Do Bicycle Helmets Protect Against Facial Fractures? An Observational Study From a Level 1 Trauma Centre.

This study investigates the impact of helmet use on the incidence of facial fractures in bicycle accidents. Analyzing data from hospitalized bicyclists between 2005 and 2016, the research focused on the correlation between helmet usage and various facial fractures. The study included 1256 bicyclists with known helmet use, among whom 277 individuals (22%) were identified with a total of 521 facial fractures. The findings revealed a significant reduction in the likelihood of facial fractures among helmeted cyclists compared with those without helmets (odds ratio, 0.65; confidence interval, 0.50-0.85; P=0.002). Specifically, the odds of sustaining fractures in the zygoma, orbit, nose, and maxilla were decreased by 47%, 46%, 43%, and 33%, respectively, among helmeted cyclists. However, helmet use did not significantly alter the odds of mandible fractures. Overall, the use of helmets in bicycling significantly lowered the risk of midface fractures but showed no notable effect on mandible fractures in severe cycling incidents.

Facial Injuries Due to Cycling are Prevalent: Improved Helmet Design Offering Facial Protection is Recommended.

PURPOSE: Safety equipment for recreational cycling is commonly designed to protect the calvarium, but not the face, in the event of a crash. The purpose of this study is to identify the prevalence of facial injuries and their most common subcategories due to cycling injuries and to serve as an anatomical guide of what facial structures most need protection. METHODS: We report a cross-sectional study of consecutive patients reported to the National Electronic Injury Surveillance System from January 1, 2010 to December 31, 2019. Patients were included in our study if they were evaluated in the emergency department (ED) for an injury due to cycling trauma. Primary outcome was injury to the face. Other variables of interest include age, sex, race, ED disposition, type of facial injury, location of facial injury, and presence of additional injuries. Descriptive and univariate statistics of the primary outcome were computed with these variables. RESULTS: There were 138,078 total patients injured due to cycling trauma reported by National Electronic Injury Surveillance System -participating EDs during the study period and, of those, 14,326 patients experienced injury to the face, revealing a 10.4% prevalence of facial injury due to cycling trauma (14,326/138,078). Thirteen percent (1,987/14,326) of facial injuries were fractures, and the most involved structures were the nose (786/1987; 40%), orbit (459/1987; 23%), and mandible (405/1987; 20%). Compared to children, adults demonstrate a greater risk of facial fracture (23.5% versus 6.5%, P < .0001) and hospital admission after facial injury (8.9 vs 2.8%, P < .0001). CONCLUSIONS: The prevalence of facial injury in the setting of cycling trauma is over 10%, and 13% of these injuries were facial fractures. With this high prevalence, there is a need for cycling helmets that include facial protection or faceguards, and we outline the commonly fractured anatomical areas that need the most protection.

Facial Protection to Prevent Facial Trauma and Allow for Optimal Protection after Facial Fracture Repair.

Facial skeletal fractures continue to affect humankind, and many methods to alleviate and prevent the injuries outright have been sought after. Prevention is desired, but the implementation and general compliance may contribute to missed opportunities to decrease the burden of facial skeletal trauma. In this article, we explore the preventative as well as postoperative options for the protection of the facial skeleton.

Head injuries in professional male football (soccer) over 13 years: 29% lower incidence rates after a rule change (red card).

BACKGROUND: Absolute numbers of head injuries in football (soccer) are considerable because of its high popularity and the large number of players. In 2006 a rule was changed to reduce head injuries. Players were given a red card (sent off) for intentional elbow-head contact. AIMS: To describe the head injury mechanism and examine the effect of the rule change. METHODS: Based on continuously recorded data from the German football magazine "kicker", a database of all head injuries in the 1st German Male Bundesliga was generated comprising seasons 2000/01-2012/13. Injury mechanisms were analysed from video recordings. Injury incidence rates (IR) and 95% confidence intervals (95% CI) as well as incidence rate ratios (IRR) to assess differences before and after the rule change were calculated. RESULTS: 356 head injuries were recorded (IR 2.22, 95% CI 2.00 to 2.46 per 1000 match hours). Contact with another player caused most head injuries, more specifically because of head-head (34%) or elbow-head (17%) contacts. After the rule change, head injuries were reduced by 29% (IRR 0.71, 95% CI 0.57 to 0.86, p=0.002). Lacerations/abrasions declined by 42% (95% CI 0.39 to 0.85), concussions by 29% (95% CI 0.46 to 1.09), contusions by 18% (95% CI 0.43 to 1.55) and facial fractures by 16% (95% CI 0.55 to 1.28). CONCLUSIONS: This rule change appeared to reduce the risk of head injuries in men's professional football.

