Tag Archives: wounds

Heel spoke wheel injuries in a community hospital in Togo

by Gamal AYOUBA PhD1*, Komla Séna AMOUZOU PhD2, Batarabadja BAKRIGA PhD3, Kouami AMAKOUTOU PhD4, Noufanague Kanfitine KOMBATE PhD5, Anani ABALO PhD2

The Foot and Ankle Online Journal 13 (2): 4

Motorcycles are one of the commonly used vehicles in our setting. Injuries caused by the wheels of the spokes to the heel engage the functional outcome of the foot and ankle. We aim to report the patterns of these injuries and the results of the treatment of such injuries in our community hospital. This prospective observational study included all cases with spoke wheel injury to the heel presenting between June 2014 to October 2018 in a community hospital in Kpalime, a city located northwest to the capital of Togo. Demographic and clinical data were collected from each patient including age, sex, occupation, injured side, and characteristics of the wounds. The wounds were grouped into those with Achilles tendon injury and those without Achilles tendon injury. The soft tissue injuries were classified according to Tscherne and Gotzen classification and managed accordingly. The AOFAS hindfoot score was used to assess the clinical outcome. Twenty-six patients were included, 13 females and 13 males. The mean age was 16 years (range 4-56 years). Seventeen patients were children (aged under 16 years). The right foot was affected in 21 patients and the left foot in 5 patients. The injury was classified as grade 2 (n=15) and grade 3 (n=11) of Tscherne and Gotzen. Wounds with Achilles tendon involvement accounted for 17 and without Achilles tendon accounted for 9. The mean time from injury to surgery was 18.4 hours (range 3-72 hours). Healing was achieved in 12 patients without complications. Complications included wound dehiscence (n=2), cutaneous necrosis and local infection (n=10), superficial infection (n=2). Secondary procedures performed were wound debridement (n=3) followed by skin graft (n=3), sural pedicled flap (n=2). The mean follow-up was 16.7 months (range 4-20 months). The average AOFAS score was 86.8 (range 64 – 100). The heel injuries are one of particularity of road traffic trauma in our setting. The outcome depends upon the involvement of Achilles tendon, an associated calcaneal fracture, and a high grade Tscherne and Gotzen classification.

Keywords: heel, spoke wheel, wounds, Achilles tendon, motorcycle, Africa

ISSN 1941-6806
doi: 10.3827/faoj.2020.1302.0004

1 – Department of orthopaedic and traumatology. Community Hospital of Kegue. University of Lomé. Togo
2 – Department of plastic and reconstructive surgery. University Hospital of Sylvanus Olympio. University of Lomé. Togo
3 – Department of orthopaedic and traumatology. University Hospital of Sylvanus Olympio. University of Lomé. Togo
4 – Department of orthopaedic surgery. University hospitals Cleveland Medical Center, Cleveland, Ohio, USA.
5 – Department of orthopaedic and traumatology. Hospital of Saint-Jean de Dieu d’Afagnan, Togo
* – Corresponding author: gamal792003@yahoo.fr

Motorcycles are one of the most popular means of transportation in developing countries including sub-Sahara African countries such as Togo. Accidents associated with motorcycles are common among road traffic accidents in urban and rural areas in developing countries [1]. In Togo, during the first semester of 2019, motorcycles were involved in more than 51.36% of road traffic accidents [2]. The incidence of motorcycle spoke injuries to the heel has shown some specific features among road traffic accidents ranging from a simple laceration to a total traumatic foot amputation. [1,3-5]. Children make up a large proportion of the victims of these accidents [2]. The involvement of the Achilles tendon makes it a challenge for the orthopedic surgeons. In these cases, the exposure of the bony part of the Achilles tendon required a vascularized soft tissue resurfacing.

The main objective was to report data related to heel injuries and the secondary objectives of this study was to report patterns of the injury to the heel caused by spoke wheel, the management of these injuries, and the functional outcome.

