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Motorcycle spoke injuries of the heel
Injury, Int. J. Care Injured 42 (2011) 356–361
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Motorcycle spoke injuries of the heel Yue-Liang Zhu a, Jun Li a,*, Wei-Qing Ma b, Liang-Bin Mei a, Yong-Qing Xu a a b
Department of Orthopaedic Surgery, Kunming General Hospital, Chengdu Military Region, Kunming, China Department of Anesthesiology, Kunming General Hospital, Chengdu Military Region, Kunming, China
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 19 August 2010
Introduction: The spoke injuries of the lower extremity seems never stop haunting the surgeons since its first report 62 years ago. A prospective study of motorcycle spoke injuries in the heel was undertaken to study the injury mechanism, the treatment protocols, and the outcomes. Patients and methods: From 2001 to 2010, 89 cases of motorcycle spoke injuries of the heel were examined. The various injury mechanisms were analysed. Flaps and other reconstruction surgeries were used to manage the involved extremity. Results: The mechanisms of the motorcycle spoke injuries of the heel had some unique features. A grading system was developed for the injuries according to the tissues involved. The surgery protocols primarily consisted of flap transfers, Achilles tendon reconstruction, and calcaneus management. Conclusions: The eradication of the motorcycle spoke injuries is a difficult task, but the treatment outcomes have been greatly improved due to the advancement of surgical techniques. ß 2010 Elsevier Ltd. All rights reserved.
Keywords: Spoke injuries Heel Achilles tendon Flaps Injury mechanism Grades
Introduction Since the first report of bicycle spoke injuries in 1948,12 the reports of the spoke injuries are not common but appears every 1 or 2 years constantly,1,3,4,6,8–11,13–17,19 Compared with the bicycles, the motorcycles caused more severe spoke injuries due to their higher energy.1,3,10,15,19 The heel is the most susceptible site of this injury. The treatment turns to be very challenging because the injury usually involves the combined defects of skin, calcaneus, and Achilles tendon which have been already broken and contaminated. Complex and repeated surgeries may be required for the limb salvage. Even so, the amputation seems unavoidable in some situations.7,19 We describe our experience in the management of these injuries over a 9-year period during which a special grade system were developed. Patients and methods Between January 2001 and December 2009, 139 cases of motorcycle spoke injuries were admitted into our center. Among them, 89 cases were the heel injuries. Of all the 89 cases, 49 cases were children or adolescents (216 years), 40 were adults. Eighty-eight cases were wearing shoes at the injury moment and one was not. The wound situations were divided into four grades according to the severity and surgery principles (Table 1). The schematic * Corresponding author at: Orthopaedic Department, Kunming General Hospital, 212#, Daguanlu Road, Posting code: 650032, Kunming, China. Tel.: +86 13577055695/08714775655; fax: +86 08714775655. E-mail addresses: [email protected], [email protected] (J. Li). 0020–1383/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2010.08.029
drawing and real cases of the grading are shown in Figs. 1 and 2. Patient’s data including age, sex, side of injury, treatment protocols and the outcomes were recorded (Table 2). The defect size of the heel skin ranged from 4 cm 2 cm to 14 cm 10 cm. The defect length of Achilles tendon ranged from 3 to 13 cm in the neutral position of the ankle joint under anaesthesia. Thirty-three cases (37.1%) of 43 fractures were noted in all the 89 cases (some had two or three sites). The fractures included the calcaneus (n = 16), the talus (n = 3), and the distal fibulae (n = 7), the distal tibia (5). The bone defects included the calcaneus (n = 6), the lateral malleolus (n = 3), and the medial malleolus (n = 1). Surgery techniques Preoperatively the wound would receive repeated debridements, daily dress changes, or vacuum assisted drainage system.5 Three cases were amputated of the involved limb. The flaps used in this series included regional pedicled flap (9 cases), the lateral supramalleolar flap (8 cases), reverse sural flap (31 cases), reverse saphenous neurocutaneous flap (15 cases), free thoracodorsal artery perforator flap (three cases), sliding gastrocnemius musculocutaneous flap20 (17 cases), and free anterolateral thigh perforator flap (three cases). Three cases of grade III injury were found in the operations that the posterior tibial artery and veins were broken or lacerated. They were just ligated for the anterior tibial arteries were intact. Only one case among the three cases had a broken tibial nerve at the ankle site. It was re-anastomosed with 9-0 nylon line under a microscope.
