Trapezium fracture: a common clinical mimic of scaphoid fracture.

PURPOSE: Fractures of the trapezium are rarely diagnosed on plain radiographs after acute wrist trauma. High-resolution cross-sectional imaging identifies fractures of the trapezium as the most common radiographically occult carpal bone fracture. We review the fracture frequency, mechanisms and patterns of trapezium fractures. METHODS: Cone beam CT was performed in patients with suspected radiographically occult radiocarpal fracture following acute injury. The frequency of carpal bone fractures was assessed and compared. RESULTS: Ninety-three radiographically occult wrist fractures were identified in 166 patients with acute trauma and negative radiographs. The trapezium was the most frequently fractured carpal bone, making up 20.4% of wrist fractures. Seventy-nine percent of trapezium fractures involved the volar ridge. The scaphoid was the clinically suspected fractured bone at initial assessment in 84% of patients with trapezium fractures. CONCLUSION: Fractures of the trapezium in acute wrist trauma are much more common than described in the literature. If initial radiographs are negative, a fracture of the trapezium is more likely to be present than one of the scaphoid, despite high levels of clinical suspicion for scaphoid injuries. Awareness of the types and mechanisms of trapezium fracture is important. Cross-sectional imaging should be considered in all cases of post-traumatic wrist pain with negative radiographs.

Effects of concentrate crude protein content on nutrient digestibility, energy utilization, and methane emissions in lactating dairy cows fed fresh-cut perennial grass.

Although many studies have investigated mitigation strategies for methane (CH4) output from dairy cows fed a wide variety of diets, research on the effects of concentrate crude protein (CP) content on CH4 emissions from dairy cows offered fresh grass is limited. The present study was designed to evaluate the effects of cow genotype and concentrate CP level on nutrient digestibility, energy utilization, and CH4 emissions in dairy cows offered fresh-grass diets. Twelve multiparous lactating dairy cows (6 Holstein and 6 Holstein × Swedish Red) were blocked into 3 groups for each breed and assigned to a low-, medium-, or high-CP concentrate diet [14.1, 16.1, and 18.1% CP on a dry matter (DM) basis, respectively], in a 3-period changeover study (25d per period). Total diets contained (DM basis) 32.8% concentrates and 67.2% perennial ryegrass, which was harvested daily. All measurements were undertaken during the final 6d of each period: digestibility measurements for 6d and calorimetric measurements in respiration chambers for 3d. Feed intake and milk production data were reported in a previous paper. We observed no significant interaction between concentrate CP level and cow genotype on any parameter. Concentrate CP level had no significant effect on any energy utilization parameter, except for urinary energy output, which was positively related to concentrate CP level. Similarly, concentrate CP content had no effect on CH4 emission (g/d), CH4 per kg feed intake, or nutrient digestibility. Cross breeding of Holstein cows significantly reduced gross energy, digestible energy, and metabolizable energy intake, heat production, and milk energy output. However, cow genotype had no significant effect on energy utilization efficiency or CH4 parameters. Furthermore, the present study yielded a value for gross energy lost as CH4 (5.6%) on fresh grass-based diets that was lower than the widely accepted value of 6.5%. The present findings indicate that reducing concentrate CP content from 18.1 to 14.1% may not be a successful way of alleviating CH4 emissions from lactating dairy cows offered good-quality fresh grass, but grazing cows could be offered a low-CP concentrate without compromising energy utilization efficiency. Further research is needed to investigate whether larger differences in dietary CP content may yield positive results.

Effects of crude protein level in concentrate supplements on animal performance and nitrogen utilization of lactating dairy cows fed fresh-cut perennial grass.

