Original research

E-­scooter incidents in Berlin: an evaluation of risk

factors and injury patterns

Emerg Med J: first published as 10.1136/emermed-2020-210268 on 7 June 2021. Downloaded from [Link] on March 1, 2025 by guest.
Deniz Uluk ‍ ‍ ,1,2 Tobias Lindner,1 Michael Dahne,3 Jens Werner Bickelmayer,4
Kassandra Beyer,2 Anna Slagman,1 Friedrich Jahn,5 Christian Willy,6 Martin Möckel,1
Undine A Gerlach1

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Handling editor Jason E Smith ABSTRACT
1
Background E-­scooters have emerged as a frequently Key messages
Department of Emergency
Medicine, Charité University used vehicle in German cities due to their high
Medicine Berlin, Berlin, Germany availability and easy access. However, investigations What is already known on this subject
2
Department of Surgery, Charité ► E-­scooters are an innovative and rising
University Medicine Berlin, about the causes and mechanisms of E-­scooter incidents
Berlin, Germany and their trauma-­specific consequences are rare. modality of mobility, especially in urban areas
3
Trauma and Reconstructive Methods We analysed all patients involved in E-­scooter worldwide. Previous investigations have mainly
Surgery, Charité University incidents from June to December 2019 who presented described the numbers of E-­scooter incidents
Hospital Berlin, Berlin, Germany and the related musculoskeletal injuries.
4
Department for Anesthesia,
to four inner-­city EDs in Berlin. The prospective data
Intensive Care, Pain Therapy included patient-­related and incident-­related data,
information on injury patterns and therapy, responses in What this study adds
and Emergency Medicine,
Bundeswehr Hospital Berlin, ► With this study, we not only identified injury
a voluntary questionnaire concerning E-­scooter use and
Berlin, Germany general traffic experience. patterns but also trauma mechanisms and
5
Orthopaedics and Trauma
Results 248 patients (129 males; median age 29 years risk factors of E-­scooter-­related incidents. As
Surgery, Evangelical Elisabeth a result, we propose stricter regulations for
Clinic Berlin-­Mitte, Berlin, (5–81)) were included: 41% were tourists and 4% were
Germany children. Most incidents (71%) occurred between July the use of E-­scooters. These should include the
6
Orthopaedics and Trauma and September 2019, the majority occurring at weekends wearing of helmets, an age limit of 18 years,
Surgery, Bundeswehr Hospital
(58%). The injury pattern was mostly multifocal, affecting a ban on alcohol and a strict adherence to
Berlin, Berlin, Germany traffic regulations, such as avoiding driving
the lower (42%) and upper limbs (37%) and the head
(40%). Traumatic brain injury was associated with on pavements. By performing technical
Correspondence to modifications to the E-­scooter platforms,
Mr Deniz Uluk, Charité alcohol consumption. Inpatient admission was recorded
providers can help to eliminate an additional
University Medicin Berlin, in 25%, surgery in 23%.
Campus Mitte, Department of source of injury.
Conclusion This study has defined the incidence of
Surgery, Charitéplatz, Berlin
110115, Germany;
injury related to E-­scooter use in a major European
​deniz.​uluk@​charite.​de city. Stricter laws governing the use of E-­scooters, the
