Live fast, die young and have a good-looking corpse," a philosophy articulated by the major character in the 1947 popular book and movie, Knock on Any Door, can all too easily be an epitaph for today's high-risk-taking youth. l Adolescents and young adults are the only age group in which death rates have risen over the last 20 years.
A great deal of effort and resources are being expended by our society to protect the very young from injury. We regard children as innocent and helpless victims who evoke great sympathy and little restraint on efforts by adults to create a safer environment for them. However, when these protected children become adolescents we not only condone but even promote activities that involve interaction with high energy sources, which all too frequently results in disabling injury and death.
ADOLESCENTS IN MOTION
Injuries occur and cluster where a concentration of high energy release and inadequate performance interact.
The bicycle leads the list of hazardous products established by the Consumer Product Safety Commission (CPSC). In 1985 there were an estimated 108 million pedacycles in use in the United States. While the death rate associated with bicycle use has doubled since the 1950s to 1,000 in 1985, the number of bicycles in use has increased almost tenfold. However, the proportion of deaths occurring among adolescents and young adults has been steadily increasing. Persons 15 years of age and older accounted for almost two thirds of the bicycle-related deaths in 1985 compared with about one fifth of the deaths in 1960, reflecting a change in use and ownership of bicycles.
The National Electronic Injury Surveillance System (NEISS) of the CPSC and other sources estimate annual injury rates of up to 1 million with one third being seen in emergency rooms. Wrong- way riding (against traffic) increases the likelihood of an accident as it places the bicycle and rider at an unexpected location at intersections. Nighttime riding, particularly on rural roads, also contributes to an increased incidence of car-bike injuries.2
Product fault was a significant factor until the CPSC set bicycle safety standards for brakes, seats, tires, reflectors, front fork frames, steering systems, and road tests. Still awaited are design changes in the wheels to prevent spoke injuries and improved use of retroreflective paint making the bicycle more visible at night. Improved safety standards have shifted the responsibility of safe bicycling to rider education, training and protection to reduce injuries and fatalities.
Loss of control by the rider has been found in over 60% of injuries. Violations of traffic rules, such as riding against traffic and disregarding signals and signs, play a part in 80% of injuries.
When falls and collisions with motor vehicles occur, head injuries account for significant morbidity and mortality. Head injuries were associated with 75% of deaths from bicycle-related injuries. A fall at a speed of 20 miles per hour can result in a fatality if the unprotected head strikes a hard object, and there is an estimated 50% chance of a head injury in a fall from a bicycle.
Awareness of the frequency and significance of head injuries has led to attempts to reduce them. One safety measure is now recognized: helmets should be a requirement for bicycle riders. In 1986, the United States Cycling Federation required helmet use for all racers. Helmet use by the general public is estimated at little more than 1%. Imaginative voluntary projects are attempting to increase helmet use in Seattle, Washington, and Suffolk County, New York but significant use may only result from mandatory requirement. Helmets should meet American National Standards Institute (ANSI) or the Snell Memorial Foundation standards of approval.
In the 1940s and 1950s, children learned to locomote by creating homemade skateboards from 2x4 inch pieces of wood with half a rollerskate at each end and a used orange crate as a front console. These were slow devices and accidents resulted in some splinters and scrapes but few serious injuries. In 1974 there were only 3,200 injuries associated with skateboard use reported.
Starting with their discovery by surfers in southern California and Florida, skateboarding suddenly became the most popular adolescent recreational activity of the 1970s. The new skateboards coming on the market are now designed for standing and high speed maneuvering. Competition created sophisticated variations from flexible, high impact plastic and fiberglass materials with polyurethane wheels. Imaginative innovations such as sails, blades for ice use, and braking devices were added to boards which measured from 2 to 7 feet long. Some skateboards were even motorized and costs ranged to well over $100. As speed capability reached 35 miles an hour, injuries to the riders also soared.
The victims of this new activity were predominantly male and injury most frequently resulted in fractures of the lower arms. Great concern arose in 1977 when injuries requiring emergency room treatment reached an estimated 140,000, and 25 deaths were reported in a three month period. The greatest number of injuries occurred in the 10 to 14 year old age group with one third of the injured sustaining fractures. Deaths resulted from head injury secondary to falls or from collisions with automobiles. It was soon recognized that skateboarding was an extremely dangerous activity that required proper protection of the rider if serious injury was to be avoided from inevitable falls and collisions. Use of skateboards peaked in 1978 with estimates of over 20 million boards in use and a projected 350,000 annual injuries anticipated. Concerned consumer groups petitioned the CPSC for a ban on the manufacture and sale of skateboards. Safety groups including the American Academy of Pediatrics (AAP) advocated rider education, appropriate equipment use, and safe facilities as an alternative to use on public streets and highways.