Impact of helmet use in equestrian-related traumatic brain injury: a matched-pairs analysis.

PURPOSE: Traumatic brain injury is an important health concern in equestrian sports. Nevertheless, the use of safety helmets, especially in recreational riding, is reported to be rare. The purpose of this study was to perform the first matched-pairs analysis of traumatic brain injury with regard to the use of helmets. MATERIALS AND METHODS: In a multicenter retrospective database analysis 40 patients (mean age: 35 ± 17.13 years; 34 female & 6 male) were combined in 20 matched pairs based on age group, gender and trauma mechanism. Admission trauma computed tomography was qualitatively analyzed for the presence or absence of fractures or intracranial hemorrhage. Quantitatively, in patients with intracranial hemorrhage dedicated volumetry of the blood volume was performed. Odds ratio and relative risk were calculated for the endpoints fractures and intracranial hemorrhage. Crude risk ratio and lesion volume differences between helmeted and unhelmeted riders were compared. RESULTS: Concerning skull fractures, in this cohort 6 patients (85.7% of all patients with fractures) did not wear a helmet and only one (14.3%) wore a helmet (p = .068).and fractures were considered more complex in the unhelmeted subgroup. Intracranial hemorrhage occurred significantly more often in the unhelmeted subgroup (10 vs. 2; p = .008). Moreover, the total lesion volume with 19.31 ± 23.93ml in the unhelmeted subgroup, presenting with intracranial hemorrhage, was significantly higher than in the control group (0.65 ± 0.35ml; p = .002). Odds ratios were 9 for intracranial hemorrhage (p = .014) and 8.14 for skull fractures without helmet (p = .09). Altogether, the relative risk for intracranial bleeding for unhelmeted riders was 5-fold higher and the relative risk reduction was 96% by wearing a safety helmet. CONCLUSIONS: Under consideration of comparable trauma mechanisms, horseback riders that do not wear a safety helmet are at risk to suffer significantly more severe brain injury than helmeted riders. Therefore, safety helmets are recommendable for all horseback riders.

Bicycle helmet use and facial injuries.

Data sourcesPubMed/Medline, Google Scholar and Cochrane Library databasesStudy selectionTwo reviewers independently selected studies. Observational studies involving patients >16 years comparing facial injuries in those wearing and not wearing cycle helmets were included. Studies were excluded if they examined the effects of helmet legislation, reported facial injuries with other injuries, compared different types of helmet or were wholly paediatric studies.Data extraction and synthesisSelection, reporting, attrition and detection bias of studies were assessed. Data were extracted on the incidence of all facial injuries reported in helmet users and non-helmet users by two reviewers independently. Odds ratios (OR) were extracted for facial injuries and facial fractures and meta-analysis conducted.ResultsThis review suggests that bicycle helmets may offer a protective benefit against facial fractures. However, it is noted that previous analyses have shown that this protection is not uniform across the face and that the upper and middle face may be protected.ConclusionsThis review suggests that bicycle helmets may offer a protective benefit against facial fractures. However, it is noted that previous analyses have shown that this protection is not uniform across the face and that the upper and middle face may be protected.

Effect of Restraining Devices on Facial Fractures in Motor Vehicle Collisions.

The aim of this systematic review is to summarize and critically evaluate the evidence for or against the effectiveness of restraining devices on facial fractures in motor vehicle collisions (MVCs).In a PubMed search, the search terms "facial bone fracture and seat belt," "facial bone fracture and air bag," and "facial bone fracture and restraining" were used. The authors abstracted the odds ratio (OR) and 95% confidence intervals (CIs) from each study. Weighted mean differences and 95% CIs were also calculated. The statistical analysis was performed with Review Manager (The Nordic Cochrane Centre).The authors found 30 potentially relevant articles, of which 6 articles met our inclusion criteria. Five studies were subgrouped, and a meta-analysis of these data suggested beneficial effects of seat belts on decreasing facial fractures in MVCs (n = 15,768,960, OR, 0.46, 95% CI = 0.35-0.60). Three studies were subgrouped, and a meta-analysis of these data suggested that there were beneficial effects of seat belts and air bags on decreasing facial fractures in MVCs (n = 15,768,021, OR, 0.59, 95% CI = 0.47-0.74). Four studies were subgrouped, and a meta-analysis of these data suggested there were no significant effects of an air bag on decreasing facial fracture in MVCs (n = 15,932,259, OR, 1.00, 95% CI = 0.72-1.39).A seat belt alone (OR, 0.46) or a seat belt and an air bag (OR, 0.59) were effective to decrease facial fractures in MVCs. However, air bags alone had no significant effect (OR, 1.00). In using air bags, seat belt should be applied together to prevent facial fractures in motor vehicle injuries.

