|Year : 2017 | Volume
| Issue : 1 | Page : 6-10
Motorcycle spokes entrapment foot injuries: Prevalence, and pattern of presentation in a private orthopedic and trauma center, Southeast Nigeria – A 10-year retrospective analysis
Thaddeus Chika Agu
Department of Surgery, First Choice Specialist Hospital, Onitsha, Anambra State; Department of Surgery, Imo State University, Owerri, Nigeria
|Date of Web Publication||2-Feb-2018|
Dr. Thaddeus Chika Agu
First Choice Specialist Hospital, Onitsha, Anambra State, Nigeria. Imo State University, Owerri
Source of Support: None, Conflict of Interest: None
Background: Pupils commuting on the backseats of motorcycles to and from schools is commonplace in cities where motorcycles are used for intracity transportation. Often times, the feet of these children get entrapped between the spokes as the motorcycles are in motion and this could cause severe injuries. This is a major health concern in Nigeria because of the increasing use of motorcycle as a transport system.
Study Design and Setting: This is a 10-year retrospective analysis of all the motorcycle spokes injured patients admitted in a private orthopedic and trauma center in the southeast region of Nigeria between January 2007 and December 2016.
Results: A total of 690 patients seen during the period under review were victims of motorcycle accidents. Seventy-one patients (10.3%) had spokes entrapment foot injuries. They were mostly between the ages of 5–<10 years, n = 50 (70.4%) with the mean of 6.2 years, standard deviation = 1.093. Majority of the injuries were Grade III and the worrisome patterns were degloved heels n = 26 (15.4%) and Achilles tendon tear n = 20 (11.8%). The most significant complication was marginal necrosis of the heel pad n = 8 (30.8%). The patients except one had full recovery and without morbidity.
Discussion: Motorcycle spokes entrapment foot injuries occur commonly in children passengers with variation in pattern and severity. Early presentation and prompt treatment made the outcome of these injuries favorable.
Conclusion: The dangling feet of a child passenger sitting on a motorcycle could get entrapped in the spoke wheel causing injuries. Strong and enforceable legislation on the use of commercial motorcycles and public enlightenment on these injury patterns are advocated.
Keywords: Child passenger, commercial motorcycle, entrapment, foot injuries, spoke
|How to cite this article:|
Agu TC. Motorcycle spokes entrapment foot injuries: Prevalence, and pattern of presentation in a private orthopedic and trauma center, Southeast Nigeria – A 10-year retrospective analysis. Afr J Trauma 2017;6:6-10
|How to cite this URL:|
Agu TC. Motorcycle spokes entrapment foot injuries: Prevalence, and pattern of presentation in a private orthopedic and trauma center, Southeast Nigeria – A 10-year retrospective analysis. Afr J Trauma [serial online] 2017 [cited 2018 Dec 15];6:6-10. Available from: http://www.afrjtrauma.com/text.asp?2017/6/1/6/224640
| Introduction|| |
Commercial motorcycles are common means of intracity transport in many Nigerian cities., There are no strictly enforceable legislations on the use of this transport method in our environment, especially with regard to the safety precautions for a child passenger. Accidents from commercial motorcycles are therefore not uncommon in any busy commercial city where every road user wants to beat the frequent traffic gridlocks  which are made possible by school runs coinciding with the rush hours when other people who do businesses go to the shops, markets, and offices. Consequently, where school bus services are not available, and schools are not within walking distances and when parents cannot afford private car drops, the usual alternative is to arrange for a commercial motorcyclist who is often without any special training to be conveying the pupil to and from school. Sometimes, the parent and the child would stand by the roadside and ride on any available commercial motorcycle.
The common precautions that are taken include the child holding unto the motorcyclist tightly from behind or the child is straddled by a parent or an older person from behind as the motorcyclist races to their destination. However, the feet of the child which cannot get down to the footrests are often seen dangling dangerously at the spoke level. Entrapment is, therefore, possible as is often the case when the child loses concentration or the motorcyclist encounters a road bump, and the foot is propelled into the spoke compartment. As the legs are in the external rotation while sitting astride the motorcycle, the pathomechanics result in the heel being entrapped first, and as the foot is propelled by the spokes, the momentum causes injuries to the posterolateral aspect of the foot as well as the posterior aspect of the ankle or lower leg., Varying types and degrees of injuries could be sustained depending on the speed of the vehicle and the duration of entrapment., Using the Tscherne and Oestern  classification of injury, this ranges from closed soft-tissue contusions (Grade 0) to minor lacerations and bruises (Grade I), then to major soft-tissues lacerations with tissue loss (Grade II) and finally to major injuries involving the tendons or neurovascular structures or fractures (Grade III).
In our subregion, the literature is awash with the major limb injuries caused by motorcycle accidents ,, but no study had described the pattern of spoke entrapment injuries. The aim of this study is to describe the prevalence and pattern of this injury in our center and to proffer ways to limit or to eliminate it in our city where motorcycle has become a major means of transport.
| Patients and Methods|| |
The work was approved by the ethical committee of the first choice specialist hospital, a Level II healthcare facility.
