Heel flap injuries in spoke wheel accidents

Manav Parveshchander Suri *, Nishal R. Naik, Santosh C. Raibagkar,Devesh R. Mehta

N.H.L Municipal Medical College, Ahmedabad, Gujarat, India

Accepted 8 January 2007

Injury, Int. J. Care Injured (2007) 38, 619—624

www.elsevier.com/locate/injury

KEYWORDSSpoke wheel injuries;Tendoachilles;Pillion rider

Summary

Aim: To compare and discuss motorcycle and bicycle spoke heel flap injuries and alsoto discuss the pathomechanics and treatment modalities of spoke wheel injuries.Methods: The study comprises 42 heel flap injuries patients who were selected fromamongst 216 cases of lower extremity trauma. The injuries were graded into threeclasses: I—III, depending upon the severity and extent of the injury. The managementwas based on this classification. Posterior heel injuries were covered with various flapsdepending upon the defect size, its exact location, associated injuries, extent of zoneof trauma, and complexity of the defect.Results: Eighty percent of the injuries were confined to the right side because of theexistence of the chain guard on the left side of the two-wheeler. Inadequate footwearwas a contributory factor. 57% of the cases were caused by motorcycle. The healingtime was prolonged in motorcycle spoke injuries. No fracture was noted. Severity ofinjury in motorcycle was due to high momentum and rigidity of spokes.Conclusion: Since the first report of bicycle spoke injuries, presented a half centuryago, prevention has not improved. Protective footwear should be made compulsory.Changes should also be made in the design of the rear wheel of motorcycle.# 2007 Elsevier Ltd. All rights reserved.

Introduction

Spoke wheel injuries commonly affect the heelregion. Many of such injuries result in an avulsionflap with or without exposure of the tendoachillesand/or calcaneum. Spoke wheel injuries oftenappear to be deceptively mild initially but can be

* Corresponding author. Tel.: +91 9898097886.E-mail address: surimanav@yahoo.com (M.P. Suri).

0020–1383/$ — see front matter # 2007 Elsevier Ltd. All rights resedoi:10.1016/j.injury.2007.01.004

a severe injury that requires admission to hospital,operation and prolonged period to full recovery.Motorcycle spoke injuries to the heel of the driverand pillion rider have not been widely noted untilthe report by Ahmed1. Viljanto10 reported bicycleand moped spoke injuries in children. Also, Drewes3

and Schulte drew attention to fractures of the leg inchildren by bicycle spokes.

We have noted an increase in posterior heelinjuries following motorcycle spoke accidents in

rved.

620 M.P. Suri et al.

Ahmedabad (western India). This may be a result ofincreasing popularity of newer, stylish and powerfulmotorcycles amongst youth. This study is aimed at:

1. C

omparing motorcycle and bicycle spoke heelflap injuries.

2. E

mphasising the pathomechanics of spokeinjuries.

3. D

Figure 1 Class I injury in a 15-year-male patient.

iscussing various treatment modalities.

Materials and methods

Between January 1999 and January 2004, 216 casesattended the emergency department of plastic andreconstructive surgery department of S.C.L Hospitalwith lower extremity trauma. These cases werethoroughly reviewed and the cases involving injuriesfrom spoke wheel were identified. Spoke injuriesaccounted for 30% (65 cases) of all lower limbtrauma cases. Of these, 64.6% (42 cases) of heelflap injuries from spokes were selected for furtherevaluation. Those patients having closed fracturesor only abrasion were not included in the study asthey were primarily managed by the orthopaedicdepartment. Patients’ data including age, sex, sideof injury, motorcycle or bicycle spoke injury, posi-tion of passenger at the time of injury, part of thewheel causing the injury, anatomical site of injury,the type of wound and total days of admission, werenoted. Some of the patients also sustained minorabrasions mainly over the knee and palm. Patientswere divided into three classes according to theseverity of the injury and their treatments werebased on the following classification:

� C

lass I: Included minor avulsion flaps (Fig. 1). � C lass II: Included extensive avulsion of the heel

with no exposure of bone and tendons (Fig. 2).

� C

Figure 2 Class II injury in a 7-year-male patient withinjury from front of rear wheel having distally based flap.

lass III: Included extensive avulsion of skin of theheel together with damage to the vessels ulti-mately leading to exposure of the tendons orunderlying bone (Fig. 3).

This classification was found to more useful forIndian conditions and for managing the patients.

