Crushing Injuries; a Heads Up
Posted: Thu Feb 27, 2014 3:01 pm
Read this on another motorcycle forum. It's good to know! Compartment Syndrome after a Motorcycle Crash
This is something we should probably all be aware of since it's pretty common in motorcycle injuries. I had it once when my foot was crushed on a rock while riding. Thankfully, didn't have to get the surgery. But, came close. Emergency rooms don't always tell you about this either - some just cast you up and send you home. That's what happened to me. Then a friend who is a surgeon said I should go see a specialist. Saved my foot.
by Steve Natt
The only thing I don't like about riding motorcycles is when my ride comes to an abrupt and unexpected end. In a word: crashing.We all, by definition, consider this an assumable risk, as unpleasant as it is. Sure there are many among us who are far more skilled than others at the art of denial (visions of riders in shorts and sneakers come to mind), but I'd argue that most of us ride with proper gear on and blinders off.
I've always tried to do just that. I have more than two decades of motorcycling behind me. I've been in more emergency rooms than I care to think about (mostly for friends) and I have some now-dusty certificates in CPR and emergency first aid. Because of all this, I thought I was better versed than most in how to handle crash-related injuries. The fact is that I knew just enough to be dangerousto myself.
It took a terrible but hardly rare combination of bad luck, bravado and ignorance for a seemingly benign bruise I sustained in a 10 mph get-off to grow into a limb-threatening injury in a matter of hours. Here's what happened: I was shooting a story for the "Bike Week" series on the new SpeedVision TV network about how much better a Harley will stop with high-end aftermarket brakes. We set up the camera on a semi-private side street to shoot me riding somebody else's $15,000 DynaGlide with the Wide-Glide front end. With an aftermarket 21" front wheel and skinny chopper-style tire, this thing had a contact patch only slightly larger than my contact lens. I had a total of two minutes of seat time on this bike when we began to roll tape. There were lots of people standing around and the thought of a national TV audience never left my awareness.
I was able to bring the Dyna to a stop from 25 mph using the stock front brake in 34'. The front wheel never locked up. In the
interest of serving our viewers, I then videotaped the aftermarket brake company's mechanic changing out the single-piston,
single-action stock caliper for one of their potent 4-pot jobs.
Thirty minutes later I was back out on the street to see how much better the Dyna would stop. I managed to lock the front wheel in the last 10' of braking, and the bike came to a stop in only 27'. Since I skidded the front tire and didn't crash the motorcycle, I felt quite good about my riding skills. In fact, we decide to do it again and go for a record (and prove once and for all that I'm an idiot). So this time I grabbed a big, dumb right handful of brake lever. The 21" front wheel locked and turned right, and the portly cruiser flopped over on my right leg. We got it all on videoit looks like the bike was moving at about 10 mph as it impaled me against the macadam.
Only a few of the many ostentatious chrome pieces were scratched. This was largely because all 600 lbs. of motorcycle came
down where the lower exhaust pipe met the bottom of my right calf. Massive internal bleeding ensued over the next few hours,
including two where I "John-Wayned-it" and joined my wife and another couple for a pleasant Italian dinner.
I knew nothing was broken, and therefore assumed that with a standard application of R-I-C-E (rest, ice, compression, elevation), I'd be fine in a day or two. Unfortunately, the bleeding was so deep in my leg that I couldn't see any discoloration and I thought that at worst I'd be sore for a while.
Well, along came my old friend serendipity. The people at the dinner table included my toddler's pediatrician, Robert Hamilton, who politely offered to check my leg when I hobbled into the restaurant on some crutches I had left over from a previous mishap (don't ask). I declined his offer, charmingly suggested that he was "off-the-clock," and that I was just a tad too old to be examined by a baby doctor. By the time we were into the Decaf and Tiramisu, my right lower leg was feeling hot, much thicker than usual and rock hard. My discomfort must have been obvious because the Doctor reached under the table and put his hand on my calf (This was done for purely medical reasons, I assure you). He blanched and said, "we're going to the emergency room." Like James Bond, he simultaneously whipped out his cellular phone and the valet parking ticket. In a flash I was sprawled across the back seat of his 300e and on the way to the E.R.
