Trauma 2004; 6: 161±168

Cycling: the risks

Richard J Hamiltona and JR Rollin Stottb

On average, 140 cyclists are killed each year on Britain’s roads and a further 22 785
injured. About a third of those injured are children. This review examines the nature
and circumstances of cycling injuries and contrasts them with the risks asso-
ciated with other modes of transport. It looks at the effectiveness of cycle hel-
met use and suggests other measures to best reduce cycling injuries.

Key words: accidents; bicycles; cycle helmets; cycling; fatalities; injuries; risks

Cycle trafŽ c
Cycle traf®c in Britain has fallen dramatically over the
past 50 years (Figure 1). In 1949 bicycles accounted
for 37% of all road traf®c. By 1995 ± with the major
exceptions of Oxford, Cambridge and York ± this had
fallen to 1% (Hillman, 1994).
Particularly noticeable, too, has been the decline in
the number of children cycling. In 1971 three quarters
of all junior school children cycled to school. By 1990
this had fallen by a half (Policy Studies Institute, 1990).
In the same period road traf®c increased in the UK
by 104% (Department of Transport, 1998).
Although bicycle ownership actually doubled
between 1975 and 1995, in the same period, the average
mileage cycled per person per year fell from 51 to 37 ± a
drop of more than a quarter (Department of Trans-
port, Local Government and the Regions, 2001). Two
in every ®ve households own a bicycle, yet only 6% of
the population regularly cycle, while a further 5% are
occasional cyclists (Wardlaw, 2000).
Commuting and leisure travel form the biggest
bicycle user groups (Department for Transport, 1998a).
Commuting accounts for nearly half of all the journeys
made by bicycle. In 1995 it was estimated that 3% of the
working population (823 000 people) used a bicycle as
their usual mode of travel to work. Most of these
a
University of Shef®eld School of Medicine, Shef®eld, UK;
b
Centre for Human Sciences, QinetiQ plc, Hants, UK.
Address for correspondence: RJ Hamilton, Well Lane House,
Lower Froyle, Alton, Hants GU34 4LP, UK.
journeys are short; a quarter of them are less than a
mile and another third between one and two miles, with
a mean journey time of 15 minutes. In inner London
and other metropolitan areas the mean journey time
is 25 minutes (Department for Transport, 1998b).
Leisure cycling accounts for a further 35% of
all journeys made by bicycle. In the 1993 General
Household Survey, cycling appeared in the top ®ve
sporting activities and a ®fth of households reported
recreational cycling in the past year. This was particu-
larly true of households with children.
Cycling accidents: facts and Ž gures
Each year about one in 40 of Britain’s cyclists requires
hospital treatment for injuries sustained in a cycling
accident (Maimaris et al., 1994). Although cyclists
comprise only 1% of road users, they account for 5%
of all road fatalities ± and 7% of all serious injuries
(Department for Transport, 2003). In absolute terms,
cyclists form the fourth largest group of road accident
casualties, after car occupants (48%), pedestrians
(22%) and motorcycle =moped users (15%) (Depart-
ment for Transport, 1998c).
A more revealing index, however, is to compare
the numbers in each category killed or seriously
injured per 100 million vehicle kilometres travelled
(Table 1). On this basis, motorcycles represent by far
the most dangerous mode of transport, with 1510
casualties per billion passenger kilometres
travelled. Cycling and walking are about half as
dangerous, with car, taxi and bus travel roughly
30 times safer again. Per kilometre travelled, cyclists