After thorough wound cleansing and debride-ment, treatment was performed according to thealgorithm and a non-adherent dressing was applied.Ankle immobilisation was with a plaster of Parisslab and the limb was elevated. Class I wounds weresutured back without tension. In class II wounds,apposing sutures were taken and the rest of thearea was covered with split skin graft (if required).Class III wounds, which were treated initially withdressing and debridement, were reassessed on third

post-traumatic day and were covered with flaps.The follow-up of the patients ranged from 1 to 5years (average 2.1 years). Statistical analysis wasdone using Z-test, Student’s t-test and Chi-squaretest.

Results

The 42 patients studied were between 3 and 60years old, with a mean age of 14.9 years. A total

Heel flap injuries in spoke wheel accidents 621

Figure 3 Class III injury in a 45-year-female patient withinjury from front of rear wheel having distally based flapwith exposed tendoachilles.

Age

range

SexF/

MRight/left

Front/bac

kofrear

wheel

Flap

sSp

litthickn

ess

skin

graft

Sec.

healing

Admissionday

s

11.51

3—60

11/3

134

/819

/23

1817

721

.76�

10.83

5.36

3—22

5/13

13/5

5/13

111

613

.78�

6.26

412

.47

3—60

6/18

21/3

14/1

017

61

27.75�

9.63

of 31 of the patients were male, and 30 were below18 years of age (Fig. 4).

Of the 42 foot injuries, the right foot was involvedin 34 of the cases; 19 were injured from the front ofthe rear wheel, causing a distally based skin flapavulsion and 23 from back of the rear wheel, causinga proximally based skin flap avulsion. No seasonalvariation was noted in our study. An examination ofthe time of day showed that 25 were injuredbetween 8 a.m. and 4 p.m. Only 3 of the 42 patientswere wearing shoes and the rest of the 39 patientswere either bare footed or wearing slippers at thetime of injury.

Out of 65 cases of spoke wheel injury 42 of theinjuries were around the region of the Achillestendon. This was followed by medial malleolus in9: the dorsum of foot in 8: and the toes in 6.

In our series we had 7 class I injuries, 17 class IIinjuries and 18 class III injuries. A total of 24 of theheel flap injuries were caused by motorcycle and 18were caused by bicycles. Of themotorcycle heel flapinjuries, 17 were class III, 6 were of class II and 1 wasclass I. In bicycle heel flap injuries 1 was class III, 11were class II, and 6 were class I.

A total of 18 patients with class III injuries requ-ired flap coverage. Split skin grafting was performed

Figure 4 Age distribution.

Table

1

Catego

ryn

Age

Total

4214

.93�

Bicycles

188.33�

Motorcycles

2419

.88�

622 M.P. Suri et al.

in 17 patients in class II, and 7 patients with class Iinjuries were closed primarily with sutures.

Wound healing lasted from 2 to 78 days (meanduration 28 days). Average duration of hospitalisa-tion with heel flap injuries was 21.76 days rangingfrom 3 to 46 days.

On comparing the motorcycle with the bicyclespoke wheel injuries, bicycle spoke wheel injurieswere more common in patients below 18 years(17) than patients above 18 years of age (1)( p < 0.001). However, in motorcycle heel flap inju-ries the difference was not significant. 13 patientswere below 18 years and 11 were above 18 years.The mean hospital stay with motorcycle heel flapinjuries was 27.75 days and with bicycle injuries13.7 days. Motorcycle spoke injuries had longerhospitalisation than their bicycle counterparts(t = 5.42, d.f. = 40 p < 0.001). These cases alsorequired more flap coverage as compared tobicycle spoke injuries (x2 = 4.37, d.f. = 1, andp < 0.05) (Table 1).

Discussion

Riess et al.8 and Ahmed1 first reported bicycle andmotor spoke wheel injuries, respectively. Afterthese reports, several articles on the topic werepublished in Europe.7,11,12 This article describes ourexperience with management of spoke wheel (heelflap) injuries and comparison of the motorcycle andthe bicycle spoke injuries. We have compared ourclassification of injury with the grades of injurygiven by Das De and Pho2 but found our classificationmore useful in an Indian setting.

Patient information

This report demonstrates that the majority ofpatients were children below 18 years of age. San-khala and Gupta9 noted a higher incidence of spokewheel injuries in the 3—5 years group. This may bedue to the high number of bicycle injuries seen in hisstudy. De das et al.2 observed that motorcycle spokewheel injuries were common in age group of 16—46years with a mean age of 20 years.

Boys were injured more often than girls in thisseries and significant statistical difference existedbetween the two sexes (Z = 3.09: p < 0.001), whichis in agreement with other reports.9 This may bedue to:

(a) M

ore active involvement in outdoor activities. (b) M ore traveling by two-wheelers in our country. (c) D ifference in the seating pattern as females

prefer to sit with both their feet placed com-

fortably on the footrest on the left side of thevehicle and it is safeguarded by a sari guard.

