Australian Dental Journal 2023; 68: 113–119
doi: 10.1111/adj.12956
E-scooters and maxillofacial fractures: a seven-year
multi-centre retrospective review
EZ Goh,*,†,‡
N Beech,*
NR Johnson*,‡,§
*Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.
†Oral and Maxillofacial Department, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia.
‡Oral and Maxillofacial Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
§School of Dentistry, University of Queensland, Brisbane, Queensland, Australia.
ABSTRACT
Background: Standing electric scooters (e-scooters) are a cost-effective and environmentally-friendly transport alternative,
but also elicit substantial concern regarding associated craniofacial injuries. This study aims to describe the patient factors, procedural factors and post-operative outcomes of maxillofacial fractures caused by e-scooter accidents.
Methods: Retrospective chart review of patients aged 18 years or older who were surgically treated for these injuries in
2014–2020 at two Australian tertiary hospitals.
Results: There were 18 cases included. Most cases were male (66%). The mean age was 35 years. Common risk factors
were alcohol use (86%) and lack of helmet use (62%). The most common fracture pattern was zygomatico-maxillary
complex (ZMC) fractures (50%). There were no associated systemic injuries. Mean operation timing was 12 days postinjury for ZMC fractures and 3 days post-injury for condyle fractures. For ZMC fractures, the most common method of
fixation was 2-point fixation (66%). For condyle fractures, the most common surgical approach was arch bars only
(83%). Post-operative complications were reported in six cases, with malocclusion being the most common (n = 3).
Revision surgeries were performed in two cases.
Conclusions: Maxillofacial fractures associated with e-scooter accidents appear to be increasing in incidence. Robust longitudinal evaluations with larger sample sizes are required to better understand associated presentations, surgical
approaches and post-operative complications.
Keywords: Alcohol, e-scooter, helmet, maxillofacial, trauma.
Abbreviations: FTA = failed to attend; ZMC = zygomatico-maxillary complex.
(Accepted for publication 4 April 2023.)
INTRODUCTION
Standing electric scooters (e-scooters) are a costeffective and environmentally-friendly transport alternative, but also elicit substantial concern regarding
their volume of associated injuries. The rapid uptake
of e-scooters in the United States since their 2017
ride-sharing launch corresponds with increasing
reports of associated injuries,1 and a similar trend is
emerging around the world.2–9 In Australia, where the
first ride-sharing scheme commenced in 2018, one
study reported 54 emergency department encounters
related to e-scooters in a large tertiary hospital within
the first two months.10
Patterns of injury in e-scooter accidents focus
around the head, upper extremities and lower
extremities, while the chest and abdomen are less
commonly involved.11 Falls are the most common
mechanism of e-scooter injury,12 and an outstretched
limb to brace against a fall may explain why injuries
commonly occur in the upper and lower extremities.
Conversely, the absence of a distal limb injury has
been found to be a significant risk factor for craniofacial injuries.13 Alcohol use is another important
risk factor, due to impaired judgement and compromised neuromuscular reflexes for head protection, as
well as less frequent helmet use.14 Injury to the craniofacial region is especially concerning, as damage
to adjacent vital structures can be fatal, while
involvement of local sensory or motor structures can
impair function.15 Additionally, the visibility of facial
defects can have significant psychological impacts.16
Our previous work, a systematic review exploring
trends in craniofacial trauma associated with escooters, found that there were only a small number
of studies investigating this emerging issue.12 It is
© 2023 The Authors. Australian Dental Journal published by John Wiley & Sons Australia, Ltd on behalf of Australian Dental Association.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and
distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
113
interesting to note that while soft tissue injuries
(58.3%) and bony fractures (398 fractures within
539 patients) were the most common injury patterns,
dental (32.9%), ophthalmological (20.6%) and brain
injuries (17.6%) were also significant.12 However,
the consistency of reporting in the included studies
was variable; for example, an individual patient
could have several fractures, but the number of
patients with fractures as opposed to the number of
fractures was not always specified. Additionally,
while approximately four in 10 fractures required
surgical management, there were significant gaps in
knowledge, especially in relation to the reporting of
post-operative outcomes.12
Accordingly, the aim of this study is to describe the
patient factors, procedural factors and post-operative
outcomes of maxillofacial fractures caused by escooter accidents. An improved understanding of these
injuries will facilitate surgical planning and preventive
strategies, which will benefit patient care and resource
allocation.