wearing of helmets and technical modifications to the E-­scooters became available in Berlin.2 3 Movement
Received 20 June 2020 E-­scooter platforms might decrease E-­scooter-­associated
Revised 12 April 2021 profiles have shown increased usage of E-­scooters
incidents and resulting injuries in the future. in central districts where micromobility plays a
Accepted 1 May 2021
Published Online First Trial registration number German Clinical Trials decisive role. At the same time, motor vehicle
7 June 2021 Registry (DRKS00018061). traffic density is high in central areas, which yields
an increased risk of incidents.
Many users indicate that E-­scooters are a good
alternative to cars in regard to covering short
INTRODUCTION distances.4 Nevertheless, the lack of public aware-
The desire for mobility as well as the recently ness for the proper use of E-­scooters and the conse-
increased awareness of the necessity for sustain- quences of incidents seem to be a problem. Data
ability and environmental protection has sparked a from the US National Electronic Injury Surveillance
growing interest in electric vehicles. In most larger System showed a dramatic increase in injuries from
cities, such vehicles are available from different E-­scooter incidents after their introduction in 2017
providers through sharing concepts. The so-­called and 2018.5 These data have been derived mainly
free-­floating concept allows customers to unlock from accounting data, especially from the state
vehicles with a simple smartphone app, to pay the accident insurance.5 Although they provide infor-
rent electronically and to park them at any time mation on the number of injured individuals, they
within a certain area. E-­scooters in particular have give less information on clinical aspects such as
© Author(s) (or their
employer(s)) 2022. Re-­use become popular in major European cities since their injury patterns, causes of incidents, therapies and
permitted under CC BY-­NC. No initial licensing in June 2019 and have immediately outcomes.
commercial re-­use. See rights led to a change in the cities’ streetscapes. Large European studies describing E-­ scooter-­
and permissions. Published With its 3.8 million residents and almost 14 specific injury patterns are still rare, mainly of
by BMJ.
million tourists every year,1 Berlin was chosen by retrospective nature and risk factors or trauma
To cite: Uluk D, Lindner T, many providers for testing and optimising new mechanisms have hardly been described. In a small
Dahne M, et al. Emerg Med J short-­distance mobility concepts, known as micro- retrospective case series, we were able to show
2022;39:295–300. mobility. In September 2019, more than 11 000 that E-­scooter-­related incidents often occur due to
Uluk D, et al. Emerg Med J 2022;39:295–300. doi:10.1136/emermed-2020-210268    295
 Original research
inexperienced users, traffic violations and alcohol consumption
Table 1 Presentation of demographic parameters of patients after
as well as due to the vehicles themselves not being roadworthy.6
E-­scooter incidents (n=248)
The aim of this large prospective study was to further investigate
our previous findings on trauma mechanisms and injury patterns Male 129 (52%)

