Injury, 15, 87-92 Printed in Great Britain 87

Heel flap injuries in motorcycle accidents

Shamai Das De and Robert W. H. Pho

Singapore General Hospital

Summary Thirteen cases of heel flap injuries following motorcycle spoke accidents have been analysed. The injuries have been graded into three Grades (I, I1 and III) depending upon the severity and extent of the injury to the foot. The different forms of management are outlined. Most of the injuries have been confined to the right side because of poor assembly of the rear wheel of the motorcycle. Inadequate footwear is a contributory factor. It is urged that protective footwear be made compulsory for both the driver and the pillion pass- enger. Changes should also be made in the design of the rear wheels of motorcycles.

INTRODUCTION MOTORCYCLE spoke injuries to the heel of the driver and pillion rider have not been widely noted until the report by Ahmed in 1978. In 1975 Viljanto reported bicycle and moped spoke injuries in children, while in 1965 Drewes and Schulte drew attention to fractures of the leg in children by bicycle spokes. We have noted an increase in heel flap injuries following motorcycle spoke accidents in Singapore. This no doubt results from the attractions which the newer, stylish and powerful motorcycles have for the younger popu- lation. The recent fuel crisis may have increased the popularity of the motorcycle as a means of transport. The severity of the injuries can vary from avulsion involving the non-weight-bearing area of the skin of the heel to severe injuries of the weight-bearing area with damage to nerves, vessels, tendons and under- lying bone.

PATIENTS AND METHODS Thirteen patients with varying degrees of severity of injuries of the heel by motorcycle spokes were seen between July 1979 and September 1982 at the Univer- sity Department of Orthopaedic Surgery at Singapore General Hospital. (Table Z).

The duration of follow-up ranged from 12 to 38 months. The ages of the patients ranged from 16 to 46 years. There were 6 men, of whom 4 were drivers and 2 were pillion riders. The right heel was involved in 4 patients, and the left in 2 of the 4 drivers. Most of the patients wore either slippers or sandals. There were 7 women, who were all pillion riders and wore either slippers or sandals. The right heel was involved in all of them.

We have attempted to grade the injuries according to their severity, the extent of damage to the skin and to the underlying tendons and neurovascular bundles.

Grade I injury includes those cases with a minor avulsion of skin not involving the weight-bearing area of the heel. Grade II injury includes extensive avul- sions of skin from the weight-bearing area. Grade III injury includes those cases with extensive avulsions of the skin of the heel together with damage to the vessels, nerves and tendons and exposing the underlying bone or ankle joint. In our series we had 6 injuries of Grade 1, 3 of Grade II and 4 of Grade III. We enquired from the patients the engine capacity of the motorcycle con- cerned. Motorcycles below 125 cc engine capacity were involved in 9 cases, of which 5 had Grade I, 3 Grade II and 1 Grade III mjuries. Motorcycles with an engine capacity of 250 cc were involved in 2 cases, 1 with Grade I and the other with a Grade III injury. In 2 cases the engine capacity could not be determined but both had Grade III injuries.

CASE REPORTS Case 1

A 30-year-old woman pillion rider on a motorcycle with a 70 cc engine, was wearing slippers only when her right heel was caught in the rear wheel. She was classified as having a Grade I injury and was treated by excision, after which the avulsed flap was sutured back in place. In addition. a Kirschner wire was used to fix the heel flap to the calcaneum (Fig. I). The flap developed only marginal necrosis, which healed with dressings (Fig. 2). Four months after injury she had difficulty in wearing proper shoes because of pain on the postero-medial scar in the region of the heel. However, she walked well wearing slippers.

Case 2 An 18-year-old man was riding a 125 cc motorcycle which skidded. His leather shoe was split and he sustained a Grade 11 injury of the right heel. The flap was replaced and sutured. There was marginal skin necrosis, which also involved the weight-bearing area (Fig. 3). After 2 months there was still a raw area at the back of his heel. He was offered a dorsalis pedis island flap transfer to resurface the defect, which he refused. After operation he was unable to bear weight for 3 months. The wound finally healed but left him with a rather ugly contracted scar (Figs 4 and 5). He was able to walk but with difficulty and could only wear slippers.