Nitrogen pollution of air and ground water from grazing cattle is of increasing concern. Although several studies have investigated mitigation strategies for nitrogen output from dairy cows fed conserved forages and concentrates, similar research on fresh-cut grass in addition to production parameters is limited. The current study, using 3dietary treatments and incorporating 2 genotypes, was designed to evaluate the effects of concentrate crude protein (CP) levels on animal production and nitrogen utilization efficiency (NUE) in lactating dairy cows. Twelve multiparous cows (6 Holstein and 6 Holstein × Swedish Red) were used in a changeover study with three 25-d periods and 3 diet treatments. Low, medium and high CP concentrate [14.1, 16.1, and 18.1%, respectively, dry matter (DM) basis] diets were fed at 32.8% DM intake combined with good-quality zero-grazed perennial ryegrass (18.2% CP, DM basis). Each period consisted of an adaptation phase (18d) housed as a single group, a 1-d adaptation phase in individual stalls, and a 6-d measurement phase with feed intake and feces, urine, and milk output recorded. We observed no significant interaction between cow genotype and concentrate CP level on any animal performance or NUE parameter. Total DM intake, milk yield and composition, and NUE were not affected by dietary treatment. However, increasing concentrate CP level increased (1) N intake by 42g/d and excretion in urine and manure by 38 and 40g/d, respectively, and (2) the ratio of urine N over manure N. Feeding high CP rather than low CP concentrate increased milk urea N (MUN) content by 3.6mg/dL and total MUN output by 1.08g/d. Crossbred cows had lower grass DM intake, total DM intake, total N intake, and energy-corrected milk yield. However, cow genotype had no significant effect on NUE or MUN parameters. Equations have been developed to predict urine N excretion using MUN output as a sole predictor or in combination with dietary CP level. The present study indicated that when grazing cows are fed good-quality pasture, feeding concentrates with a protein content as low as 14.1% may not negatively affect productivity. In addition, reducing concentrate CP concentration may be successful in reducing the urinary N excretion of lactating dairy cattle on pasture-based systems, but further research is needed to investigate the long-term effects of supplementary concentrate CP content on milk production.

Fracture of the scapular neck sustained in an arm wrestling match.

The sport of arm wrestling requires very little equipment, and can take place anywhere a flat surface is available. As such, undertrained participants often compete, with inevitable injury. Humeral fractures, and elbow injuries are well described, but scapular fractures have not previously been reported in the literature.

Antimicrobial effects of XF drugs against Candida albicans and its biofilms.

Compared with antibiotics for treating bacterial infections, there are a limited number of antifungal agents. This is due to several factors, including the difficulties of identifying suitable antifungals that target the fungal cell without damaging host cells, and the reduced rates of diagnosis of fungal infections compared with those caused by bacteria. The problem of treating fungal infections is exacerbated by an increasing incidence of antifungal resistance among human fungal pathogens. Three XF drugs (XF-73, XF-70, and DPD-207) have previously displayed innate bactericidal effects and a low propensity for microbial resistance, with XF-73 and XF-70 having a second, light-activated mechanism of action [known as photodynamic therapy (PDT)]. In an effort to expand the repertoire of antifungal agents, this research assessed the in vitro activity of XF drugs via both mechanisms of action against six strains of the fungal pathogen Candida albicans in both planktonic and biofilm cultures. In addition, this research examined the effects of XF drug treatment on biofilms of C. albicans in a reconstituted human oral epithelium model. All C. albicans strains tested were susceptible to XF-73 and XF-70, with minimum inhibitory concentrations (MICs) between 0.25 µg/mL and 2 µg/mL; DPD-207 was less potent, with MICs between 4 µg/mL and 16 µg/mL, and light activation did not enhance these MICs. Complete biofilm eradication was not reported at the tested XF drug concentrations. However, live and dead staining of C. albicans cells in biofilms after XF drug treatment demonstrated that XF-73 and XF-70 were active against most Candida biofilms tested from 64 µg/mL; again, light activation did not enhance anti-biofilm activity. Candida biofilms were more resistant to DPD-207, with fungicidal effects occurring from 256 µg/mL. XF-73 and XF-70 reduced penetration of C. albicans biofilm into reconstituted human oral epithelium (RHOE) and resulted in less damage (as determined by reduced lactate dehydrogenase release) than untreated biofilms. Overall, the results highlight the potential of XF drugs as new drugs for the management of topical infections caused by C. albicans. Further studies are warranted on the development of XF drugs as antifungals, particularly for XF-73 and XF-70.

Resolution of experimental pulmonary emboli with heparin and streptokinase in different dosage regimens.