Emerg Med J: first published as 10.1136/emermed-2020-210268 on 7 June 2021. Downloaded from [Link] on March 1, 2025 by guest.
in order to identify risk factors and suggest improvements for Sex Female 119 (48%)
the use of E-­scooters. Age Median, years 29 (Q1: 23; Q3: 39)
Range 5–81
Age groups <18 years 10 (4%)
PATIENTS AND METHODS 18–25 years 71 (29%)
Data collection 26–40 years 113 (45%)
We undertook a prospective observational multicentre study

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41–64 years 47 (19%)
across four central EDs in the district of Berlin-­Mitte: Charité ≥65 years 7 (3%)
Campus Mitte (CCM), Charité Campus Virchow-­ Klinikum Touristic visit Yes 101 (41%)
(CVK), Bundeswehrkrankenhaus (BWK) and Evangelische Elis-
Place of residence Berlin 144 (58%)
abeth Klinik (ELI).
Unknown 3 (1%)
All patients who presented to these EDs between June and
Incident on the way to or from Yes 20 (8%)
December 2019 after E-­scooter incidents were included in this work
study. Patients either self-­presented or were brought in by the
EDs CCM 99 (40%)
ambulance service.
CVK 61 (25%)
Patient-­specific data as well as information on the severity,
BWK 47 (19%)
diagnosis and treatment of injuries were recorded prospectively
ELI 41 (16%)
in the hospitals’ electronic documentation system. Traumatic
brain injury (TBI) was defined as head injury with resulting loss Values are given as numbers and percentage or in means±SD and median with
of consciousness reported by first helpers, the ambulance service range and quartiles. Q1: 25%-percentile, Q3: 75%-percentile.
BWK, Bundeswehrkrankenhaus; CCM, Charité Campus Mitte; CVK, Charité Campus
or in case of patient’s amnesia. Patients received either ambula- Virchow-­Klinikum; ELI, Evangelical Elisabeth Clinic.
tory interventions like wound care and cast immobilisation or
were admitted as inpatients for surgery, comprehensive moni-
toring or extensive wound management. In order to identify risk
factors for E-­scooter incidents, patients presenting to the EDs RESULTS
of CCM and CVK received a questionnaire asking for the cause Patient population
of the incident, previous experience with E-­scooters, possession A total of 248 patients were admitted to the four EDs and
of a driving licence, alcohol consumption and the wearing of included during the 6-­month study period.
a helmet. The completion of the questionnaire was carried out The demographic details are given in table 1.
voluntarily after a declaration of consent had been given by the More than half of the patients (58%) were Berlin residents and
patient or their legal guardian. If alcohol consumption was indi- 41% were tourists. In 20 patients (8%), the incidents happened
cated by the patient or otherwise presumed, an alcohol breath on the way to or from work.
test was performed. Patients presenting to the EDs of BWK and The survey regarding possession of a driving licence and
ELI did not complete questionnaires so that only clinical data previous experience with E-­scooters was carried out exclusively
could be obtained. at CCM and CVK, where 120 patients (48% of all patients)
volunteered to answer the questionnaire.

Statistical analyses
Times of incident
The data analysis was carried out using Excel software (Microsoft
The majority of E-­scooter incidents (75%) occurred between July
Excel V.2016, Microsoft Corporation, Redmond, Washington,
and September. Regarding the time of day, we noticed a peak of
USA) and SPSS V.26.0. Descriptive analyses were reported as the
E-­scooter incidents in the afternoon between noon and 18:00
means and SDs, medians and both quartiles and ranges, or abso-
(40%) and in the evening from 18:00 until midnight (29%). In
lute numbers and percentage referring to the study group.
addition, there was a notable increase of E-­scooter injuries on
For parameters with a Gaussian distribution, statistical
weekends between Friday afternoon and Sunday night (58%)
significance was defined using Student’s t-­test. Significant asso-
(figure 1).
ciations among categorial variables were investigated by the Χ2
test or Fisher’s exact test. For the convenience of the reader,
we additionally performed McNemar tests to compare two Causes of incidents
correlated proportions considering the injury distribution to The causes of incidents are summarised in table 2. Most
emphasise the most affected body regions and the most frequent E-­scooter riders reported that they fell off the vehicle because
type of injury. The ORs for the defined risk factors (previous they had lost control due to inattention, single-­handed driving
experience with E-­scooters, driving licence, alcohol consump- for indicating a direction change, lack of practice or inappro-
tion, wearing of helmet) and their association regarding inpa- priate speed. Another reason for incidents was collision with
tient admission and traumatic brain injury (TBI) have also been other vehicles or inanimate objects, like kerbs, road obstacles or
calculated. To show quantitative associations concerning non-­ tram tracks. Injuries caused from contact with the sharp edges or
normally distributed variables, the Mann-­Whitney U test was protruding screws of the E-­scooter occurred mainly during the
performed. The statistical significance level was set at values process of acceleration by pushing off from the ground or while
of p<0.05. All p values provided in this paper are considered trying to brake (figure 2). Pedestrians were injured in 12 cases
part of the exploratory analysis and have not been adjusted for (5%), either by getting hit by an E-­scooter (n=9) or by tripping
multiple testing. over a parked vehicle (n=3).
296 Uluk D, et al. Emerg Med J 2022;39:295–300. doi:10.1136/emermed-2020-210268
 Original research