Materials and Methods

This prospective study was carried out between June 2014 and October 2018 and included patients treated for motorcycle spoke injuries to the heel in the Department of Surgery at the community hospital of Kpalime, a city located 120km northwest from the capital of Togo in West Africa. The following demographic and clinical data of patients were recorded: gender, age, type of occupation, affected side, injury of Achilles tendon, associated injuries, number of surgical procedures and the course of treatment. We identified two groups of patients according to the clinical presentation of the wound: wounds with Achilles tendon involvement and wounds without Achilles tendon involvement. Soft tissue injuries were classified according to Tscherne and Gotzen [6] classification. Anteroposterior and lateral X-rays of the ankle were obtained in the Emergency Department. The functional outcomes were assessed using the AOFAS score (The American Orthopedic Foot and Ankle Score).


Clinical and socio-demographic characteristics

The study included 26 patients, 13 males and 13 females. The average age of the patients was 16 years (range, 4-56 years). Children (under 16 years old) accounted for 17, while adults (patients above 16 year-old) accounted for 9. All the adult patients were on the back seat and were wearing sandals at the time of the accident. As a mechanism of injury, the spokes of the wheel caught the heel of the patient just after the wheels had slipped over a bump of the road. The children were seated between their mother on the back seat and the rider of the motorcycle. Their feet were dangling and caught by wheel spoke. The wound was located on the vertical bony aspect of the heel or in some cases extended from the medial to lateral aspect of the heel. The wound was located on the posterior bony surface and extended 2 to 6 cm proximally in nine cases (Figure 1A), on the posteromedial aspect in 5 cases and on posterolateral (Figure 1B) aspect in 2 patients.

Figure 1 A: Posterior wound with complete section of Achilles tendon, B: Postero-lateral wound laceration, Achilles tendon partially sectioned, C: Semicircular laceration with Achilles tendon tearing and calcaneus fracture.

In the group with Achilles tendons involvement (17 patients): 7 had tendon tearing, 8 had complete section and 2 had partial section of the Achilles tendon. The wound of the heel was semi-circular in 10 patients (Figure 1C).

In 10 patients there were some associated injuries such as calcaneus fracture (5, 19%), tibia fibula third distal fracture (4, 15%), a particular calcaneus enucleation and one toes extensors tendons section. The demographic characteristics of the patients and the clinical presentations are reported in Table 1.

Treatment protocol

All patients received upon arrival in the emergency department, IV antibiotic (amoxicillin acid clavulanic 1g) and tetanus prophylaxis. The wounds were treated with abundant irrigation, drainage, and debridement. All sectioned Achilles tendons were sutured using the Kessler suture technique using non-absorbable suture. In a case of osseous disinsertion, the tendon was fixed to the calcaneal tubercle using a non-absorbable suture. The ankle was kept in a plantar flexion with circular POP for 3 weeks in all patients with Tscherne and Gotzen grade 3. In patients presenting with grade 2, an anterior POP slab maintained the ankle in a moderate plantar flexion for 10 days. In all cases, there was a window for the wound’s daily assessment during the first week (Figure 2) and until the wound is totally healed. In 4 patients tibial and or distal fibula fractures were associated with heel injury.

Figure 2 Window in the plaster contention for the wound assessment.

Figure 3 A: healing after skin graft, B: healing after sural pedicled flap.

The treatment of these fractures was a non-operative management using a long leg slab which was kept until wound healing. Then, the POP slab was replaced by circular contention. In a particular patient with calcaneus enucleation, after wound debridement a bone cement was used to fill the space. All patients received postoperatively the IV amoxicillin and clavulanic acid as antibiotic prophylaxis for 3 days. Rehabilitation began after removal of the splint in all patients. All adult patients were sent to physiotherapy for 2 consecutive weeks. Self-physiotherapy was established and encouraged in children.

Therapeutic Results

The average waiting time for surgery was 18.4 hours (range, 3-72 hours). The outcome after surgery at 3-weeks follow-up is summarized in Table 2. The healing of the wound was obtained in 12 patients (48%) without any complication.

Revision procedures were required in 14 patients. For a patient who had an enucleation of the calcaneus, the bone cement, which was put in during the index procedure, was removed after two weeks and then the wound was closed. The calcaneus space was filled with soft tissue. The Achilles tendon was fixed to soft tissues in a neutral position of the ankle. Table 3 summarizes the different revision procedures in the Tscherne and Gotzen grades.