Unpredictably, the injury rate suddenly declined and a marked decrease in the popularity of skateboarding occurred. 3 In 1982 the CPSC reported only 14, 700 skateboard-associated injuries. Was skateboarding just another passing fad? It appeared so until the movie "Back to the Future" appeared with sequences of daring and life-threatening skateboarding. Imitative behavior in the tradition of the Evel Knievel syndrome appeared from riders with dusted-off skateboards, but the resurgence of use did not develop a broad following and use returned to minimal levels.
POWERED OFF-ROAD USE CYCLES
For over 20 years, a variety of motorized cycles have been marketed as recreational vehicles for off-road use by children and adolescents. Injuries associated with their use have caused significant concern and attempts have been made to curtail and regulate usage. Because these vehicles do not meet motorcycle safety standards, they can only be sold for off-road use where licensure is generally not required for vehicle or rider and there are no federal safety standards to guide the manufacturer.
Minibikes and Minicycles
Minibikes weigh less than 100 pounds and are constructed with bicycle style frames and engines of less than 4 horsepower allowing speeds up to 30 miles per hour. Riders of minibikes generally have a fourfold greater risk of injury than do bicycle riders. Peak injury occurs in the 10 to 14 year old age group.
Minicycles are miniature motorcycles that have suspension systems and multiple-speed transmissions and can vary in size and horsepower.
Larger than minicycles, these vehicles are specially equipped for trail riding. In the early 1970s, the CPSC estimated injury rates of 75,000 from these vehicles annually with nearly one half of the injuries occurring in the 10 to 15 year old age group and another fifth among 15 to 20 year olds. Eighty percent of the injured were male. The leg was the body part injured most frequently, followed by the arm and head. In the past five years, injury incidence has reached a plateau at about 33,000 annually. The CPSC has documented 24 deaths associated with the use of these vehicles since 1980. A lack of safety devices or defective and poorly constructed components were involved in one third of 21 in-depth investigations made by the CPSC.
Although most of these vehicles are intended for offroad use, many of the injuries result from motor vehicle collisions indicating an illegal use of these vehicles on the roadway. In addition, injury occurs from falls or collisions with fixed objects or by body contact with the drive train or the exhaust system. The off-road use cycles are particularly dangerous due to poor handling because of a short wheelbase, small tires, slow acceleration, inadequate brakes and small size.
The AAP Committee on Accident and Poison Prevention (COAPP) issued a statement advising pediatricians to counsel parents regarding the inherent hazard these vehicles pose to children. The use of these unlicensed two-wheeled motorized cycles, particularly by children less than 14 years of age, was discouraged.4
POWERED STREET-USE CYCLES
Mopeds are generally classified as bicycles with motors and are legal for street use. In many respects, they share the operating characteristics of bicycles and lightweight motorcycles. The motor size is limited to 50 cc giving them a top speed of up to 30 miles per hour. Commonly used in Europe, they achieved popularity in the United States as a result of scarce and expensive fuel in the late 1970s.
Because of their classification as bicycles, mopeds are exempt from registration requirements in most states. Operating permits and helmet use are generally not required. Although most states require that the rider be over 16 years of age, some permit use by 14 or 15 year olds.
Mopeds are fast enough to cause serious injury in a fall or collision, but their acceleration capability is often inadequate for mixing with city traffic, creating dangerous situations. The most common injury patterns involve the head and lower extremities.
The necessary skill and judgment for safe moped operation depends on the individual adolescent. It is therefore difficult to establish an age for safe handling of these vehicles. Strong parental judgment is the only guideline as to whether a young teen has the maturity and expertise for safe operation of these vehicles. Few states have legal requirements for protective clothing, so the responsibility for appropriate guidance again falls upon the parents. Most European countries require moped operators to wear helmets and both Great Britain and France report a reduction of about one third in serious head injuries.