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Figure 2 Soft tissue laceration at the medial malleolus of a 30-­year-­
old female patient after hitting the rear screw while accelerating the
Figure 1 Percentage distribution of the emergency admissions
E-­scooter.
according to the months, the time groups and the day (weekdays:
Monday–Thursday, weekend: Friday–Sunday). The numbers on top of
the bars show the absolute numbers.
Eight patients (3%) had ligamentous or meniscal damage, mainly
to the knee, without a fracture.
Injury patterns On the upper limbs, the numbers of soft tissue injuries and
Injury patterns are summarised in figure 3. fractures were nearly the same (18% vs 17%, p=0.749). The
Limb injuries were recorded in 178 patients and made up the upper limbs were significantly more often affected by frac-
majority of all injuries (72%). They were divided into soft tissue tures than the lower limbs (17% vs 6%, p=0.001). Fractures
injuries, joint dislocations and fractures. The lower limbs were of the upper limbs occurred mostly at the elbow joint or more
affected more frequently than the upper limbs (34% vs 30%, distally, and 21 patients (8%) required surgery. Four patients had
p=0.477). Seventeen patients (7%) suffered from injuries of the shoulder dislocations without any fracture.
upper and lower limbs simultaneously. Only one patient suffered from fractures of both lower and
On the lower limbs, we observed significantly more soft tissue upper extremities.
injuries than fractures (31% vs 7%, p<0.001). Soft tissue inju- In total, 135 head injuries were recorded in 101 patients. All
ries were contusions, abrasions, bruises, grazes and lacerations, head injuries were divided into soft tissue injuries (27%), frac-
which were often observed at the medial malleolus resulting tures (19%) and tooth damage (17%). Fractures affected the
from pushing off the ground to gain speed (figure 4). A total midface or mandible with the exception of one skull fracture.
of 17 patients had a fracture of the lower limb, with the need One patient had an intracerebral haemorrhage.
for surgical treatment in 13 patients. Figure 5 presents an over- Among all patients, 32 (13%) had concomitant TBI of mild
view of the localisation and the frequency of extremity fractures. severity and 22 of them (9% of all patients) required hospital

Table 2 Causes of incidents and analysis of risk factors with regard to inpatient admission and TBI
Causes of incident Loss of control/balance 141 (57%)
Hurt themselves at E-­scooter 27 (11%)
Tram tracks 20 (8%)
Hit an object 18 (7%)
Hit by motorised vehicle 12 (5%)
During braking 12 (5%)
Hit by E-­scooter 9 (4%)
Tandem driving 5 (2%)
Trip over 3 (1%)
Twisted ankle while getting off 1 (<1%)
Wearing a helmet Yes 3 (1%) Inpatient, n=2 Not applicable due to small patient numbers
TBI, n=1
Alcohol consumption Yes 48 (20%) Inpatient, n=18 OR 2.1, 95% CI: 1.1 to 4.0 p=0.033
TBI, n=15 OR 5.2, 95% CI: 2.3 to 11.6 p<0.001
Driving licence* Yes 82 (68%) Inpatient, n=17 OR 0.9, 95% CI: 0.4 to 2.5 p=0.968
TBI, n=9 OR 0.7, 95% CI: 0.2 to 2.0 p=0.458
Previous experience* Yes 58 (48%) Inpatient, n=15 OR 1.6, 95% CI: 0.7 to 3.8 p=0.302
1–3 times 15 (12%)
3–5 times 7 (6%)
>5 times 36 (30%) TBI, n=11 OR 3.3, 95% CI: 0.9 to 11.2 p=0.042
Values as numbers and percentage.
Inpatient=inpatient admission.
*Referring to voluntary questionnaire (n=120).
TBI, traumatic brain injury.

