Motorcycles are a common means of transportation in low and middle income countries. Their use is associated with high prevalence of injuries; a major public health concern1. Previous studies2,3 indicated a direct relationship between the frequency of motorcycle usage and injuries in different countries. Injuries due to motorcycle crashes are highest in South East Asian countries compared to other countries1.

In Nigeria, maxillo-facial injuries due to motorcycle riding constituted 50.5% to 57% of the road traffic accidents4,5. In East Africa, the trend of fatalities due to motorcycle crashes is much lower and varies with countries: 16%, Rwanda; 7%, Uganda and Tanzania, and 1%, Kenya6. Overall, injuries due to motorcycle crashes in Kampala metropolitan is estimated at about 25%7 and those involving the head region constitute about 35.5%8.

Kampala metropolitan is congested with public service vehicles; estimated at 15,000 minibuses and 30,000 motorcycles9. Currently, more motorcycles are being imported into Uganda6,7, 8, 9, 10, particularly for public transportation because of their ability to circumvent traffic congestion, versatility in reaching remote places inaccessible to public passenger vehicles and provision of employment to youths. Galukande et al.8 estimated that riding motorcycles for public transport provides employment to about 100,000 youths in Uganda. The role of helmets in protection against maxillofacial injuries is still conflicting. Some studies111213 have implicated helmets in exacerbating maxillofacial injuries (especially of the mandible), others1415 reported that helmets protect the face against severe injuries, while others1617 indicated that helmet use significantly reduced traumatic brain injuries. Although motorcycles provide quick public transport in Uganda, they are a risk to injury89101112131415161718. A few studies818 on motorcycle crashes in Uganda reported general injuries of the body without specifying the maxillofacial injuries, while Kamulegeya et al.19 had a cursory information relating maxillofacial injuries and motorbikes/helmet use. The purpose of the present study was to investigate the role of helmet use in severity and pattern of maxillofacial injuries among motorcycle crash victims attending Mulago Hospital, Uganda

The study sample constituted 105 participants (male/female: 97/8). Most participants (n= 74; 70.5%) were riders and none of them a female. They all rode the saddle motor cycles. Overall, the participants were aged 15 to 63 (mean, 29.01 ± 9.5) years with majority 62.9%, n=66) aged 21 to 30 years. The riders were aged 18 to 59 (mean, 28 ± 8.7) years while the passengers were 15 to 63 (mean, 29 ± 11.4) years. The helmeted riders were aged 18 to 59 years (mean, 30.4 ± 9.3) years and the non helmeted counterparts were 18 to 50 (mean, 27.1 ± 7.8) years. Based on the units of study, the helmeted riders were 22, 11 and 4 in Oral and maxillofacial, Neurosurgery and Orthopaedic Surgery unit, respectively.

There are several scoring systems, but with challenges related to their use as previously discussed212223242526272829303132 though without reaching a consensus. In the present study, FISS was used to record severity of maxillofacial injury because of its reliability21 and easy to compute22.

We observed most of the participants were from Kampala and the neighboring districts probably because the study site (Mulago Hospital) is within Kampala and in proximity of the surrounding districts. Furthermore, Kampala metropolitan has more motorcycles compared to other regions9, hence the high frequency of the injured. Additionally, although Mulago Hospital is a national referral health facility, some of the trauma patients from distant districts may have been managed in regional referral health facilities33.

In the present study, the motorcycle riders were aged 18 to 59 (mean, 28 ± 8.7) years, which is consistent with other studies elsewhere4,5,8,16,34, but higher than reported in Indianapolis, United States of America35. The lowest age permissible for acquiring a motorcycle riding license varies in different countries because of varying socio-economic, political and cultural backgrounds. In Uganda, motorcycles are mainly used for public transport, a business mainly involving youths8, while in other countries they are used so much in sports, leisure and children (as young as 14 years) commuting to school36,37.