MATERIALS AND METHODS
Study design
This study was a seven-year multi-centre retrospective review of patient records at two tertiary hospitals in Queensland, Australia. The study was
reviewed and approved by the hospitals’ ethics committees prior to commencement. Inclusion criteria
were patients aged 18 years or older with available
electronic records, who were surgically treated for
maxillofacial fractures caused by e-scooter accidents
from 2014 to 2020. Electronic records were available
at Hospital 1 from May 2014 and at Hospital 2
from December 2015.
Data collection
A computerised search utilising International Classification of Diseases 10th Revision (ICD-10) procedure
codes for the surgical repair of maxillofacial fractures
was performed to access the electronic records of all
eligible patients from May 2014 to December 2020
(Hospital 1) and December 2015 to December 2020
(Hospital 2). Patient records included data from operating theatres, outpatient clinics and inpatient wards.
Data were extracted in a de-identified format as per
the pre-defined categories of: patient factors (demographics, medical history, mechanism of injury, fracture pattern and associated injuries); procedural
factors (operation timing, surgical approach, reconstruction material if any); and post-operative outcomes (complications, revision surgeries).
114
Data analysis
Analyses for statistical significance to investigate associations between patient/procedural factors and postoperative outcomes were deemed impractical due to
the small sample size.
RESULTS
There were 2702 patients who were surgically treated
for maxillofacial fractures in 2014–2020. Of these,
there were 18 patients whose fractures were caused
by e-scooter accidents.
Patient factors
Patient factors are presented in Table 1. There were
eight cases in 2020, seven cases in 2019, three cases
in 2018 and no cases in 2014–2017. Most cases were
male (66%). The mean and median ages were both
35 years, with a range of 19 to 63 years. Relevant
medical conditions were present in eight cases (44%),
with asthma being the most common (n = 4). Relevant medications were present in one case (corticosteroids). One-third of cases were current smokers
(n = 6). Risk factors consisted of alcohol use, present
in 12 of 14 cases (86%), and lack of helmet use, present in 8 of 13 cases (62%). Middle third fractures
were twice as common as lower third fractures, with
no upper third fractures reported. The most common
fracture patterns were zygomatico-maxillary complex
(ZMC) fractures (n = 9, 50%) and condyle fractures
(n = 6, 33%). There were no associated injuries of the
brain, cervical spine, thorax, abdomen and long
bones.
Procedural factors
Procedural factors are presented in Table 2. Operation
timing (measured in days post-injury) overall had a
mean of 9, a median of 9 and a range of 1 to 21; for
ZMC fractures, a mean of 12, a median of 10 and a
range of 8 to 21; and for condyle fractures, a mean of
3, a median of 2 and a range of 1–8. Of the nine
cases with ZMC fractures, the most common fixation
method was 2-point fixation (n = 6). Of the six cases
with condyle fractures, the most common surgical
approach was arch bars only (n = 5).
Post-operative outcomes
Post-operative outcomes are presented in Table 3.
Almost all cases (n = 16, 89%) attended the first
post-operative review (T1), while 56% (n = 10)
attended the second post-operative review (T2). Postoperative complications were experienced by six cases,
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EZ Goh et al.
Table 1. Patient factors (n = 18)
Case
Year
Sex
Age
(y)
Relevant medical
conditions†
n
Details
Relevant
medications‡
n
Smoker?