Walking in off the street into any emergency room immediately teaches you the meaning of "oxymoron." It doesn't matter if you're bleeding, choking or have a javelin sticking out of your head, you are the only person who sees it as an emergency, and there's never enough room to get comfortable. But coming in with a Doctorespecially one who regularly works at that hospitalis a whole different story. Faster than the service JFK got at Dallas General, I went straight to a gurney and the attending resident was at my side in two minutes flat.
No triage, no interminable interview where I'm forced to teach them how to spell as they struggle through the forms. It took less than a minute for me to get the diagnosiscompartment syndrome (which is not a kind of claustrophobia) as a result of a traumatic crush injury.
Ten more minutes and a call from our friendly pediatrician's cell phone brought one
of the best orthopedic trauma surgeons in Southern California to my side: Thomas
Knapp, MD. He has treated hundreds of people with compartment syndrome, and
here's why this should matter to you: the vast majority of them are motorcyclists.
"This is one of the very few true orthopedic emergencies," he wryly remarked when
I spoke with him at his Santa Monica office. "We see it a lot in motorcyclists
because even what may seem like a relatively innocuous motorcycle accident can
cause a crush injury that could trigger compartment syndrome. Of course it's more
commonly associated with a fracture."
He told me it was a very good thing that I wasn't left in the waiting room with the
useless panacea of a bag of ice while my leg killed itself.
"If you get thrown over the handlebars, you're probably not going to develop
compartment syndrome unless you break a bone," he later said. "It's when you get
pinned, or a car sideswipes you and pins your leg against your bike, or if you fall and
your leg hits a curb. It's the isolated crush that happens very quickly in a concentrated small area that you have to watch out for.
That said, there is also the possibility that a larger more widespread bruisingnot an arterial injurycan develop into compartment
syndrome, but this would be of a more insidious onset taking 12-24 hours to set in. It would go from a generalized ache to 'Wow,
this REALLY HURTS!' to 'My foot is numb and it feels cold.'"
That was exactly how I was feeling, and it had only been six hours since my crash. When he met me that night at the emergency room, he brought with him a rare and wonderful gadget for measuring the internal pressure of the various compartments in my leg. Here's fair warning: those of you with weak stomachs should now leave the room. Since the human leg is not equipped with a schrader valve, Dr. Knapp's device uses a needle big enough to sink the USS Enterprise. Normal internal pressures range from 2mm of mercury to 10mm. When he inserted the "horse-killer" into my calf you could practically hear the weight shoot up to ring the bell and the carny guy scream, "Step right up and win a cupie doll!" My poor crunched leg had pumped up to an internal pressure of just over 60mm of mercury. The surgeon blithely said, "Steve, if I don't cut you open and relieve the pressure right now, you will lose your leg from the knee down." Apparently the unseen internal bleeding and swelling was literally killing the muscles and nerves in my lower legI was getting gangrene. Never having been interested in having my moniker become "Stumpy," I quickly agreed.
They made me a nice cocktail consisting of a potent narcotic injection and an anesthetic spinal block that cut off all feeling from my waist down. They then broke out the Ginsu kit and in less than 30 seconds, I realized why the entire surgery team was wearing plastic splash guard masks. Simply put, it was a gushing mess.