Uluk D, et al. Emerg Med J 2022;39:295–300. doi:10.1136/emermed-2020-210268 297

 Original research

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Figure 3 Distribution of injuries with regard to body region. The
numbers represent the number of patients suffering from each injury.
Multiple localisations might be affected. A total of 136 head injuries
occurred in 101 patients. Thus, multiple injury entities are possible per
patient. ICH, intracerebral haemorrhage; TBI, traumatic brain injury.

admission and monitoring for at least 6 hours due to their

symptoms. Figure 5 Distribution of the fractures and their location at the upper
Trunk injuries were rare and mainly affected the soft tissue extremities (left) and at the lower extremities (right) (n=number of
(figure 3). Severe injuries occurred in a total of six patients: a patients). One patient suffered from fractures at upper and lower limbs
liver and a spleen laceration, a unilateral and a bilateral pneu- (fracture of the thumb and pertrochanteric femur fracture on same side).
mothorax, a haemothorax and a stable vertebral body fracture.
Figure 6 illustrates the distribution of the injury entities for the
entire study population. Ambulatory and inpatient treatment
A total of 122 patients (49%) required a surgical intervention
either ambulatory or as inpatients. Ambulatory treatment was
performed in 65 patients (26%) and included wound care,
suturing and cast immobilisation. Sixty-­one patients (25%) were
admitted as inpatients, 57 of them (23%) underwent surgery.
The median hospital stay was 3 days (1–12 days). Patients with
TBI were hospitalised for a median of 1 day (1–6 days) compared
with the remaining hospitalised patients who stayed for a median
of 4 days (1–12 days; p<0.001). One patient had to be trans-
ferred to another hospital due to a large skin defect. No patient
died.

Risk factors
Table 2 summarises the risk factors for the incidence of E-­scooter
injuries. Of the 120 patients who participated in the voluntary
survey, 82 had a driving licence (68%), and 58 participants (48%)
reported having had previous experience in riding E-­scooters.

Figure 6 Total distribution of injury types. Soft tissue damage

including bruises, grazes, laceration and other wounds. Ligamentous
damage occurred especially in combination with luxation or in case of
Figure 4 Screw at rear wheel of an E-­scooter. clinically suspected.
298 Uluk D, et al. Emerg Med J 2022;39:295–300. doi:10.1136/emermed-2020-210268
 Original research
In 49 patients (20%), the alcohol breath test was positive. Furthermore, the narrow E-­scooter wheels are prone to get stuck
Among patients with alcohol consumption, 15 patients had TBI in the tram tracks.
(31%). A positive alcohol test was associated with a fivefold In contrast to cyclists, E-­ scooter riders hardly ever wear
increase in the odds of TBI (p<0.001) and a twofold increase in a helmet, which is confirmed by several international

Emerg Med J: first published as 10.1136/emermed-2020-210268 on 7 June 2021. Downloaded from [Link] on March 1, 2025 by guest.
the odds of inpatient admission (p=0.033) (table 2). Fifty-­eight studies.8 10 12–14 18 21–23 In Germany, helmets are mandatory for
patients had previous experience with E-­scooters but showed a riders of most motorised vehicles; for E-­scooters however, they
threefold increase in the odds of TBI (p=0.042). are only recommended.
Of note, within the 15 patients who had a positive alcohol test While the Muenster bicycle study and the European Commis-
and TBI, 12 patients stated that they had previous experience sion for Monitoring Road Safety identified head injuries in
with E-­scooters. 25% of bicycle incidents,19 20 ours and other studies reported
Only 1% of the E-­scooter riders wore a helmet. considerably higher rates in E-­scooter incidents, reaching up to