The average duration of immobilization was 3.3 weeks (range, 3-6 weeks). The average healing time was 25 days (range to 20-49 days). The average length of stay in hospital was 10.3 days (range, 2-24 days). Postoperative complications included cutaneous necrosis in 13 patients, and superficial infection in 2 patients, Achilles tendon necrosis in one case. The long-term complications included an obvious disturbance in walking patterns in four cases, ankle instability in four cases, hindfoot varus of 6° in two cases. The flexion/extension range of motion of the ankle was between 15° and 30° in four cases. There were unsightly and retractile scars in eight cases. The mean follow-up (Figure 3) was 16.7 months (range, 4-20 months). The average AOFAS score was 86.8 (range, 64 – 100). The AOFAS score in patients who had Achilles tendon injury was 86.1 versus 88.2 for patients without Achilles tendon injury (p = 0.67).


The incidence of motorcycle spoke injuries to the heel has been increasing in developing countries especially in Africa and Asia [3,5,7]. In Nigeria an incidence of 4.26% has been reported among all road traffic trauma in a 10 years retrospective analysis published in 2017 by Agu TC [1]. These specific injuries occurring in the road traffic trauma affected mostly children [1,3,5,7] as confirmed in the current study. The overload of the motorcycle, inadequate footwear and sometimes bumpy roads are the main contributing factors to spoke injuries to the heel [2,4].

Our study, as well as past several studies, showed that motorcycle spoke injury is always unilateral, mostly confined to the right foot [3,4, 8]. This could be explained by the fact that the left foot is often protected by the motorcycle chain guard cover shield and therefore rarely injured.

Items N %
Sex Male 13 50
Female 13 50
Age Adult [>16 y] 9 35
Children [≤16 y] 17 65
Occupation Students 21 81
Farmers 4 15
Craftworker 1 4
Affected side Right 21 81
Left 5 19
Tscherne and Gotzen classification Grade 1 0
Grade 2 15 58
Grade 3 11 42
Achilles tendon involvement Without Achilles tendon involvement 9 35
With Achilles tendon involvement 17 65
Associated injuries None 15 58
Toes Extensors tendon section 1 4
Calcaneus fracture 5 19
Calcaneus enucleation 1 4
Tibia / fibula distal fracture 4 15

Table 1 Demographic and clinical data of the patients.

Grade Tscherne and Gotzen Healing Dehiscence of the wound Cutaneous necrosis Superficial infection Total
Grade 2 8 2 4 1 15
Grade 3 4 0 6 1 11
Total 12 2 10 2 26

Table 2 Three weeks postoperatively follow-up in the Tscherne and Gotzen grades.

Grade of Tscherne and Gotzen Healing by secondary intention Debridement + healing by secondary intention Skin graft Sural reverse pedicled flap Total
Grade 2 3 2 1 1 7
Grade 3 3 1 2 1 6
Total 6 3 3 2 14

Table 3 Second procedures according to the stage of Tscherne and Gotzen.

The shoe wearing could reduce the severity of the injuries, but the study of Naumeri et al. did not confirm this precaution [3]. The injuries are less severe (grade 0 and 1) in case of involvement of bicycle thus to low velocity of them [9]. But in our study the injuries were severe (grade 2 and 3) with extensive wound, degloving of the heel pad, and multiple associated injuries (tibia /fibula fractures, extensor tendon injuries, and a rare case of calcaneus extirpation). The injury can extend to all aspects of the heel in a semi-circular shape. In case of rupture of the Achilles tendon, the location could vary between 1 and 8 cm according to the different authors [4,10,11]. The severity of the soft tissue damages associating multiples injuries have been described by several authors [2,5,11]. This is a high velocity trauma due to wheel spokes, especially when riding at high speed. No main vascular pedicle was injured in our study. This complication has not been reported in the literature. There is no unanimous classification to describe motorcycle spoke injuries of the heel. Most authors used the classification of Tscherne and Gotzen. In our study, the treatment as well as the prognosis were evaluated using this classification. However, this classification gives little details about the fracture of the calcaneus, the rupture of the Achilles tendon and the other associated injuries.

The Grade 2 injuries required debridement and suturing of the wound without tension. The monitoring of the wound is important especially over 48 hours postoperative because secondary necrosis and sepsis are common at this step [3]. In some cases, in this study, patients initially classified grade 2 were managed secondarily for a reverse sural flap due to cutaneous necrosis. All grade 3 injuries in our study had Achilles tendon injury which was a partial or a complete rupture. The repair technique was similar to the common technique used in the literature [2,9]. Two sural pedicled flaps were performed because of secondary skin necrosis. This is the most common flap for the management of skin loss of the heel [3], [12,13]. Postoperative complications are common in motorcycle spoke injuries of the heel because of the extent of the injury and the population that is mostly affected [4,7,11].

