Figure 136-1 Foot caught in bicycle spokes.
What To Do:
Obtain a detailed history, perform a general examination to rule out any possible associated injuries, and then perform a focal examination of the foot and ankle. Note any darkened areas of skin crush, and examine for underlying areas of bony tenderness by applying indirect stress and/or axial loading to the metatarsals and malleoli.
Cleanse the area with a gentle scrub (ShurClens, Betadine).
Provide any tetanus prophylaxis required (see Appendix H), and apply a temporary normal saline/povidone-iodine dressing.
Perform radiographic studies to rule out any fracture. Apply ice to the affected area to reduce pain and swelling while awaiting radiographs.
Dress the wound with a nonadherent cover, such as oil emulsion (Adaptic) gauze. Incorporate a bulky compressive dressing consisting of gauze fluffs, knitted cotton roller gauze (Kerlix), and a mildly compressive Ace wrap (or equivalent dressing material).
Have the patient keep the foot strictly elevated above the level of her heart over the next 24 hours, and then schedule her for a wound check within 48 hours.
Inform the parents that the crushed skin is not a simple abrasion. There is a greater risk for infection, and any darkened area may not survive. They should understand that a slow-healing sore might result or skin grafting might be required, and therefore close follow-up is necessary with surgical referral if warranted.
Encourage the patient and the parents to wear proper closed-toe footwear when riding a bicycle to minimize the chance of future injuries.
Consider modifications to the bicycle to minimize the chance of injury, including bicycle chain and spoke guards.
Take advantage of time with parents to emphasize the importance of wearing a helmet whenever riding a bicycle.
What Not To Do:
Do not assume that the injury is merely a simple abrasion because the radiographs are negative.
Discussion
Bicycle spoke injuries are similar to but not as serious as historic wringer injuries. Fractures are not commonly associated with these injuries, but often there is severe soft tissue injury. Consequences of a crush injury can be minimized by the use of compression dressings, elevation, and early follow-up.
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