metrology, Quality and Technology (INMETRO) which is responsible for verifying minimum safety levels, and 3 types of helmet are acceptable: fixed full-face, articulated full-face, and open-face (Fig. 1).15 Studies on the wearing of helmets by motorcyclists in urban areas have highlighted 2 main points: the effectiveness of laws aimed at increasing their use, and the protection provided against brain injuries and death.16–18 Even with the increased use of helmets, little is known about how effectively they protect the face. Therefore, we aimed to evaluate the association between the type of helmet and type of facial injury.
Continuous variables were described using measures of central tendency and dispersion, and categorical variables using absolute and relative frequency. The association between the type of helmet and area of facial trauma was done using Pearson’s chi square or Fisher’s exact test, as appropriate. Logistic regression models were used to evaluate the odds of surgical treatment according to the type of helmet worn. The Ethics Committee of the ABC School of Medicine approved the study.
Results A total of 1628 patients presented with facial injuries at CHMSA in 2011. Of these, 157 had been involved in motorcycle accidents (10%) (mean age 26 years, range 14 – 61) and 143 (91%) of them were male. A total of 75 patients (48%) had worn fixed full-face helmets, 34 (22%) open-face or articulated full-face helmets, and 48 (31%) had worn no helmet. To analyse the impact of the type of helmet, those who had not been wearing one were excluded. The remaining sample was stratified into 2 groups: those wearing full-face (n = 75) and those wearing open-face (n = 34) helmets. Table 1 shows that the type of helmet was not associated with the area of face injured. The prevalence of operation in patients who had worn an open-face helmet was twice that of those wearing a full-face model (p = 0.013) (Table 2). Table 3
Methods This was a case-control study of 157 patients treated at Santo André Municipal Hospital Centre (CHMSA), Sao Paulo, Brazil, between January and December 2011. Only patients injured in the face in a motorcycle accident were included. Those with injuries to any other part of the body or whose injuries resulted in death were excluded. Variables included were age, sex, area of facial trauma, treatment, and type of helmet approved by Brazilian law. The types of helmet were grouped into 2 categories according to the extent of facial protection: full-face (fixed full-face), and open-face (open-face or articulated full-face) helmets (Fig. 1).
Table 1 Number (%) of injuries by type of helmet worn. Type of injury
Facial contusion Zygomatic fracture Nasal fracture Mandibular fracture Orbital fracture Dentoalveolar fracture Jaw fracture
Group
p value
Open-face helmet (n = 34)
Full-face helmet (n = 75)
No.
(%)
No.
(%)
13 9 5 8 5 3 2
(38) (27) (15) (24) (15) (9) (6)
42 12 12 8 9 3 2
(56) (16) (16) (11) (12) (4) (3)
0.09 0.20 0.86 0.09 0.76 0.37 0.59
M.A. Cini et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 789–792 Table 2 Type of treatment by type of helmet worn. Type of treatment
Conservative Operation
Group
p value
Open-face helmet (n = 34)
Full-face helmet (n = 75)
No.
(%)
No.
(%)
20 14
(59) (41)
61 14
(81) (19)
0.013 -
Table 3 Odds ratio (OR) and 95% confidence interval (CI) for operation according to the type of helmet worn. Helmet
OR
95% CI
p value
Full-face Open-face
1.00 3.05
1.24 to 7.48
0.015
shows the odds of operation for facial injuries in patients wearing both types of helmet.
791
was found between the type of helmet and type of injury. However, we found that the odds of undergoing an operation for facial fracture in those who wore open-face helmets were increased two-fold. We know of few studies that compare the type of the treatment given (conservative or surgical) with the type of helmet, so comparison with other published reports is difficult. Our study shows that the type of helmet is associated with the type of treatment required, and it emphasises the need for further debate about the use of open-face helmets by motorcyclists.