How safe is your motorcycle helmet?

PURPOSE: Motorcycle crash helmets do not totally prevent head and facial trauma. The aim of this study was to investigate if protection offered by helmets differs according to helmet type. MATERIALS AND METHODS: In this retrospective cohort study, outpatient records of motorcyclists were analyzed for the Facial Injury Severity Scale (FISS), traumatic brain injury (TBI), facial fractures, and helmet use. Statistical analysis was conducted using the Fisher and Bonferroni tests, bivariate regression analysis, and 1-way analysis of variance. RESULTS: There were 253 motorcyclists who sustained craniomaxillofacial injuries and were referred for outpatient treatment (men, 88.9%; mean age, 29.64 ± 11.6 yr); 60.1% had up to 9 years of formal education; 156 patients reported not using crash helmets, 51 were using open-face helmets, and 46 were using full-face helmets. The mean FISS score was significantly higher for unhelmeted riders compared with full-face helmet riders (P = .047), with no difference between unhelmeted riders and open-face helmet users (P = 1.00). Results for TBI were statistically greater for those wearing open-face helmets compared with full-face helmets (P = .035). CONCLUSION: In this study, a large percentage of motorcyclists had facial fractures and TBI, and crash helmets did not always offer adequate protection against craniomaxillofacial injury, especially open-face helmets. Thus, further investigation into helmet types and quality of protection offered is recommended.

Assessment of nose protector for sport activities: finite element analysis.

There has been a significant increase in the number of facial fractures stemming from sport activities in recent years, with the nasal bone one of the most affected structures. Researchers recommend the use of a nose protector, but there is no standardization regarding the material employed. Clinical experience has demonstrated that a combination of a flexible and rigid layer of ethylene vinyl acetate (EVA) offers both comfort and safety to practitioners of sports. The aim of the present study was the investigation into the stresses generated by the impact of a rigid body on the nasal bone on models with and without an EVA protector. For such, finite element analysis was employed. A craniofacial model was constructed from images obtained through computed tomography. The nose protector was modeled with two layers of EVA (1 mm of rigid EVA over 2 mm of flexible EVA), following the geometry of the soft tissue. Finite element analysis was performed using the LS Dyna program. The bone and rigid EVA were represented as elastic linear material, whereas the soft tissues and flexible EVA were represented as hyperelastic material. The impact from a rigid sphere on the frontal region of the face was simulated with a constant velocity of 20 m s(-1) for 9.1 µs. The model without the protector served as the control. The distribution of maximal stress of the facial bones was recorded. The maximal stress on the nasal bone surpassed the breaking limit of 0.13-0.34 MPa on the model without a protector, while remaining below this limit on the model with the protector. Thus, the nose protector made from both flexible and rigid EVA proved effective at protecting the nasal bones under high-impact conditions.

Full-face motorcycle helmets to reduce injury and death: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: While motorcycle helmets reduce mortality and morbidity, no guidelines specify which is safest. We sought to determine if full-face helmets reduce injury and death. METHODS: We searched for studies without exclusion based on: age, language, date, or randomization. Case reports, professional riders, and studies without original data were excluded. Pooled results were reported as OR (95% CI). Risk of bias and certainty was assessed. (PROSPERO #CRD42021226929). RESULTS: Of 4431 studies identified, 3074 were duplicates, leaving 1357 that were screened. Eighty-one full texts were assessed for eligibility, with 37 studies (n = 37,233) eventually included. Full-face helmets reduced traumatic brain injury (OR 0.40 [0.23-0.70]); injury severity for the head and neck (Abbreviated Injury Scale [AIS] mean difference -0.64 [-1.10 to -0.18]) and face (AIS mean difference -0.49 [-0.71 to -0.27]); and facial fracture (OR 0.26 [0.15-0.46]). CONCLUSION: Full-face motorcycle helmets are conditionally recommended to reduce traumatic brain injury, facial fractures, and injury severity.