Y.-L. Zhu et al. / Injury, Int. J. Care Injured 42 (2011) 356–361 Table 1 Grades of motorcycle spoke injuries of the heel. Grade Injured tissues
Surgery principles
I
Heel skin defected Achilles tendon Exposed
Flap transfer
II
Heel skin defected Achilles tendon ruptured
Flap transfer Achilles tendon reconstruction
and defected III
IV
Heel skin defected Flap transfer Achilles tendon ruptured and defected Achilles tendon reconstruction Calcaneus fractured Calcaneus reconstruction or defected Heel mangled
Amputation
The fractures were mostly fixed with screws or Kirschner wires. For grade II injury, Achilles tendons were sutured or reattached to the calcaneus tubercle with unabsorbable Exicon lines in the cases covered by the reverse sural flap, the reverse saphenous flap, and the sliding gastrocnemius musculocutaneous flap; and in the three cases treated by free thoracdorsal artery perforator flap, the defected Achilles tendons were bridged by the transfer of the ipsilateral flexor hallucis longus tendon. For grade III injury, Arthrex anchors were used to strengthen the reattachment of the
[(Fig._1)TD$IG]
357
tendon with the calcaneus after the bone was debrided or fixed; in the three cases treated by free anterolateral thigh perforator flap, the defected Achilles tendons were also bridged by the transfer of the ipsilateral flexor hallucis longus tendon. Flaps were loosely sutured and Penrose drains were used to prevent accumulation of blood and serum. A bulky light-pressure dressing with long plaster splint were used to protect the wound and immobilise the injured ankle. Full weight-bearing ambulation of grade II and III was not attempted until 3 months postoperatively. The management of a typical case is shown in Fig. 3. Results There was no complete flap loss; however, nine of the flaps suffered distal necrosis and were allowed to heal spontaneously. There were no problems with the donor site in any of these patients either immediately or at subsequent follow-up. One case had calcaneus osteomyelits 3 months postoperatively and the wound healed after debridement and removal of dead bones. The hind foot of three cases (3.4%) was mangled and amputated. Forty-three cases of type II (23 cases) and type III (22 cases), who had their Achilles tendon reconstructed, were found to have the loss of maximal ankle dorsiflexion (5–258) compared with the contralateral side in the 12 months follow-up. None of them complained that it compromised their normal walking. The injured lower limbs of 12 cases with the lost of 10–258 of maximal ankle dorsiflexion
Fig. 1. A schematic drawing of the grades of motorcycle spoke injuries of the heel.
[(Fig._2)TD$IG]
Fig. 2. Higher grades mean more structures involved and more serious of the outcomes. Grade I may be treated by a reverse sural flap; grade II by a bi-pedicled sliding gastrocnemius musculocutaneous flap; grade III by the flap coverage, Achilles tendon reconstruction, and the fixation of calcaneus fracture; grade IV by the amputation which would be the optimal choice with the necrosis and defects of the tibial nerve, vessels, tendons, and bones of the ankle joint.
[(Fig._3)TD$IG]
358
Y.-L. Zhu et al. / Injury, Int. J. Care Injured 42 (2011) 356–361
Fig. 3. The left heel of a 6-year-old boy was injured by motorcycle spokes. Eighteen days later he was transferred to our center with combined defects of Achilles tendon and overlying skin (a). With the fractured calcaneus (b), he was diagnosed as grade III spoke injuries of the heel. He was treated with a bi-pedicled sliding gastrocnemius musculocutaneous flap for one-stage reconstruction of the defects (c). Achilles tendon was reattached to the calcaneus tubercle with non-absorbable Ethicon lines. The tiptoeing of the left foot was good at postoperative months 6 (d).