Ethics statement/confirmation of patient permission This study was approved by the Ethics Committee of the ABC School of Medicine (n◦ 81102 – Date: 22/08/2012)
References Discussion The new Brazilian traffic code, which came into effect on 22 January 1998, established harsher penalties for motorcyclists who do not wear helmets when driving. Since then, the use of helmets among victims of traffic accidents has increased from 31.2% to 66.2%,19 which is similar to our findings (69.5%), and it seems to have contributed to the reduction in related injuries. In Maryland (United States), Auman et al20 found that the mortality rate for motorcycle accidents dropped by 37% when helmets were made mandatory. Other studies showed even greater reductions – for example, there was a reduction of 44% in Taiwan.18 The mean age of our study sample was 26 years, which is similar to that in a study by Koizumi,21 who also studied patterns of injuries in victims of motorcycle accidents in São Paulo. Other studies reported age ranges from around 20 to 30 years.11,16 With regard to sex, more men are injured in motorcycle accidents than women,11,16,21 which agrees with our results. In our study, 69% had worn fixed full-face helmets, and 31% articulated full-face or open-face helmets, which agree with findings reported by Amirjamshidi et al (76% and 24%, respectively).22 Reported studies show that full-face helmets protect against severe head injuries that are caused by motorcycle accidents. Peek-Asa et al23 reported that 75% of victims wearing open-face helmets sustained a severe head injury, and Hitosugi et al24 found a significant difference in the type of head injury between those wearing open-face and full-face helmets. Yu et al25 found that people who did not wear helmets were 4 times more likely to sustain a head injury than those who did. Also, the risk of head injuries associated with openface helmets was twice that of full-face helmets. These data differ from our findings in which no significant association
1. Krug EG, Sharma GK, Lozano R. The global burden of injuries. Am J Public Health 2000;90:523–6. 2. Reichenheim ME, de Souza ER, Moraes CL, de Mello Jorge MH, da Silva CM, Minayo MC. Violence and injuries in Brazil: the effect, progress made, and challenges ahead. Lancet 2011;377:1962–75. 3. Cavalcante JR, Guimarães KB, Vasconcelos BC, Vasconcellos RJ. Epidemiological study of patients with facial trauma treated at the Antônio Targino Hospital - Campina Grande/Paraíba. Braz J Otorhinolaryngol 2009;75:628–33. 4. Crivello Jr O, Luz JG, Lemos JB, Rezende JR. [Statistical considerations of isolated maxillofacial fractures in Sao Paulo]. Rev Stomatol Chir Maxillofac 1989;90:100–3. In French. 5. Klenk G, Kovacs A. Etiology and patterns of facial fractures in the United Arab Emirates. J Craniofac Surg 2003;14:78–84. 6. Bisson JI, Shepherd JP, Dhutia M. Psychological sequelae of facial trauma. J Trauma 1997;43:496–500. 7. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances and challenges. Lancet 2011;377:1778–97. 8. Barker R, Hockey R, Spinks D, Miles E. Facial injury. Injury Bulletin: Queensland Injury Surveillance Unit 2003;79:1–6. Available from URL: http://fulltext.ausport.gov.au/fulltext/2003/qld/qisuissue79.pdf 9. Crompton JG, Oyetunji T, Stevens KA, Efron DT, Haut ER, Haider AH. Motorcycle helmets save lives, but not limbs: a National Trauma Data Bank analysis of functional outcomes after motorcycle crash. J Surg Res 2010;158:1–5. 10. Mackenzie EJ. Epidemiology of injuries: current trends and future challenges. Epidemiol Rev 2000;22:112–9. 11. Wulkan M, Parreira Jr JG, Botter DA. [Epidemiology of facial trauma]. Rev Assoc Med Bras 2005;51:290–5. In Portuguese. 12. Koizumi M, Mello Jorge M. [Motorcycle traffic in Brazil: the leisure to work tool]. Revista ABRAMET 2007;25:12–21. In Portuguese. 13. Andrade SM, Jorge MH. [Characteristics of the victims of traffic accidents in a city of the southern region of Brazil]. Rev Saude Publica 2000;34:149–56. In Portuguese. 14. Liberatti CL, de Andrade SM, Soares DA, Matsuo T. [Helmet use by motorcyclists injured in traffic accidents in Londrina, southern Brazil]. Rev Panam Salud Publica 2003;13:33–8. In Portuguese. 15. http://www.denatran.gov.br/download/Resolucoes/Resolucao203 06.pdf 16. Norvell DC, Cummings P. Association of helmet use with death in motorcycle crashes: a matched-pair cohort study. Am J Epidemiol 2002;156:483–7.