Case 3 A 30-year-old woman pillion rider sustained an avulsion injury of the right heel ofGrade III type (Fig. 6). At the oper- ation it was noted that she had lost a segment of the posterior tibia1 vessels and nerve with exposure of the underlying bone and ankle joint. In view of gross contamination ofthe wound

Tab

le I

.

Mo

de

Gra

de

Cas

e D

rive

r/

Sid

e F

oo

t-

Mo

tor-

o

f o

f N

o.

Init

ials

A

ge

Sex

R

ace

Pill

ion

in

volv

ed

wea

r cy

cle

acci

den

t in

jury

T

reat

men

t R

esu

lts

-

CH

30

F

C

h

Pill

ion

YC

T

18

M

Ch

D

rive

r

HB

C

30

F

Ch

P

illio

n

CM

Y

18

F

Ch

P

illio

n

LPH

20

M

C

h

Dri

ver

R

Slip

per

s

R

Sh

oes

R

San

dal

s

R

San

dal

s

R

Slip

per

s

70

cc

ACC.

125

cc

Imp

act

? AC

C.

125

cc

Act

.

?

Imp

act

I II III

II III

Deb

rid

men

t &

h

eel

flap

re

pla

ced

b

y ‘K

’ w

ire

fixa

tio

n

to O

S c

alci

s an

d

sutu

re.

Hee

l fl

ap

rep

lace

d

and

su

ture

d.

Wo

un

d

deb

rid

emen

t D

elay

ed

cro

ss

thig

h

sura

l n

erve

b

rid

ge

mo

nth

s la

ter.

and

su

ture

. fl

ap.

15

cm

gra

ft

fou

r

Inad

equ

ate

init

ial

trea

tmen

t el

se-

wh

ere.

W

ou

nd

in

fect

ed.

Hea

led

af

ter

dai

ly

dre

ssin

gs,

an

tib

ioti

cs

and

sec

on

dar

y su

ture

o

f w

ou

nd

.

Wo

un

d

deb

rid

emen

t &

su

ture

. R

edu

ctio

n

of

asso

ciat

ed

frac

ture

d

islo

cati

on

o

f ta

rsu

s.

Sp

lit

skin

g

raft

ap

plie

d.

Po

or

scar

. F

ree

gro

in

flap

at

tem

pte

d

bu

t fa

iled

. S

ub

- se

qu

entl

y h

ad

ET

A

and

p

ost

erio

r ca

psu

lar

rele

ase

and

a

cro

ss

leg

fl

ap.

Wo

un

d

hea

led

p

rim

arily

. W

alki

ng

p

ain

less

ly

wit

h

slip

per

s an

d s

ho

es.

Dev

elo

ped

p

ain

ful

scar

o

ver

wei

gh

t-b

eari

ng

ar

ea

of

hee

l. W

ears

sl

ipp

ers

bu

t u

nab

le

to w

ear

sho

es

bec

ause

o

f p

ain

ful

scar

. N

ot

keen

o

n f

urt

her

su

rger

y.

Wo

un

d

hea

led

. R

eco

vere

d

full

sen

sati

on

in

so

le.

TP

D

ove

r d

ista

l so

le

12

mm

. H

yper

aest

hes

ia

ove

r h

eel.

An

kle

and

su

bta

lar

mo

ve-

men

ts

- 50

%

no

rmal

. W

ears

sl

ip-

per

s an

d s

oft

sh

oes

.

Wo

un

d

has

h

eale

d.

Pro

min

ent

scar

. W

ears

sl

ipp

ers.

P

ain

ful

wea

r-

ing

sh

oes

.

Wo

un

d

hea

led

. G

oo

d

hee

l cu

sh-

ion

. W

eari

ng

sl

ipp

ers.

C

han

ge

of

occ

up

atio

n

fro

m

po

licem

an

to p

ri-

vate

b

usi

nes

s.

6 7 8 9

10

11

12

13

MO

17

F

M

al

LS

F

46

F

Ch

TC

Y

20

M

Ch

TC

K

28

M

Ch

WO

M

16

F

Ch

P

illio

n

JL

19

M

Ch

L

C

anva

s sh

oes

R

So

ft

sho

es

250

cc

Imp

act

TH

S

24

M

Ch

Dri

ver

Pill

ion

12

5 cc

A

ct.