were found to be not in accord with the contralateral side in running. The presumed mechanisms of the injury are as follows. The motorcycle had no spoke guards or guards poorly designed. The heels of the pillion passenger were suddenly trapped between the spokes and the frames. This may be induced by the unconscious swing of the leg, the wrong position of the passenger, or the overturning of the motorcycle (Fig. 4). The motorcycle would be stopped abruptly by its collapse or by the screams from passengers. But before its full stopping, the structures of the heels would be further crushed and grinded by the continuous rotating wheels. A typical radiating wound was created (Fig. 5). Often the real severity of the injury is not unveiled until several days later. With the infection and necrosis, the wound turns to be the combined defects of skin, Achilles tendon, calcaneus, or other structures. There are four types of motorcycles in this area (Southwestern China) according to the spoke guard situations (Fig. 6). Some motorcycle drivers strengthen their own spoke guards with very simple but effective materials (Fig. 7). As we checked the involved motorcycles in this series, we found some were equipped with good guards. During the accident, these motorcycles were overturned and still trapped the feet of the passengers. Discussions We believed that the mechanism and severity between the bicycle and motorcycle spoke injuries were very different though they used to be studied as one group in previous literature.10,15,18 Motorcycle spokes produce a more severe injury to the foot and ankle because of their higher speed and energy. The reconstruc-
tion required more skills and experience. Motorcycle spoke injures seem to occur more often in Asian countries such as India,10 Thailand,19 Pakistan,2 and western China as showed in this study. With the improved economy, more people in these areas now can afford to buy motorcycles as their primary communication vehicles. Meanwhile the bumpy roads and multi-passengers-on-one-motorcycle exacerbated the occurrence of the injury. In Das De’s report,3 13 cases of heel flap injuries following motorcycle spoke accidents were analysed. Most of the injuries had been confined to the right side because of poor assembly of the rear wheels. Our investigations showed that the ratio of right side to the left side was 51:38. They found that inadequate footwear was a contributory factor of the injuries. In our study of the 89 cases, however, there was only one case without wearing shoes. The shoes of the other 88 feet were either rotated away or crushed to pieces. Many authors have emphasised that the motorcycle wheel needs to be redesigned for the protection of the foot.1,3,18,19 The pity is that surgeons are not motorcycle manufacturers and their appeals have very limited effects. Fortunately there have been more motorcycles with rear guards and more people are taking further precautions against the heel injuries as shown in Figs. 6 and 7. The mass awareness of the spoke injuries is being improved. As mentioned before, some injuries occurred in those motorcycles with well-equipped rear shields. The motorcycle accidents could not be eradicated as long as there are motorcycles in running, so are the spoke injuries of the heel. In the study of Segers et al.,16 Mine et al.,11 and Suri et al.,18 the minor lacerations of the heel skin were taken as one group. Our experience showed that these minor injuries, which were very common in bicycle spoke injures, were rarely encountered
[(Fig._4)TD$IG]
Y.-L. Zhu et al. / Injury, Int. J. Care Injured 42 (2011) 356–361
359
Fig. 4. Common risky situations of the motorcycle spoke injuries of the heel: the pillion passenger could not hold fast to the motorcycle with a heavy bag on his back and the cycle is overtaking a car with great speed and without spoke guards (a); the motorcycle is running on a bumpy and muddy road without any spoke guards for the protection of the passenger’s feet (b); the motorcycle has a good spoke guard, but the passenger sits with a backward position. Any minor turning or swaying of the motorcycle will easily crush her feet (c). Three or more passengers on one running motorcycle without guards. The lateral sitting which is always favoured by Asian ladies makes her left heel nearly touch the spokes. If the cycle is overturned, the feet of the girl who sits in the middle could be injured too (d).
in the motorcycle spoke injuries. Therefore they are not taken as a group in our grading system. Whereas the bicycle spoke injuries usually caused greenstick fractures 6, or un-displaced fractures,4 motorcycle spoke injures caused displaced fractures, bone defects, osteomyelitis and even amputations.19 The general amputation rate, however, may be higher than 3.4% in this study
[(Fig._5)TD$IG]
Fig. 5. A fresh wound of the motorcycle spoke injuries of the heel is typically radiating.
because many cases were not transferred to our center if they were judged to be unreconstructible and amputated in primary hospitals. The fractures and amputation play important roles in this grading system. In the classification system of Mine et al.11 and Suri et al.,18 those patients with fractures were not included. In our series, 37.1% had fractures and required more challenging surgeries. Compared with the other fractures around the ankle, the calcaneus fracture or defect is far more common and troublesome for it is the attachment site of the Achilles tendon. Those with the calcaneus fracture or defect, therefore, are separately taken as grade III. From grade I to III, the reconstructive ladder of the surgery becomes higher and higher as more important structures involved. Compared with the previous classification systems,3,11,16,18 this grading system seemed to be simpler and more special for motorcycle spoke injuries of the heel. To our experience, the choice of the flaps was mainly based on the defect size of the wound. For grade I injury which usually had relatively small defect sizes, any regional flaps or traditional supramalleolar flap was good for the coverage. For larger defect sizes in grade I, grade II, or grade III injury, reverse sural flap or reverse saphenous flap was used instead. And the exact wound situations would decide which one of them was more convenient for the transfer. Usually we prefer the reverse sural flap because this flap was more dependable and preserved the great
[(Fig._6)TD$IG]
Y.-L. Zhu et al. / Injury, Int. J. Care Injured 42 (2011) 356–361
360
Fig. 6. From low to high, the safe classes of spoke guards may have four types: those without guards (a), with poorly designed guards (b), with well designed guards (c), and with double guards of a protective cover and the metal guard (d).
saphenous vein. The greatest advantage of the sliding gastrocnemius musculocutaneous flap was that this flap finished the reconstruction of both skin and Achilles tendon in one-stage with no need of microsurgical expertise.20 The incisions of this flap were big though, the transfer was quick and convenient. We
used three free thoracdorsal artery perforator flaps and three free anterolateral thigh perforator flaps in this series for the coverage of the biggest soft tissue defects around the heel. The two free perforator flaps had the advantages of great size and less donor site morbidity compared to traditional free flaps.