792
M.A. Cini et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 789–792
17. Scalassara MB, de Souza RK, Soares DF. [Characteristics of mortality in traffic accidents in an area of southern Brazil]. Rev Saude Publica 1998;32:125–32. In Portuguese. 18. Tsai MC, Hemenway D. Effect of the mandatory helmet law in Taiwan. Inj Prev 1999;5:290–1. 19. Liberatti CL, Andrade SM, Soares DA. The new Brazilian traffic code and some characteristics of victims in southern Brazil. Inj Prev 2001;7: 190–3. 20. Auman KM, Kufera JA, Ballesteros MF, Smialek JE, Dischinger PC. Autopsy study of motorcyclist fatalities: the effect of the 1992 Maryland motorcycle helmet use law. Am J Public Health 2002;92:1352–5. 21. Koizumi MS. [Injury patterns of motorcycle accident victims]. Rev Saude Publica 1992;26:306–15. In Portuguese.
22. Amirjamshidi A, Ardalan A, Nainei KH, Sadeghi S, Pahlevani M, Zarei MR. Comparison of standard and nonstandard helmets and variants influencing the choice of helmets: a preliminary report of cross-sectional prospective analysis of 100 cases. Surg Neurol Int 2011;2:49. 23. Peek-Asa C, McArthur DL, Kraus JF. The prevalence of non-standard helmet use and head injuries among motorcycle riders. Accid Anal Prev 1999;31:229–33. 24. Hitosugi M, Shigeta A, Takatsu A, Yokoyama T, Tokudome S. Analysis of fatal injuries to motorcyclists by helmet type. Am J Forensic Med Pathol 2004;25:125–8. 25. Yu WY, Chen CY, Chiu WT, Lin MR. Effectiveness of different types of motorcycle helmets and effects of their improper use on head injuries. Int J Epidemiol 2011;40:794–803.
British Journal of Oral and Maxillofacial Surgery 52 (2014) 789–792
Influence of type of helmet on facial trauma in motorcycle accidents Marcelo Augusto Cini a , Bárbara Grassi Prado b,∗ , Patricia de Fragas Hinnig c , Walter Yoshinori Fukushima c , Fernando Adami d a
Health Science at ABC School of Medicine - São Paulo, Brazil School of Public Health at University of São Paulo - São Paulo, Brazil c ABC School of Medicine – São Paulo, Brazil d Health Science Program at ABC School of Medicine - São Paulo, Brazil b
Accepted 13 May 2014 Available online 23 June 2014
Abstract The mandatory use of helmets by motorcyclists has lowered the incidence of facial trauma, but we know little about the effects of different models of helmet on such injuries. We aimed to find out how different types of helmet affect facial injuries. We collected retrospective data from the medical records of 157 patients treated in a trauma centre in metropolitan São Paulo between January and December 2011. Patients wearing open-face helmets were twice as likely to require an operation as those wearing full-face helmets. The type of helmet is strongly associated with the treatment required. © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Motorcycle; facial trauma; traffic accidents; head protection devices
Introduction In Brazil, accidents are responsible for about 16 000 deaths each day, and thousands of other injuries result in disabling or permanent sequelae.1 In 2007, nearly 30% of all deaths from external causes were traffic-related, and the proportion of motorcyclists killed out of the total killed in traffic-related accidents rose from 4% in 1996 to 28% in 2007. The large increase in the number of motorcycles sold in recent years has been an important contributing factor.2
∗
Corresponding author. E-mail addresses: [email protected] (M.A. Cini), [email protected], [email protected] (B.G. Prado), [email protected] (P.d.F. Hinnig), [email protected] (W.Y. Fukushima), [email protected] (F. Adami).