# Arnold 2004 10.1191 =1460408604ta309oa

162 RJ Hamilton and JR Rollin Stott
Figure 1 Cycle trafŽ c in Great Britain. Source: Department for Transport, 1998d
are 14 times more likely to be killed or seriously
injured in road accidents than car drivers. It is
interesting, too, to note that although the number of
cyclists killed on the roads in Britain has declined
by 43% between 1970 and 1995, cycle traf®c has
seen a similar (37%) fall during this period and the
casualty rate per 100 million vehicle kilometres among
cyclists actually increased ± by 17% (Department
for Transport, 1998c).
Accidents involving cars account for 44% of those
cyclists killed and 73% of those seriously injured
(Table 2). Accidents involving heavy goods vehicles
account for the second largest proportion of casualties
(25%), and a quarter of all cyclist fatalities ± most
frequently as a result of left turning lorries.
Ninety per cent of accidents involving cyclists, and
53% of fatalities, occur in built-up areas, in 30 mph
zones, a ®fth of them in London (Department for
Transport, 1998c). Two out of every three cycling
accidents are caused by cyclist error. Three quarters
of them are at road junctions. Roundabouts, too, are
particularly dangerous for cyclists. Forty-four per cent
Table 1 Passenger killed and seriously injured (KSI) rates by mode: 1994
Number KSI
Pedal cycle 4000
Walk 12 924
Motorcycle 6665
Car and taxi 23 891
Bus and coach 752
Source: Department for Transport, 1998e
Trauma 2004; 6: 161±168
of fatalities occur on nonbuilt-up roads, at traf®c
speeds in excess of 30 mph.
About 80% of cycling accidents occur in daylight,
between 8.00 and 9.00 a.m. and 3.00 and 6.00 p.m. ±
when most cycling takes place ± with accidents rising to
their highest during the summer when cycling’s popu-
larity peaks. Fifty-two per cent of child casualties and
37% of adult casualties are injured from May to
August (Department for Transport, 1998c).
Cyclist casualties are not evenly distributed by age
and sex. Men account for 80% of all adult cycling
casualties (Department for Transport, 1998c), largely a
re¯ection of the fact that men do more than three times
the annual cycle mileage of women (Department for
Transport, 1998a). Even so, there is a small excess of
male casualties per mile travelled. Nearly a third of
those injured are children, the highest casualty rate for
both sexes being between the ages of 12 and 15. Children
in this age group have an accident rate of 22 per 100 000
population, compared with the all ages rate per head
of population of 7 per 100 000. Injuries to both men
and women decline with increasing age (Figure 2).
Billion passenger Rate: KSI per
kilometres billion pass. kms
4.4 910
18.2 710
4.4 1510
570.7 40
43.0 20
 Cycling: the risks 163

Table 2 Other vehicles involved in bicycle accidents: 1994

Killed Seriously injured

Number Percentage Number Percentage

Total cyclist casualties 172 100 3828 100
No one else involved 12 7 331 9
Accidents with a pedestrian 0 0 14 0
Accidents with one other vehicle:
Bicycle 1 1 37 1
Two-wheeled motor vehicle 1 1 72 2
Car 76 44 2799 73
Bus or coach 7 4 66 2
Light goods vehicle 14 8 191 5
Heavy goods vehicle 43 25 134 4
Other vehicles 3 2 26 1
Accidents with two or more other vehicles 15 9 155 4

Source: Department for Transport, 1998e

Types of accident and injury
patterns
Of®cial statistics tend to underestimate the morbidity
from cycle accidents. Of 86 children seen with bicycle
related injuries in the UK, only two were recorded
in police road traf®c accident data and only 10 in hospital
discharge records (Leonard et al., 1999). A similar
disparity has been noted in a study from North
Carolina (Stutts et al., 1990) in which only 10%
of emergency room cases were duplicated on the
state accident ®les.

Figure 2 Pedal cyclist casualty rate per 100 000 population by age and gender.
Source: Department of the Environment, Transport and the Regions, 1998a