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58%.5 8 10 12–15 17 18 21 23 Thus, an obligation for E-­scooter riders to
wear a helmet seems inevitable to improve safety. In this context,
DISCUSSION a study from Brisbane showed a significant reduction in head
This study shows that E-­scooter riders were mainly aged 18–40 injuries with the introduction of mandatory helmets and the
years. The lower limbs were affected the most, mainly with soft simultaneous handing out of helmets by E-­scooter distributors.15
tissue damage, followed by head injuries. Fractures requiring Nevertheless, it should be noted that in this investigation and
surgery occurred more frequently in the upper limbs. E-­scooter in almost all international studies, approximately one-­quarter
incidents occurred mainly in the afternoon and evening, and of severe head injuries were severe midface fractures, which
rather on weekends than on weekdays. They were often caused would most likely not have been prevented by classic bicycle
by a violation of traffic regulations, the user’s inattentiveness or helmets.5 8 10 12–15 17 18 21 23 24
a risk-­taking driving style such as one-­handed driving, jumping Two international studies have described the musculoskeletal
over kerbs and alcohol consumption. injuries after E-­scooter incidents as the second most frequented
Driving under the influence of alcohol yielded a signifi- cause in trauma surgery in 2019.16 17
cantly higher risk of TBI, even if the riders were experienced In this study, fractures of the lower extremities were surpris-
in handling E-­scooters. This is important to note, because the ingly rare; instead, soft tissue lacerations of the medial malleolus
permitted blood alcohol limit for E-­scooter driving in Germany were frequently observed, which have not yet been described
is at 0.05%, and exceeding this limit is subject to a fine and may in the literature. These lacerations were caused by hitting the
be a criminal offence.7 Other international studies confirm our sharp-­edged platforms or the protruding screws of the E-­scoot-
results by revealing that positive blood alcohol tests occur in up er’s rear wheel and could be reduced by technical modifications
to one-­third of E-­scooter incidents.8–14 on the vehicle, such as rubber covers.
Trivedi et al were the first to investigate the consequences of This study reports the largest cohort of patients involved in
E-­scooter injuries within 1 year after their registration in Cali- E-­scooter incidents in Europe. Nevertheless, minor injuries may
fornia. They noted that there were more E-­scooter injuries at the be under-­ represented because some patients were treated by
ED than in cyclists or pedestrians during the same time period.15 general practitioners or did not demand medical care at all. The
Other studies published similar results with an incidence of up study was located in EDs in the Berlin city centre. Thus, different
to 60 per 100 000 E-­scooter rides within 6 months, resulting in numbers and causes of incidents or injury patterns might be
a short-­term ban of E-­scooters in selected cities.8 9 present in outlying districts. Also, the voluntary questionnaire
Frequently discussed risk factors for E-­ scooter injuries are was only handed out in two EDs and may show different results
the young age of the riders, a lack of experience in handling if given to a larger cohort.
E-­scooters and the absence of a driving licence. Under German Our results present the most frequent and serious injuries after
law, E-­scooters can be driven from the age of 14 years and hence E-­scooter incidents. An obligation for E-­scooter riders to wear a
a driving licence is not required. However, according to our helmet, strict controls on rider’s alcohol consumption, the intro-
study, neither the possession of a driving licence nor the previous duction of an age limit for riders and technical modifications to
experience with E-­ scooters prevented incidents. In contrast, E-­scooters should be considered in order to reduce incidents and
TBI occurred more frequently in patients with previous expe- injuries in the interest of all traffic participants.
rience and young age seems to be a more relevant risk factor,
because at least one-­third of E-­scooter incidents involved chil- Correction notice This paper has been updated to amend author name ’Martin
dren.5 12 13 15–18 Consequently, the Californian government intro- Möckel’. The author Undine Gerlach has also been updated to include the middle
initial A.
duced an age limit of 18 years and a driving licence requirement
for renting E-­scooters. Contributors DU and UG contributed to the study conception and design, analysis,
interpretation of data and writing of the manuscript. TL, MD, JWB, KB, AS and FJ
E-­scooters are often compared with bicycles, and although
participated in the acquisition and analysis of data. CW and MM contributed to the
the injury patterns resulting from incidents are in fact similar, analysis and interpretation of data, the study conception and the critical review of
their causes are different. A study on bicycle incidents in Muen- the manuscript.
ster (Germany) reported collisions with motorised vehicles as Funding The authors have not declared a specific grant for this research from any
the major cause of incidents, especially in younger patients.19 20 funding agency in the public, commercial or not-­for-­profit sectors.
In contrast, most E-­ scooter incidents occur without external Competing interests None declared.
influence and are related to inattention of the E-­scooter users
Patient and public involvement Patients and/or the public were not involved in
or violation of traffic regulations. Although E-­scooters are only the design, or conduct, or reporting, or dissemination plans of this research.
allowed to be used on cycle paths and roads, up to one-­quarter
Patient consent for publication Obtained.
of E-­scooter incidents take place on pavements, often injuring
Ethics approval The study was approved by the ethics committee of the
pedestrians.8 12 13 15 Typically, the riders lose stability when
Charité (EA2/171/19). Within the scope of patient registration and further
hitting the kerb to get onto the pavement, because the E-­scooter analyses, compliance with ethical aspects and data protection regulations was
front wheel is rather small in diameter and thus acts as a fulcrum. ensured.