Facial injuries, including fractures, have serious implications for the management of patients with multiple injuries.3 The implementation of laws that require seat belts to be worn in cars and helmets to be worn by motorcyclists is likely to have an impact on the incidence of facial trauma,4 and in developed countries this has been the case.5 Facial injuries can have emotional and functional consequences, and can result in permanent deformity.6 In 2010, the Brazilian Federal Government spent about R$ 44,303,497,000 on health, of which 52% was invested in outpatient and inpatient hospital care. Spending was US$ 771.56 per capita, and R$ 3,198,391,200 was spent on admissions for operations.7 Facial trauma accounts for 7.4% - 8.7% of admissions to accident and emergency (A&E) departments.8,9 The vulnerability of the face and the lack of protection provided by
http://dx.doi.org/10.1016/j.bjoms.2014.05.006 0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
790
M.A. Cini et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 789–792
Fig. 1. Types of helmet approved by Brazilian law.
open-face helmets may explain the high incidence of injury including severe injury in this area. Head injuries, which may account for half of all trauma-related deaths,10 often require treatment by a multidisciplinary team including specialists from ophthalmology, general surgery, plastic, oral and maxillofacial surgery, and neurosurgery.11 In Brazil, the number of motorcyclists injured in traffic accidents is gradually overtaking that of other road users. Motorcycles are increasingly being used to transport passengers (“mototaxis”) and for commercial purposes (“motoboys”),12 and riders are more vulnerable to injury than occupants of other motor vehicles.13,14 Resolution 203 of the Brazilian Traffic Code (September 2006) made the wearing of helmets by motorcyclists mandatory on public roads. The regulations state that helmets must display a safety stamp from the National Institute of Metrology, Quality and Technology (INMETRO) which is responsible for verifying minimum safety levels, and 3 types of helmet are acceptable: fixed full-face, articulated full-face, and open-face (Fig. 1).15 Studies on the wearing of helmets by motorcyclists in urban areas have highlighted 2 main points: the effectiveness of laws aimed at increasing their use, and the protection provided against brain injuries and death.16–18 Even with the increased use of helmets, little is known about how effectively they protect the face. Therefore, we aimed to evaluate the association between the type of helmet and type of facial injury.
Continuous variables were described using measures of central tendency and dispersion, and categorical variables using absolute and relative frequency. The association between the type of helmet and area of facial trauma was done using Pearson’s chi square or Fisher’s exact test, as appropriate. Logistic regression models were used to evaluate the odds of surgical treatment according to the type of helmet worn. The Ethics Committee of the ABC School of Medicine approved the study.
Results A total of 1628 patients presented with facial injuries at CHMSA in 2011. Of these, 157 had been involved in motorcycle accidents (10%) (mean age 26 years, range 14 – 61) and 143 (91%) of them were male. A total of 75 patients (48%) had worn fixed full-face helmets, 34 (22%) open-face or articulated full-face helmets, and 48 (31%) had worn no helmet. To analyse the impact of the type of helmet, those who had not been wearing one were excluded. The remaining sample was stratified into 2 groups: those wearing full-face (n = 75) and those wearing open-face (n = 34) helmets. Table 1 shows that the type of helmet was not associated with the area of face injured. The prevalence of operation in patients who had worn an open-face helmet was twice that of those wearing a full-face model (p = 0.013) (Table 2). Table 3
Methods This was a case-control study of 157 patients treated at Santo André Municipal Hospital Centre (CHMSA), Sao Paulo, Brazil, between January and December 2011. Only patients injured in the face in a motorcycle accident were included. Those with injuries to any other part of the body or whose injuries resulted in death were excluded. Variables included were age, sex, area of facial trauma, treatment, and type of helmet approved by Brazilian law. The types of helmet were grouped into 2 categories according to the extent of facial protection: full-face (fixed full-face), and open-face (open-face or articulated full-face) helmets (Fig. 1).