Impact of automobile restraint device utilization on facial fractures and fiscal implications for plastic surgeons.

In 2009, the National Highway Traffic Safety Administration projected that 33,963 people would die and millions would be injured in motor vehicle collisions (MVC). Multiple studies have evaluated the impact of restraint devices in MVCs. This study examines longitudinal changes in facial fractures after MVC as result of utilization of restraint devices. The Pennsylvania Trauma Systems Foundation-Pennsylvania Trauma Outcomes Study database was queried for MVCs from 1989 to 2009. Restraint device use was noted, and facial fractures were identified by International Classification of Diseases-ninth revision codes. Surgeon cost data were extrapolated. More than 15,000 patients sustained ≥1 facial fracture. Only orbital blowout fractures increased over 20 years. Patients were 2.1% less likely every year to have ≥1 facial fracture, which translated into decreased estimated surgeon charges. Increased use of protective devices by patients involved in MVCs resulted in a change in incidence of different facial fractures with reduced need for reconstructive surgery.

Evaluation of Patient-Specific Cranial Implant Design Using Finite Element Analysis.

BACKGROUND: Various studies have investigated the load-bearing capacity of patient-specific cranial implants. However, little attention has been given to the evaluation of the design of ceramic-titanium (CeTi) implants. METHODS: A biomechanical evaluation of 3 patient-specific cranial implants was performed using finite element analysis. RESULTS: The results of the analyses allowed the identification of the implant regions as well as the magnitudes of the maximum stresses on, and displacements along, these regions after traumatic impact. The analyses also showed that polyether ether ketone cranial implants offer inferior brain and neurocranial protection due to their high flexibility and local peak stresses at the bone-screw interface. In contrast, CeTi implants were able to evenly distribute the stresses along the interface and thus reduced the risk of neurocranial fracture. The scaffold structure at the border of these implants reduced stress shielding and enhanced bone ingrowth. Moreover, brain injuries were less likely to occur, as the CeTi implant exhibits limited deflection. CONCLUSIONS: From the finite element analyses, CeTi cranial implants appear less likely to induce calvarial fractures with a better potential to protect the brain under impact loads.

Protection of children restrained in child safety seats in side impact crashes.

BACKGROUND: The performance of child restraint systems (CRS) in side impact motor vehicle crashes has been under study due to the injury and fatality burden of these events. Although previous research has quantified injury risk or described injured body regions, safety advances require an understanding of injury causation. Therefore, the objective was to delineate injury causation scenarios for CRS-restrained children in side impacts and document probable contact points in the vehicle interior. METHODS: Two in-depth crash investigation databases, the Crash Injury Research and Engineering Network and the Partners for Child Passenger Safety Study, were queried for rear-seated, CRS-restrained children in side impact crashes who sustained Abbreviated Injury Scale 2+ injury. These cases were reviewed by a multidisciplinary team of physicians and engineers to describe injury patterns, injury causation, and vehicle components that contributed to the injuries. RESULTS: Forty-one occupants (average age, 2.6 years) met the inclusion criteria. Twenty-four were near side to the crash, 7 were far side, and 10 were center seated. The most common injuries were to the skull and brain with an increasing proportion of skull fracture as age increased. Head and spine injuries without evidence of head contact were rare but present. All thoracic injuries were lung contusions and no rib fractures occurred. Near-side head and face contacts points were along the rear vertical plane of the window and the horizontal plane of the window sill. Head and face contact points for center- and far-side occupants were along the edges of the front seat back and front seat head restraint. CONCLUSIONS: Head injuries are the target for injury prevention for children in CRS in side impact crashes. Most of these injuries are due to the contact; for near-side occupants, contact with the CRS structure and the door interior, for far- or center-seated occupants, contact with the front seat back. These data are useful in developing both educational and technological interventions to reduce the burden of injury to these children.

Soccer-related facial fractures: postoperative management with facial protective shields.

