Despite increases in helmet use, powered two wheelers (PTWs – mopeds, motorcycles, scooters) remain the most dangerous form of travel on today’s roads. This study sought to identify helmet use rates, mortality rates, and injury patterns among PTW users in Spain using a cross‐sectional, ecological study design. Overall helmet use rates for 2005‐2008 were obtained from sample‐based observational studies performed by the Spanish Dirección General de Tráfico (DGT). Injury distributions among non‐fatally‐injured PTW users (age 14+) were obtained from a census of injury‐related hospital discharge records. Fatality data were obtained from a census of police‐reported roadway fatalities. Helmet use ranged from 85% to 100%. The most common injuries among non‐fatally injured patients were fractures of the lower extremity (23% of injuries) and upper extremity (18%), and traumatic brain injury (12%). Fatality rates ranged from 0.8 to 3.0 per 100,000 population, per year. Neither the fatality rates nor the percent of non‐fatal hospital cases exhibiting an AIS 3+ head injury correlated significantly with fluctuations in overall helmet use (within the range observed). These observations highlight challenges in PTW user safety remaining in populations that exhibit high helmet use rates. Future work includes re‐examining risk factors in these populations to identify continuing opportunities for intervention.