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Bicycle spoke injuries of the foot and ankle in children: An underestimated “minor” injury
Bicycle Spoke Injuries of the Foot and Ankle in Children: An Underestimated “Minor” In jury By ROBERT J. IZANT, JR., BRUCE F. ROTHMANNANDVICTOR H. FRANKEL
B
ICYCLE SPORE INJURIES to the lower extremeties, especially the malleoli, of children present a significant problem in management because of the “minor” appearance of the initial injury. Treatment is frequently casual because the extent of the injury is not recognized and its potential harm not appreciated. Injury usually results from the sudden, forceful trapping of the foot between the spokes and frame of a bicycle. It is probably a common injury, since more than 150,000 pedal bicycle injuries occur in the United States of America each year.l Our experience in the past 4 years with 60 cases under 14 years of age prompts us to call attention to this entity as injury that requires -special consideration. CLINICALEXPERIENCE Mode of Znjury There is a striking similarity of bicycle spoke injury to “wringer” injury of the arm in that the initial examination may not reveal the true extent of the injury.2s3 In almost every instance, the injury has occurred while 2 children were on a bicycle built for one (Fig. 1). The passenger usually rides on the handle bar, the cross arm of the frame or the rear fender. Either foot may become impinged in the area between the spokes of the wheel and the frame of the cycle. This rapidly stops the bicycle and transmits the kinetic energy to the trapped foot. The resultant injury is a combination of several forces; however, the term “bicycle spoke” injury is descriptive and seems adequately to set this lesion apart from other types of injury. This accident is most common between the ages of 2 and 8 (average 5) when the leg length subjects the foot and ankle to involvement. From the Case Western Reserve University School of Medicine, Cleveland, Ohio. ROBERT J. IZANT, JR., M.D.: Associate Professor of Pediatric Surgery, Case Western Reserve University School of Medicine, Director Divison of Pediatric Surgery, University Hospitals of Cleveland and School of Medicine, Case Western Reserve University. BRUCE F. ROTHMANN, M.D.: Assistant Clinical Professor Pediatric Surgery, Case Western Reserve University School of Medicine; Chief of Surgery, The Children’s Hospital of Akron, Akron, Ohio. VICTOR H. FRANKEL, M.D.: Associate Professor of Orthopedic Surgery, Case Western Reserve University, School of Medicine, Assistant Orthopedic Surgeon University Hospitals of Cleveland. Supported in part by The Rainbow Hospital Pediatric Surgery Fund and the Elizabeth Wilson Goetz Pediatric Surgery Research Fund. Presented before the British Association of Paediatric Surgeons, University College, Dublin, August 27-29, 1969. 654
JOURNAL OF PEDIATRICSURGERY,VOL. 4, No. 6 (DECEMBER), 1969
655
BICYCLESPOKEINJURIES
Fig.
l.-Diagram
of the three danger positions of 2 persons on a bicycle built for
one. Mechanism
of Injury
There are usually three aspects to this specific trauma: ( 1) Laceration of the tissue from the knife-like action of the spoke, (2) crushing from the impingement between the wheel and frame of the bicycle and (3) shearing injury from the coefficient of these two forces. The laceration usually involves the malleoli, Achilles tendon area of the heel or dorsum of the foot. Loss of the tissue over the malleoli may be complete, including the periosteum. Tendons may be exposed dorsally. The flap of tissue involving the heel area is usually based distally and, therefore, subject to necrosis. Simple suture closure commonly leads to dehiscence of the wound and prolonged secondary healing. The extent of the necrotic devascularized tissue is not apparent at initial examination, and the decision to graft skin must either await delineation by necrosis or follow wide debridement. The compression of tissue produces necrosis that may not be apparent for several days until the injured blood vessels have thrombosed and produced devitalization, frequently not apparent for 3 or 4 days. The shearing produced by the abrupt stretching of the soft tissue from the fixed points about the ankle not only separates the layers of tissue and interrupts the blood supply but is also probably the mechanism by which tibia1 and fibular fractures occur. There were 2 in this group: fractured phalanges in 3 lateral toes and a spiral fracture of the tibia. TREATMENT
After fracture has been ruled out or treated, areas of abrasion or tissue loss are treated as second- or third-degree burns or wringer injuries by mild compression with multilayered cotton bandage covered by an elastic bandage. Fura-
656
IZANTET AL.