A nine-inch incision on one side of my leg was followed by a six-incher on the other side. I must have dozed through the part
where he tied off the blown artery and massaged out about a pint of black, deoxygenated blood. I came to just as he began
snapping as many as 50 staples across the gaping wound. (It was a strangely funny experience, leaning up on my elbows and see him quickly ka-chunk, ka-chunk the stainless fasteners into my new seam. When the stapler jammed, I wryly asked, "What are we going to try next, twine? Mucilage? Is Office Depot still open?" Everyone had a good laugh and he immediately ordered the anesthesiologist to knock me out again.) He later told me what he found during the surgery. "What the crash did was it slammed the post-tibial artery, which is deep in your leg, against the tibia bone. That weakened the blood vessel, and as it continued to pump blood it began to pouch out like a hose getting ready to rupture. So what happened was over the first couple hours the pain probably wasn't too bad, but when the artery ruptured, the pressure went up and the veins collapsed. At this point there is no turning back. The pressure around the vein compresses the veins and there is no way to get the blood back out of the leg. And there is nothing you can do to stop the cycle of the pressure getting higher and taking off very quickly. Besides a lot of pain in the area, you begin to have decreased sensation in the foot, in the area controlled by the nerve going through the pressurized compartment. Also, the blood supply to the muscle is compromised so that the muscle begins to die. Muscle can survive about six hours without blood supply before the damage is irreversible. And obviously, the higher the pressure the faster the muscle dies, because what can happen in elevated cases is that even the artery is unable to pump more blood and what you get is a tense, almost solid mass. That's what I found with youyou didn't have a pulse in your foot."
When I went in for my final follow-up exam, I asked him how any of us non-medical professionals are supposed to know if it's just a bruise or something far more serious. Dr. Knapp suggests the best rule of thumb (or leg, or arm) is this: "Pain normally starts off high and gets better. If it's a bruise, local first aid measures should make it feel better relatively quickly. If the pain starts to escalate after half an hour to an hour, that's when you should start thinking about seeing a physician."
But what would happen if this kind of injury happened in some remote place, like a dual sport trip through Baja? He smiled wanly and said, "That would beuhbad. Just remember that this is a time where elevation is actually worse than not elevating it, because if you elevate it the veins will collapse prematurely. So if you suspect this, you want to keep the leg nice and level. My suggestion would be get to a hospital just as quickly as possible. This is not the kind of thing you can tough out. You can't put a tourniquet on it, you can't take a couple of aspirinthe only thing to do is get to a hospital for emergency surgery because once the pain escalates, you've got about six hours or you'll lose the limb."
All told I spent a couple of days in the hospital, had about 20 physical therapy sessions and, except for the scars, am completely healed. I am very lucky and will forever be grateful to the pediatrician who diagnosed my condition and the surgeon who relieved it. As a motorcyclist, I've learned a couple of important things: don't take any crash lightly, carry good health insurance and always, always squeeze (never grab) the brake lever.
This is something we should probably all be aware of since it's pretty common in motorcycle injuries. I had it once when my foot was crushed on a rock while riding. Thankfully, didn't have to get the surgery. But, came close. Emergency rooms don't always tell you about this either - some just cast you up and send you home. That's what happened to me. Then a friend who is a surgeon said I should go see a specialist. Saved my foot.
by Steve Natt
The only thing I don't like about riding motorcycles is when my ride comes to an abrupt and unexpected end. In a word: crashing.We all, by definition, consider this an assumable risk, as unpleasant as it is. Sure there are many among us who are far more skilled than others at the art of denial (visions of riders in shorts and sneakers come to mind), but I'd argue that most of us ride with proper gear on and blinders off.
I've always tried to do just that. I have more than two decades of motorcycling behind me. I've been in more emergency rooms than I care to think about (mostly for friends) and I have some now-dusty certificates in CPR and emergency first aid. Because of all this, I thought I was better versed than most in how to handle crash-related injuries. The fact is that I knew just enough to be dangerousto myself.
It took a terrible but hardly rare combination of bad luck, bravado and ignorance for a seemingly benign bruise I sustained in a 10 mph get-off to grow into a limb-threatening injury in a matter of hours. Here's what happened: I was shooting a story for the "Bike Week" series on the new SpeedVision TV network about how much better a Harley will stop with high-end aftermarket brakes. We set up the camera on a semi-private side street to shoot me riding somebody else's $15,000 DynaGlide with the Wide-Glide front end. With an aftermarket 21" front wheel and skinny chopper-style tire, this thing had a contact patch only slightly larger than my contact lens. I had a total of two minutes of seat time on this bike when we began to roll tape. There were lots of people standing around and the thought of a national TV audience never left my awareness.
I was able to bring the Dyna to a stop from 25 mph using the stock front brake in 34'. The front wheel never locked up. In the
interest of serving our viewers, I then videotaped the aftermarket brake company's mechanic changing out the single-piston,
single-action stock caliper for one of their potent 4-pot jobs.
