Orthopedic trauma surgeon Dr. Lisa Cannada treats some of the most severe injuries that come to the emergency department.

But she also has another mission: “I always try to dig deeper with any patient about how and why they got injured, and what I can do to prevent that for others,” said Cannada, who treats patients in both the emergency room and in the Novant Health Orthopedic Fracture Clinic in Charlotte.

For example: After treating multiple pickleball players with fractures, Cannada dove into data and discovered that there had been a 90-fold increase in pickleball-related fractures over two decades — starting national conversations about staying safe while playing.

Now she’s sounding the alarm again — this time, about e-bike injuries.

What is an e-bike?

E-bikes look similar to regular bikes, but have a battery and motor that help riders move faster.

Some e-bikes require continuous pedaling for the motor to assist, while others are activated by a throttle and don’t require pedaling. They can travel as fast as 20 to 28 mph, depending on the model.

In 2022, more than 1 million e-bikes were sold in the U.S., with sales expected to grow year-over-year.

Cannada understands the appeal: “People go out thinking it’s going to be fun,” Cannada said, “and when gas prices are way up like they are right now, people use them because it’s cheaper.”

But as an orthopedic trauma surgeon, she gets a view others don’t: “People don’t understand the severity of what an e-bike injury can be,” Cannada said.

Why are e-bikes more dangerous than regular bikes?

Although e-bikes look like regular bikes, accident injury patterns aren’t similar between the two, Cannada said. She treats adults in emergency rooms, but she’s all too aware of the dangers for riders of all age groups.

Injuries from regular bikes are typically isolated to one body part, like a wrist, clavicle or ribs, and rarely extend into the lower body, Cannada said.

But patients Cannada treats after e-bike accidents often have severe damage to at least two body areas (a medical condition called “multisystem trauma”).

Head and facial trauma are common. So are pelvic fractures, which can cause severe internal bleeding, disrupted nerves and blood vessels, organ damage and sexual dysfunction.

Cannada’s treated multiple e-bike riders with broken shinbones that pierce the skin and other fractures — serious injuries with a high risk for infection that take up to a year to recover from if things go well.

One patient even needed their leg amputated. “It was not salvageable,” Cannada said.

Why are injuries from e-bike accidents more severe than bike accidents? Blame Newton’s second law of motion — the bigger and faster something is, the harder it hits.

An e-bike is 20 to 40 pounds heavier than a regular bike, and e-bike riders are often traveling at the speed of top Tour de France riders — without the closed course.

“When you’re going up to 28 miles per hour, you can have significant injuries,” Cannada said. “It’s not just the speed they were going, but what they hit — did they jump onto a curb and fall down, hit a moving car or hit a solid object? Were they on a path, and was it soft, gravel or paved?”

And that’s before risky behaviors enter the picture.

“I’m sure you’ve seen two people on a bike, riders weaving in and out of traffic, e-bikes being driven as off-road vehicles, e-bikes at night with no reflective gear or coming from the partying parts of town and bars,” Cannada said. “You see 12-year-olds riding them, going fast in your neighborhood.”

And in one study, fewer than half of e-bikers seen in the emergency department after an e-bike accident had worn a helmet. (North Carolina law requires children under the age of 16 to wear a properly fastened helmet when riding a bike. South Carolina has no law requiring the use of bicycle helmets.)

Another study found that 30% of e-bike injuries involved a motor vehicle. Pedestrians have also been injured and killed after being struck by e-bikes.

A study on national emergency room data showed that from 2017 to 2022, there was a 30-fold rise in e-bike injuries in the U.S.; study authors noted that the actual number of injuries could be higher, because some people never seek treatment or they get care outside of the ER.

Cannada isn’t the only medical professional who’s concerned. The American College of Surgeons calls e-bikes an emerging “public health hazard," the American Academy of Orthopaedic Surgeons warns of “rising injury risks for [e-bike] riders of all ages," and the American Association of Neurological Surgeons called e-bikes and e-scooters “a serious health and safety risk to riders and pedestrians alike.”

Cannada’s take: E-bikes can be more dangerous than motorcycles.

Under current laws, Cannada believes that riding an e-bike can be riskier than riding a motorcycle.

That’s because federal laws don’t regulate e-bikes like motor vehicles; instead, regulations vary based on geography.

Cannada points out that drivers must be licensed to operate motorcycles and cars — but don’t need a license to ride an e-bike. She’s also concerned that helmet laws vary by age and location — and aren’t always enforced.

Another concern is road-sharing: “Drivers are used to motorcycles and how to respond,” Cannada said. “But people aren’t used to e-bikes.”

And laws haven’t caught up with how people use e-bikes, Cannada said, adding, “Have you ever seen or read that anyone’s been arrested for driving under the influence on an e-bike? No, but people do it.”

While Cannada treats adults rather than children, she's watching injury trends across age groups.

The rising rates of e-bike injuries in kids are getting national media attention, but Cannada’s also concerned about another age group: “Older people are riding them more — and people over 50 years old with poor bone density will have more injuries,” Cannada said.

How to stay safe if you ride an e-bike

Here’s Cannada’s honest opinion: She’s a cyclist — on weekends, during the daytime hours — but wouldn’t get on an e-bike.

But here’s her advice if you make a different choice:

• Location matters: Go on a path that’s paved with a stable surface, at a time of day where the path isn’t busy.
• Have the right protective gear: Wear an e-bike-specific helmet instead of just a bike helmet, install lights on your e-bike, and wear a reflective vest and patches on your helmet.
• Avoid the fastest e-bikes: Class 1 and 2 e-bikes have a maximum speed of 20 miles per hour, while Class 3 can go up to 28 miles per hour. The faster you’re going, the more energy will go into any crash.
• Be aware — not impaired: Don’t drink alcohol, be aware of your surroundings, and follow the rules of the road.
• Don’t let young children ride them: The American Academy of Pediatrics advises against e-bike use for children younger than 12.

Cannada hopes future legislation addresses where e-bikes can be ridden and creates age limits and licensing requirements.

In the meantime, she’s trying to do her part to raise awareness of the risk.

“People go out thinking, ‘It's going to be fun — let's go ride it to go to lunch,’ and it can destroy their whole year,” Cannada said. “They have fractures and injuries that impact their work life and personal life — just from doing something leisurely. E-bikes are not to be taken lightly.”