TM

K

.24

F

Ch

P

illio

n

R

Sh

oes

12

0 cc

Im

pac

t

Pill

ion

Pill

ion

Dri

ver

Pill

ion

R

Slip

per

s

R

Slip

per

s

L

Slip

per

s

R

soft

leat

her

sh

oes

(s

plit

)

R

San

dal

s

100

cc

Imp

act

125

cc

Act

.

90

cc

Act

.

125

cc

AC

C.

250

cc

Act

.

II I I I III I I III

Hee

l fl

ap

rep

lace

d

and

su

ture

d.

Hee

l fl

ap

hea

led

. T

ibia

1 fr

actu

re

SS

G.

Ass

oci

ated

co

mp

ou

nd

ti

bia

1 u

nit

ed.

Wal

kin

g

pai

nle

ssly

w

ith

fr

actu

re.

sho

es.

Deb

rid

emen

t an

d

sutu

re

of

hee

l W

ou

nd

h

eale

d.

Wal

ks

pai

nle

ssly

fl

ap.

wit

h

sho

es.

Deb

rid

emen

t an

d

sutu

re

of

hee

l W

ou

nd

h

eale

d.

Wal

ks

pai

nle

ssly

fl

ap.

wit

h

sho

es.

Deb

rid

emen

t an

d

sutu

re

of

hee

l fl

ap.

Mar

gin

al

flap

n

ecro

sis.

N

o

SS

G.

Wo

un

d

hea

led

. W

alks

p

ain

less

ly

wit

h

sho

es.

Deb

rid

emen

t an

d p

rim

ary

rep

air

of

torn

p

ost

erio

r ti

bia

1 te

nd

on

an

d

po

ster

ior

tib

ia1

ner

ve.

SS

G.

De-

ve

lop

ed

pai

nfu

l co

ntr

acte

d

scar

. F

ree

do

rsal

is

ped

is

com

po

site

fl

ap

fro

m

oth

er

foo

t.

Su

cces

sfu

l fr

ee

flap

w

ell.

To

o

earl

y to

as

sess

w

alki

ng

ab

ility

w

ith

fo

otw

ear.

Deb

rid

emen

t an

d

sutu

re

of

hee

l W

ou

nd

h

eale

d.

Wal

ks

pai

nle

ssly

fl

ap.

wit

h

sho

es.

Deb

rid

emen

t an

d

sutu

re

of

hee

l fl

ap.

Mar

gin

al

flap

n

ecro

sis.

N

o

SS

G.

Wo

un

d

fin

ally

h

eale

d.

Wal

ks

pai

n-

less

ly w

ith

sh

oes

.

Deb

rid

emen

t an

d

hee

l fl

ap

re-

pla

ced

b

y ‘K

’ w

ire

fixa

tio

n

to

OS

ca

lcis

an

d s

utu

re.

Del

ayed

w

ou

nd

h

ealin

g.

Hyp

er-

sen

siti

ve

scar

. W

alks

w

ith

d

iffi

- cu

lty.

A

ble

to

w

ear

on

ly

slip

per

s.

No

t ke

en

on

fu

rth

er

surg

ery.

SS

G =

Sp

lit s

kin

gra

ft.

TP

D =

Tw

o

po

int

dis

crim

inat

ion

. A

ct.=

P

atie

nt

acci

den

tly

intr

od

uce

d

hee

l in

sid

e m

ovi

ng

re

ar

wh

eel.

No

veh

icle

ac

cid

ent.

Im

pac

t=ln

itia

l ve

hic

le

acci

den

t ca

usi

ng

su

bse

qu

ent

hee

l in

jury

. E

TA=

Elo

ng

atio

n

of

Ten

do

-Ach

illes

.

90 Injury: the British Journal of Accident Surgery, Vol. 1 ~/NO. 2

Fig. 2. Case I. Heel flap has survived with only marginal necrosis.

Fig : 1. Case I. A Grade I injury of the heel flap I rep ‘laced and transfixed with a Kirschner wire.

has been

Figs 4 and 5. Case 2. A Grade II injury. Final healed result. Scar over weight-bearing area.