Thirty minutes later I was back out on the street to see how much better the Dyna would stop. I managed to lock the front wheel in the last 10' of braking, and the bike came to a stop in only 27'. Since I skidded the front tire and didn't crash the motorcycle, I felt quite good about my riding skills. In fact, we decide to do it again and go for a record (and prove once and for all that I'm an idiot). So this time I grabbed a big, dumb right handful of brake lever. The 21" front wheel locked and turned right, and the portly cruiser flopped over on my right leg. We got it all on videoit looks like the bike was moving at about 10 mph as it impaled me against the macadam.
Only a few of the many ostentatious chrome pieces were scratched. This was largely because all 600 lbs. of motorcycle came
down where the lower exhaust pipe met the bottom of my right calf. Massive internal bleeding ensued over the next few hours,
including two where I "John-Wayned-it" and joined my wife and another couple for a pleasant Italian dinner.
I knew nothing was broken, and therefore assumed that with a standard application of R-I-C-E (rest, ice, compression, elevation), I'd be fine in a day or two. Unfortunately, the bleeding was so deep in my leg that I couldn't see any discoloration and I thought that at worst I'd be sore for a while.
Well, along came my old friend serendipity. The people at the dinner table included my toddler's pediatrician, Robert Hamilton, who politely offered to check my leg when I hobbled into the restaurant on some crutches I had left over from a previous mishap (don't ask). I declined his offer, charmingly suggested that he was "off-the-clock," and that I was just a tad too old to be examined by a baby doctor. By the time we were into the Decaf and Tiramisu, my right lower leg was feeling hot, much thicker than usual and rock hard. My discomfort must have been obvious because the Doctor reached under the table and put his hand on my calf (This was done for purely medical reasons, I assure you). He blanched and said, "we're going to the emergency room." Like James Bond, he simultaneously whipped out his cellular phone and the valet parking ticket. In a flash I was sprawled across the back seat of his 300e and on the way to the E.R.
Walking in off the street into any emergency room immediately teaches you the meaning of "oxymoron." It doesn't matter if you're bleeding, choking or have a javelin sticking out of your head, you are the only person who sees it as an emergency, and there's never enough room to get comfortable. But coming in with a Doctorespecially one who regularly works at that hospitalis a whole different story. Faster than the service JFK got at Dallas General, I went straight to a gurney and the attending resident was at my side in two minutes flat.
No triage, no interminable interview where I'm forced to teach them how to spell as they struggle through the forms. It took less than a minute for me to get the diagnosiscompartment syndrome (which is not a kind of claustrophobia) as a result of a traumatic crush injury.
Ten more minutes and a call from our friendly pediatrician's cell phone brought one
of the best orthopedic trauma surgeons in Southern California to my side: Thomas
Knapp, MD. He has treated hundreds of people with compartment syndrome, and
here's why this should matter to you: the vast majority of them are motorcyclists.
"This is one of the very few true orthopedic emergencies," he wryly remarked when
I spoke with him at his Santa Monica office. "We see it a lot in motorcyclists
because even what may seem like a relatively innocuous motorcycle accident can
cause a crush injury that could trigger compartment syndrome. Of course it's more
commonly associated with a fracture."
He told me it was a very good thing that I wasn't left in the waiting room with the
useless panacea of a bag of ice while my leg killed itself.
"If you get thrown over the handlebars, you're probably not going to develop
compartment syndrome unless you break a bone," he later said. "It's when you get
pinned, or a car sideswipes you and pins your leg against your bike, or if you fall and
your leg hits a curb. It's the isolated crush that happens very quickly in a concentrated small area that you have to watch out for.
That said, there is also the possibility that a larger more widespread bruisingnot an arterial injurycan develop into compartment
syndrome, but this would be of a more insidious onset taking 12-24 hours to set in. It would go from a generalized ache to 'Wow,
this REALLY HURTS!' to 'My foot is numb and it feels cold.'"
