Journal of Orthopaedic Surgery 2010;18(3):338-41
Bicycle-spoke injuries of the foot in children Anil Agarwal,1 Manish Pruthi2 1 2
Department of Orthopaedics, Chacha Nehru Bal Chikitsalaya, Delhi, India Department of Orthopaedics Surgery, Government Medical College and Hospital, Chandigarh, India
ABSTRACT Purpose. To evaluate the characteristics of bicyclespoke injuries in a suburban Indian population. Methods. 30 male and 11 female children aged 4 to 12 (mean, 6) years with bicycle-spoke injuries were prospectively studied. Data collected included patient age, gender, position at the time of injury, site, type, and characteristics of the injury. According to the Oestern and Tscherne classification, soft-tissue injuries were classified into grades 0 to 3. Results. 37 patients injured the right foot, and 4 the left foot; 34 by the rear wheel and 7 by the front wheel. All front-wheel injuries involved the forefoot and midfoot. 73% of injuries involved the lateral aspect of the ankle. The most common injury site was the posterior ankle (n=30), followed by the medial midfoot (n=7), and the forefoot (n=3). Partial avulsion of heel flap and an exposed Achilles tendon were each noted in 2 patients. 10, 13, 14, and 4 patients sustained soft-tissue injuries of grades 0, 1, 2, and 3, respectively. Eight patients had associated
fractures. All fractures healed uneventfully. Marginal necrosis of the wound was noted in 5 patients, but none required a skin graft. No patient had functional impairment or residual tenderness of the foot. Conclusion. Bicycle-spoke injuries usually affected the ankle region, and the wound was usually deeper than it appeared on initial examination. Reassessment of the wound after 48 hours is recommended. Severity of soft-tissue injury was the determinant of overall function; bone fractures by themselves did not alter the duration of recovery. To prevent bicyclespoke injuries, spoke guards and foot rests should be used, and children being carried on a bicycle should wear proper shoes. Education on injury mechanism, severity, and preventive measures is also important. Key words: ankle injuries; bicycling; child; foot injuries
INTRODUCTION Bicycles are a common mode of transport in suburban India. 52% of bicycle-spoke injuries involve children aged 3 to 5 years.1,2 Such injuries occur when the
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foot of a passenger (usually a child) is caught in the spokes of a rotating wheel. The passenger usually sits on the handle bar, the bar connecting the handle and the seat, or the pillion, with feet dangling on one side (side-saddle position) or both. The right foot is usually closer to the wheel in the side-saddle position and hence more commonly injured (Fig. 1). The mode of injury is comparable to human tooth clenched fist bites, which cut deep and inoculate the stretched and devascularised tissue.3 The usual injuries are: (1) lacerations of the tissue, (2) crushing of the foot, and (3) shearing injuries due to these 2 forces.4–6 We evaluated the characteristics of bicycle-spoke injuries in a suburban Indian population. MATERIALS AND METHODS Between June 2005 and May 2009, 30 male and 11 female children aged 4 to 12 (mean, 6) years who presented with bicycle-spoke injuries were prospectively studied. Data collected included patient age, gender, position at the time of injury, site, type, and characteristics of the injury. According to the Oestern and Tscherne classification,7 soft-tissue injuries were classified into grade 0 (closed, only soft-tissue swelling), grade 1 (superficial abrasion or contusion/bruising), grade 2 (deep abrasion or laceration with full thickness skin loss), and grade 3 (extensive soft-tissue injury and/ or open fracture, with damage to the vessels/nerves/ tendons and/or exposure of bone) [Fig. 2]. Grade 0 injuries were treated conservatively with
Bicycle-spoke injuries of the foot in children 339
crammer wire splintage and limb elevation, and were reassessed after 48 hours. Grade 1 injuries were treated with thorough wound washing (with 0.9% saline) followed by dressing (with an antibiotic-vaseline gauze), crammer wire splintage, and limb elevation. The wounds were reassessed after 48 hours for signs of local infection and to reassess severity. Splintage of the ankle in neutral position was maintained until the abrasions were dressed. A below-knee plasterof-Paris backsplint was applied for 2 weeks. Grade 2 injuries were treated with thorough wound washing (sometimes under anaesthesia) and dressing. The wounds were reassessed after 48 hours and a below-knee backsplint was applied for 3 to 4 weeks, depending on the condition of the wound. Grade 3 injuries were treated with thorough debridement under anaesthesia with tendon repair if required. After 48 hours, a second debridement was carried out if necessary. As soon as the wound condition permitted, a supervised rehabilitation programme was started to regain ankle motion. An ankle foot orthosis enabled exercises while the dressings were still in place. In patients with associated fractures, closed reduction was attempted. If that failed, open reduction and internal fixation was performed. Open fractures were treated with debridement, lavage, and external fixation. Broad spectrum antibiotics were administered as appropriate to patients with grade 2 or 3 injuries. The duration of wound healing, residual tenderness in the foot/heel, range of ankle joint motion, and difficulty in walking were assessed at the final follow-up.
Figure 1 The passenger usually sits on the pillion or the bar connecting the handle and the seat. The right foot is usually closer to the wheel in the side-saddle position.
Journal of Orthopaedic Surgery
340 A Agarwal and M Pruthi
Figure 2 Oestern and Tscherne classification of soft-tissue injuries of grades 0, 1, 2 and 3.