We observed all the riders were males, who coincidentally, are the ones mostly involved in riding motorcycles for public transport in Uganda. This finding is similar to previous studies5,8,38 in Africa. Elsewhere in the world, there are variable proportions of female riders: 2.2% in Mersey and North Wales, UK34; 24.6% in Athens, Greece39; 30% in Indianapolis, USA35; 11.9% in Hyderabad, India40 and 24% in Kerala, India15.

The absence of female motorcycle riders in the present study and elsewhere in Africa may probably be due to the type of motorcycles on the market, the straddle type which do not favor mounting by female and child riders unlike the scooters, which are more appealing and commonly used in recreational and sporting activities41.

In the present study, 50% of the riders used helmet (Table 1 and Table 2) which was higher than the 17.7%8 and 29%33 earlier reported among patients attending Mulago Hospital. The older participants were more likely to put on helmet compared to the younger age group (Table 1) and this was similar to observation in Vietnam42. However, this was self motivated usage of helmet because although there is a law43 on mandatory use, it is not adequately enforced in Uganda similar to observation in Nigeria4, and contrary to the United Kingdom where the law is enforced and usage rate is 93.1%34.

Other reasons for not willing to wear helmet include: discomfort, obscuring of vision, disturbance of hearing, ruffling up hair style, cost or thefts of helmets while others said helmets are responsible for crashes39. However, in the present study, we were not able to interview the participants on the opinion about helmet use.

In the present study, about three quarters (27/37) of the riders wore helmets of Three Quarter Shell design and because of the limited variability, the relationship between helmet design and type of maxillofacial injuries could not be assessed. However, amongst the non helmeted participants, the injuries were predominantly mandibular fractures and the associated soft tissue injuries while the helmeted group had panfacial fractures in addition to mandibular fractures. Overall, most participants had injuries of the lower two thirds of the face irrespective of helmet use (Table 2). Furthermore, it may also be assumed that the Three Quarter Shell helmets predominantly used by the study participants lack the chin bar, which leaves the lower two third of the face exposed to injury. However, Yates and colleagues12 reported higher incidence of mandibular fractures amongst the riders wearing Full Face type of helmet (with chin bar) as compared to non helmeted counterparts.

We found significantly more helmeted riders had severe maxillofacial injuries (with 2 of them losing an eye each) as compared to the non helmeted counterparts (Table 3), in support of Gopalakirshna et al.11 Gopirikan et al.14 and Jayadevan et al.15, but contrary to findings from Yates et al.12. Earlier on, Brian et al.13 revealed no significant difference in severe injuries between the helmeted and nonhelmeted groups. Our finding could be due to poor quality44 or improper use of helmets like the size and fastening of the straps. However, we were neither able to assess the quality of the helmets nor the adequacy of their use.

Overall, we found the riders had sustained significantly more severe maxillofacial injuries as compared to the passengers contrary to previous workers45 who found no significant difference between the riders and passengers. Additionally, the passengers had the least severe maxillofacial injuries compared to the riders (Table 3). It could be postulated that the bodies of the riders could have shielded the passengers who ordinarily sit behind the riders. However, one female passenger lost an eye (Figure 3) and it was an isolated case where she was ejected from the motorcycle to some distance on the tarmac. This is consistent with Gopalakrishna et al.11 report that participants with maxillofacial injuries were those who were ejected from the motorcycle to some distance during the crash.

One previous study46 that used FISS as a scoring system recorded the most severely injured subject with FISS score of 11, which was much lower than 19 seen in the present study, The difference may probably be due to factors like differences in quality of the roads and motorcycle overloading. We could not assess the influence of gender on FISS score because of skewed gender distribution among the study participants.

About a third of the participants and only riders used helmets particularly of the Three Quarter Shell design at the time of injury. None of the passengers had a helmet. Generally, helmeted riders had severe maxillofacial injuries and of panfacial category as compared to other participants.

Although the present study generated baseline data, it was daunted with various limitations indicative of further studies to elucidate on factors such as the quality of helmets and their adequate use as well as mechanism of maxillofacial injuries during motorcycle crashes.