Injuries to the right side are more predominantbecause of the chain guard on the left side of themotorcycle andbicycle.We founda significant differ-encebetween the sideof injury (Z = 4.02:p < 0.001).

This is in concordance with the findings of otherauthors.1,8,6,9

Hourly and seasonal variations

No seasonal variation was noted in our study. Mostpatients were injured between 8 a.m. and 4 p.m.This might be due to:

(a) M

ost motorcycles and bicycles being used forthe office and school during these working hours.

(b) W

ith Ahmedabad remaining hot and humid formost of the year, there is no change in pattern oftravel and footwear.

Von der leyen11 described a child’s fatigue as thecause of this injury. We did not find fatigue to haveany relevance to the incidence of injury.

Position of passenger at time of injury

Information about the patients seating positionat the time of injury was retrieved in 39 cases. (Thisinformation was unavailable in three cases.) Theposterior heel flap spoke injuries were caused by theankle getting trapped in the spokes of the wheel.Sankhala and Gupta9 reported injuries whichoccurred when the foot of child, sitting on horizon-tal bar of a bicycle gets trapped in the spokes of thefront wheel. However, we did not come across anysuch patient, during this study. In 16% of cases ofbicycle spoke injuries an optional child’s seat waspresent and the injury still occurred. Our findingslead us to support the view that an optional seat maynot be enough to prevent this type of trauma.

Types of wounds and management

We noted that following factors were responsible forthe pattern of spoke heel flap injuries:

(a) B

luntness and flexibility of spokes. (b) T rapping of the soft tissue between the calca-

neum (hard structure) and spokes of the wheel(firm structure), causing a compression effectand avulsion of the skin and subcutaneous tissueover the posterior heel region.9

Abrasion and ecchymoses often seem to bea superficial wound initially, but they are often

Heel flap injuries in spoke wheel accidents 623

deeper than expected and require prolonged heal-ing time. Spoke wheel injuries might initially give adeceptive appearance and are dismissed as minorinjuries.2 This type of wound is particularly challen-ging to manage because the non-viable tissue is notimmediately apparent. Our healing time was longerthan healing by first intention. The difference inhealing time between all the three classes was notstatistically significant ( p > 0.1). This increase inhealing time is suspected to be a result of thefriction burns that occurred in all three classes ofinjury. Griffith and Mackellar4 in their series ofbicycle spoke wheel injuries in children describedit as ‘doubling injury’ as it commonly occurs whentwo children are riding on bicycle. In their seriesthere were 16 children requiring admission, with amean age of 55 months, 8 required skin grafting and4 suturing. In their study healing time ranged from 7to 365 days with a mean of 56 days.

The posterior heel was the commonest site ofspoke injuries in our series leading to laceration andavulsion of tissue in tendoachilles region. We notedthat class III injuries were more common in motor-cycle and class II injuries in bicycle. Class I injurieswere more common in bicycle as compared to

motorcycle spoke wheel injuries. This could bebecause motorcycles spokes cause more severeinjury.

Injuries leading to exposed tendoachilles mostlyoccur in areas that have relatively poor circulation.The lacerations should not be closed with excessivetension or too many sutures to avoid skin necrosisaround the margins of the wound. The treatment ofspoke injuries requires proper wound debridement,splintage and elevation. Since children cannot keeptheir limbs still, the use of a splint is encouraged toincrease the blood supply to the region. It took a fewdays before final assessment of wound was made, as

necrotic and devitalised tissue was not apparent oninitial examination. Debridement was carried outafter demarcation of necrotic tissue and the woundwas covered appropriately. No complication exceptscar formation was seen in our study.

Injury also may cause swelling, bruises and abra-sion, spiral fractures of lower third of tibia evenleading to disarticulation of hallux of metatarsopha-langeal joint.9 We had no fracture cases because ourpatients were selected from a plastic surgery emer-gency department and if on X-ray fracture wasdiagnosed, patients were referred to orthopaedicsfor treatment. Lodha6 observed that simple sutureclosure leads to dehiscence and culminates in pro-longed secondary healing. He advised that graftingof the wound should be undertaken only whennecrosis takes place.

The decision on skin cover and the choice of flap ismore important with class III injuries. We coveredthese injuries with flaps depending on defect size,exact location, associated injuries, extent of zoneof trauma and complexity of defect. A distally basedsuperficial sural artery flap was performed in 7, alateral calcaneal artery flap in 9 and microvasculartissue transfer in 2 cases.

