Cycling: To Race or to Live – Reflections on Skewed Priorities?

Most of us were no doubt dramatically shocked while watching the live broadcast of Wouter Weylandt’s death following a horrific crash on the third stage of the Tour of Italy. While travelling at high speed negotiating a descent, the left pedal of the Belgian rider’s cycle briefly touched a wall at the side of the road, propelling him 20 m to the ground below, where he landed heavily on his face. He died nearly instantly from fatal skull and facial injuries and there was also reported damage to his neck, pelvis and a broken leg. Regrettably, this was not an isolated incident. 2 days after Weylandt’s accident, during the fifth stage of the Tour, Tom-Jelte Slagter crashed his face on gravel after getting his water bottle, and suffered a broken right eye socket (orbit) and head concussion. Fortunately, he survived the crash with no residual brain damage. A few weeks later, 2 other professional cyclists suffered from severe head injuries. Mauricio Soler collided with a spectator and crashed heavily in the sixth stage of the Tour of Switzerland, losing consciousness. The rider was immediately airlifted to hospital where he was diagnosed as having a skull fracture and cerebral edema. Last but not least, Ivan Basso needed 15 stitches after suffering a facial injury during a training crash. As such, these 4 consecutive crash injuries raise a reasonable question, being: what can be done to prevent such dramatic road cycling injuries?

Safety in sports has been long debated [6] [11], and much progress has been made across most fields, especially motor racing [9]. Cycling accidents, especially those resulting in head injuries, remain however a substantive cause of disability and death. The mandatory use of the helmets developed by the International Cycling Union (ICU) since the year 2003 in elite cycling events has probably prevented a huge amount of deaths or disabilities after head injuries [10]. However, the helmet was not sufficient to save Weylandt, nor was it effective in protecting Slagter’s and Basso’s faces. As such, extra efforts should be ensued to identify additional means to safeguard cyclists, although it seems that some would hardly be suitable ([Table 1]).

Table 1 Potential solutions to reduce the deleterious effects of maxillofacial fractures in cyclists.

– use of integrated helmets with visor, brim or face shield

– renewed road surfaces built with materials less prone to become slick and soft in the hot weather

– avoiding zebra crossings

– establishment of temporary crash protection barriers

– elimination of earpieces

The first important aspect is the evaluation of the dynamics of both accidents, with both riders heavily crashing onto their faces on the gravel. The current cycling “open” helmets, even when appropriately worn, do not assure any kind of protection for this type of crash. A Cochrane meta-analysis – including 5 well conducted case-control studies – showed that the use of traditional cycling helmets reduces injuries to the upper and mid facial areas by 65%, although is not effective to prevent lower facial injuries [16]. Moreover, recent publications reflect the sports community’s concern about the helmet protection ability against head impacts in youth ice hockey players as well as in American football players [13]. In a prospective study on cyclists with maxillofacial injuries, Harrison et al. also reported that the currently accepted design for cycle safety helmets does not provide any protection – directly or indirectly – against maxillofacial fractures, concluding that significant reduction in morbidity might be achieved by providing protection to the upper and middle facial regions [4]. In this perspective, the use of “full”, “closed” or full-face motocross-type helmets (i. e., with integrated visor, brim or face shield) would have substantially mitigated the severity of the orofacial trauma in these accidents. Whilst understandable that the latter type of protection would be awkward for the athletes, ergonomic considerations might be outweighed by the undeniable benefit of face protection considering the dramatic consequences of these four crashes. It is also noteworthy that “full” helmets (i. e., time trial helmets) are already used widely by athletes to achieve the lowest aerodynamic resistance, whereas motocross-type helmets are commonplace in down-hill and free-ride mountain biking. Along with more protective helmets, the use of efficient shielding measures for other commonly and severely traumatised body parts (e. g., neck, limb, and legs), might be proposed (e. g., knee and elbow pads, neck protections). While the direct introduction of the HANS carbon fibre collar seems unsuitable in this type of sport, neck braces can be reengineered to fulfil the requirements of road cyclists and prevent occipitoatlantal dislocation and acute neurogenic shock (1.3% of cyclists killed in traffic crashes), another potential injury in road cyclists [1] that Weylandt also suffered in his fall.

