A comprehensive scoping review of the literature was conducted using databases – PubMed (NCBI, Bethesda, MD, United States [US]), Scopus (Amsterdam, the Netherlands), and Web of Science (London, United Kingdom [UK]). Eligible studies were limited to those conducted in South Africa or involving South African populations and published or available in English translation between 2020 and 2025. The reference lists of included articles were examined to identify any other pertinent articles. The search strategy was designed with a combination of Medical Subject Headings and Emtree terms. Search criteria included topics pertaining to motorbike, motorcycle, or scooter utilisation; delivery or food-delivery services; and outcomes such as injury, trauma, fracture, or musculoskeletal injury (Table 1). All records obtained were evaluated in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Two reviewers independently examined titles and abstracts utilising the Rayyan QCRI tool (Cambridge, MA, US).⁷ Articles were included only after consensus among reviewers was reached.

Data extraction was conducted with a standardised collection sheet. References were compiled using Mendeley v1.19.8 (London, UK). Each reviewer performed data extraction independently, and any inconsistencies were reconciled through discussion until consensus was reached. Selected full-text publications were meticulously evaluated, and the retrieved data were compiled into a Microsoft Excel spreadsheet (Redmond, WA, US) for analysis.

Our search strategy revealed 287 studies from PubMed, 14 from Scopus, and 154 from Web of Science. Following the elimination of duplicates, a total of 438 records were retained for screening. A total of 435 studies failed to satisfy the inclusion criteria and were therefore excluded after the comprehensive screening process. Three studies satisfied the inclusion criteria (Figure 1) and their characteristics are presented in Table 1.

Three studies,^8,9,10 reporting on 161 injuries in 133 patients, were included in this review. The distribution and severity of orthopaedic injuries sustained by delivery motorbike drivers were analysed across three distinct studies in South African public hospitals: a study focusing on Cape Town metropole, a study conducted at Tembisa Provincial Tertiary Hospital (TPTH) focusing on Ekurhuleni municipality, and a study conducted at Steve Biko Academic Hospital in Tshwane municipality. All studies assessed injury patterns in victims of motorbike accidents, whereas two studies examined the associated economic effects. The main features of these investigations are presented in Table 1.

The injuries sustained by delivery motorcyclists are characterised by high-energy mechanisms, severe orthopaedic injuries, and a significant demand on hospital resources. The cumulative incidence of injuries sustained by this group was reported as 118 per 10 000 patients (1% of total orthopaedic trauma) treated in Tembisa over 7 months (Pretoria and Cape Town). This population group consists almost exclusively of young, healthy males (mean age 32 years in one study; 20–44 years, with an average age of 29 years, in another). In the Cape Town study, all included patients were foreign nationals. The vast majority are considered self-employed (86% in the Cape Town study) via mobile phone applications, such as Uber, Mr Delivery, Checkers Sixty60, and Bolt. These findings are summarised in Table 2.

Accidents are common after hours during peak traffic, with 60% of patients in one study arriving at the emergency department after 16:00. The predominant mechanism of injury reported was the motorbike being struck by another vehicle. The majority (77% in Pretoria, 78% in Tembisa) included long bone fractures and/or major joint dislocations. The injuries are often high velocity in nature and include femur fractures (36% of 57 injuries in Cape Town study; 52% of lower limb injuries in Pretoria study, 26% in Tembisa) and tibial fractures (32% in Tembisa study, 24% in Cape Town study). Open fractures are reported in all studies, including those involving the tibia and femur.

For this review, polytrauma was defined as an Injury Severity Score (ISS) greater than 15 or, when ISS was unavailable, as the presence of injuries affecting multiple body systems requiring admission to intensive or high-level care. Polytraumatised patients constituted 29% of the injured drivers in the Cape Town study, with 13% requiring admission to an intensive or high care unit. An overwhelming majority of these patients required surgical management. In one study, 86% of delivery motorcyclists were managed surgically. The most common procedure was long bone intramedullary nailing. The majority had a prolonged hospital stay: the median length of admission was 8 days in the Cape Town study, and over 50% of patients in the Pretoria study stayed longer than 5 days. Prolonged hospitalisation increases the consumption of hospital resources and affects patients’ productivity.

The initial orthopaedic surgical management of 44 uninsured delivery motorcyclists in Cape Town over 1 year cost the state an estimated R3.99 million. The median cost per injured driver for initial surgical management was R52 061.00 (~United Stated dollar [USD] 3183.00) (with a range up to R348 894.00 [~USD21 347.00]). In Gauteng, an estimated total treatment cost of R2 781 941.70 (~USD170 217.00) was incurred for 30 surgically managed e-hailing drivers at TPTH over 7 months. This contributed 0.0047% of the provincial health budget for 2022/2023. These costs are resource-intensive, driven by factors, such as prolonged hospital and intensive care unit (ICU) stays. Total costs for in-hospital admission and ICU stay in the Cape Town study amounted to over R2m (~USD122 373.00) (median length of ICU stay was 4 days, and median cost of R80 045.00) ~ (USD4897.00). The total cost of implants was R1.33m (~USD81 000.00), and the cost of imaging, including X-rays, computed tomography scans, and fluoroscopy, was estimated at R417 594.00 (~USD25 551.00).