Table 1 Number (%) of injuries by type of helmet worn. Type of injury
Facial contusion Zygomatic fracture Nasal fracture Mandibular fracture Orbital fracture Dentoalveolar fracture Jaw fracture
Group
p value
Open-face helmet (n = 34)
Full-face helmet (n = 75)
No.
(%)
No.
(%)
13 9 5 8 5 3 2
(38) (27) (15) (24) (15) (9) (6)
42 12 12 8 9 3 2
(56) (16) (16) (11) (12) (4) (3)
0.09 0.20 0.86 0.09 0.76 0.37 0.59
M.A. Cini et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 789–792 Table 2 Type of treatment by type of helmet worn. Type of treatment
Conservative Operation
Group
p value
Open-face helmet (n = 34)
Full-face helmet (n = 75)
No.
(%)
No.
(%)
20 14
(59) (41)
61 14
(81) (19)
0.013 -
Table 3 Odds ratio (OR) and 95% confidence interval (CI) for operation according to the type of helmet worn. Helmet
OR
95% CI
p value
Full-face Open-face
1.00 3.05
1.24 to 7.48
0.015
shows the odds of operation for facial injuries in patients wearing both types of helmet.
791
was found between the type of helmet and type of injury. However, we found that the odds of undergoing an operation for facial fracture in those who wore open-face helmets were increased two-fold. We know of few studies that compare the type of the treatment given (conservative or surgical) with the type of helmet, so comparison with other published reports is difficult. Our study shows that the type of helmet is associated with the type of treatment required, and it emphasises the need for further debate about the use of open-face helmets by motorcyclists.
Ethics statement/confirmation of patient permission This study was approved by the Ethics Committee of the ABC School of Medicine (n◦ 81102 – Date: 22/08/2012)
References Discussion The new Brazilian traffic code, which came into effect on 22 January 1998, established harsher penalties for motorcyclists who do not wear helmets when driving. Since then, the use of helmets among victims of traffic accidents has increased from 31.2% to 66.2%,19 which is similar to our findings (69.5%), and it seems to have contributed to the reduction in related injuries. In Maryland (United States), Auman et al20 found that the mortality rate for motorcycle accidents dropped by 37% when helmets were made mandatory. Other studies showed even greater reductions – for example, there was a reduction of 44% in Taiwan.18 The mean age of our study sample was 26 years, which is similar to that in a study by Koizumi,21 who also studied patterns of injuries in victims of motorcycle accidents in São Paulo. Other studies reported age ranges from around 20 to 30 years.11,16 With regard to sex, more men are injured in motorcycle accidents than women,11,16,21 which agrees with our results. In our study, 69% had worn fixed full-face helmets, and 31% articulated full-face or open-face helmets, which agree with findings reported by Amirjamshidi et al (76% and 24%, respectively).22 Reported studies show that full-face helmets protect against severe head injuries that are caused by motorcycle accidents. Peek-Asa et al23 reported that 75% of victims wearing open-face helmets sustained a severe head injury, and Hitosugi et al24 found a significant difference in the type of head injury between those wearing open-face and full-face helmets. Yu et al25 found that people who did not wear helmets were 4 times more likely to sustain a head injury than those who did. Also, the risk of head injuries associated with openface helmets was twice that of full-face helmets. These data differ from our findings in which no significant association
