The
most severe injuries from bicycling tend to permanently
impact the victim’s
capacity to earn a living, take care of him/herself
and enjoy life through social relationships and the
pursuit of hobbies, exercise, recreational, and leisure
activities, including cycling. |
Common Injuries
Bicycle
injuries range from minor to lethal.
The more severe the injury the more likely it is that litigation
will follow, because the innocent victim cannot absorb the costs
of hospital care, medical care, time off work and lost wages & benefits without
compensation from the wrongdoer’s liability insurance. The most severe
injuries from bicycling tend to permanently impact the victim’s capacity
to earn a living, take care of himself or herself and enjoy life
through social relationships and the pursuit of hobbies, exercise, recreational,
and leisure activities, including cycling.
The value of an injury in court cannot be determined solely with regards to its kind (e.g. muscle tear vs. fracture, rib fracture vs. hip fracture). Consideration must also be given to whether the injury is disfiguring, disabling and temporary or permanent in nature; whether the victim lost time from work and if so the amount of the wage loss; the financial cost of past and future medical care; and how the injury has impacted and will continue to impact the individual's functioning in all important aspects of his/her life.
Not all victims of negligence are created equal. The capacity to endure, recover from and overcome the effects of injury is related to the individual's age, gender and unique genetic, physical and psychological factors. At the bottom of this page is a discussion of cycling injuries and the older cyclist in his 60s to 80s. Examples of bicycle injuries which we have handled over the years, include the following:
Avulsion Injury
Avlusion refers to the forcible tearing off a body part from its point of attachment. A portion of a tendon, ligament, muscle or nerve can be avulsed from a cycling accident, especially when a car runs over a cyclist. Avulsion injury typically requires surgery to re-attach the disrupted tissue. Sometimes the tissue cannot be saved, and the area will later fill in with scar tissue.
When the tissue avulsed from the body is skin, doctors refer to this as a degloving injury. When a cyclist sustains a partial or full thickness tear of the skin, the potential for traumatic tatooing exists from debris embedded in the wound. A cyclist with such a wound should go to an emergency room for debriding and cleansing of the wound with removal of debris.
Blunt Trauma
A somewhat common injury occurs when a cyclist falls and his/her abdomen or flank sustains blunt trauma from contact with the handlebar. Blunt handlebar trauma can cause hernia of the abdominal wall, rupture of the diaphragm, rupture off the small intestine with bleeding and bowel obstructing clot formation and damage to the kidney or ureters. Abdominal pain, flank pain, abdominal distention and blood in the urine are all potential signs of intra-abdominal injury from striking the handlebar, and should be taken very seriously.
Crush Injury
When a car crashes directly into the lower body of a cyclist on his/her bike, there is a potential for crush injury to tissues in the hip, thigh, knee, calf, ankle or foot. Structures that can be crushed include the sub dermal fat, muscles, nerves, blood vessels, lymph vessels and bones. Crush injuries tend to cause acute pain, inflammation and swelling. They can leave chronic problems from scar tissue and inflammation in the damaged body part. Other permanent problems from a tissue crush injury include numbness, weakness and enlargement of or reduced drainage of the crushed body part.
Death
The bicycle is a two wheeled, human powered vehicle that offers no crash protection. Cyclists are at the mercy of cars. Between 1932, when bicycle crash fatality statistics were first kept, until 2002, there have been 47,000 deaths of cyclists from bicycle related injuries. 90% of all cycling deaths from a collision with a car. In 66% of the situations the crash occurred due to a traffic law violation. In 66% of the situations the immediate cause of death was a traumatic brain injury (TBI).