Thrombolytic agents may be useful in acute pulmonary embolism, but their optimal dosage remains uncertain. We have examined the relative efficacy of heparin and different doses of streptokinase, either alone or in combination, in acute experimental pulmonary embolism. A standardized massive embolus of autologous blood clot incorporating canine [(125)I]-fibrinogen was given to 40 dogs; the degree of resolution after 24 h was quantitated by measuring the radioactivity in the lungs and was compared with detailed postmortem observations. The amount of residual embolus was 49% in control animals, 28% after heparin (200 U/kg loading dose and 800 U/kg/24 h maintenance dose), and 6% after high dose streptokinase (250,000 U loading dose and 100,000 U/h maintenance dose); it was 31% after low dose streptokinase (25,000 U loading dose and 10,000 U/h maintenance dose), 7% after low dose streptokinase with heparin, 14% after very low dose streptokinase (5,000 U/h without a loading dose) with heparin, and 9% after short course streptokinase (250,000 U loading dose and no maintenance dose) with heparin. The combination of heparin and low doses or brief courses of streptokinase appeared to be synergistic and produced as much resolution as did standard high dose streptokinase alone. The enhanced resolution of pulmonary emboli in heparin-treated animals may have been due to the prevention by heparin of further deposition of fibrin on the embolus. It appears that dosage regimens of thrombolytic therapy other than those in current use may be worthy of clinical examination.

The role of laparoscopic sleeve gastrectomy as a treatment for morbid obesity; review of outcomes.

BACKGROUND: Global prevalence of obesity has soared. Where lifestyle and medical treatments have failed, laparoscopic sleeve gastrectomy (LSG) is increasingly regarded as a good surgical procedure for morbid obesity. Following the introduction of LSG, we assessed our surgical outcomes. METHODS: We reviewed a consecutive series of LSGs from January 2009 to January 2015. Our primary focus was to assess the success of this procedure on the percentage excess body weight loss (%EWL), Body Mass Index (BMI), hypertension and diabetes. Additionally, we evaluated the rate of procedure-related complications. RESULTS: There were 183 consecutive patients evaluated. Median age was 45 years (24-73). The majority were female (73.2 %, n = 134). At 1 year post-op, median %EWL was 57.6 %. There was an associated median reduction in BMI of 16 kg/m2 (0-33). At 2 years, median %EWL was sustained at 58.4 %. The median reduction in BMI was 16 kg/m2 (4-32). At 2-year post-op, 78.9 % of diabetic patients had their diabetic medications completely discontinued, while a further 15.8 % having their medication reduced. 34.6 % of hypertensive patients had their antihypertensives discontinued, with 50 % having medications reduced. There was no procedure related mortality. 3.3 % (n = 6) of patients had a confirmed staple-line leak. CONCLUSION: This study shows LSG is a safe and successful management strategy for morbid obesity. In addition to the direct effects of sustained weight loss, it highlights indirect effects that LSG has on obesity-related health issues, with substantial reduction in diabetic and anti-hypertensive medications. Our results reaffirm international studies of the beneficial effects of LSG on Type II diabetes and hypertension.

Carpal tunnel release using local anaesthetic and a forearm tourniquet.

Carpal tunnel release can be performed under general or local anaesthetic. However, many surgeons believe the upper arm tourniquet is not tolerated by the patient when awake. We use a forearm tourniquet for carpal tunnel decompression under local anaesthesia. The aim of this study is to assess patient tolerance of the technique. Between January 1st 1996 and December 31st 2000, 74 patients had carpal tunnel release performed using local anaesthesia. We sent a postal questionnaire to each, asking the patient to rate different aspects of the procedure. Fifty-eight patients replied (78% response). Forty-four of the respondents (76%) tolerated the tourniquet well, finding it to be 'no problem' or only 'mildly painful'. The same number reported they would prefer to have local anaesthesia again in the event of their requiring a similar operation on their hand. We believe carpal tunnel release using local anaesthetic and a forearm tourniquet is well tolerated by the patient.

Self-administered psychotherapy for depression using a telephone-accessed computer system plus booklets: an open U.S.-U.K. study.