Table 2 The patient data, flap transfers and ankle function 1 year postoperatively according to the grading system (n = 89). Grade
Cases
Sex (F/M)
Mean age (years)
Side of injury (Rt/Lt)
Flaps
Ankle function
I
41
13/26
11.3
22/19
Regional pedicled flap (9) Lateral supramalleolar flap (8) Reverse sural flap (12) Reverse saphenous flap (12)
Normal (41)
II
23
5/20
23.4
13/10
Reverse sural flap (7) Reverse saphenous flap (3)
Normal (2) Maximal dorsiflexion loss of 5–108 (18) Maximal dorsiflexion loss of 10–258 (4)
Sliding gastrocnemius musculocutaneous flap (10) Free thoracodorsal artery perforator flap (3) III
22
9/13
26.7
13/9
Reverse sural flap (12) Sliding gastrocnemius musculocutaneous flap (7) Free anterolateral thigh perforator flap (3)
Normal (1) Maximal dorsiflexion loss of 5–108 (13) Maximal dorsiflexion of 10–258 (8)
IV
3
1/2
32.1
3/0
Amputation
–
Total
89
28/61
19.3
51/38
–
–
[(Fig._7)TD$IG]
Y.-L. Zhu et al. / Injury, Int. J. Care Injured 42 (2011) 356–361
361
References
Fig. 7. A paper box (the arrow) effectively prevents the child feet from being entrapped between spokes through the frame gaps of the metal guard.
Conclusions The eradication of spoke injuries of the heel has a long way to go as the motorcycle continues to be the favourite vehicle for some people; the treatment outcomes have been greatly improved due to the advancement of surgical techniques. Conflict of interest statement The authors confirm that they have received no financial assistance relevant to this paper and have no conflict of interest regarding this paper.
1. Ahmed M. Motorcycle spoke injury. Br Med J 1978;2:401. 2. Akhtar S, Hameed A. Versatility of the sural fasciocutaneous flap in the coverage of lower third leg and hind foot defects. J Plast Reconstr Aesthet Surg 2006;59:839–45. 3. Das De S, Pho RW. Heel flap injuries in motorcycle accidents. Injury 1983;15:87–92. 4. D’Souza LG, Hynes DE, McManus F, et al. The bicycle spoke injury: an avoidable accident? Foot Ankle Int 1996;17:170–3. 5. Fleischmann W, Strecker W, Bombelli M, et al. Vacuum sealing as treatment of soft tissue damage in open fractures. Unfallchirurg 1993;96:488–92. 6. Griffiths DM, MacKellar A. Bicycle-spoke and “doubling” injuries. Med J Aust 1988;149:618–9. 7. Hostetler SG, Schwartz L, Shields BJ, et al. Characteristics of pediatric traumatic amputations treated in hospital emergency departments: United States, 1990– 2002. Pediatrics 2005;116:e667–74. 8. Izant Jr RJ, Rothmann BF, Frankel VH. Bicycle spoke injuries of the foot and ankle in children: an underestimated “minor” injury. J Pediatr Surg 1969;4:654–6. 9. Kravitz HL. Preventing injuries from bicycle spoke. Pediatr Ann 1977;6:713–6. 10. Lodha SC. Spoke heel injuries in children. Indian J Surg 1973;92–5. 11. Mine R, Fukui M, Nishimura G. Bicycle spoke injuries in the lower extremity. Plast Reconstr Surg 2000;106:1501–6. 12. Riess J. Verletzungen durch Fahrradspeichen. Klin Med 1948;3:797. 13. Roffman M, Moshel M, Mendes DG. Bicycle spoke fracture. Clin Orthop Relat Res 1979;144:230–2. 14. Roffman M, Moshel M, Mendes DG. Bicycle spoke injuries. J Trauma 1980;20:325–6. 15. Sankhala SS, Gupta SP. Spoke-wheel injuries. Indian J Pediatr 1987;54: 251–6. 16. Segers MJ, Wink D, Clevers GJ. Bicycle-spoke injuries: a prospective study. Injury 1997;28:267–9. 17. Subrahmanyam M. Bicycle injury pattern among children in rural India. Trop Geogr Med 1984;36:243–7. 18. Suri MP, Naik NR, Raibagkar SC, Mehta DR. Heel flap injuries in spoke wheel accidents. Injury 2007;38:619–24. 19. Waikakul S, Vanadurongwan V, Wongtrakul S. Revascularization of subtotal amputation at the ankle in children following motorcycle-spoke injury. Injury 1999;30:51–6. 20. Zhu YL, Xu YQ, Yang J, Li J. One-stage reconstruction of Achilles tendon and skin defects by the sliding gastrocnemius musculocutaneous flap without anastomosis. J Trauma 2009;66:1129–34.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Motorcycle spoke injuries of the heel Yue-Liang Zhu a, Jun Li a,*, Wei-Qing Ma b, Liang-Bin Mei a, Yong-Qing Xu a a b
Department of Orthopaedic Surgery, Kunming General Hospital, Chengdu Military Region, Kunming, China Department of Anesthesiology, Kunming General Hospital, Chengdu Military Region, Kunming, China
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 19 August 2010