The second aspect to be considered is the race contest. Since the road is and will obviously remain the natural playground for cycling competitions, the introduction of more efficient protective measures alongside the route might be considered. Thus, the road surface should be in the best possible condition, accurately rehabilitated before the race to eliminate holes, cracks and bumps, and built with materials less prone to become slick and soft in hot weather. Introduction of permeable paving might also be advisable to prevent slippery surfaces during rainy weather. Riding over zebra crossings with a slippery paint surface should be avoided, whenever possible. Additional considerations should be made to introduce – throughout the most dangerous parts of the route – temporary crash protection barriers made of foam pads, as these may absorb the crash energy and thereby prevent athletes from bouncing heavily onto the gravel. Although it is understandable that modification of routes of cycling events over distances as long as 3 500 km [12] (i. e., the 3 national big tours) would be extremely expensive, some of these solutions might consistently help reduce the severity of such road injuries. Changing the route (e. g., eliminating the descents) may instead be unrealistic. Most cycling competitions develop through ascents and descents – some of which have made the history of this sport (e. g., Col du Tourmalet, Alpe d’Huez, Passo del Mortirolo, Passo dello Stelvio, Alto de El Angliru, etc.) – so that the elimination of the descents would pervert the nature of competitive cycling.

As regards medical assistance, nothing extra could have been contributed to that already provided. Unfortunately, Weylandt died immediately after the crash and – even if this would have not been the case – there is very little than can be done to treat that kind of head injury outside the setting of a hospital or a neurosurgery department. Slagter was immediately and efficiently assisted after the crash (i. e., within 30 s), which confirms that the medical assistance was adequate.

Recently, the cycling authorities have also raised some concerns about additional issues such as the use of earpieces, since they distort the nature of the sport as well as distract the athletes during the riding of their bikes. A working group was established in 2008 to consider this and, finally, earpieces have been banned in some competitions in order to make cycling races more exciting and safe. Accordingly, it is advisable that an international working group, most likely under the auspices of the UCI, might be formed to study new technologies and methods to increase safety in cycling races as well as to discuss and evaluate roadside hazards. Finally, race organizations should be prepared to permit additional forms of communication to inform cyclists about potential dangers of this sport.

Maxillofacial traumas include any injury to the bony structure, surrounding tissue, nerves, or vascular supply of the face. Although this type of injury is rarely life-threatening, it is frequently associated with bone fractures (i. e., mandibular, zygomatic and orbital), esthetical disturbances, permanent facial dysfunction, airway and breathing problems, haemorrhages as well as brain contusion and cerebral damage, requiring hospitalization and surgical intervention in the vast majority of cases [2] [3] [8] [14]. The incidence as well as the severity of a head injury is strongly related to the zone of impact, being typically associated with Le Fort III fractures (i. e., extending across the zygomatic arches and lateral and medial orbits connecting along the inferior orbits below the optic nerves, joining in the midline at the nasal root), or traumas to the upper third of the face – namely the temporal and frontal regions [4]. Orofacial injuries represent the most common type of trauma in road cyclists [7], and nearly one fifth of all these injuries observed at emergency departments are due to accidental bicycle falls [7] [8]. Moreover, the sport of cycling contributes to a large number (up to 45%) of these traumas among all sport disciplines [2] [17]. Cyclists with head and face trauma might also frequently present with traumatic brain injuries (14.4% of cases), intracranial injuries (3.9%) and concomitant neck injuries (9.7%) [5]. Finally, it has been recently shown that professional cyclists live longer than the general population [15] and we must keep fighting to keep it that way by doing whatever possible to protect their health.

• References

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