Comparison between motorcycle andbicycle injuries

None of the previous studies compared injuries fromspokes of motorcycle and bicycle wheels. We calcu-lated the ratio of injury of motorcycle to bicycle inour series was 1.3:1 and number of bicycles tomotorcycle was 3:1. However, in our study 57% ofcases were caused by motorcycles spokes. This maybe due to

(a) I

ncreasing use of stylish and powerful motor-cycles.

624 M.P. Suri et al.

(b) D

ue to more severe injuries occurring due tospokes of motorcycles.

(c) H

igh momentum of the motorcycle. (d) R igidity of spokes of the wheel of motorcycle

whereas the spokes of the bicycle wheel are lessrigid and therefore bend easily, dissipating apart of energy, which lessens the ultimateimpact borne by the foot.

(e) T

reatment might be taken at another nearbyinstitute where the injury took place. Thedifference between the two was statisticallysignificant (t value = 3.71, d.f. = 40, andp < 0.001).

Figure 5 Motorcycle showing spoke shields.

Motorcycle spoke injuries, due to the severedegree of injury, required more flap coverage andlonger hospital stay compared to bicycle spokeinjuries.

The ultimate effect of any force applied on abody is decided by its IMPACT, which is defined, asFDt where F is the magnitude of force and Dt is thetime for which it acts on the body.

IMPACT ¼ FDt ¼ D p

¼ change in momentum

ðNewton0s second law of motionÞ:

Momentum of a body (P) is defined as the productof mass and velocity of the body. Therefore, motor-cycles having higher mass and velocity are morelikely to produce a greater impact on the foot whenit is caught in the spoke wheel. Moreover, a bicyclerider immediately stops the bicycle when the injuryoccurs but the motorcycle has to be switched offfollowing the injury and the foot is trapped betweenthe spokes and horizontal bar and severely injured.The severity of injury also depends upon the dis-tance of the tissue injured from center of the wheeland also on the rate of deceleration of the vehicleafter the impact, which are difficult parameters toassess.

Conclusion

As motorcycles become more popular and fashion-able, it is anticipated that injuries of the heel bymotorcycles will increase and become more com-mon. Proper precautions may decrease the fre-quency of spoke wheel injuries.5 A stiff plasticnet that fits on to the bicycle frame and coversthe wheel and spoke guard have been describedto prevent ‘‘doubling’’ injuries.4 Parents and othermembers of the community should be educated

regarding the potentially serious nature of thisinjury. These injuries can be prevented if two-wheeler manufacturers were to supply vehiclesalready fitted with spoke shields (Fig. 5) and wheelguards. Also, having a proper footrest would preventthe hanging foot accidentally becoming entrappedin a moving spoke. Protective footwear may alsoreduce the effect of spoke wheel injuries.2 Provisionof adequate road dividers may also help in reducingsuch injuries. Strict rules regarding avoidance ofmore than one pillion rider would also lead to adecrease in the incidence of spoke wheel injury.

References

1. Ahmed M. Motorcycle spoke injury. Br Med J 1978;2:401.2. Das De S, Pho RW. Heel flap injuries in motorcycle accidents.

Injury 1983;15(2):87—92.3. Drewes J, Schulte HD. Bruche im Bereich des Unterschenkels

bei Kindern infolge von Fahrradspeichenverletzungen. DerChirurg 1965;36:464.

4. Griffiths DM, Mackellar A. Bicycle-spoke and ‘‘doubling’’injuries. Med J Aust 1988;149(11—12):618—9.

5. Kravitz HL. Preventing injuries from bicycle spoke. PediatrAnn 1977;6:713—6.

6. Lodha SC. Spoke wheel injuries in children. Indian J Surgery1973;92—5.

7. Ramstad KR. Ankelskader hos smarbarn ved sykkelulykker.Tidsskr Nor Laegeforen 1960;80:558.

8. Riess J. Verletzungen Durch Fahrradspeichen. Klin Med1948;3:797.

9. Sankhala SS, Gupta SP. Spoke-wheel injuries. Indian J Pediatr1987;54(2):251—6.

10. Viljanto J. Bicycle and moped spoke injuries in children:analysis of 103 conservative cases. Ann Chir Gynaecol Fenn1975;64:100.

11. Von der Leyen UE. Uber die Haufigkeit kindlicher Unfalle.Zschr Kinderheilkd 1960;83:319.

12. Von Holzer H. Unfall im Kindesalter. Dtsch Gesund-heitwes1958;13:1153.