Trauma 2004; 6: 161±168

164 RJ Hamilton and JR Rollin Stott
Mishaps from cycling occur frequently. In a ques-
tionnaire survey of US college students (Kruse and
McBeath, 1980), 13% of cyclists had been involved
in an accident in the previous year, a third of whom
sustained an injury that required medical attention.
The majority of cycle accidents do not involve another
vehicle. About two thirds of cycle injuries treated in
one Dutch hospital accident unit were in the category
of single vehicle accidents (Kingma, 1994). Not
surprisingly, injuries in this group tend to be less
severe. More than 90% of fatalities to cyclists result
from collision with another vehicle (Spence et al.,
1993; Frank et al., 1995).
Accidents involving child cyclists are often the
result of the child playing, doing tricks, riding too
fast or losing control. Cyclist error was considered
to be the cause in 66% of accidents in children aged
8±12 years and no less than 87% of accidents in
children less than eight years old (Simpson and
Mineiro, 1992). The conclusion of this study was that
no child under the age of eight should be allowed to
cycle on a public road. For teenage and adult cyclists,
accidents are more likely to involve collisions with
other vehicles (Royal Society for the Prevention
of Accidents, 2003).
A study from Finland of the degree of disability
resulting from cycle accidents (Olkkonen et al., 1993)
examined the cases of 278 children and 264 adults seen
in two Helsinki hospitals over a two-year period. Of
those who required admission to hospital, some degree
of disability was still present six months after the
accident in 32% (11% of children, 47% of adults and
67% of elderly). Three per cent of adult inpatients
suffered from permanent work disability.
A study looking at deaths of cyclists in Greater
London between 1985 and 1992 was able, tentatively,
to group some of the 178 fatalities according to the
manoeuvre being performed (Gilbert and McCarthy,
1994). In 30 cases (17%) a vehicle turned left across the
cyclist’s path ± in all but one of which the vehicle was a
heavy goods vehicle. In a further four instances both
the vehicle and the cyclist were apparently turning left
together. Sixteen collisions (9%) occurred when the
cyclist was on the nearside of a vehicle going straight
ahead. A further 22 (12%) were hit from behind and
eight were said to have swerved into a vehicle’s path. Of
the 35 children aged µ16, 14 (40%) were struck by a
vehicle after cycling off the pavement. Four cyclists
died after being hit by vehicle drivers opening their
car doors and two died while cycling across zebra
crossings. In addition to the 178 fatal accidents
Trauma 2004; 6: 161±168
involving cyclists, ®ve pedestrians crossing the road
and two motorcyclists died in collisions with cyclists.
Another study in 1994 looked more speci®cally at
the injury patterns of cyclists attending the acci-
dent and emergency department at Addenbrooke’s
Hospital in Cambridge (Maimaris et al., 1994). Of
the 1042 cases reviewed, the majority (63%) had fallen
from their bicycles. Twenty-eight per cent had been in
a collision with a motor vehicle, 7% in collision with
another bicycle and 2% in collision with a pedestrian.
Most of the attendees (70%) had soft tissue injuries
only (abrasions, contusions and lacerations). Twenty-
eight per cent had received single fractures and =or
dislocations, while 1% had multiple fractures and =or
dislocations. Ten per cent had head injuries, 22% had
injuries to the face or neck; 5% had injuries to their
trunk; 45% received injuries to their arms and 25% to
their legs. A number of studies have drawn attention
to the risk of intra-abdominal injury from impact
with bicycle handlebars. A retrospective study of 32
children injured by handlebars (Clarnette and Beasley,
1997) described trauma to the spleen, liver and
pancreas, perforation of the bowel, urethral injury,
and lacerations of the abdominal wall and inguino-
scrotal region.
Head injuries and cycle helmets
According to the Royal Society for the Prevention of
Accidents, 70% of cyclists killed on the road have had
major head injuries, and over half of cyclists injured
have head injuries (Royal Society for the Prevention
of Accidents, 2003). In America, head injuries account
for 85% of cycling related deaths and two thirds
of cycling related hospital admissions (Wasserman
et al., 1988). Several studies show that a signi®cantly
higher proportion of cyclists sustain head injuries in
accidents than motorcyclists (Waters, 1986; Simpson
et al., 1988).
Of the 1042 patients in the Addenbrooke’s study,
104 (10%) had received head injuries, of whom two
died ± one due to an extensive head injury associated
with a chest injury, the other due to a high cervical
spine injury. A greater proportion of accidents invol-
ving motor vehicles resulted in head injuries (18%)
than did other accidents (7%).
The Addenbrooke’s study looked closely at the
bene®t conferred by wearing cycle helmets and found
that head injury (de®ned as skull fracture, brain injury,
loss of consciousness or post-traumatic amnesia) was