Study design and setting
The study was a retrospective analysis of patients who had motorcycle spokes entrapment injuries of the feet from January 1, 2007, to December 31, 2016, and who were seen and treated in a specialist orthopedic and trauma center, Southeast Nigeria. The center is a 25-bedded hospital that has an average annual registration of 202 patients and located in a densely populated commercial city of Onitsha. The population was estimated in 2015 by GeoNames geographical database to be 561,066. All of the patients were managed by the same orthopedic team consisting of resident medical officers and a consultant orthopedic surgeon as well as the support staff.
The patients' documentations, which were compiled as case files and kept routinely with the medical records department of the center were retrieved using motorcycle accident and spokes injury as the search words. Additional information were also obtained from the operation registers. Data analyzed included age, sex, occupation, diagnosis, injury type, treatment carried out, duration of hospital stay, complications, and mortality.
All of the patients were resuscitated, and those who had major injuries needing repair were identified, admitted, and worked up for operations. These ranged from debridement, primary suturing, and primary repair of degloved heel pads and torn tendon Achilles, Kirschner wire (K wire) transfixation of phalangeal fractures to cast immobilization. Second-look debridement after 48 h was carried out in majority of the patients because of the anticipated evolution of the injuries. Aftercare included antibiotics and wound dressing, and where necessary, secondary procedures were also done.
The data were subjected to statistical analysis using Statistical Package for Social Sciences by International Business Machine (SPSS IBM for Windows) version 20, Armonk NY 2011, USA. Z-test was used for equality of proportions, and one sample t-test was used for the predominance of variables. The significant statistical inference was made when the equivalent P < 0.05.
| Results|| |
A total of 1668 patients were seen for trauma-related ailments during the period under review. The patients that had motorcycle accidents were 690 (41.4%) and seventy-one (10.3%) of them had spokes entrapment injuries to their feet. There is a slight male predominance as shown in [Table 1] with a Z-score of 1.51 which is not statistically significant (significant value is >1.96). The patients mostly affected were between 5 and 10 years, n = 50 (70.4%) with mean age of 6.2 years, minimum 5, maximum 9, range 4, and standard deviation = 1.093. Sixty-four (90.1%) of them were nursery and primary school pupils. The patients had different injuries of varying degrees with some having two or more injury patterns to their feet. Dorsal and plantar lacerations were found in the majority of the patients irrespective of the other associated pattern of injury, n = 77 (45.6%) as shown in [Table 2], and this is statistically significant from one sample t-test, P = 0.017. The Grade III injuries were heel pad degloving n = 26 (15.4%), Achilles tendon tear n = 20 (11.8%), and fractures of the phalanges and calcaneus as shown in [Table 2]. The right foot was more involved n = 47 (66.2%).
|Table 1: Age and gender distribution of the patients with motorcycle spokes entrapment injuries|
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Dorsal and plantar lacerations dominated other patterns of injuries, and there is also slightly more number of degloved heel injury and Achilles tendon tear among the Grade III injuries [Table 2].
The number and the varying pattern of injuries, especially Grade III mean that each patient had an average of two or three distinct injuries to the foot. The duration of hospital stay depended on the degree of injuries, and most of the patients spent <3 weeks [Table 3]a and [Table 3]b.
|Table 3a: The distribution of patients according to duration of stay and the main pattern of injuries|
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The complications that were noteworthy were traumatic toe gangrene in two patients and heel flap marginal necrosis in eight patients n = 8 (30.8%). Wound-related complications such as infection and dehiscence were minor and did not affect the outcome significantly.
The operations carried out were mainly wound repairs, K-wire trans-fixation with additional cast immobilization in the majority of the patients as shown in [Table 4].
| Discussion|| |
Motorcycle spokes entrapment injuries involving the foot is relatively common in our subregion, constituting 4.3% of all trauma patients that presented to our center. There is no study in Nigeria showing the incidence, but it varies widely in countries like Thailand and India , where there is no strong legislation on the use of motorcycles and bicycles as commercial modes of transport. There was an insignificant male dominance in our study, unlike some reports that showed a statistically significant male predominance., However, there is a significantly greater involvement of the right foot in this study similar to other studies possibly because of the usual presence of chain guard on the left side of the motorcycle which protected the left foot from the spokes., There was no case of bilateral injuries.
The patients presented within few hours of injuries to our center because concerned adults were always available and because the wounds were usually open and associated with bleeding and pain. The apparent perception of the seriousness of these open injuries in a child was often the compelling reason for early presentation and resuscitation, and debridement was carried out urgently. The injuries vary in number and degree and the majority of our patients presented with Grade III injuries which consisted of heel pad avulsion, Achilles tendon tear, and fractures. These patterns of injuries were reported in other similar studies , but less so for entrapment injuries from the more malleable bicycle spokes. Following debridement, antibiotics were instituted because the wounds were usually contaminated. The second look was undertaken usually after 48 h to determine any further tissue death. This is because, in the evolution of the tissue injury, an apparently healthy tissue at presentation could become nonviable at a later date. The few patients that were treated as day case were in no imminent danger but were seen after 2 days for reassessment. Marked swelling from inflammation and plantar hematoma could resolve by elevation  provided; there is no acute compartment syndrome which must be relieved by plantar fasciotomy. The morbidity that is often associated with acute compartment syndrome can only be avoided by prompt diagnosis followed by emergency decompression., However, there was no case of compartment syndrome of the foot in our patients.