Details
Risk factors
Alcohol
use
Lack
of
helmet
use
Fracture pattern
Middle third
Lower third
1
2020
M
46
0
–
0
–
No
Yes
No
2
2020
M
29
0
–
0
–
Yes
Yes
Yes
3
2020
M
39
1
0
–
Yes
Yes
Yes
4
5
2020
2020
M
F
23
21
0
1
0
0
–
–
No
Yes
Yes
NR
NR
No
ZMC (unilateral)
–
6
2020
M
19
0
Chronic lung
disease
(asthma)
–
Chronic lung
disease
(asthma)
–
Le Fort I (bilateral),
nasal bone
(bilateral)
Le Fort I (bilateral),
Le Fort II
(bilateral), nasoorbito-ethmoid
complex (bilateral)
ZMC (unilateral)
0
–
No
Yes
NR
–
7
2020
M
63
2
0
–
No
No
Yes
ZMC (unilateral)
8
2020
M
38
1
0
–
NR
Yes
Yes
ZMC (unilateral)
–
9
2019
F
51
0
Cardiovascular
disease
(hypertension),
diabetes
mellitus (type
II)
Chronic lung
disease
(asthma)
–
–
Condyle
(bilateral),
symphysis
Condyle
(unilateral),
parasymphysis
(unilateral)
–
0
–
No
Yes
Yes
–
10
2019
M
25
1
0
–
Yes
Yes
No
11
12
2019
2019
M
F
36
21
0
2
0
1
–
Corticosteroids
– budesonide
No
No
Yes
Yes
Yes
No
ZMC (unilateral)
–
–
Condyle
(bilateral),
symphysis
13
2019
F
27
0
Autoimmune
disease
(ankylosing
spondylitis)
–
Chronic lung
disease
(asthma),
depression
–
Nasal bone
(bilateral), ZMC
(unilateral)
ZMC (unilateral)
0
–
Yes
NR
NR
–
14
2019
F
27
0
–
0
–
No
NR
Yes
Nasal bone
(bilateral)
–
15
2019
M
41
0
–
0
–
No
Yes
NR
–
16
17
2018
2018
F
M
60
34
0
1
–
Depression
0
0
–
–
Yes
No
NR
Yes
NR
No
18
2018
M
38
1
Depression
0
–
No
No
Yes
ZMC (unilateral)
Maxillary
dentoalveolar
process (bilateral)
ZMC (unilateral)
–
–
–
–
Condyle
(unilateral)
Condyle
(bilateral)
–
Condyle
(bilateral)
–
F = female; M = male; NR = not reported; ZMC = zygomatico-maxillary complex.
Relevant medical conditions were: autoimmune disease; cancer; cardiovascular disease; chronic lung disease; depression; diabetes mellitus; head
and neck radiotherapy; immunosuppression.
‡
Relevant medications were: anticoagulants and antiplatelets; antiresorptives; chemotherapy drugs; corticosteroids; non-steroidal antiinflammatory drugs.
†
of which malocclusion was the most common (n = 3).
Of these six cases, three had relevant medical conditions, one was taking relevant medications, and two
were current smokers; four cases had condyle
fractures, while no cases had ZMC fractures. Approximately one third of cases who attended the reviews
had complications (five at T1, three at T2). Revision
surgeries were performed for two cases.
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115
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E-scooters and maxillofacial fractures
Table 2. Procedural factors, consisting of operation
timing (n = 18) and surgical approach for ZMC fractures (n = 9) and condyle fractures (n = 6)
Table 3. Post-operative outcomes, consisting of postoperative complications (n = 6) and revision surgeries
(n = 2)
Case
Case
1
2
3
Operation
timing (days
post-injury)
9
10
9
Surgical approach
ZMC
fractures
4
10
5
4
NA
NA
1-point
fixation
(ZM)
1-point
fixation
(ZM)
NA
6
1
NA
7
21
8
8
9
10
10
17
11
10
12
2
2-point
fixation (IO,
ZM)
2-point
fixation (IO,
ZF)
2-point
fixation (ZF,
ZM)
1-point
fixation (IO)
3-point
fixation (IO,
ZF, ZM)
NA
13
14
14
2
NA
NA
15
8
NA
16
17
17
2
2-point
fixation (IO,
ZM)
NA
18
8
2-point
fixation (IO,
ZM)
Condyle fractures
1
NA
NA
NA
5
6
NA
Arch bars (screwretained) only
Arch bars (screwretained) only
NA
NA
NA
T1
T2
T1
T2
T1
T2
12
T1
T2
13
T1
17
T2
T1
T2
Arch bar causing ulcer
Malocclusion
FTA
FTA
Malocclusion
Sensory deficit of
mandibular nerve
Sensory deficit of
mandibular nerve
Motor deficit of facial
nerve
Motor deficit of facial
nerve (improving)
Unacceptable aesthetics
(nasal deviation)
FTA
Malocclusion
No complications
Revision surgeries
None
None
None
Removal of loose screw
causing temporomandibular
joint pain at 179 days
Repair of nasal deviation at
5 days
None
FTA = failed to attend; T1 = first post-operative review (1–
3 weeks); T2 = second post-operative review (6–8 weeks).