There were 5,472,000 motorcycles in use in 1985. The mileage death rate for motorcycle riders during that year was estimated to be 36 deaths per 100 million miles of motorcycle travel compared with an overall motor vehicle death rate of 2.58. The motorcycle rider's chances of being killed or seriously injured are much greater than those of a rider in a vehicle affording more protection. There were 4,500 deaths and an estimated 490,000 injuries to motorcycle riders in 1985. 5
As would be expected, accidents tend to occur in the warm months and on weekends. Ninety percent of the operators are male and about 60% are less than 25 years old.
Federal requirements resulted in mandatory helmet use laws in all but three states by 1975. The repeal of federal requirements in 1976 resulted in a steady repeal of state laws. By 1982, nine states had no helmet laws and 22 states had amended their laws with many requiring helmets only for teenage riders. Predictably deaths from motorcycle accidents increased by 49% in the years 1976 to 1980. One third of the deaths occurred in the under 20 year old age group. Helmet use has been shown to reduce morbidity and mortality. A nonhelmeted rider is five times as likely as a helmeted rider to acquire a severe or critical injury.
The three- and four-wheeled all terrain vehicles (ATVs) are the most recent addition to off-road use vehicles. Although available for 15 years prior to 1982, their popularity did not begin to manifest until the mid-1980s. Aided by an extensive advertising campaign, often aimed at children and adolescents, sales of these predominantly Japanese imports soared to an estimated 780,000 in 1985. There are currently an estimated 2.5 million ATVs in use in the United States; they are used predominantly as recreational vehicles. The vehicles rest on three or four large soft tires, have a high center of gravity, lack a rear wheel differential, often have only a limited or no suspension system, and can achieve speeds of 30 to 50 miles per hour. With increased use, particularly by children and adolescents, it became apparent that a new major hazard had developed that far overshadowed the concern previously held for the two-wheeled off-road use vehicles.
Although appearing stable, the three- wheeled vehicles are especially unstable and prone to turning over particularly if used on hard surfaces. These vehicles are rider active requiring the rider's participation in a variety of maneuvers when turning or traversing changing terrain. Loss of operator control is responsible for the majority of injuries.
CPSC injury and death data show an escalating hazard associated with ATV usage particularly among children and young adults. From 1984 to 1985 annual emergency room injuries related to ATVs rose from 63,900 to 85,900. Thirty percent of the injuries occurred in the 5 to 14 year old age group and two thirds in those less than 25 years old. More than 40% of deaths were children under 16 years of age. Severe injuries, including spinal cord damage resulting in quadriplegia and paraplegia, were also reported.
A lack of rapid definitive action by the CPSC to address this new morbidity in recreational off-road ATV use prompted the Committee on Government Operations of the House of Representatives in July 1986 to recommend that the CPSC issue a recall of three-wheeled ATVs in use and place a ban on the future production of these vehicles unless an acceptable standard was promulgated to deal with the hazards these vehicles presented. The AAP supported the recall and ban and recommended that manufacturers call a voluntary moratorium on the sale of new ATVs for recreational use until engineering improvements can assure greater safety.
In May 1987, the CPSC updated ATV-related data to March 2, 1987. Injuries for 1986 topped 86,000 and cumulative deaths have risen to 696. California led the nation with 55 cumulative deaths and New York was second with 51 deaths. Children continued to be disproportionately represented with 45% of the victims under 16 years of age and 20% under 12 years of age. The CPSC issued the recommendations listed in the Table.6
CPSC Caution for Three and FourWheeled All-Terrain Vehicles
After reviewing the data associated with injuries and deaths to adolescents participating in the activities described above, the question repeatedly arises: Why does our society continue to accept and promote this toll of injuries and deaths? While waiting for answers from researchers, physicians must continue an advocacy role for measures of protection known to reduce the morbidity and years of life lost among the adolescent age group.
1. Motely W: Knock On Any Door. New York. D Appleton-Century, 1947.
2. Acculent Facts. Chicago. National Safety Council, 1986. ? 45.
3. Greensher J. Mofenson HC: Injuries at play. Peáiatr Clin North Am 1985; 32:127.
4. Committee on Accident and foison Prevention: Injury Control for Children and Youth. Elk Grove Village, American Academy of Pediatrics. 1987, ? 256.
5. Accident Facts. Chicago, National Safety Council, 1986, ? 56.
6. US Consumer Product Safety Commission: Consumer product safety alert - CPSC Urges caution for three and four-wheeled all-terrain vehicles. Washington, DC, CPSC, May 1987.
CPSC Caution for Three and FourWheeled All-Terrain Vehicles