The healing time and the duration of the hospital have not been reported to the grade of Tscherne and Gotzen. These parameters had been influenced by the complications in many patients requiring a secondary procedure. Also, Agu TC [1] found that the average duration of hospital stay was more than 3 weeks, and this depended on the degree of the injury. The major injuries including heel pad avulsions and ankle fractures stayed beyond 3 weeks in the hospital [1]. Naumeri and al [3] found that healing time was markedly increased in grade III injuries. Nevertheless, the global outcome was excellent in all patients on the AOFAS grading. However, there has been a better outcome (p=0.67) in the group of patients without Achilles tendon involvement compared to the group with Achilles tendon injuries. Only two patients that were poor had calcaneus enucleation (AOFAS=64) and Achilles tendon necrosis (AOFAS=65). In the patient with Achilles tendon necrosis, the infection and delayed treatment have hindered the reconstruction of the necrosed Achilles tendon leading to the poor result. In the second patient the loss of calcaneus had led to lack of heeling support with disturbance in walking pattern and loss of hind foot alignment which was 11° of valgus.

This excellent outcome due to the early presentation of the patients, the appropriate and timely care given, and the young ages of patients involved.


The heel injuries caused by motorcycle spoke wheels are a one of particularity of road traffic trauma in our setting. The difficulty to manage such patients starts with the difficulty to clinically assess the wound as no classification exists for such injuries, and to obtain reliable skin coverage. The high rate of complications works against patients that are part of the population that needed to stand for its daily food. The outcome depends upon the involvement of Achilles tendon, and a high grade of Tscherne and Gotzen and associated injuries such as calcaneus fracture. We had a satisfactory final outcome in mostly all of our patients. A dedicated team of orthopedic and plastic surgery could contribute to minimize the complications and expedite care, thus resulting in a faster return to work.

Funding declaration.

No funding to declare

Conflict of interest.

Authors declare that they have no competing interest in relation with this manuscript


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Bad ink: A case of a chronic ulceration of the lower extremity secondary to tattooing

by Larissa Rolim DPM, MS1; Christopher Blanco DPM, FACFAS1; Sara Lewis DPM1pdflrg

The Foot and Ankle Online Journal 9 (1): 7

Introduction:  Tattoos are a vastly popular form of body modification. However, there are no government regulations in regards to tattoo ink compositions. In this paper we report a case of chronic ulceration secondary to tattoo.
Case presentation: A 42-year-old female presented with a history of a non healing ulcer on her leg over a recent tattoo. Surgical excision of ulcerated area as well as negative pressure vacuum therapy and weekly wound care visits were performed and patient was fully healed by her 16 week follow up.
Conclusion:  The composition of commonly used Tattoo ink can cause ulcerative lesions.

Key words: tattoo, ulceration, wounds, lower extremity

ISSN 1941-6806
doi: 10.3827/faoj.2016.0901.0007

1 – South Miami Hospital, South Miami, FL
* Correspondence: Larissa_rolim@hotmail.com

Since the word tattoo was introduced to the Western Hemisphere by explorer James Cook, it has gained widespread popularity through all social classes including the likes of Winston Churchill himself. However, increases in popularity also come with increases in documented complications such as allergic, granulomatous and lichenoid reactions [1]. We present a rare case of a non-healing ulceration and allergic reaction caused by a tattoo.

Case Report

A 42 year-old female presented to our wound care center with complaints of a six-month history of a non-healing ulceration to her lateral left ankle. The patient stated that one-year prior she received a tattoo to her left ankle while vacationing in Cuba. The tattoo initially healed with no issues. At 6 months after the initial tattoo application the patient noticed a raised area where red ink had been placed, which eventually ulcerated.

The patient attempted to treat the area with topical over-the-counter cortisone creams and triple antibiotic ointment, with no improvement. The patient complained of mild discomfort and pruritus to the area but there was no noteworthy pain.  The patient had no significant past medical history and no known drug allergies. The patient was not currently taking any medications at home.