That was exactly how I was feeling, and it had only been six hours since my crash. When he met me that night at the emergency room, he brought with him a rare and wonderful gadget for measuring the internal pressure of the various compartments in my leg. Here's fair warning: those of you with weak stomachs should now leave the room. Since the human leg is not equipped with a schrader valve, Dr. Knapp's device uses a needle big enough to sink the USS Enterprise. Normal internal pressures range from 2mm of mercury to 10mm. When he inserted the "horse-killer" into my calf you could practically hear the weight shoot up to ring the bell and the carny guy scream, "Step right up and win a cupie doll!" My poor crunched leg had pumped up to an internal pressure of just over 60mm of mercury. The surgeon blithely said, "Steve, if I don't cut you open and relieve the pressure right now, you will lose your leg from the knee down." Apparently the unseen internal bleeding and swelling was literally killing the muscles and nerves in my lower legI was getting gangrene. Never having been interested in having my moniker become "Stumpy," I quickly agreed.
They made me a nice cocktail consisting of a potent narcotic injection and an anesthetic spinal block that cut off all feeling from my waist down. They then broke out the Ginsu kit and in less than 30 seconds, I realized why the entire surgery team was wearing plastic splash guard masks. Simply put, it was a gushing mess.
A nine-inch incision on one side of my leg was followed by a six-incher on the other side. I must have dozed through the part
where he tied off the blown artery and massaged out about a pint of black, deoxygenated blood. I came to just as he began
snapping as many as 50 staples across the gaping wound. (It was a strangely funny experience, leaning up on my elbows and see him quickly ka-chunk, ka-chunk the stainless fasteners into my new seam. When the stapler jammed, I wryly asked, "What are we going to try next, twine? Mucilage? Is Office Depot still open?" Everyone had a good laugh and he immediately ordered the anesthesiologist to knock me out again.) He later told me what he found during the surgery. "What the crash did was it slammed the post-tibial artery, which is deep in your leg, against the tibia bone. That weakened the blood vessel, and as it continued to pump blood it began to pouch out like a hose getting ready to rupture. So what happened was over the first couple hours the pain probably wasn't too bad, but when the artery ruptured, the pressure went up and the veins collapsed. At this point there is no turning back. The pressure around the vein compresses the veins and there is no way to get the blood back out of the leg. And there is nothing you can do to stop the cycle of the pressure getting higher and taking off very quickly. Besides a lot of pain in the area, you begin to have decreased sensation in the foot, in the area controlled by the nerve going through the pressurized compartment. Also, the blood supply to the muscle is compromised so that the muscle begins to die. Muscle can survive about six hours without blood supply before the damage is irreversible. And obviously, the higher the pressure the faster the muscle dies, because what can happen in elevated cases is that even the artery is unable to pump more blood and what you get is a tense, almost solid mass. That's what I found with youyou didn't have a pulse in your foot."
When I went in for my final follow-up exam, I asked him how any of us non-medical professionals are supposed to know if it's just a bruise or something far more serious. Dr. Knapp suggests the best rule of thumb (or leg, or arm) is this: "Pain normally starts off high and gets better. If it's a bruise, local first aid measures should make it feel better relatively quickly. If the pain starts to escalate after half an hour to an hour, that's when you should start thinking about seeing a physician."
But what would happen if this kind of injury happened in some remote place, like a dual sport trip through Baja? He smiled wanly and said, "That would beuhbad. Just remember that this is a time where elevation is actually worse than not elevating it, because if you elevate it the veins will collapse prematurely. So if you suspect this, you want to keep the leg nice and level. My suggestion would be get to a hospital just as quickly as possible. This is not the kind of thing you can tough out. You can't put a tourniquet on it, you can't take a couple of aspirinthe only thing to do is get to a hospital for emergency surgery because once the pain escalates, you've got about six hours or you'll lose the limb."
All told I spent a couple of days in the hospital, had about 20 physical therapy sessions and, except for the scars, am completely healed. I am very lucky and will forever be grateful to the pediatrician who diagnosed my condition and the surgeon who relieved it. As a motorcyclist, I've learned a couple of important things: don't take any crash lightly, carry good health insurance and always, always squeeze (never grab) the brake lever.