NA
NA
Open reduction internal
fixation (endoscopicassisted)
NA
Arch bars (wire-retained)
only
Arch bars (screwretained) only
NA
Arch bars (screwretained) only
NA
IO = infraorbital rim; NA = not applicable; ZF = zygomaticofrontal suture; ZM = zygomatico-maxillary buttress; ZMC =
zygomatico-maxillary complex.
DISCUSSION
The aim of this study was to describe the patient factors, procedural factors and post-operative outcomes
of maxillofacial fractures caused by e-scooter accidents. This is a growing area of interest due to the
increasing volume of injuries caused by e-scooter accidents, of which injury to the craniofacial region forms
a significant portion.1 In this study, all cases occurred
in 2018–2020, which corresponds to the 2018 local
commencement of the ride-sharing scheme. Additionally, the increasing frequency of cases each year
116
Post-operative
complications
highlights the crucial public health nature of this
issue. However, our previous work, a systematic
review exploring trends in craniofacial trauma associated with e-scooters, found that only a small number
of studies had been conducted to investigate this
emerging issue.12 Additionally, post-operative data for
such injuries was a significant gap in knowledge,
despite approximately four in 10 fractures requiring
surgical management.12
Demographics-wise, the findings of this study are
consistent with that of our previous work, where
these injuries are most common in males in their 30s,
and in the middle facial third.12 The presence of relevant medical conditions and medications as well as
being a current smoker did not feature in a majority
of cases, both overall and among cases with complications. There were no associated injuries to the long
bones, which is consistent with the lack of distal
extremity injuries being a significant risk factor for
craniofacial trauma caused by e-scooter accidents.13
Other important risk factors include alcohol use
(range 10–82%)4,13,17–21 and lack of helmet use
(range 47–100%).4,13,19,20,22 Alcohol use has been
found to be a significant risk factor for craniomaxillofacial injuries, with Shiffler et al. reporting a ten-times
risk (5% versus 53%).13 In this study, alcohol use
(86%) exceeded previous figures, which may be linked
to above-average rates of alcohol consumption in Australia compared to the rest of the world.23 However,
the lack of helmet use (62%) reported was towards
the lower end of the previously reported range, which
may be explained by national laws mandating helmet
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EZ Goh et al.
use.24 These risk factors and legislative implications
for e-scooter use may be comparable to those for
bicycle use, especially when considering that the former is potentially more unsafe with regards to deceleration profile and design stability.25 E-scooter
accidents have been shown to result in more facial
fractures, dental injuries and facial soft tissue injuries
than bicycle accidents.26 In bicycle injuries, alcohol
use is an established risk factor for traumatic brain
injuries,27 while helmet use is an established protective factor for head injuries and facial fractures.28
Focus group findings by a bicycle ride-sharing company found that the most common reason for lack of
helmet use was due to most trips being unplanned
and not having a helmet on hand.29 Subsequent provision of helmets with the bicycles dramatically
increased short-term usage of their services.29 This
may be an effective strategy to promote helmet use
for e-scooters too.24 Blood alcohol testing as well as
issue of fines and demerit points for e-scooter use
while intoxicated are also emerging approaches to
target alcohol use.30 Overall, these findings encourage
preventive strategies and regulation surrounding alcohol and helmet use while riding e-scooters, similar to
that for bicycle use.
Procedural factors in this study consisted of operation timing and surgical approach, with focus on
ZMC fractures and condyle fractures as these were
the most common fracture patterns. Operation timing
for ZMC fractures ranged from 1 to 3 weeks, and this
likely represents a balance between allowing the resolution of soft tissue oedema, which decreases technical
difficulty and minimises scarring, and allowing callus
formation at bone ends, which increases technical difficulty and risk of inadequate fracture reduction.31
There were no reported complications for cases of
ZMC fractures in this study. Conversely, condyle fractures were repaired within a week. The majority utilised arch bars only, which are recommended for
condyle fractures that are non-dislocated, nondisplaced and reducible.32 In these cases, early immobilisation of the fracture site would be a priority.
Post-operative outcomes in this study consisted of
post-operative complications and revision surgeries.
Complications were reported in six cases, of which
malocclusion was the most common. Two such cases
occurred after an arch bar only approach for condyle
fractures. While these approaches avoid typical surgical risks, requirements for non-function and elastics
use can be difficult for patients, which may result in
post-operative malocclusion. Arch bars can also cause
ulcers, which was another reported complication.
