Kids who wear helmets and are involved in all-terrain vehicle (ATV) crashes are less likely to suffer a severe brain injury, new research suggests.

In a retrospective cohort study of almost 700 children assessed over a 10-year period, two thirds of those injured while riding a dirt bike or an ATV were not wearing a helmet at the time. Only one child who was wearing a helmet sustained a brain injury.

Although these results are not that surprising, it’s important to drive home the message that “helmets are clearly effective,” co-investigator Aaron Yengo-Kahn, MD, a 6-year neurosurgery resident at Vanderbilt University Medical Center, Nashville, Tennessee, told Medscape Medical News.

Clinicians who work with kids need to raise the issue of helmets, he added.

“We need to be telling them that if you wear a helmet, your chance of having a brain surgery from an accident is almost zero percent,” Yengo-Kahn said.

The findings were presented at the American Association of Neurological Surgeons (AANS) 2021 Annual Meeting.

High-Speed Vehicles

ATVs are heavy motorized vehicles with three or four large wheels. Some are decked out with cages, roofs, and speakers. Dirt bikes are two-wheeled motorized bicycles that also have relatively thick tires.

Both types of vehicles can get up to high speeds, but ATVs are typically more powerful. They are designed for use on private property or off public roads.

These recreational vehicles are a major cause of injury, especially for youngsters. Of the more than 100,000 injuries per year linked to these vehicles, more than a quarter occur in persons younger than 16 years; 16% of all fatalities occur in this age group.

Many of these kids also engage in risky behavior, such as riding without a helmet or being a passenger on a one-person vehicle.

“We see a lot of injured people who jumped on with a driver without a helmet,” said Yengo-Kahn. “They’re getting ejected or tossed off, and that’s where lot of the injuries come from.”

The current study included 680 children who presented at a level I pediatric trauma center between January 2010 and December 2019 and for whom information on helmet status was available. The pediatric trauma center is the largest in the region, and many of the patients came from out of state.

About 66% of the study population were not wearing a helmet at the time of their crash. About 94% of these kids had a mild traumatic brain injury (TBI); the rest suffered a moderate or severe TBI.

Those not wearing a helmet were slightly older (mean age, 11.69 years, vs 11.01 years) and were more likely to be girls (often the girlfriend of the rider). Passengers rarely wore a helmet.

Helmet vs No Helmets

Of the patients who were not wearing a helmet, mechanisms of injury were slightly less severe, such as a rollover that led to hospitalization. Among those who wore helmets, mild mechanisms of injury did not result in a hospital visit.

“The people who had helmets on usually needed a higher velocity, higher impact for them to come in. So they were crashing with other vehicles and crashing into objects,” Yengo-Kahn explained.

The analysis showed that unhelmeted riders were more likely to undergo head imaging than helmeted riders (70.9% vs 48.3%) and were more likely to receive a neurologic consult (16.2% vs 9.1%).

They also suffered more skull fractures (17.8% vs 1.7%) and intracranial hemorrhage (16.2% vs 3.9%) and underwent more neurosurgical procedures (2.7% vs 0.4%).

“It’s important to point out that only one neurosurgical procedure was performed on a helmeted patient over the entire 10 years,” said Yengo-Kahn.

After accounting for age, sex, vehicle type, driver status, and injury mechanism, helmet use was associated with a 75% reduced likelihood of a neurosurgical consult (odds ratio [OR], 0.25; P < .001), an 83% reduced chance of intracranial injury (OR, 0.17; P < .001), and a 76% reduced risk of having a moderate or severe TBI (OR, 0.24; P = .015).

Over a 10-year period, if only four children consistently wore a helmet, it would save save one intracranial injury, Yengo-Kahn noted.

Length of hospital stay was relatively short, at a median of 2 days, and did not differ between groups. There was also no difference in the Glasgow Outcome Scale score at a mean follow-up of about 6 months. At that time point, 98% had good recovery and only minor deficits, Yengo-Kahn reported.

“More Granular” Analysis Needed

In the future, the researchers hope to collect data on specific locations where education on helmet use is most needed. Using ZIP code information to collect “geo-location” data may help identify counties for outreach, said Yengo-Kahn. That may involve discussions with parents and providing helmet education in schools.

“Our study is sort of pointing out the problem and the solution, and now we need to apply the solution at a county-by-county individualized level,” Yengo-Kahn noted.

The investigators also aim to conduct a “more granular analysis” to assess whether helmet use can reduce missed school days and improve neurocognitive outcomes, such as headaches and quality of life.

Asked by a meeting delegate whether the type of helmet made a difference, Yengo-Kahn said charts did not typically capture this information.

He expanded on the point to Medscape Medical News, saying that not all helmets afford the same protection. Certain helmets cover the entire head, and some are equipped with mouth guards and visors.

Responding to a query about helmet laws, Yengo-Kahn noted that Tennessee requires riders younger than 18 to wear a helmet. “So 66% of our patients were technically breaking the law” by riding without a helmet, he pointed out.

“Even though we have these laws, we’re clearly not able to enforce them very well,” he said.

Yengo-Kahn has reported no relevant financial relationships.

American Association of Neurological Surgeons (AANS) 2021 Annual Meeting: Neurotrauma session. Presented August 23, 2021.

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