TBI tends to occur when the crash impact from a car causes the cyclist to strike his or her head against a solid surface (street, curb or wall) when ejected from his/her bike or slammed to the ground with bike shoes clipped to the pedals. To give people some perspective, there are 85 million bike riders in the United States, and each year there is an average of 800 people killed on bikes. In 1990, 859 cyclists died at an average age of 28 years. In 1995, 833 died. In 2000, 693 died. In 2001, 732 cyclists died at an average age of 36. In 2002, 662 died. Of those who died in 2002, 23% of the cyclists had a blood alcohol of .08% or higher and 85% were not wearing helmets. Between 1990 and the present it would appear that the average number of annual cycling deaths is declining while the average age of the victim is increasing. It also appears that to decrease the risk of dying on a bicylcle, one must never ride after drinking alcohol and one must always wear a good fitting bicycle helmet. Over the years, death rates have been consistently higher for males vs. females, in urban vs. rural areas, in the summer vs. other seasons, on Fridays vs. other days and between the hours of 5 pm - 9pm. To understand how bike crash fatalities occur and to help state and local traffic engineers and bike route planners reduce the risk of fatalities, two federal agencies (the Federal Highway Administration and the National Highway Traffic Safety Administration) created a computer software program called PBCAT -- Pedestrian Bicycle Crash Analysis Tool. It is a database containing the circumstances of motor vehicle/bicycle crashes as to location; time of day; gender and age of victim; and type of crash (e.g. car or bike turning left in front of the other, or car or bike overtaking and passing the other). To access this database, see www.bicyclinginfo.org/matrix For information regarding what monetary damages are recoverable by statute in a wrongful death lawsuit by heirs of the deceased bicyclist, please go to the Your Rights section of this website accessible on the topic bar at the top of this page. Every so often we read in the newspaper about a drunk driver veering off into the bike lane and killing a cyclist wearing a helmet. These events are tragedies, but they are not accidents. The drivers at fault could have chosen not to drink or to designate a buddy to drive them home or to eat a meal and wait a decent interval before driving or to pull over and rest when they started to weave. The drivers at fault should be punished to the full extent of the criminal aw, and should be sued in civil court for all the damages they have caused to the surviving family members of the cyclist they killed. There are other situations where drivers who were stone cold sober killed cyclists due to speeding or talking distractedly on a cell phone, and never stopped to render aid. It is crucial that these people be apprehended and held accountable. For this reason, cyclists should bring a cell phone to report crashes from the scene or at least carry paper and a pen in their seat pack to write down the license plate of the vehicle that hit a cyclist and fled the scene.
Dental Trauma
While a motorcyclist can wear a full face helmet that protects his mouth and jaw, all a bicyclist can get is a helmet to protect his scalp, skull and brain. Cyclists who fly over their handlebars can suffer much more than a bruised or broken collar bone. They are at risk of jaw fractures, jaw joint trauma with malalignment and TMJ syndrome, chipped teeth, loosened teeth, complete loss of one or more teeth, bruising of their lips, abrasions of the mucosa lining the inside of their lips, biting damage to their tongue and more. A Board Certified Oral Surgeon should be consulted for conditions such as a fractured jaw or TMJ. Endodontists, who do root canals, are the experts on damage to the inner part or pulp of a damaged tooth. Periodontists are the experts on broken teeth or tooth roots. Traumatic damage to the teeth may require root canal, post implantation, fabrication of a new crown, bridge work or other expensive procedures. Finding the right specialist can be difficult. If you trust your dentist, go to him or her for a complete check up, x-rays and a referral list.
Eye Trauma
To protect against eye injury while cycling, optometrists recommend sturdy street frames with polycarbonate lenses and a strap to secure the glasses. Despite all precautions, the eyes can be injured from traumatic falls caused by cars or bad road conditions. Foreign bodies can get into and irritate the outer membrane known as the conjunctiva or the cornea. The soft tissue around the eye can be bruised, causing a "black eye." The cornea can be abraded. Blunt trauma can cause bleeding in the anterior chamber of the eye known as hyphema. Perhaps the worst eye injury one can suffer is an orbital fracture, a crack or cracks in the bones that encircle and define the eye socket. These are sometimes called orbital blow out fractures. Such fractures often involve the floor of the eye socket and may be associated with double vision from entrapment of the muscles that swivel the eyeball in the fracture fragments. When an orbital blowout fracture is suspected it is imperative to get a CT scan of the eye region to search for the existence and location of fractures.