Fig. 3. Case 2. A Grade II injury involving the beai -ing area of the heel has been treated by replacing and showing marginal necrosis over heel and sole.

Fig. 6. Case 3. A Grade III injury damage to posteri or tibia1 els and nerve and tibialis nosterior tendon. Wound

weight- the flap

margins have been excised. Fig. 7. Case 3 after flap from thigh.

Das De and Pho: Heel flap injuries

Fig. 8. Case 3 after thigh flap and cable nerve grafting showing final healed result.

Fig. 9. The vulnerability of the exposed right heel of the pillion rider as it lies close to the unprotected rear wheel of the motorcycle.

Fig. 10. The protection offered to the left heel by the chain case.

initially, only toilet and suture ofthe wound was carried out. On the second post-operative day it was decided that the wound was not infected and could be safely covered by a flap from the other thigh (Fig. 7). This healed uneventfully. Four months later a 15 cm sural nerve graft was used to bridge the gap in the posterior tibia1 nerve in order to restore sensation in the sole. She recovered two-point discrimination of 12 mm in the sole. She has some stiffness in her ankle and subtalar joints but she is able to wear slippers and has some trouble in wearing proper shoes (Fig. 8).

DISCUSSION Injury of the heel by the spokes of the rear wheels of motorcycles is a relatively new entity in Singapore and usually affects the right heel of the pillion rider. This is because with most motorcyles, the right side of the rear wheel is poorly protected and the bare heel of the pillion rider can easily come into contact with it (Fig. 9). The left heel is less often injured because the chain- case separates the spokes from the foot (Fig. 10). In the tropics, as in Singapore, most motorcycle drivers and pillion riders prefer to wear sandals or slippers because of the heat and humidity. Wearing flared trousers can also be dangerous, as in two of our patients with injur- ies of the heel. In only 4 patients was there a history of a true collision.

We agree with Ahmed (1978) that the higher speed of the motorcycle and its rigid spokes were responsible for the severe injuries of the heel in the adults. In chil-

dren, the slower speed of the pedal cycles’ spokes and the nature of the bones tend to result in fracture of the leg bones (Drewes and Schulte, 1965).

There is no controversy about the management of the simple Grade I injury with a wide based flap. It does well with wound excision and suture of the flap to its original bed without tension. Although some flaps may develop marginal necrosis and possible dis- comfort over the postero-medial aspect, the patients can walk well with shoes or slippers. In two of the three Grade II injuries, initial management followed the above principles but partial necrosis of the flap in Case 2 required split skin grafting which later gave a contracted, unhealthy scar over the edge of the weight- bearing area (Figs 4 and 5).

In this type of case a better procedure would have been a dorsalis pedis island flap (McGraw and Furlow, 1975). The advantage of such a flap is that the skin is thin and hairless, it has a long and relatively wide vascular pedicle and a cutaneous branch from the musculo-cutaneous nerve. In such a case, as the scar is not directly over the weight-bearing area of the heel, little padding by subcutaneous fat is required and a dorsalis pedis flap looks better than, for instance, a free groin or cross-leg flap. It also precludes the need for secondary thinning procedures.

The decision on skin cover and the choice of flap is more important with Grade III injuries, especially when there has been damage to the posterior tibia1 vessels and nerves. For these the dorsalis pedis island flap is dangerous because it may compromise the cir- culation to the foot. However, this can be overcome by inserting a vein graft into the interrupted segment of the dorsalis pedis artery or posterior tibia1 artery (Robinson, 1976).

In addition, the so-called cosmetic advantage of the dorsalis pedis flap may turn out to be a disadvantage in a patient when the weight-bearing area of the heel is involved. Here a free flap or one from the other thigh or leg, with adequate subcutaneous tissues, would be a distinct advantage before proceeding to a second operation involving nerve grafting to provide sen- sation. Fractures of underlying bone such as tibia or calcaneum or involvement of the ankle joint can lead to osteitis or septic arthritis if the initial management has been inadequate or the severity of the injury has

92

been underestimated. In this series there have been no instances of sepsis of bone or joint, However, one patient had persistent stiffness of the ankle joint because of direct involvement of a Grade III injury.