Introduction: The spoke injuries of the lower extremity seems never stop haunting the surgeons since its first report 62 years ago. A prospective study of motorcycle spoke injuries in the heel was undertaken to study the injury mechanism, the treatment protocols, and the outcomes. Patients and methods: From 2001 to 2010, 89 cases of motorcycle spoke injuries of the heel were examined. The various injury mechanisms were analysed. Flaps and other reconstruction surgeries were used to manage the involved extremity. Results: The mechanisms of the motorcycle spoke injuries of the heel had some unique features. A grading system was developed for the injuries according to the tissues involved. The surgery protocols primarily consisted of flap transfers, Achilles tendon reconstruction, and calcaneus management. Conclusions: The eradication of the motorcycle spoke injuries is a difficult task, but the treatment outcomes have been greatly improved due to the advancement of surgical techniques. ß 2010 Elsevier Ltd. All rights reserved.
Keywords: Spoke injuries Heel Achilles tendon Flaps Injury mechanism Grades
Introduction Since the first report of bicycle spoke injuries in 1948,12 the reports of the spoke injuries are not common but appears every 1 or 2 years constantly,1,3,4,6,8–11,13–17,19 Compared with the bicycles, the motorcycles caused more severe spoke injuries due to their higher energy.1,3,10,15,19 The heel is the most susceptible site of this injury. The treatment turns to be very challenging because the injury usually involves the combined defects of skin, calcaneus, and Achilles tendon which have been already broken and contaminated. Complex and repeated surgeries may be required for the limb salvage. Even so, the amputation seems unavoidable in some situations.7,19 We describe our experience in the management of these injuries over a 9-year period during which a special grade system were developed. Patients and methods Between January 2001 and December 2009, 139 cases of motorcycle spoke injuries were admitted into our center. Among them, 89 cases were the heel injuries. Of all the 89 cases, 49 cases were children or adolescents (216 years), 40 were adults. Eighty-eight cases were wearing shoes at the injury moment and one was not. The wound situations were divided into four grades according to the severity and surgery principles (Table 1). The schematic * Corresponding author at: Orthopaedic Department, Kunming General Hospital, 212#, Daguanlu Road, Posting code: 650032, Kunming, China. Tel.: +86 13577055695/08714775655; fax: +86 08714775655. E-mail addresses: [email protected], [email protected] (J. Li). 0020–1383/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2010.08.029
drawing and real cases of the grading are shown in Figs. 1 and 2. Patient’s data including age, sex, side of injury, treatment protocols and the outcomes were recorded (Table 2). The defect size of the heel skin ranged from 4 cm 2 cm to 14 cm 10 cm. The defect length of Achilles tendon ranged from 3 to 13 cm in the neutral position of the ankle joint under anaesthesia. Thirty-three cases (37.1%) of 43 fractures were noted in all the 89 cases (some had two or three sites). The fractures included the calcaneus (n = 16), the talus (n = 3), and the distal fibulae (n = 7), the distal tibia (5). The bone defects included the calcaneus (n = 6), the lateral malleolus (n = 3), and the medial malleolus (n = 1). Surgery techniques Preoperatively the wound would receive repeated debridements, daily dress changes, or vacuum assisted drainage system.5 Three cases were amputated of the involved limb. The flaps used in this series included regional pedicled flap (9 cases), the lateral supramalleolar flap (8 cases), reverse sural flap (31 cases), reverse saphenous neurocutaneous flap (15 cases), free thoracodorsal artery perforator flap (three cases), sliding gastrocnemius musculocutaneous flap20 (17 cases), and free anterolateral thigh perforator flap (three cases). Three cases of grade III injury were found in the operations that the posterior tibial artery and veins were broken or lacerated. They were just ligated for the anterior tibial arteries were intact. Only one case among the three cases had a broken tibial nerve at the ankle site. It was re-anastomosed with 9-0 nylon line under a microscope.