tin” gauze is used as a dressing next to the wound. The injured extremity is elevated and weight bearing is not permitted. If severe injury is apparent, a plaster-splint is applied to insure complete immobilization. The dressings are changed frequently and the status of the wound evaluated. Debridement of devitalized tissue is performed as necrosis becomes apparent. Most patients have been managed as outpatients and hospitalized only when surgical treatment became necessary. Early skin grafting of the dorsum of the foot or malleoli has reduced the time required for healing and provides a more physiologic coverage for a lifetime of use. A 5-day homograft has contributed significantly to the “take” of the autograft. Closure of a laceration should be done only after careful debridement, with special attention directed toward defatting the thick skin flaps about the heel. RESULTS All patients have regained normal function of the foot and ankle. The morbidity has been substantial, as mentioned previously by Strauch.4 The average time required for complete healing under ideal circumstances has been 5 to 6 weeks. Initial treatment has been aggressive until an adequate assessment of the extent of damage is possible. Absence of normal skin over prominent areas as the malleoli, heel or dorsum of the foot may lead to a lifetime of discomfort, recurrent ulceration and pain. CONCLUSIONS Most pedal cycle accidents have been the result of 2 persons riding a bicycle built for one. Injury to the foot and ankle while riding a bicycle is the result of lacerating, compressing and shearing forces. The extent of injury when first seen is frequently not appreciated. The possibility of this injury must be stressed in any discussion of bicycle safety. Only one person should be permitted to ride on a bicycle built for one. Bicycle manufacturers should be encouraged to design more imaginative protective screening. SUMMARIO
IN INTERLINGUA
Trauma de1 malleolos, de1 calce, o de1 dorso de1 pede occurre coma resultato de un subite intrappamento de1 pede inter le radios de1 rota e le chassis de un bicycletta. In quasi omne le cases, le accidente occurre quando 2 personas occupa un bicycletta construite pro un sol. Le resultante lesion es le effect0 de un combination de fortias lacerante, comprimente, e cisorial. Le evalutation initial de1 vulnere usualmente non revela le ver exfension de1 damno. Le guarition require inter 4 e 6 septimanas e necessita in certe cases graffage cutanee. REFERENCES 1. Statistical Bulletin: Metropolitan Life Insurance Co. Vol. 48, pp. 4-6. July 1967. 2. MacCollum, D. W., Bernard, W. R. and Banner, R. C.: The treatment of wringer arm injuries. New Eng. J. Med., pp. 247; 750; 754, 1952.
3. MacCollum, D. W.: Wringer Arm, A report of twenty-six cases. New Eng. J. Med., pp. 218; 549; 554, 1938. 4. Strauch, B., Bicycle spoke injuries in children. Journal Trauma 6: pp. 61-64, 1966.
B
ICYCLE SPORE INJURIES to the lower extremeties, especially the malleoli, of children present a significant problem in management because of the “minor” appearance of the initial injury. Treatment is frequently casual because the extent of the injury is not recognized and its potential harm not appreciated. Injury usually results from the sudden, forceful trapping of the foot between the spokes and frame of a bicycle. It is probably a common injury, since more than 150,000 pedal bicycle injuries occur in the United States of America each year.l Our experience in the past 4 years with 60 cases under 14 years of age prompts us to call attention to this entity as injury that requires -special consideration. CLINICALEXPERIENCE Mode of Znjury There is a striking similarity of bicycle spoke injury to “wringer” injury of the arm in that the initial examination may not reveal the true extent of the injury.2s3 In almost every instance, the injury has occurred while 2 children were on a bicycle built for one (Fig. 1). The passenger usually rides on the handle bar, the cross arm of the frame or the rear fender. Either foot may become impinged in the area between the spokes of the wheel and the frame of the cycle. This rapidly stops the bicycle and transmits the kinetic energy to the trapped foot. The resultant injury is a combination of several forces; however, the term “bicycle spoke” injury is descriptive and seems adequately to set this lesion apart from other types of injury. This accident is most common between the ages of 2 and 8 (average 5) when the leg length subjects the foot and ankle to involvement. From the Case Western Reserve University School of Medicine, Cleveland, Ohio. ROBERT J. IZANT, JR., M.D.: Associate Professor of Pediatric Surgery, Case Western Reserve University School of Medicine, Director Divison of Pediatric Surgery, University Hospitals of Cleveland and School of Medicine, Case Western Reserve University. BRUCE F. ROTHMANN, M.D.: Assistant Clinical Professor Pediatric Surgery, Case Western Reserve University School of Medicine; Chief of Surgery, The Children’s Hospital of Akron, Akron, Ohio. VICTOR H. FRANKEL, M.D.: Associate Professor of Orthopedic Surgery, Case Western Reserve University, School of Medicine, Assistant Orthopedic Surgeon University Hospitals of Cleveland. Supported in part by The Rainbow Hospital Pediatric Surgery Fund and the Elizabeth Wilson Goetz Pediatric Surgery Research Fund. Presented before the British Association of Paediatric Surgeons, University College, Dublin, August 27-29, 1969. 654
JOURNAL OF PEDIATRICSURGERY,VOL. 4, No. 6 (DECEMBER), 1969
655
BICYCLESPOKEINJURIES
Fig.