Primary wound repairs were carried out under general anesthesia and also were primary repairs of the torn Achilles tendons. In the later cases, especially, cast immobilization with the ankles in 10°–20° plantar-flexion were carried out to avoid tension on the repaired tendons. The healing in these patients was uneventful and without equinus deformity except for one older patient who later had elongation of tendon Achilles (ETA). The fractures were treated by K-wire transfixation and additional cast immobilization when indicated. Some authors had found external fixators useful in treating these fractures. The average duration of hospital stay was less than 3 weeks, and this was dependent on the degree of injuries. While, minor cases were treated as day case, major injuries involving heel pad avulsions and ankle fractures stayed beyond 3 weeks. This is because those that had marginal necrosis of the heel pads had to undergo further debridement and wound care. However, one older patient needed skin grafting to achieve wound cover of a 2 cm by 2 cm nonhealing ulcer. A more viable option for a larger heel pad loss is sural flap or gastrocnemius myocutaneous flap  because flap is more durable and provides a better padding for the heel to function as a pressure point.
All of the patients had excellent outcome except two patients that had ray amputations for toe gangrene and one patient that had ETA as a secondary procedure with associated morbidity of ankle stiffness. The fractures united and patients were able to return to their normal activities without pain, especially for those followed up beyond 6 months. This was expected because of the early presentations, the appropriate and timely care given and the young ages of patients involved. However, long-term follow-up is important to detect early ankle and foot changes that are occasionally associated with undiagnosed physeal injuries that may have occurred during the entrapment.
There is a great need for legislation and adequate enforcement of same on the use of commercial motorcycles. One maximum recommendation would be to enact a law prohibiting preschoolers, pupils as well as preadolescents from riding on motorcycles or to use only motorcyclists especially trained in child transportation. Furthermore, there is a need for the use of only motorcycle with spoke guards on both sides and with adjustable footrests and straps, especially for child passenger. In addition, protective leather shoes must be worn by any child who must ride on a motorcycle.
| Conclusion|| |
Motorcycle spokes entrapment foot injuries could present with a spectrum of tissue damages. Adequate control of the use of commercial motorcycles will likely reduce incidence of this type of injury.
I thank Jide Onyekwelu, a biostatistician for his contribution.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Oluwadiya KS, Oginni LM, Olasinde AA, Fadiora SO. Motorcycle limb injuries in a developing country. West Afr J Med 2004;23:42-7.
Agu TC, Ojiaku ME. The indications for major limb amputations: 8 years retrospective study in a private orthopedic & trauma center in the South East, Nigeria. J Clin Orthop Trauma 2016;7:242-7.
Suri MP, Naik NR, Raibagkar SC, Mehta DR. Heel flap injuries in spoke wheel accidents. Injury 2007;38:619-24.
Safda CA. Bicycle and motorcycle spoke injuries in children as passengers. J Coll Physicians Surg Pak 2005;15:802-4.
Bevan CA, Babl FE, Bolt P, Sharwood LN. The increasing problem of motorcycle injuries in children and adolescents. Med J Aust 2008;189:17-20.
Tscherne H, Oestern HJ. A new classification of soft-tissue damage in open and closed fractures (author's transl). Unfallheilkunde 1982;85:111-5.
Sholagberu BA, Ofoegbu CK, Nasir AA, Ogundipe OK. Motorcycle injuries in a developing country and the vulnerability of the riders, passengers and pedestrians. Inj Prev 2006;12:266-8.
Agrawal A, Pruthi M. Bicycle spoke injuries of the foot in children. J Orthop Surg 2010;18:338-41.
Sankhala SS, Gupta SP. Spoke wheel injuries. Indian J Pediatr 1987;54:251-6.
Das De S, Pho RW. Heel flap injuries in motorcycle accidents. Injury 1983;15:87-92.
Jeffers RE, Tan HB, Nicolopoulos C, Kamath R, Giannoudis PV. Prevalence and patterns of foot injuries following motorcycle trauma. J Orthop Trauma 2004;18:87-91.
Agu TC, Ikwu AC. A case report of acute compartment syndrome of the leg from tight traditional bone setter's splint with an underlying close tibia fracture: A need for early recognition and emergency fasciotomy. IOSR J Dent Med Sci 2016;15:30-5.
Zhu YL, Li J, Ma WQ, Mei LB, Xu YQ. Motorcycle spoke injuries of the heel. Injury 2011;42:356-61.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]