Facial fractures are one of the most common orofacial injury sustained during participation in sporting events.The frequency of maxillofacial lesions varies according to the popularity that each sport has in a particular country. Soccer is the most popular sport in Italy, and it is responsible for a large number of facial traumas.Traumas and fractures in soccer mainly involve the zygomatic and nasal regions and are especially caused by direct contact that takes place mainly when the ball is played with the forehead. In particular, elbow-head and head-head impacts are the most frequent dangerous contacts.Soccer is not a violent sport, and the use of protective helmets is not allowed because it could be dangerous especially when players play the ball with the head. The use of protective facial shields are exclusively permitted to preserve players who underwent surgery for facial fractures.The use of a facial protection mask after a facial fracture treatment has already been reported. This article describes a clinical experience of management of 4 soccer-related facial fractures by means of fabrication of individual facial protective shields.

Helmets for preventing injury in motorcycle riders.

BACKGROUND: Motorcycle crash victims form a high proportion of those killed or injured in road traffic crashes. Injuries to the head, following motorcycle crashes, are a common cause of severe morbidity and mortality. It seems intuitive that helmets should protect against head injuries but it has been argued that motorcycle helmet use decreases rider vision and increases neck injuries. This review will collate the current available evidence on helmets and their impact on mortality, and head, face and neck injuries following motorcycle crashes. OBJECTIVES: To assess the effects of wearing a motorcycle helmet in reducing mortality and head and neck injury following motorcycle crashes. SEARCH STRATEGY: We searched the Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials (The Cochrane Library issue 2, 2007), MEDLINE (up to April 2007), EMBASE (up to April week 16, 2007), CINAHL (January 1982 to February 2003), TRANSPORT (up to issue 12, 2006) (TRANSPORT combines the following databases: Transportation Research Information Services (TRIS) International Transport Research Documentation (ITRD) formerly International Road Research Documentation (IRRD), ATRI (Australian Transport Index) (1976 to Feb 2003), Science Citation Index were searched for relevant articles. Websites of traffic and road safety research bodies including government agencies were also searched. Reference lists from topic reviews, identified studies and bibliographies were examined for relevant articles. SELECTION CRITERIA: We considered studies that investigated a population of motorcycle riders who had crashed, examining helmet use as an intervention and with outcomes that included one or more of the following: death, head, neck or facial injury. We included any studies that compared an intervention and control group. Therefore the following study designs were included: randomised controlled trials, non-randomised controlled trials, cohort, case-control and cross-sectional studies. Ecological and case series studies were excluded. DATA COLLECTION AND ANALYSIS: Two authors independently screened reference lists for eligible articles. Two authors independently assessed articles for inclusion criteria. Data were abstracted by two independent authors using a standard abstraction form. MAIN RESULTS: Sixty-one observational studies were selected of varying quality. Despite methodological differences there was a remarkable consistency in results, particularly for death and head injury outcomes. Motorcycle helmets were found to reduce the risk of death and head injury in motorcyclists who crashed. From four higher quality studies helmets were estimated to reduce the risk of death by 42% (OR 0.58, 95% CI 0.50 to 0.68) and from six higher quality studies helmets were estimated to reduce the risk of head injury by 69% (OR 0.31, 95% CI 0.25 to 0.38). Insufficient evidence was found to estimate the effect of motorcycle helmets compared with no helmet on facial or neck injuries. However, studies of poorer quality suggest that helmets have no effect on the risk of neck injuries and are protective for facial injury. There was insufficient evidence to demonstrate whether differences in helmet type confer more or less advantage in injury reduction. AUTHORS' CONCLUSIONS: Motorcycle helmets reduce the risk of death and head injury in motorcycle riders who crash. Further well-conducted research is required to determine the effects of helmets and different helmet types on mortality, head, neck and facial injuries. However, the findings suggest that global efforts to reduce road traffic injuries may be facilitated by increasing helmet use by motorcyclists.

Comments on Depreitere et al. Lateral head impacts and protection of the temporal area by bicycle safety helmets. J. Trauma. 2007;62:1440.

The side of the head is vulnerable to trauma in bicycle injuries. Depreitere et al., demonstrated contact between a flat-faced pendulum, and the side of cadaver heads, when bicycle helmets was worn. Computer design methods were used to interpret these experiments, showing that typical helmets safely absorbed 75% of the impact kinetic energy before pendulum-to-head contact occurred. Furthermore, in typical oblique impacts with the road, two factors improve the head protection. The tangential velocity component slightly improves the helmet performance, whereas prior shoulder impact on the road decreases the head impact velocity. It is concluded that current helmets provide adequate protection for typical lateral head impacts.