OBJECTIVE: To evaluate the efficacy and acceptability of a self-help program for mild-to-moderate depression that combined treatment booklets and telephone calls to a computer-aided Interactive Voice Response (IVR) system. METHOD: In an open trial, 41 patients from Boston, Massachusetts; Madison, Wisconsin; and London, England, used COPE, a 12-week self-help system for depression. COPE consisted of an introductory videotape and 9 booklets accompanied by 11 telephone calls to an IVR system that made self-help recommendations to patients based on information they entered. RESULTS: All 41 patients successfully completed the self-assessment in the booklets and telephone calls; 28 (68%) also completed the 12-week self-help program. Hamilton Rating Scale for Depression (HAM-D) and Work and Social Adjustment scores improved significantly (41% and 42% mean reduction in the intent-to-treat sample, respectively, p < .001). Eighteen (64%) of the 28 completers were considered responders on the basis of > or = 50% reduction in their HAM-D scores. There was a higher percentage of completers in the pooled U.S. sites (82% vs. 43%), and U.S. completers improved more than those in the United Kingdom (73% vs. 43% were responders). Most (68%) of the calls were made outside usual office hours, Monday-Friday, 9:00 a.m. to 5:00 p.m. Expectation of effectiveness and time spent making COPE calls (more treatment modules) correlated positively with improvement over 12 weeks. Mean call length for completers was 14 minutes. CONCLUSION: A self-help system comprised of a computer-aided telephone system and a series of booklets was used successfully by people with mild-to-moderate depression. These preliminary results are encouraging for people who cannot otherwise access ongoing, in-person therapy.

Predicting non-elective hospital readmissions: a multi-site study. Department of Veterans Affairs Cooperative Study Group on Primary Care and Readmissions.

OBJECTIVE: To determine clinical and patient-centered factors predicting non-elective hospital readmissions. DESIGN: Secondary analysis from a randomized clinical trial. CLINICAL SETTING: Nine VA medical centers. PARTICIPANTS: Patients discharged from the medical service with diabetes mellitus, congestive heart failure, and/or chronic obstructive pulmonary disease (COPD). MAIN OUTCOME MEASUREMENT: Non-elective readmission within 90 days. RESULTS: Of 1378 patients discharged, 23.3% were readmitted. After controlling for hospital and intervention status, risk of readmission was increased if the patient had more hospitalizations and emergency room visits in the prior 6 months, higher blood urea nitrogen, lower mental health function, a diagnosis of COPD, and increased satisfaction with access to emergency care assessed on the index hospitalization. CONCLUSIONS: Both clinical and patient-centered factors identifiable at discharge are related to non-elective readmission. These factors identify high-risk patients and provide guidance for future interventions. The relationship of patient satisfaction measures to readmission deserves further study.

Is universal neonatal hemoglobinopathy screening cost-effective?

OBJECTIVE: To determine whether and where universal neonatal screening for hemoglobinopathies, chiefly sickle-cell disease, could be performed at socially acceptable costs. METHODS: We made projections of the cost-effectiveness of nonuniversal and universal sickle-cell disease screening throughout the United States. We then compared the cost-effectiveness of universal sickle-cell disease screening with that of universal phenylketonuria screening. Finally, we asked if "high-cost" states, that is, those in which the cost of finding a case of sickle-cell disease exceeded one half the cost of finding a case of phenylketonuria, could enhance their cost-effectiveness by joining demographically complementary states in screening cooperatives. RESULTS: If all states conducted independent screening and if the value of finding a case of sickle-cell disease were no more than one half that of finding a case of phenylketonuria, seven of the 19 states that do not currently conduct universal screening for hemoglobinopathies would begin to do so, but six of the 34 that currently do so would stop. Of the six that would stop, three have already formed a screening cooperative, reducing their projected average costs for finding either sickle-cell disease or phenylketonuria or both; the other three could similarly improve cost-effectiveness through cooperative arrangements. Nineteen states realize economies of scale in six cooperative groups; more could do so. CONCLUSION: Universal neonatal hemoglobinopathy screening can be made available at socially acceptable costs to the citizens of demographically various states.

Hysterectomy in Veterans Affairs Medical Centers.

OBJECTIVE: To examine the indications and surgical morbidity for women veterans who underwent hysterectomies in Department of Veterans Affairs Medical Centers (VAs). METHODS: Data on hysterectomies performed in VAs from 1991 to 1997 were abstracted from a surgical quality improvement program. RESULTS: Records of 1722 women who had hysterectomies in VAs over 6 years were examined. Women were predominately white (62%) and their average age was 42.5 years. Operations included abdominal (74%), vaginal (22%), and laparoscopic-assisted (4%) methods. The most common indications for surgery included uterine leiomyomas (31%), abnormal uterine bleeding (14%), and endometriosis (11%). Indications differed by race (P <.01); nonwhite women were most likely to have surgery for leiomyoma (51%), whereas white women had hysterectomies for leiomyomas (19%), abnormal bleeding (15%), endometriosis (13%), and genital prolapse (11%). The mean postoperative stay was significantly longer for abdominal hysterectomies (4.51 days) than either vaginal or laparoscopic-assisted hysterectomies (2.92 and 2.21 days, respectively; P <.001). The overall complication rate within 30 days was 9%, and the most frequent complication was urinary tract infection (3.3%). CONCLUSION: Women who underwent hysterectomies in VAs had low complication rates, comparable to hysterectomy complication rates in the United States generally.