From this study it is clear that most of the injuries were confined to the right side because of the poor design of the rear wheel assembly. The other obser- vation was that because of the local weather most of the patients were wearing inadequately protective footwear.

As motorcycles become more popular and fashion- able it is anticipated that injuries of the heel by motor- cycles’ spokes will increase and become very common. It is suggested that drivers and pillion riders should all be required to wear strong protective footwear. As with the introduction of the helmet, the incidence of head injuries in road accidents have lessened, we believe similarly that the morbidity of heel flap injuries could also be reduced by the compulsory wearing of strong protective footwear. This may not however be easy to implement in a warm and humid country. Conversely more attention should be made in the design changes of the motorcycles, especially over the right rear wheel section, where the right foot is so susceptible to injury.

Acknowledgements We wish to thank the Consultants of the University Department of Orthopaedic Surgery, Singapore General Hospital for permission to study these cases. We would also like to thank Mr S. S. Moorthy and Mr S. H. Tow for the illustrations and Miss J. Soh for secretarial assistance.

EDITORIAL NOTE One of our Editorial referees (a plastic surgeon) who recommended acceptance of this contribution to the Journal suggested that a cautionary warning should be added as a postscript to those who, after reading this paper, may become yap happy’ before they can really !Y.

. . . It is rarely necessary to use free-flap transfers or island flap transfers for this particular type of injury: both techniques have their fair share of complications and are hardly ever one-stage procedures. It is often far simpler and safer to excise these wounds properly, dress the wounds carefully and leave the dressings undisturbed for 7 to 10 days when the patient is taken to the operation theatre for skin-grafting, using freshly-cut split skin, not skin that was cut at the time of the original operation and stored in the refrigerator. This simple technique is efective even ifbare but viable tendons and open joints were noted at the original

Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 2

wound excision. It is a manoeuvre that is safe and simple, both useful points to remember when dealing with untidy crush wounds. ’

Free flap transfer, indeed any flap repair, is best carried out unhurriedly as a set operation, preferably when the patient’s wounds are clean or healed and at a time when the added strain of a longish operation will not put his life or his limb at risk.

This comment was shown to Professor Pho who replies as follows:

‘As indicated in this paper we have noted that patients who sustained a Grade I & II type of injury usually did well with simple replacement and suture of the avulsed heelflap although in many cases there will be marginal necrosis from poor venous return. In one case (Case 2) there was a painful tethered scar over the heel at the edge of the weight-bearing area and he was ofleered surgery which he refused and we noted that he was relatively disabled from this contracted unhealthy scar tissue.

Those cases with Grade III type of injury had sig- niJcant disability from a painful and tethered scar as a result of a split skin grafting procedure. We would advocate resurfacing with either a cross leg or@eeflap procedure in such cases. Basically this is to provide a good bed for further reconstruction such as nerve graf. We would agree that these procedures should be car- ried out in a specialised centre accustomed to doing such procedures routinely and best carried out unhur- riedly as a set operation as suggested by the editor.

We share your view that implementing compulsory protective footwear for the driver and pillion rider in a warm and humid country may be dificult. Perhaps more attention should be paid to the design changes of the motorcycles especially over the rear wheel section. ’

REFERENCES

Ahmed M. (1978) Motorcycle spoke injury. Br. Med. J. 2, 401.

Drewes J. and Schulte H. D. (1965) Bruche im Bereich des Unterschenkels bei Kindern infolge von Fahrradspeichen- verletzungen. Der Chirurg. 36,464.

McGraw J. B. and Furlow L. T. Jr. (1975) The dorsalis pedis arterialized flap. Plast. Reconstr. Surg. 55, 177.

Robinson D. W. (1976) Microsurgical transfer ofthedorsalis pedis neurovascular island flap. Br. J. Plast. Surg. 29,209.

Viljanto J. (1975) Bicycle and moped spoke injuries in chil- dren. Analysis of 103 consecutive cases. Ann. Chir. Gynaecol. Fenn. 64, 100.

Paper accepted 18 November 1982.

Requests for reprinls should be addressed IO: Dr Robert Pho, Department of Orthopaedic Surgery, National University of Singapore, Singapore General Hospital, Singapore 03 16.