Consistent with standard scoping review methodology, a formal risk-of-bias assessment was not undertaken.¹¹ The aim of this review was purely to map the existing literature and identify knowledge gaps, rather than to evaluate the effectiveness of interventions.

This review draws on recent South African literature examining orthopaedic injuries sustained by delivery motorbike drivers, summarising the observed clinical and economic burdens, and detailing subsequent policy and legislative advocacy. Since the COVID-19 pandemic, there has been a reported increase in the number of these drivers on South African roads. The job incentivises drivers to work long hours, often in adverse weather and low-visibility conditions, further increasing their risk of crashes.

The injury patterns observed in this review are consistent with high-energy mechanisms typically seen in road traffic trauma in low- and middle-income countries (LMICs). Long-bone fractures of the femur and tibia were among the most frequently reported injuries across the included studies, reflecting the vulnerability of motorbike riders during collisions with larger vehicles. These injuries frequently require operative fixation and prolonged hospitalisation, placing substantial strain on already resource-limited orthopaedic trauma services. Similar patterns have been reported in other trauma registries in LMICs, where road traffic injuries disproportionately consume trauma theatre capacity and intensive care resources. Strengthening trauma systems, including improved dedicated orthopaedic trauma capacity, could reduce morbidity and disability associated with these injuries. Evidence from LMIC trauma system strengthening initiatives has demonstrated that improved trauma care infrastructure can significantly reduce mortality following road traffic injuries.¹²

The impacts of these crashes extend beyond the direct hospital costs. The orthopaedic injuries sustained place a significant financial burden on the public healthcare sector, particularly because most injured drivers are uninsured. The reported costs are likely to be underestimates of the true burden, as they exclude costs related to the emergency centre, treatment of associated non-orthopaedic systemic injuries (such as head injuries), outpatient care, chronic care, follow-up, re-admissions, and general consumables. The resources consumed by managing these severe trauma cases divert theatre time and capacity away from other hospital services, such as elective surgery. Because many drivers lack formal employment contracts, the costs that would typically be claimed from an occupational injury compensation fund are instead borne by the state medical system.

They also have a direct economic effect because of the loss of productivity among a young, economically active demographic. The injured drivers are often breadwinners, and their inability to earn an income for weeks or months post-injury creates a societal problem.

In South Africa, e-hailing drivers are generally considered independent contractors. They are therefore typically not entitled to the full range of employee benefits, including those related to occupational health and safety.⁶ The National Land Transport Amendment Act, 2023 (Act No. 23 of 2023, assented to in June 2024) (NLTAA) and the Occupational Health and Safety Act, 1993 (OHSA) (Act No. 85 of 1993), intersect with the reality of e-hailing drivers primarily through regulation, vehicle safety requirements, and the contentious issue of worker classification and protection.¹³ The NLTAA specifically inserts the definition of an ‘electronic hailing service’ or ‘e-hailing service’ – regulation of the E-hailing Application (Section 66A).¹⁴ This section, however, has no specific provisions or descriptions for food-delivery e-hailing drivers. It provides for a simplified procedure for obtaining temporary licences ‘over the counter’ and a simplified application process for replacing a vehicle specified in the operating licence. A person or an organisation that provides the e-hailing software application (apps) commits an offence if they permit an operator to use the app to operate a vehicle without a valid operating licence or permit or if it has lapsed or been cancelled. We suggest that specific policy reforms should include amendments to the NLTAA to incorporate provisions for delivery motorbike operators and the extension of occupational protection under the Compensation for Occupational Injuries and Diseases Act (COIDA) to delivery motorbike drivers.

If e-hailing drivers were recognised as employees, they would be entitled to OHSA protections. They would also be entitled to education on labour laws, safety equipment and maintenance, as well as training on the hazards associated with their work, among other benefits. Many e-hailing drivers are young migrant workers who frequently lack formal safety training and work under poorly regulated conditions. These factors may predispose them to unsafe practices, increase their risk of road traffic crashes, and leave them with limited occupational risk recognition, injury insurance, and unemployment protection.

The clinical and economic burdens identified in the literature lead to specific recommendations for policy and legislative change, primarily focusing on mandated insurance and on provisions for benefits and protections for self-employed delivery drivers similar to those afforded to employees. The core highlighted issue is that many delivery drivers are considered self-employed through apps and lack formal employment contracts, leaving them without recourse to claim under the COIDA in the event of an accident. We strongly advocate amending existing legislation and policies to protect this vulnerable demographic and shift the financial burden away from the state. Legislative reforms mandating insurance coverage for delivery motorbike drivers should be considered. The medical expenses incurred by the public sector would otherwise have been claimed from the occupational injury compensation fund had the drivers held formal contracts.