l.-Diagram
of the three danger positions of 2 persons on a bicycle built for
one. Mechanism
of Injury
There are usually three aspects to this specific trauma: ( 1) Laceration of the tissue from the knife-like action of the spoke, (2) crushing from the impingement between the wheel and frame of the bicycle and (3) shearing injury from the coefficient of these two forces. The laceration usually involves the malleoli, Achilles tendon area of the heel or dorsum of the foot. Loss of the tissue over the malleoli may be complete, including the periosteum. Tendons may be exposed dorsally. The flap of tissue involving the heel area is usually based distally and, therefore, subject to necrosis. Simple suture closure commonly leads to dehiscence of the wound and prolonged secondary healing. The extent of the necrotic devascularized tissue is not apparent at initial examination, and the decision to graft skin must either await delineation by necrosis or follow wide debridement. The compression of tissue produces necrosis that may not be apparent for several days until the injured blood vessels have thrombosed and produced devitalization, frequently not apparent for 3 or 4 days. The shearing produced by the abrupt stretching of the soft tissue from the fixed points about the ankle not only separates the layers of tissue and interrupts the blood supply but is also probably the mechanism by which tibia1 and fibular fractures occur. There were 2 in this group: fractured phalanges in 3 lateral toes and a spiral fracture of the tibia. TREATMENT
After fracture has been ruled out or treated, areas of abrasion or tissue loss are treated as second- or third-degree burns or wringer injuries by mild compression with multilayered cotton bandage covered by an elastic bandage. Fura-
656
IZANTET AL.
tin” gauze is used as a dressing next to the wound. The injured extremity is elevated and weight bearing is not permitted. If severe injury is apparent, a plaster-splint is applied to insure complete immobilization. The dressings are changed frequently and the status of the wound evaluated. Debridement of devitalized tissue is performed as necrosis becomes apparent. Most patients have been managed as outpatients and hospitalized only when surgical treatment became necessary. Early skin grafting of the dorsum of the foot or malleoli has reduced the time required for healing and provides a more physiologic coverage for a lifetime of use. A 5-day homograft has contributed significantly to the “take” of the autograft. Closure of a laceration should be done only after careful debridement, with special attention directed toward defatting the thick skin flaps about the heel. RESULTS All patients have regained normal function of the foot and ankle. The morbidity has been substantial, as mentioned previously by Strauch.4 The average time required for complete healing under ideal circumstances has been 5 to 6 weeks. Initial treatment has been aggressive until an adequate assessment of the extent of damage is possible. Absence of normal skin over prominent areas as the malleoli, heel or dorsum of the foot may lead to a lifetime of discomfort, recurrent ulceration and pain. CONCLUSIONS Most pedal cycle accidents have been the result of 2 persons riding a bicycle built for one. Injury to the foot and ankle while riding a bicycle is the result of lacerating, compressing and shearing forces. The extent of injury when first seen is frequently not appreciated. The possibility of this injury must be stressed in any discussion of bicycle safety. Only one person should be permitted to ride on a bicycle built for one. Bicycle manufacturers should be encouraged to design more imaginative protective screening. SUMMARIO
IN INTERLINGUA
Trauma de1 malleolos, de1 calce, o de1 dorso de1 pede occurre coma resultato de un subite intrappamento de1 pede inter le radios de1 rota e le chassis de un bicycletta. In quasi omne le cases, le accidente occurre quando 2 personas occupa un bicycletta construite pro un sol. Le resultante lesion es le effect0 de un combination de fortias lacerante, comprimente, e cisorial. Le evalutation initial de1 vulnere usualmente non revela le ver exfension de1 damno. Le guarition require inter 4 e 6 septimanas e necessita in certe cases graffage cutanee. REFERENCES 1. Statistical Bulletin: Metropolitan Life Insurance Co. Vol. 48, pp. 4-6. July 1967. 2. MacCollum, D. W., Bernard, W. R. and Banner, R. C.: The treatment of wringer arm injuries. New Eng. J. Med., pp. 247; 750; 754, 1952.
3. MacCollum, D. W.: Wringer Arm, A report of twenty-six cases. New Eng. J. Med., pp. 218; 549; 554, 1938. 4. Strauch, B., Bicycle spoke injuries in children. Journal Trauma 6: pp. 61-64, 1966.