1. Krug EG, Sharma GK, Lozano R. The global burden of injuries. Am J Public Health 2000;90:523–6. 2. Reichenheim ME, de Souza ER, Moraes CL, de Mello Jorge MH, da Silva CM, Minayo MC. Violence and injuries in Brazil: the effect, progress made, and challenges ahead. Lancet 2011;377:1962–75. 3. Cavalcante JR, Guimarães KB, Vasconcelos BC, Vasconcellos RJ. Epidemiological study of patients with facial trauma treated at the Antônio Targino Hospital - Campina Grande/Paraíba. Braz J Otorhinolaryngol 2009;75:628–33. 4. Crivello Jr O, Luz JG, Lemos JB, Rezende JR. [Statistical considerations of isolated maxillofacial fractures in Sao Paulo]. Rev Stomatol Chir Maxillofac 1989;90:100–3. In French. 5. Klenk G, Kovacs A. Etiology and patterns of facial fractures in the United Arab Emirates. J Craniofac Surg 2003;14:78–84. 6. Bisson JI, Shepherd JP, Dhutia M. Psychological sequelae of facial trauma. J Trauma 1997;43:496–500. 7. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances and challenges. Lancet 2011;377:1778–97. 8. Barker R, Hockey R, Spinks D, Miles E. Facial injury. Injury Bulletin: Queensland Injury Surveillance Unit 2003;79:1–6. Available from URL: http://fulltext.ausport.gov.au/fulltext/2003/qld/qisuissue79.pdf 9. Crompton JG, Oyetunji T, Stevens KA, Efron DT, Haut ER, Haider AH. Motorcycle helmets save lives, but not limbs: a National Trauma Data Bank analysis of functional outcomes after motorcycle crash. J Surg Res 2010;158:1–5. 10. Mackenzie EJ. Epidemiology of injuries: current trends and future challenges. Epidemiol Rev 2000;22:112–9. 11. Wulkan M, Parreira Jr JG, Botter DA. [Epidemiology of facial trauma]. Rev Assoc Med Bras 2005;51:290–5. In Portuguese. 12. Koizumi M, Mello Jorge M. [Motorcycle traffic in Brazil: the leisure to work tool]. Revista ABRAMET 2007;25:12–21. In Portuguese. 13. Andrade SM, Jorge MH. [Characteristics of the victims of traffic accidents in a city of the southern region of Brazil]. Rev Saude Publica 2000;34:149–56. In Portuguese. 14. Liberatti CL, de Andrade SM, Soares DA, Matsuo T. [Helmet use by motorcyclists injured in traffic accidents in Londrina, southern Brazil]. Rev Panam Salud Publica 2003;13:33–8. In Portuguese. 15. http://www.denatran.gov.br/download/Resolucoes/Resolucao203 06.pdf 16. Norvell DC, Cummings P. Association of helmet use with death in motorcycle crashes: a matched-pair cohort study. Am J Epidemiol 2002;156:483–7.
792
M.A. Cini et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 789–792
17. Scalassara MB, de Souza RK, Soares DF. [Characteristics of mortality in traffic accidents in an area of southern Brazil]. Rev Saude Publica 1998;32:125–32. In Portuguese. 18. Tsai MC, Hemenway D. Effect of the mandatory helmet law in Taiwan. Inj Prev 1999;5:290–1. 19. Liberatti CL, Andrade SM, Soares DA. The new Brazilian traffic code and some characteristics of victims in southern Brazil. Inj Prev 2001;7: 190–3. 20. Auman KM, Kufera JA, Ballesteros MF, Smialek JE, Dischinger PC. Autopsy study of motorcyclist fatalities: the effect of the 1992 Maryland motorcycle helmet use law. Am J Public Health 2002;92:1352–5. 21. Koizumi MS. [Injury patterns of motorcycle accident victims]. Rev Saude Publica 1992;26:306–15. In Portuguese.
22. Amirjamshidi A, Ardalan A, Nainei KH, Sadeghi S, Pahlevani M, Zarei MR. Comparison of standard and nonstandard helmets and variants influencing the choice of helmets: a preliminary report of cross-sectional prospective analysis of 100 cases. Surg Neurol Int 2011;2:49. 23. Peek-Asa C, McArthur DL, Kraus JF. The prevalence of non-standard helmet use and head injuries among motorcycle riders. Accid Anal Prev 1999;31:229–33. 24. Hitosugi M, Shigeta A, Takatsu A, Yokoyama T, Tokudome S. Analysis of fatal injuries to motorcyclists by helmet type. Am J Forensic Med Pathol 2004;25:125–8. 25. Yu WY, Chen CY, Chiu WT, Lin MR. Effectiveness of different types of motorcycle helmets and effects of their improper use on head injuries. Int J Epidemiol 2011;40:794–803.