There were two cases of nerve injury. One was related
to sensory deficit of the mandibular nerve, which may
be anatomically explained by surgical repair at a parasymphyseal fracture site. The other was a case of
facial nerve injury, which was linked to an intraoral
endoscopic-assisted open reduction internal fixation
procedure for condyle fractures. This is an important
complication, and occurs at similar rates for both
endoscopic and extra oral approaches.33 Fortunately,
most are transient,34 as is likely in this case which
was reported to be improving at the second postoperative review. This case proceeded to have a revision surgery after approximately six months, due to
an unrelated late complication of a loose screw causing temporomandibular jaw pain. Conversely, the
other case requiring a revision surgery received it five
days post-operatively, for a repeat repair of fractured
nasal bones due to the presence of unacceptable nasal
deviation.
This study has several limitations. First, while the
findings contribute to further understanding of this
emerging issue, the small sample size as well as missing data due to lack of attendance at review appointments mean that the results of this study should be
interpreted cautiously. Additionally, this study population was sourced from two large Australian metropolitan tertiary hospitals, which tend to care for
more medically complex patients, as well as receive
transfers from other sites without a resident maxillofacial surgical team. Although unable to be statistically analysed, the impact of potentially increased
medical and surgical complexity on post-operative
outcomes in this population and different distribution
of ride-share schemes in non-metropolitan areas
should be considered when applying the findings to
other populations. Finally, eligible patients were identified through ICD-10 codes associated with relevant
patient encounters; hence it is possible that additional
patients who were surgically treated for maxillofacial
fractures were not identified due to inaccurate
coding.
However, the findings of this study present great
potential for further research into related areas.
Patients with dental trauma presenting to dental hospitals or private dental practices would represent a
valuable research cohort in improving understanding
of the overall dental and maxillofacial impact of escooter accidents. Other areas of interest include: epidemiological studies on the incidence of e-scooter use
within the overall incidence of injuries in Australia;
other types of e-scooter injuries apart from maxillofacial fractures; and the effect of strategies to increase
helmet use and minimise alcohol use.
In conclusion, this study describes common presentations, surgical approaches and post-operative complications of maxillofacial fractures caused by escooter accidents. Robust longitudinal evaluations
with larger sample sizes are required to better understand this emerging trend. There is also potential for
further research into related areas.
© 2023 The Authors. Australian Dental Journal published by John Wiley & Sons Australia, Ltd on behalf of Australian Dental Association.
117
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E-scooters and maxillofacial fractures
ACKNOWLEDGEMENTS
The authors would like to acknowledge and thank
Dr. Nicole Milham and Dr. Matthew Gilmore for
their roles as site contacts. Open access publishing
facilitated by The University of Queensland, as part
of the Wiley - The University of Queensland agreement via the Council of Australian University
Librarians.
FUNDING INFORMATION
Australian and New Zealand Association of Oral and
Maxillofacial Surgeons (ANZAOMS) Research &
Education Foundation Grant. Australian Government
Research Training Program Scholarship.
CONFLICT OF INTEREST
14. Harada MY, Gangi A, Ko A, et al. Bicycle trauma and alcohol
intoxication. Int J Surg 2015;24:14–19.
15. Vujcich N, Gebauer D. Current and evolving trends in the
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16. Sahni V. Psychological impact of facial trauma. Craniomaxillofac Trauma Reconstr 2018;11:15–20.
17. Lentzen M-P, Grandoch A, Buller J, Kreppel M, Z€
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18. Thoenissen P, Salewski D, Heselich A, et al. Patterns of craniomaxillofacial trauma after e-scooter accidents in Germany. J
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19. Yarmohammadi A, Baxter SL, Ediriwickrema LS, et al. Characterization of facial trauma associated with standing electric
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20. Kim HS, Kim WS, Kim HK, Kang SH, Bae TH. Facial injury
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21. Smit R, Graham D, Erasmus J. E-scooter injuries referred to
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Address for correspondence
Elizabeth Goh
Faculty of Medicine
University of Queensland
288 Herston Road
Herston
QLD 4006
Australia
Email: elizabeth.goh@uq.net.au
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E-scooters and maxillofacial fractures