sustained by 4% of helmet wearers, compared with
11% of non wearers ± a three-fold reduction that was
present in all ages and for all accident types. None of
the patients with skull fractures and severe brain
injury, including the two deaths, had been wearing a
helmet.
A number of similar studies report comparable
®ndings. A meta-analysis of 11 studies carried out in
Australia, the USA, Canada and the UK between 1987
and 1998 (Attewell et al., 2000) concluded that the
summary odds ratio estimate of ef®cacy was 0.40 (0.29,
0.55) for head injury, 0.42 (0.26, 0.67) for brain injury,
0.53 (0.39, 0.73) for facial injury and 0.27 (0.1, 0.71) for
fatal injury. However, data from three studies that
reported the incidence of neck injury suggested an
unfavourable effect from helmet wearing with a sum-
mary odds ratio estimate of 1.36 (1.0, 1.86). A recent
Cochrane Review of ®ve case controlled studies from
different countries similarly concluded that cycle
helmets decrease the risk of head and brain injury by
between 65 and 88% and decrease the risk of facial
injury by 65% (Thompson et al., 2000).
A number of studies have looked at cycle helmets
themselves. A study of 100 head injuries in Portsmouth
found that 70% of the cyclists’ heads had hit the road
®rst. By plotting the sites of impact on the cyclists’
Figure 3 UK cyclists killed or seriously injured (1974–1997)
Cycling: the risks 165
heads it was estimated that 50% would have been
covered by a helmet (Worrell, 1987), though protection
to the temporal area of the head is poor (McIntosh
et al., 1998). Provided a helmet is designed to conform
to current standards (for example EN 1078: 1997)
(British Standards Institution, 1997), and is worn
properly, it has been suggested that deaths due to
head injuries could be reduced by as much as 90%
(Dorsch et al., 1987).
Butting heads
Even so, helmet use remains a matter of controversy.
The total number of deaths to cyclists has fallen almost
continually, from 1536 in 1934 to 141 in 2002, in large
part re¯ecting a decrease in cycle use (Department for
Transport, 1998c). Equally, the proportion of cyclist
casualties that involve fatal or serious injuries has also
fallen, from 24% in 1974 (the ®rst year for which full
statistics were available) to 18% in 1998 (Department
for Transport, 1998c) (Figure 3).
It is interesting to compare this fall with the rise in
cycle helmet use. Over the decade to 1996, nationwide,
cycle helmet use rose from close to zero to around 16%.
In London cycle helmet use increased to around 40%
Trauma 2004; 6: 161±168
166 RJ Hamilton and JR Rollin Stott
(the highest in Britain) (Department for Transport,
1998c). Even so, cyclist casualty data for the UK shows
no evidence of a `helmet effect’, with accidents con-
tinuing to decline at the same rate as they had prior to
helmet use becoming more popular. This ®nding is
consistent with research in the USA (Rogers, 1988),
Canada (Transport Canada, 2003), Australia (ARA-
PRU, 1999) and New Zealand (Scuffham and Langley
1997), which found no evidence of any signi®cant
decrease in head injuries with increased helmet use in
large population samples. Even in countries such as
Australia and Canada, where, in some states, cycle
helmet use has become mandatory, reported reduc-
tions in head injuries (Carr, 1995; Leblanc et al., 2002)
have been countered by studies citing reduced cycle use
following the introduction of legislation as the major
cause (Wardlaw, 2002). In Australia, for example,
admissions from head injury fell by 15±20% (Robin-
son, 1996b), but the level of cycling fell by 35%
(Robinson, 1996a). Indeed, in 1988, the largest survey
of cycling casualties ever undertaken in Britain con-
cluded that increased helmet use correlated well with
an increased risk of death (Rogers, 1988), leading some
to argue that promoting cycle helmets confers a false
sense of security to wearers and detracts from the real
issues of promoting caution and good road sense and
reducing traf®c speeds (Franklin).
Protecting cyclists
Cyclists stand to gain more from road safety than
any other road users. In a MORI poll, half of those