Y.-L. Zhu et al. / Injury, Int. J. Care Injured 42 (2011) 356–361 Table 1 Grades of motorcycle spoke injuries of the heel. Grade Injured tissues
Surgery principles
I
Heel skin defected Achilles tendon Exposed
Flap transfer
II
Heel skin defected Achilles tendon ruptured
Flap transfer Achilles tendon reconstruction
and defected III
IV
Heel skin defected Flap transfer Achilles tendon ruptured and defected Achilles tendon reconstruction Calcaneus fractured Calcaneus reconstruction or defected Heel mangled
Amputation
The fractures were mostly fixed with screws or Kirschner wires. For grade II injury, Achilles tendons were sutured or reattached to the calcaneus tubercle with unabsorbable Exicon lines in the cases covered by the reverse sural flap, the reverse saphenous flap, and the sliding gastrocnemius musculocutaneous flap; and in the three cases treated by free thoracdorsal artery perforator flap, the defected Achilles tendons were bridged by the transfer of the ipsilateral flexor hallucis longus tendon. For grade III injury, Arthrex anchors were used to strengthen the reattachment of the
[(Fig._1)TD$IG]
357
tendon with the calcaneus after the bone was debrided or fixed; in the three cases treated by free anterolateral thigh perforator flap, the defected Achilles tendons were also bridged by the transfer of the ipsilateral flexor hallucis longus tendon. Flaps were loosely sutured and Penrose drains were used to prevent accumulation of blood and serum. A bulky light-pressure dressing with long plaster splint were used to protect the wound and immobilise the injured ankle. Full weight-bearing ambulation of grade II and III was not attempted until 3 months postoperatively. The management of a typical case is shown in Fig. 3. Results There was no complete flap loss; however, nine of the flaps suffered distal necrosis and were allowed to heal spontaneously. There were no problems with the donor site in any of these patients either immediately or at subsequent follow-up. One case had calcaneus osteomyelits 3 months postoperatively and the wound healed after debridement and removal of dead bones. The hind foot of three cases (3.4%) was mangled and amputated. Forty-three cases of type II (23 cases) and type III (22 cases), who had their Achilles tendon reconstructed, were found to have the loss of maximal ankle dorsiflexion (5–258) compared with the contralateral side in the 12 months follow-up. None of them complained that it compromised their normal walking. The injured lower limbs of 12 cases with the lost of 10–258 of maximal ankle dorsiflexion
Fig. 1. A schematic drawing of the grades of motorcycle spoke injuries of the heel.
[(Fig._2)TD$IG]
Fig. 2. Higher grades mean more structures involved and more serious of the outcomes. Grade I may be treated by a reverse sural flap; grade II by a bi-pedicled sliding gastrocnemius musculocutaneous flap; grade III by the flap coverage, Achilles tendon reconstruction, and the fixation of calcaneus fracture; grade IV by the amputation which would be the optimal choice with the necrosis and defects of the tibial nerve, vessels, tendons, and bones of the ankle joint.
[(Fig._3)TD$IG]
358
Y.-L. Zhu et al. / Injury, Int. J. Care Injured 42 (2011) 356–361
Fig. 3. The left heel of a 6-year-old boy was injured by motorcycle spokes. Eighteen days later he was transferred to our center with combined defects of Achilles tendon and overlying skin (a). With the fractured calcaneus (b), he was diagnosed as grade III spoke injuries of the heel. He was treated with a bi-pedicled sliding gastrocnemius musculocutaneous flap for one-stage reconstruction of the defects (c). Achilles tendon was reattached to the calcaneus tubercle with non-absorbable Ethicon lines. The tiptoeing of the left foot was good at postoperative months 6 (d).