Fractured Clavicle
The clavicle or collar bone is joined at one end with the acromium of the scapula in the shoulder, and at the other end with the sternum or breastbone in the chest. It acts as the strut that lets the arm move freely away from the chest. Fracture of the clavicle is the most common fracture from a cycling fall, usually occurring when the cyclist goes over the handle bars from hitting his front brake hard, hitting an obstacle such as a car door or having his front wheel deflected sideways by a road defect. As Tyler Hamilton showed us, you can ride with a non-displaced clavicle fracture under medical supervision, but it is very painful to do so and not recommended. Displaced clavicle fractures usually result in a shortened clavicle with a bony deformity from the callus that grows at the fracture site. A shortened clavicle will cause pain and restrict shoulder movement. This injury should be x-rayed, placed in a sling and treated by an orthopedist who will prescribe medication and physical therapy. Reconditioning by strength training at the appropriate time after healing is recommended.
Fractured Hip
This injury typically occurs from direct compression, either from a car striking the cyclist or from the cyclist striking a pavement defect and taking a hard fall onto his side. Hip fractures are more likely to occur in older cyclists with thinner, more brittle bones, but no one is immune when the impact forces are high enough. The weakest link in the human hip is the femoral neck that joins the long shaft of the thigh bone with the femoral head (the ball that fits into the hip socket). Since the hip is a weightbearing joint, a hip fracture is a very serious and painful injury. Often the treatment is ORIF (open reduction with internal fixation), which involves insertion of a plate held in place by bone screws. Cycling with a plate in one's hip is physically possible but risky, because new trauma to the hip from a fall could cause the plate to crack the hip like a metal ramrod and lead to the need for a total hip replacement. Cyclists will usually wait one or more years for the hip fracture to heal, and then have surgery to remove the plate and screws. For about six months after such surgery, the cyclist is at elevated risk of a new fracture if he falls, because the screw holes are still being filled in by new deposition of bone. One potential complication of a hip fracture is a dying off of the hip bone from reduced blood circulation to the damaged bone, a condition called avascular necrosis. This is associated with fractures of the femoral neck, not fractures of the thick shaft of the femur. Depending upon age at time of injury, severity of injury and presence/absence of complications, some cyclists are able to resume cycling after a hip fracture, but typically not at the same level. Finding a good physical therapist for rehabilitation is crucial to making optimal recovery following this injury.
Fractured Ribs
The adult human has 7 pairs of true ribs that are attached to the sternum and 5 pairs of false ribs that are attached to each other by costal cartilage. A hard bicycle crash to the street can fracture one or more true ribs and leave the victim in acute pain for up to two months, made worse with coughing, laughing or other upheavals of the chest. There is no treatment for a fractured rib, just pain medications and a rib belt that can be worn under your clothes. A more serious consequence of some rib fractures is pneumothorax (partial or total collapse of a lung from compression by a fractured rib) or hemothorax (bleeding inside the lung from puncture by a fractured rib). Cyclists should learn first aid, including how to re-inflate a collapsed lung in situations where no phone is available to call 911 or the ambulance will be substantially delayed. Other potential consequences of chest trauma from cycling are damage to the rib cartilage that connects the ribs to the sternum, the capsules that encase these costo-sternal rib joints, the ligaments that hold those capsules in place, the inter-costal muscles that move the ribs in and out during the breathing process, the tendons that insert the intercostal muscles or the nerves that activate them.
Fractured Scapula
The scapula stabilizes the movement of the arm. It is the fan shaped bone that connects at the top to the clavicle and at the bottom to the posterior ribs. The large but shallow cup of the scapula (called the glenoid) holds the head of the arm bone or humerus with a soft tissue known as the labrum. The gleno-humeral joint is fully encased in a joint capsule (a fluid filled synovial membrane). The muscles of the posterior shoulder and upper back attach to it. Non-displaced fractures of the scapula are quite painful but should heal well. They occur when a cyclist twists his upper torso as he falls, and lands on his flank or back. Displaced fractures may require surgery.