Uluk D, et al. Emerg Med J 2022;39:295–300. doi:10.1136/emermed-2020-210268 299

 Original research
Provenance and peer review Not commissioned; externally peer reviewed. 10 Puzio TJ, Murphy PB, Gazzetta J, et al. The electric scooter: a surging new mode of
transportation that comes with risk to riders. Traffic Inj Prev 2020;21:175–8.
Data availability statement Data are available upon reasonable request. All
11 Mitchell G, Tsao H, Randell T, et al. Impact of electric scooters to a tertiary emergency
collected data have been entered into an Excel data sheet and patient’s privacy
department: 8-­week review after implementation of a scooter share scheme. Emerg
information has been pseudonymised. The Excel document itself is password
Med Australas 2019;31:930–4.
protected and saved upon a password-­protected server of the Department of

Emerg Med J: first published as 10.1136/emermed-2020-210268 on 7 June 2021. Downloaded from [Link] on March 1, 2025 by guest.
12 Beck S, Barker L, Chan A, et al. Emergency department impact following
Emergency Medicine at Charité University Medicine Berlin with restricted access.
the introduction of an electric scooter sharing service. Emerg Med Australas
Data protection is following the data protection declaration of the respective
institution and will be available upon reasonable request. 2020;32:409–15.
13 Blomberg SNF, Rosenkrantz OCM, Lippert F, et al. Injury from electric scooters in
Open access This is an open access article distributed in accordance with the Copenhagen: a retrospective cohort study. BMJ Open 2019;9:e033988.
Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which 14 Wüster J, Voß J, Koerdt S, et al. Impact of the rising number of Rentable E-­scooter
permits others to distribute, remix, adapt, build upon this work non-­commercially, accidents on emergency care in Berlin 6 months after the introduction: a maxillofacial
and license their derivative works on different terms, provided the original work is perspective. Craniomaxillofac Trauma Reconstr 2021;14:43–8.

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IMAGE CHALLENGE
Put your hands up!
CLINICAL INTRODUCTION
A 91-­year-­old obese man presented to our ED, having symp-
toms of severe pain and inability to move the right shoulder after
falling against a parked car.
Patient’s comorbidities included chronic obstructive pulmo-
nary disease, chronic kidney disease, ischaemic and valvular
cardiomyopathy, atrial fibrillation.
Vitals were in range, except for marked tachypnoea. On
inspection, the arm was held abducted and overhead. A marked
protuberance was visible over the axillary area. Range of motion
was extremely limited. No neurovascular deficits were apparent.
A right shoulder X-­ray was performed (figure 1).
Figure 1 Right shoulder: X-­ray—anteroposterior view.
QUESTION
According to findings in figure 1, what is the patient suffering
C. Luxatio erecta humeri with scapular and glenoid fractures.
from?
D. Right pneumothorax with concomitant glenoid fracture
A. Lytic osseous lesions secondary to occult lung cancer
B. Posterior shoulder dislocation with acromio-­clavicular dias-
For answer see page 342
tasis

300 Uluk D, et al. Emerg Med J 2022;39:295–300. doi:10.1136/emermed-2020-210268