were found to be not in accord with the contralateral side in running. The presumed mechanisms of the injury are as follows. The motorcycle had no spoke guards or guards poorly designed. The heels of the pillion passenger were suddenly trapped between the spokes and the frames. This may be induced by the unconscious swing of the leg, the wrong position of the passenger, or the overturning of the motorcycle (Fig. 4). The motorcycle would be stopped abruptly by its collapse or by the screams from passengers. But before its full stopping, the structures of the heels would be further crushed and grinded by the continuous rotating wheels. A typical radiating wound was created (Fig. 5). Often the real severity of the injury is not unveiled until several days later. With the infection and necrosis, the wound turns to be the combined defects of skin, Achilles tendon, calcaneus, or other structures. There are four types of motorcycles in this area (Southwestern China) according to the spoke guard situations (Fig. 6). Some motorcycle drivers strengthen their own spoke guards with very simple but effective materials (Fig. 7). As we checked the involved motorcycles in this series, we found some were equipped with good guards. During the accident, these motorcycles were overturned and still trapped the feet of the passengers. Discussions We believed that the mechanism and severity between the bicycle and motorcycle spoke injuries were very different though they used to be studied as one group in previous literature.10,15,18 Motorcycle spokes produce a more severe injury to the foot and ankle because of their higher speed and energy. The reconstruc-
tion required more skills and experience. Motorcycle spoke injures seem to occur more often in Asian countries such as India,10 Thailand,19 Pakistan,2 and western China as showed in this study. With the improved economy, more people in these areas now can afford to buy motorcycles as their primary communication vehicles. Meanwhile the bumpy roads and multi-passengers-on-one-motorcycle exacerbated the occurrence of the injury. In Das De’s report,3 13 cases of heel flap injuries following motorcycle spoke accidents were analysed. Most of the injuries had been confined to the right side because of poor assembly of the rear wheels. Our investigations showed that the ratio of right side to the left side was 51:38. They found that inadequate footwear was a contributory factor of the injuries. In our study of the 89 cases, however, there was only one case without wearing shoes. The shoes of the other 88 feet were either rotated away or crushed to pieces. Many authors have emphasised that the motorcycle wheel needs to be redesigned for the protection of the foot.1,3,18,19 The pity is that surgeons are not motorcycle manufacturers and their appeals have very limited effects. Fortunately there have been more motorcycles with rear guards and more people are taking further precautions against the heel injuries as shown in Figs. 6 and 7. The mass awareness of the spoke injuries is being improved. As mentioned before, some injuries occurred in those motorcycles with well-equipped rear shields. The motorcycle accidents could not be eradicated as long as there are motorcycles in running, so are the spoke injuries of the heel. In the study of Segers et al.,16 Mine et al.,11 and Suri et al.,18 the minor lacerations of the heel skin were taken as one group. Our experience showed that these minor injuries, which were very common in bicycle spoke injures, were rarely encountered
[(Fig._4)TD$IG]
Y.-L. Zhu et al. / Injury, Int. J. Care Injured 42 (2011) 356–361
359
Fig. 4. Common risky situations of the motorcycle spoke injuries of the heel: the pillion passenger could not hold fast to the motorcycle with a heavy bag on his back and the cycle is overtaking a car with great speed and without spoke guards (a); the motorcycle is running on a bumpy and muddy road without any spoke guards for the protection of the passenger’s feet (b); the motorcycle has a good spoke guard, but the passenger sits with a backward position. Any minor turning or swaying of the motorcycle will easily crush her feet (c). Three or more passengers on one running motorcycle without guards. The lateral sitting which is always favoured by Asian ladies makes her left heel nearly touch the spokes. If the cycle is overturned, the feet of the girl who sits in the middle could be injured too (d).
in the motorcycle spoke injuries. Therefore they are not taken as a group in our grading system. Whereas the bicycle spoke injuries usually caused greenstick fractures 6, or un-displaced fractures,4 motorcycle spoke injures caused displaced fractures, bone defects, osteomyelitis and even amputations.19 The general amputation rate, however, may be higher than 3.4% in this study
[(Fig._5)TD$IG]
Fig. 5. A fresh wound of the motorcycle spoke injuries of the heel is typically radiating.
because many cases were not transferred to our center if they were judged to be unreconstructible and amputated in primary hospitals. The fractures and amputation play important roles in this grading system. In the classification system of Mine et al.11 and Suri et al.,18 those patients with fractures were not included. In our series, 37.1% had fractures and required more challenging surgeries. Compared with the other fractures around the ankle, the calcaneus fracture or defect is far more common and troublesome for it is the attachment site of the Achilles tendon. Those with the calcaneus fracture or defect, therefore, are separately taken as grade III. From grade I to III, the reconstructive ladder of the surgery becomes higher and higher as more important structures involved. Compared with the previous classification systems,3,11,16,18 this grading system seemed to be simpler and more special for motorcycle spoke injuries of the heel. To our experience, the choice of the flaps was mainly based on the defect size of the wound. For grade I injury which usually had relatively small defect sizes, any regional flaps or traditional supramalleolar flap was good for the coverage. For larger defect sizes in grade I, grade II, or grade III injury, reverse sural flap or reverse saphenous flap was used instead. And the exact wound situations would decide which one of them was more convenient for the transfer. Usually we prefer the reverse sural flap because this flap was more dependable and preserved the great
[(Fig._6)TD$IG]
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Fig. 6. From low to high, the safe classes of spoke guards may have four types: those without guards (a), with poorly designed guards (b), with well designed guards (c), and with double guards of a protective cover and the metal guard (d).
saphenous vein. The greatest advantage of the sliding gastrocnemius musculocutaneous flap was that this flap finished the reconstruction of both skin and Achilles tendon in one-stage with no need of microsurgical expertise.20 The incisions of this flap were big though, the transfer was quick and convenient. We
used three free thoracdorsal artery perforator flaps and three free anterolateral thigh perforator flaps in this series for the coverage of the biggest soft tissue defects around the heel. The two free perforator flaps had the advantages of great size and less donor site morbidity compared to traditional free flaps.