Fractured Skull
Approved cycling helmets are designed to avoid skull fracture by deflecting the force of a head contact injury away from the head. The breakage of the thick Styrofoam rim is a way of deflecting traumatic force away from the head. Unfortunately the helmet must allow for good vision of the road, and for good hearing. This leaves the forehead, the area around the eyes and the temple area vulnerable to skull fracture despite wearing a helmet. Clients of our office have sustained skull fractures in these areas despite wearing safety approved helmets. While a person can sustain a skull fracture without a brain injury, it is common for brain injury to occur in conjunction with a skull fracture. This can occur from a depressed skull fracture involving a piece of the skull actually moving inward into the outer surface of the brain. More typically it results from violent bouncing of the brain within the skull in response to a force great enough to cause skull fracture. Fellow cyclists should not attempt to remove their fallen comrade’s helmet as this could exacerbate the injury. Obvious signs of significant head injury include coma (a total lack of responsiveness); confusion; difficulty speaking, moving or following commands; racoon eyes (black pockets of blood around the eyes), Battle's sign (extreme tenderness behind the ear over the mastoid), and blood or clear fluid (cerebrospinal fluid) leaking from the ears or nose. If any of these signs are present, call 911 immediately if not sooner.
Laceration
In car vs. bicycle crashes there is a potential for deep lacerations that expose or nearly expose underlying bone. In the Emergency Department such lacerations will be explored, cleansed and sutured, stapled or glued shut. It is a good idea to discuss prophylactic antiobiotics and prevention of scarring with your doctor. Different techniques of closing a wound tend have different rates of post-closure infection and scarring. One client of our office developed a fever with a line of smelly, yellow pus down her shin consequent to the sutures in her left knee laceration becoming infected. Lacerations may also mask more serious injury. Long after a cut on one's elbow, hip or knee heals, the joint may continue to ache, swell, or both, due to undiagnosed joint damage from the trauma. Sometimes it is a good idea to defer an x-ray or take a follow up x-ray after soft tissue swelling from the trauma has resolved, so the joint can be more clearly inspected by the radiologist.
Rotator Cuff Injury
The rotator cuff is a soft tissue structure that stabilizes the shoulder, and is composed of muscles and tendons that are designated by their anatomic location as supraspinatus, spinatus or infraspinatus. The cuff can be bruised, strained, partially torn or full torn by trauma. The most typical mechanism is landing on one’s hand with the arm fully outreached to stop a sudden fall. The usual injury involves the supraspinatus tendon, leaving the victim unable to raise his injured arm overhead or place it behind his back without a lot of pain, if at all. Sometimes the fluid filled sac called the subacromial bursa (which lubricates the joint) gets swollen from the same mechanism. X-ray is typically negative, but MRI will reveal a partial or full tear with swollen, congested tissues, be they tendons, bursa or both. Pain medication, oral anti-inflammatories, cortisone shots and physical therapy are common treatments for strains and partial tears. Arthroscopy is used for partial tears that remain symptomatic despite conservative treatment. Open joint surgery is used to repair a full tear.
Traumatic Brain Injury
Short of death, TBI is the worst injury one can suffer, because it has the potential to leave permanent impairment of one’s ability to think, remember, read, speak, stay organized, resist distraction, complete tasks, control and manage one’s feelings and behavior, relate to others, keep a job, maintain balance and equilibrium, maintain coordination and dexterity of one’s limbs, fingers and toes, and other important functions. TBI comes in 3 grades: mild, moderate and severe. One out of every eight reported cycling injuries is a TBI.
Most TBIs are mild. A mild TBI may occur without skull fracture and without any loss of consciousness, so long as there is a brief period of dazing, confusion or amnesia. It is the medical equivalent of what is popularly called a concussion.
