title: The effect of motorcycle helmet type, components and fixation status on facial injury in Klang Valley, Malaysia: a case control study.
abstract: BACKGROUND
  The effectiveness of helmets in reducing the risk of severe head injury in motorcyclists who were involved in a crash is well established. There is limited evidence however, regarding the extent to which helmets protect riders from facial injuries. The objective of this study was to determine the effect of helmet type, components and fixation status on the risk of facial injuries among Malaysian motorcyclists.
  
  
  METHODS
  755 injured motorcyclists were recruited over a 12-month period in 2010-2011 in southern Klang Valley, Malaysia in this case control study. Of the 755 injured motorcyclists, 391 participants (51.8%) sustained facial injuries (cases) while 364 (48.2%) participants were without facial injury (control). The outcomes of interest were facial injury and location of facial injury (i.e. upper, middle and lower face injuries). A binary logistic regression was conducted to examine the association between helmet characteristics and the outcomes, taking into account potential confounders such as age, riding position, alcohol and illicit substance use, type of colliding vehicle and type of collision. Helmet fixation was defined as the position of the helmet during the crash whether it was still secured on the head or had been dislodged.
  
  
  RESULTS
  Helmet fixation was shown to have a greater effect on facial injury outcome than helmet type. Increased odds of adverse outcome was observed for the non-fixed helmet compared to the fixed helmet with adjusted odds ratio (AOR) = 2.10 (95% CI 1.41- 3.13) for facial injury; AOR = 6.64 (95% CI 3.71-11.91) for upper face injury; AOR = 5.36 (95% CI 3.05-9.44) for middle face injury; and AOR = 2.00 (95% CI 1.22-3.26) for lower face injury. Motorcyclists with visor damage were shown with AOR = 5.48 (95% CI 1.46-20.57) to have facial injuries compared to those with an undamaged visor.
  
  
  CONCLUSIONS
  A helmet of any type that is properly worn and remains fixed on the head throughout a crash will provide some form of protection against facial injury. Visor damage is a significant contributing factor for facial injury. These findings are discussed with reference to implications for policy and initiatives addressing helmet use and wearing behaviors.
authors.affiliation: Department of Oral and Maxillofacial Surgery, Universiti Kebangsaan Malaysia Medical Centre, 56000 Jalan Yaacob Latif, Kuala Lumpur, Malaysia. roszalina@ppukm.ukm.edu.my.
authors.forename: Roszalina
authors.initials: R
authors.lastname: Ramli
authors.forename: Jennifer
authors.initials: J
authors.lastname: Oxley
authors.forename: Peter
authors.initials: P
authors.lastname: Hillard
authors.forename: Ahmad Farhan
authors.initials: AF
authors.lastname: Mohd Sadullah
authors.forename: Roderick
authors.initials: R
authors.lastname: McClure
mesh_terms: D000063:Accidents, Traffic; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D005151:Facial Injuries / Q000209:etiology* / Q000517:prevention & control; D005260:Female; D006260:Head Protective Devices; D006801:Humans; D016015:Logistic Models; D008296:Malaysia; D008297:Male; D008875:Middle Aged; D009049:Motorcycles; D016017:Odds Ratio; D012307:Risk Factors; D055815:Young Adult
references.citation: Accid Anal Prev. 1993 Jun;25(3):347-53
references.pmid: 8323668
references.citation: Accid Anal Prev. 2003 Nov;35(6):833-40
references.pmid: 12971916
references.citation: J Trauma Stress. 1996 Apr;9(2):223-34
references.pmid: 8731544
references.citation: Accid Anal Prev. 2008 Nov;40(6):1937-42
references.pmid: 19068297
references.citation: Med J Malaysia. 2000 Mar;55(1):40-4
references.pmid: 11072489
references.citation: Ann Emerg Med. 1994 Apr;23(4):802-6
references.pmid: 8161050
references.citation: BMC Public Health. 2009 Jan 12;9:11
references.pmid: 19134225
references.citation: Accid Anal Prev. 1994 Jun;26(3):391-7
references.pmid: 8011052
references.citation: Accid Anal Prev. 1996 Mar;28(2):193-200
references.pmid: 8703277
references.citation: Neuroepidemiology. 2004 Nov-Dec;23(6):269-74
references.pmid: 15297792
references.citation: Med Sci Monit. 2005 Oct;11(10):RA316-21
references.pmid: 16192914
references.citation: Am J Public Health. 1996 Jan;86(1):41-5
references.pmid: 8561240
references.citation: Accid Anal Prev. 2011 Jan;43(1):214-9
references.pmid: 21094316
references.citation: Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003 May;95(5):515-20
references.pmid: 12738941
references.citation: J Adv Nurs. 2004 Aug;47(4):417-26
references.pmid: 15271161
references.citation: J Trauma. 1997 Sep;43(3):496-500
references.pmid: 9314314
references.citation: J Pain. 2010 May;11(5):420-30
references.pmid: 20439055
references.citation: Accid Anal Prev. 2009 Jul;41(4):710-22
references.pmid: 19540959
references.citation: N Engl J Med. 1987 Dec 24;317(26):1630-4
references.pmid: 3683502
references.citation: Cochrane Database Syst Rev. 2008 Jan 23;(1):CD004333
references.pmid: 18254047
references.citation: Arch Surg. 2012 Jul;147(7):674-6
references.pmid: 22802066
references.citation: Accid Anal Prev. 1999 May;31(3):229-33
references.pmid: 10196599
references.citation: J Trauma. 2000 Mar;48(3):490-4
references.pmid: 10744290
references.citation: Int J Epidemiol. 2011 Jun;40(3):794-803
references.pmid: 21389036
references.citation: Traffic Inj Prev. 2008 Jun;9(2):135-43
references.pmid: 18398777
references.citation: J Craniofac Surg. 2005 May;16(3):355-60
references.pmid: 15915097