surveyed said they would cycle for short journeys if
roads were made safer (Naitonal Cycling Forum,
1999). While a cyclist has a 95% chance of surviving
a collision with a car travelling at 20 mph, this is
reduced to only 15% at 40 mph (Department of
Transport, 1997). In York, for example, where 20%
of all journeys are made by bicycle, a 30% reduction
in casualties has been achieved by restricting vehicle
speeds on 23 miles of residential roads (Hardwick
Cycling Campaign, 2000). Similarly, in Denmark and
the Netherlands, where 10% of all journeys are made
by bicycle, despite little helmet use, cyclists form a
much smaller proportion of those killed or injured on
the road on account of safety programmes to reduce
traf®c speeds to 30 km =h and cycle lanes to separate
cyclists from fast moving traf®c (Department of
Transport, 1997).
Trauma 2004; 6: 161±168
Training for cyclists, particularly children, is also of
great potential bene®t. In Britain between 200 000 and
250 000 receive some sort of cycle training each year,
although there is no national standard and quality and
effectiveness may vary (Royal Society for the Preven-
tion of Accidents, 2001). A study that compared the
accident and casualty rates of trained and untrained
children concluded that those trained are three times
less likely to become a casualty than those who had
not been trained (Transport Research Laboratory,
1989). Another study, however, cautioned that children
who had taken a course may then be at greater risk,
possibly because parents believed their children to be
more competent than they were (Carlin, 1998).
Discussion
Many injury based studies have indicated that there
is a protective effect from the wearing of a cycle helmet.
It seems, at ®rst sight, dif®cult to reconcile the con-
clusions of these injury based studies with population
studies that have been unable to demonstrate any
reduction in the incidence of death or serious injury
to cyclists attributable to helmet wearing. In countries
in which helmet use has been made compulsory, there
is evidence of a fall in the numbers cycling. A possible
reason for this is that the introduction of cycle
helmets focuses public attention on the dangers of
cycling, with the result that more cautious, risk averse
cyclists, who are perhaps least likely to suffer an
accident, are deterred from cycling. A comment, perti-
nent to this discussion, though made in connection
with the introduction of smoke detectors and seat belt
legislation, is that `unless compliance is virtually
universal, the higher rates of death and injuries
among high risk populations are likely to mask the
effectiveness of the devices for the majority of people’
(McLoughlin et al., 1985).
Given the high proportion of head injury related
deaths and hospital admissions among cyclists, it
seems eminently sensible to wear a good, well ®tted
helmet. The British Medical Association has strongly
recommended the wearing of cycle helmets by all
cyclists, especially children, as part of a wider safe
cycling strategy that includes cyclist training courses
and cycle awareness in driver training and the Driving
Test (Board of Education and Science, 1999). But the
dangers of cycling need to be kept in context. Seventy
per cent of British adults take exercise less than once a
month (Hillsdon and Thorogood, 1996). According to

the BMA, when considered alongside the dangers asso-
ciated with inactivity, the overall health bene®ts of
cycling exceed the risks by a factor of 20 (Hillman, 1994).
The government’s White Paper A New Deal for
Transport hopes to see a quadrupling of cycle use by
2012 (Department of the Environment, Transport
and the Regions, 1998). To achieve this, cycling
needs to be considered in the round. Improved security
arrangements for bikes and adequate facilities
to shower and change at work, for instance, are,
ultimately, just as important as traf®c calming
measures, cycle lanes and promoting good road sense
if cycling is to achieve its full potential.
Acknowledgements
We thank Alastair Hamilton for his help with
graphics.
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