RESULTS The mean interval from injury to presentation was 6 (range, 2–24) hours. 37 patients injured the right foot, and 4 the left foot; 34 by the rear wheel and 7 by the front wheel. All front-wheel injuries involved the forefoot and midfoot. 73% of injuries involved the lateral aspect of the ankle, with equal involvement of the anterolateral and posterolateral regions. The most common injury site was the posterior ankle (n=30), followed by the medial midfoot (n=7), and the forefoot (n=3). There was one patient with a finger entrapment injury. Partial avulsion of the heel flap and an exposed Achilles tendon were each noted in 2 patients. 10, 13, 14, and 4 patients sustained soft-tissue injuries of grades 0, 1, 2, and 3, respectively. The grading changed to a higher grade on reassessment in 8 patients (5 from grade 0 to 1 and 3 from grade 1 to 2), owing to the presence of tissue necrosis and/ or superimposed infection. Patients with grade 0 or 1 injuries returned to function and weight bearing earlier than those with grade 2 or 3 injuries (mean, 28 [range, 5–40] vs. 40 [range, 14–90] days). Marginal necrosis of the wound was noted in 5 patients, but none required a skin graft. No patient had functional impairment or residual tenderness of the foot.
Eight patients had associated fractures: 3 sustained medial tibial epiphyseal fractures (2 of whom were treated conservatively and one with open reduction and Kirschner wire fixation), 4 sustained distal tibial fractures (3 of whom were treated conservatively and one with debridement and external fixation), and one sustained a fracture of the proximal phalanx of the fourth toe and was treated conservatively. All fractures healed uneventfully. The mean healing time was 18 (range, 5–66) days. DISCUSSION 63% of bicycle-spoke injuries occur in the area around the Achilles tendon.8 More severe soft-tissue injuries affect the posterolateral aspect of the ankle and extend to the Achilles tendon,6 which is consistent with our series. There is no universally accepted classification for such injuries. Besides the Oestern and Tscherne classification,7 soft-tissue injuries can be classified into simple abrasions or laceration with partial avulsion,8 or oedema and bruising, bruising with abrasions or full thickness skin defects.6 In our study, treatment and prognosis correlated with the classification. Abrasions and ecchymoses usually affect the ankle region and appear deeper on re-examination.
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Bicycle-spoke injuries of the foot in children 341
Figure 3 Spoke guards and foot rests should be attached to prevent bicycle-spoke injuries.
The skin and soft-tissue vascularity is poor because of underlying internal degloving, with a high risk of wound infection. It is therefore mandatory to reassess the wound for infection and necrosis after 48 hours, and adjust the wound grade and management accordingly. Below-knee backsplints applied for 2 to 3 weeks with the ankle in a neutral position are recommended. An ankle foot orthosis enables both wound care and exercise to be performed. Despite leaving large uncovered areas, debridement (even delayed) is also recommended, as is split skin grafting to hasten healing in cases of wound necrosis.4,9 Lacerations of the posterior ankle region with exposure of the Achilles tendon or heel flap avulsions resulting from the shearing effect of spokes risk becoming necrotic. Heel flap avulsions require thorough lavage, debridement, suturing, and splintage. In cases of heel flap necrosis or development of painful contractures, it may be necessary to delay covering the injury with a flap.8,10
In our study, the severity of the soft-tissue injury was the determinant of overall function; bone fractures by themselves were simple and healed uneventfully and did not alter the duration of recovery in each grade. Nonetheless, radiological screening and longterm follow-up are recommended for patients with associated fractures, as growth disturbances are possible. To prevent bicycle-spoke injuries, spoke guards and foot rests should be used (Fig. 3), and children being carried on a bicycle should wear proper shoes. Education on injury mechanisms, severity, and preventive measures is also important. Bicycle spokes can cause injuries resulting in a combination of devascularisation, internal degloving, and contamination. Such injuries may be deeper than they first appear. Reassessment after 48 hours provides better evaluation of the wound. Multiple debridements may be necessary to prevent contamination.
REFERENCES 1. Sankhala SS, Gupta SP. Spoke-wheel injuries. Indian J Pediatr 1987;54:251–6. 2. Jaiswal A, Nigam V, Jain V, Kapoor S, Dhaon BK. Bicycle and cycle rickshaw injury in suburban India. Injury 2006;37:423– 7. 3. Phair IC, Quinton DN. Clenched fist human bite injuries. J Hand Surg Br 1989;14:86–7. 4. Izant RJ Jr, 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. 5. Ahmed M. Motorcycle spoke injury. Br Med J 1978;2:401. 6. Segers MJ, Wink D, Clevers GJ. Bicycle-spoke injuries: a prospective study. Injury 1997;28:267–9. 7. Oestern HJ, Tscherne H. Pathophysiology and classification of soft issue injuries associated with fractures. In: Tscherne H, editor. Fractures with soft tissues injuries. New York: Springer-Verlag; 1984:1–9. 8. Mine R, Fukui M, Nishimura G. Bicycle spoke injuries in the lower extremity. Plast Reconstr Surg 2000;106:1501–6. 9. Lodha SC. Spoke wheel injuries in children. Indian J Surg 1973;35:92–5. 10. Suri MP, Naik NR, Raibagkar SC, Mehta DR. Heel flap injuries in spoke wheel accidents. Injury 2007;38:619–24.