Physical examination revealed full thickness ulceration to the lateral aspect of the ankle. The ulceration measured 0.6cm x 0.6cm x 0.3 cm. The wound base was a mixture of fifty percent granular and fifty percent fibrotic tissue. The periwound area had a raised verrucous appearance in a 2cm diameter with xerosis and erythema. There was no noted drainage or purulence (Figure 1).  Patient had strong pedal pulses bilaterally. Varicose veins were noted as well as corona phlebectatica. A punch biopsy was performed at the initial visit. The pathology report revealed acanthotic and parakeratotic epidermis with surface suppurative inflammation and superficial dermal mixed acute and chronic inflammation, hypocellular and partially necrotic dermal collagen and pigment in the dermis.


Figure 1 Initial wound presentation.

The patient underwent wide excision of the ulceration with 2mm margins surrounding. The tissue was sent for pathology and cultures. The area was debrided of any non-viable tissue and a bovine collagen graft (Integra) was applied and secured with staples. Negative pressure therapy (KCI wound VAC) was initiated at that time

Post excision pathology report showed skin ulceration with acute and chronic inflammation, focal abscess formation and collections of histiocytes. There were no organisms found on AFB or PAS stains. Surgical cultures revealed heavy growth of Methicillin-Resistant Staphylococcus Aureus. An infectious disease consultation was obtained and the patient was treated with IV vancomycin while inpatient and oral trimethoprim/Sulfa at discharge for ten days [2].

We continued use of negative pressure wound VAC therapy (KCI wound VAC) and weekly sharp debridement. Wound VAC therapy was discontinued at 7 weeks. Weekly debridement of any fibrotic tissue and the use of multi-layer compressive dressings were continued. The patient was completely healed at their 16-week follow up and was discharged from our care at that time (Figure 2).


Figure 2 Final appearance of healed wound.


The growing popularity of tattoos has lead to an increase in the rate of complications associated with tattoo application. A review of the literature depicts complications of tattooing as early as 1952 where Lubek et al documented four separate pathologic consequences of tattooing, namely Boeck’s sarcoid, secondary syphilis, discoid lupus and a mercury sensitivity reaction.  Currently, the FDA has no approved tattoo inks and do not regulate their composition [3]. In April of 2014 the FDA launched a “think before you ink” campaign warning consumers of substantial risks including infection, allergies, scarring, granulomas and MRI complications [4]. Tattoo inks include different pigments ranging from inorganic metallic salts, organic molecules and organic dyes. Kluger et al reported known allergenic metals, nickel, cobalt, chromium and mercury, found in tattoo inks. While there are documented complications from all tattoo pigments, hypersensitivity reactions to red pigments are the most common [3,5]. Particularly reactions to red pigments containing cinnabar, which is composed of mercuric sulfide. Reactions to red pigment have been associated with allergic contact dermatitis, lichenoid dermatitis, pseudolymphomatous and sarcoid reactions [5].

Hypersensitivity reactions and complications are not isolated to the lower extremity. There have been a number of documented cases of adverse reactions to tattoos involving all areas of the body [4]. Tattooing has the potential to spread infectious diseases, namely hepatitis, chanchroid, MRSA and atypical mycobacterial diseases, among others and lowers the ability to fight infections in the tattooed area [2,6]. The process of tattooing in itself induces a chronic inflammatory response that can be seen years later [6]. Currently there are no set standards in the treatment of tattoo related reactions. Tattoo related reactions have variable presentation and the treatment and management of these dermatologic inflammatory reactions are based on the presenting pathology with the use of biopsy and cultures [7,8]. Tattoo related ulceration appears to be uncommon with only a few cases documented in the literature [4,7,8]. Our case presents the rare occurrence of tattoo-associated ulceration while also highlighting a novel method of management that ultimately led to wound healing.

Moving forward it is critical to stress the importance of patient awareness of the risks associated with tattooing. Though these risks may appear minimal, they can be disfiguring and lead to the introduction of deadly infectious agents. Tattooing has been around for centuries and its popularity is unlikely to decrease, so timely recognition of adverse reactions to tattooing such as allergic reaction, granulomatous and ulcerating reactions should be reported and managed promptly to ensure optimal patient outcomes.


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