Table 2 The patient data, flap transfers and ankle function 1 year postoperatively according to the grading system (n = 89). Grade
Cases
Sex (F/M)
Mean age (years)
Side of injury (Rt/Lt)
Flaps
Ankle function
I
41
13/26
11.3
22/19
Regional pedicled flap (9) Lateral supramalleolar flap (8) Reverse sural flap (12) Reverse saphenous flap (12)
Normal (41)
II
23
5/20
23.4
13/10
Reverse sural flap (7) Reverse saphenous flap (3)
Normal (2) Maximal dorsiflexion loss of 5–108 (18) Maximal dorsiflexion loss of 10–258 (4)
Sliding gastrocnemius musculocutaneous flap (10) Free thoracodorsal artery perforator flap (3) III
22
9/13
26.7
13/9
Reverse sural flap (12) Sliding gastrocnemius musculocutaneous flap (7) Free anterolateral thigh perforator flap (3)
Normal (1) Maximal dorsiflexion loss of 5–108 (13) Maximal dorsiflexion of 10–258 (8)
IV
3
1/2
32.1
3/0
Amputation
–
Total
89
28/61
19.3
51/38
–
–
[(Fig._7)TD$IG]
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361
References
Fig. 7. A paper box (the arrow) effectively prevents the child feet from being entrapped between spokes through the frame gaps of the metal guard.
Conclusions The eradication of spoke injuries of the heel has a long way to go as the motorcycle continues to be the favourite vehicle for some people; the treatment outcomes have been greatly improved due to the advancement of surgical techniques. Conflict of interest statement The authors confirm that they have received no financial assistance relevant to this paper and have no conflict of interest regarding this paper.
1. Ahmed M. Motorcycle spoke injury. Br Med J 1978;2:401. 2. Akhtar S, Hameed A. Versatility of the sural fasciocutaneous flap in the coverage of lower third leg and hind foot defects. J Plast Reconstr Aesthet Surg 2006;59:839–45. 3. Das De S, Pho RW. Heel flap injuries in motorcycle accidents. Injury 1983;15:87–92. 4. D’Souza LG, Hynes DE, McManus F, et al. The bicycle spoke injury: an avoidable accident? Foot Ankle Int 1996;17:170–3. 5. Fleischmann W, Strecker W, Bombelli M, et al. Vacuum sealing as treatment of soft tissue damage in open fractures. Unfallchirurg 1993;96:488–92. 6. Griffiths DM, MacKellar A. Bicycle-spoke and “doubling” injuries. Med J Aust 1988;149:618–9. 7. Hostetler SG, Schwartz L, Shields BJ, et al. Characteristics of pediatric traumatic amputations treated in hospital emergency departments: United States, 1990– 2002. Pediatrics 2005;116:e667–74. 8. Izant Jr RJ, Rothmann BF, Frankel VH. Bicycle spoke injuries of the foot and ankle in children: an underestimated “minor” injury. J Pediatr Surg 1969;4:654–6. 9. Kravitz HL. Preventing injuries from bicycle spoke. Pediatr Ann 1977;6:713–6. 10. Lodha SC. Spoke heel injuries in children. Indian J Surg 1973;92–5. 11. Mine R, Fukui M, Nishimura G. Bicycle spoke injuries in the lower extremity. Plast Reconstr Surg 2000;106:1501–6. 12. Riess J. Verletzungen durch Fahrradspeichen. Klin Med 1948;3:797. 13. Roffman M, Moshel M, Mendes DG. Bicycle spoke fracture. Clin Orthop Relat Res 1979;144:230–2. 14. Roffman M, Moshel M, Mendes DG. Bicycle spoke injuries. J Trauma 1980;20:325–6. 15. Sankhala SS, Gupta SP. Spoke-wheel injuries. Indian J Pediatr 1987;54: 251–6. 16. Segers MJ, Wink D, Clevers GJ. Bicycle-spoke injuries: a prospective study. Injury 1997;28:267–9. 17. Subrahmanyam M. Bicycle injury pattern among children in rural India. Trop Geogr Med 1984;36:243–7. 18. Suri MP, Naik NR, Raibagkar SC, Mehta DR. Heel flap injuries in spoke wheel accidents. Injury 2007;38:619–24. 19. Waikakul S, Vanadurongwan V, Wongtrakul S. Revascularization of subtotal amputation at the ankle in children following motorcycle-spoke injury. Injury 1999;30:51–6. 20. Zhu YL, Xu YQ, Yang J, Li J. One-stage reconstruction of Achilles tendon and skin defects by the sliding gastrocnemius musculocutaneous flap without anastomosis. J Trauma 2009;66:1129–34.