CT scans and MRI are nearly always negative for mild TBI, but this does not mean the brain has escaped injury, because the injury is to microscopic structures in the brain such as the long, thin axons that connect the brain cells in the cortex to the spinal cord. Axonal strain injury does not show up on CT or MRI unless it is severe enough to cause large rips in the white matter. Mild TBI is often called post-concussion syndrome by medical doctors, and the diagnosis is made when following head trauma the victim exhibits some or all of the following symptoms: headache; nausea; vomiting; tinnitus (ringing in the ears); vertigo (dizziness); blurred or double vision; slowed cognitive processing speed; impaired attention and concentration; impaired memory for new information; impaired multi-tasking; insomnia; depression; irritability; fits of anger or crying; and excessive day time fatigue. A particularly worrisome symptom would be complete loss of smell and taste, which indicate the olfactory nerves under the pre-frontal lobes have been torn by brain trauma.
The old “wisdom” about mild TBI was that it always cleared up in a matter of a few weeks to a few months and never left permanent problems. In the 1970s it became known that some 15-20% of persons with mild TBI remained symptomatic indefinitely. Within the past decade, some newer studies suggest that upwards of 25-30% of all persons who sustain a mild TBI will never return fully to normal. Risk factors for poor outcome include prior closed head injuries; age over 40; possession of the genetic mutation associated with Alzheimer’s Disease (the apoe-e4 allele); co-morbid problems such as chronic pain; pre-injury personality traits or psychological conditions that lead to magnification of injury or to pessimism about recovery; lack of good social and medical support; lack of education about TBI; and having a job with very high intellectual demands.
With moderate and severe TBI, the question is not whether the person will have some permanent deficits, but how many and which ones and what forms of medical care, retraining and living assistance will be needed. On the Glasgow Coma Scale, mild TBI is 13-15, moderate is 9-12 and severe is 3 (the lowest score a live person can get) to 8. Persons with severe TBI are non-responsive or barely responsive but only to painful stimuli. They typically have skull fractures and bleeding within the cranium. Examples are subdural and epidural hematomas, which are blood clots that develop from tearing of blood vessels that run through the membranes covering the brain, the 3 meninges (the dura, arachnoid and pia mater). Epidural hematomas grow very rapidly and have the capacity to kill or severely damage the brain of the victim if not quickly removed, by compressing the brain tissue and squeezing its arterial blood supply shut. Subdural hematomas develop from slow leaks and can be quite insidious. Sometimes symptoms do not develop for days. That is why ER Departments give people a closed head injury sheet telling to return if they feel OK at first, but subsequently develop headache, blurred vision, nausea or vomiting.
Any TBI, however mild, should be taken care of by a neurologist and assessed for cognitive problems by a qualified neuropsychologist, who can recommend appropriate therapies such as occupational, cognitive or speech and language. To learn more about TBI visit my other website at www.headinjurylaw.com.
Consequences of Injury to the Older Bicyclist
A significant number of our clients were in their 60s or 70s when they suffered a serious, disabling injury while bicycling. All of these clients were retired and cycling was a major life focus and source of enjoyment for them. Having this activity taken away caused them ongoing depression which required psychological treatment. As we age our metabolism slows, so inactivity due to injury in one's 60s-80s can cause significant weight gain. This is a serious matter because obesity is associated with increased risk of death from many different causes. See K Adams, "Overweight, Obesity and Mortality in a Large Prosepctive Cohort of Persons 50-71 Years Old" N Engl J. Med 355:8 page 763 (8/24/06).
Physical inactivity is also a trigger for onset of dementia in the older population. This is because physical activity stimulates release of neurotrophic growth factors in the brain that keep neurons healthy and protected against aging, and because physical activity stimulates neurogenesis (i.e. the birth of new brain cells) in the the hippocampus, the brain region responsible for memory. See article by Eva Carro, Journal of Neuroscience April 15, 2000 20(8)2926-2933. Studies by geriatrician Wayne McCormick of the University of Washington in published in the Annals of Internal Medicine and epidemiologist Constantine Lyketsos of Johns Hopkins University both showed that regular excercise lowers the risk of dementia by 30-40% in the older population. Thus it is important for an injured cyclist who can no longer ride in his 60s-80s to focus attention on getting psychological evaluation for depression (with treatment if appropriate), working with a nutritionist to keep their weight in check and findingnew ways to keep physically active that do not involve bicycling, as well as making sure to stay as mentally active as possible.