Bicycle helmets are protective against facial injuries, including facial fractures: a meta-analysis.

Cycling is a popular activity. However there are risks associated with cycling, including facial injury. Helmets are often worn to prevent head injury. Evidence for their protection against facial injury is limited. This meta-analysis investigated the effect of bicycle helmets on the incidence of facial injury. The PubMed/MEDLINE, Google Scholar, and Cochrane Library databases were searched. Studies included were observational and involved adult participants. Paediatric studies, studies on helmet legislation, and those combining facial injuries with other injury types were excluded. The studies were evaluated by two reviewers. Risk of bias was assessed using the RevMan bias assessment tool. Odds ratios (OR) were extracted for facial injuries and facial fractures. Two meta-analyses were performed using these categories. Nine of the 102 studies identified were included. Helmets were protective against facial injury (OR 0.69, 95% confidence interval 0.63-0.75, P<0.0001). Five studies reported facial fracture rates; helmets were protective against these also (OR 0.79 95% confidence interval 0.70-0.90, P=0.0003). There are no randomized controlled trials on this topic and the number of studies available is small. Bicycle helmets offer protection against facial injuries and this should be considered by cyclists when deciding whether or not to use one.

Modeling and Optimization of Airbag Helmets for Preventing Head Injuries in Bicycling.

Bicycling is the leading cause of sports-related traumatic brain injury. Most of the current bike helmets are made of expanded polystyrene (EPS) foam and ultimately designed to prevent blunt trauma, e.g., skull fracture. However, these helmets have limited effectiveness in preventing brain injuries. With the availability of high-rate micro-electrical-mechanical systems sensors and high energy density batteries, a new class of helmets, i.e., expandable helmets, can sense an impending collision and expand to protect the head. By allowing softer liner medium and larger helmet sizes, this novel approach in helmet design provides the opportunity to achieve much lower acceleration levels during collision and may reduce the risk of brain injury. In this study, we first develop theoretical frameworks to investigate impact dynamics of current EPS helmets and airbag helmets-as a form of expandable helmet design. We compared our theoretical models with anthropomorphic test dummy drop test experiments. Peak accelerations obtained from these experiments with airbag helmets achieve up to an 8-fold reduction in the risk of concussion compared to standard EPS helmets. Furthermore, we construct an optimization framework for airbag helmets to minimize concussion and severe head injury risks at different impact velocities, while avoiding excessive deformation and bottoming-out. An optimized airbag helmet with 0.12 m thickness at 72 ± 8 kPa reduces the head injury criterion (HIC) value to 190 ± 25 at 6.2 m/s head impact velocity compared to a HIC of 1300 with a standard EPS helmet. Based on a correlation with previously reported HIC values in the literature, this airbag helmet design substantially reduces the risks of severe head injury up to 9 m/s.

Security "high-tech" individual extra-light device mask 2.0: CAD/CAM evolution.

In 2008, we presented our security "high-tech" individual extra-light device mask (SHIELD), a protective shield based on the face cast of an injured soccer player that can be customised. It allows a shortened convalescent period, is comfortable, fits well, and allows the patient to continue to play at a professional level in their chosen sport or activity in the shortest time possible. It has been used often in both amateur and professional categories of many sports, and we now present an update.

Frontal sinus fractures: a 28-year retrospective review.

OBJECTIVES: To analyze 202 consecutive frontal sinus fracture (FSF) patients treated between 1974 and 2002 at the University of California, Davis. METHODS: A retrospective chart review was performed, including all patients with frontal sinus fractures from 1987 to 2002. This and 72 previously reported patients (1974-1986) were analyzed, comparing age, gender, fracture type, associated fractures, procedure type, and complications. RESULTS: Frontal sinus fractures resulting from motor vehicle accidents (MVAs) decreased from 71% to 52% (P < 0.05). Fractures from assaults increased from 9% to 21% (P < 0.05). The incidence of "through and through" fractures decreased from 40% to 11% (P < 0.05). Whereas combined anterior/posterior table fractures increased from 36% to 57% (P < 0.05). CONCLUSION: The etiology and severity of FSF has changed from 1974 to 2002. This is reflected in a reduced number of fractures resulting from MVAs as well as a reduced severity of injury. The most likely explanation is the use of safety belts and airbags.