Metabolism of styrene by mouse and rat isolated lung cells.

Styrene is pneumotoxic in mice. It is metabolized by pulmonary microsomes of both mouse and rat to styrene oxide (SO), presumed to be the toxic metabolite of styrene, and known to be genotoxic. To determine which pulmonary cell types are responsible for styrene metabolism, and which cytochromes P450 are associated with the bioactivation of styrene, we isolated enriched fractions of mouse and rat Clara and type II cells in order to determine the rate of styrene metabolism, with and without chemical inhibitors. Mouse Clara cells readily metabolized styrene to SO. Diethyldithiocarbamate, a CYP2E1 inhibitor, caused less inhibition of SO formation in Clara cells isolated from mice than previously found with pulmonary microsomes. As in microsomes, 5-phenyl-1-pentyne, a CYP2F2 inhibitor, inhibited the formation of both enantiomers. alpha-Naphthoflavone, a CYP1A inhibitor, did not inhibit SO formation in Clara cells. alpha-Methylbenzylaminobenzotriazole, a CYP2B inhibitor, exhibited minimal inhibition of SO production at 10 microM and less at 1 microM. The microsomal and isolated cell studies indicate that CYP2E1 and CYP2F2 are the primary cytochromes P450 involved in pulmonary styrene metabolism. Styrene metabolizing activity was much greater in Clara cells than in type II pneumocytes, which demonstrated essentially no activity. Styrene-metabolizing activity was several-fold higher in the mouse than in rat Clara cells. The more pneumotoxic and genotoxic form, R-SO, was preferentially formed in mice, and S-SO was preferentially formed in rats. These findings indicate the importance of Clara cells in styrene metabolism and suggest that differences in metabolism may be responsible for the greater susceptibility of the mouse to styrene-induced toxicity.

System for digital acquisition of gastrointestinal images.

Previous theoretical work and clinical experience with digital acquisition of fluoroscopic images have identified several problems which needed to be solved. These are: image resolution; blurring due to patient motion, combined with long exposure times; and excessive x-ray quantum mottle levels. We will show that application of pulsed progressive readout (PPR) methods to the TV camera solves these problems. By permitting a high-intensity x-ray pulse to be delivered, all motion is stopped and quantum mottle is reduced to acceptable levels. It will be shown that 1024 x 1024 digital matrices provide adequate resolution and 8-bit digitization is sufficient to permit the same quality as is used in conventional 100-mm photofluorography. User acceptance can be made easier by incorporation of existing photofluorographic controls (with which the radiologist is already familiar) to acquire the digital images. It is possible to interface PPR video systems using existing 100-mm exposure circuits without much modification and the resulting system can be regarded as a digital 100-mm camera.

Predicting the performance of a strategic alliance: an analysis of the Community Clinical Oncology Program.

OBJECTIVE: This study is designed to examine the effects of environment and structure of the Community Clinical Oncology Program (CCOP) on performance as measured by patient accrual to National Cancer Institute (NCI)-approved treatment protocols. DATA SOURCES/STUDY SETTING: Data and analysis are part of a larger evaluation of the NCI Community Clinical Oncology Program during its second funding cycle, June 1987-May 1990. Data, taken from primary and secondary sources, included a survey of selected informants in CCOPs and research bases, CCOP grant applications, CCOP annual progress reports, and site visits to a subsample of CCOPs (N = 20) and research bases (N = 5). Accrual data were obtained from NCI records. STUDY DESIGN: Analysis involved three complementary sets of factors: the local health care resources environment available to the CCOP, the larger policy environment as reflected by the relationship of the CCOP to selected research bases and the NCI, and the operational structure of the CCOP itself. A hierarchical model examined the separate and cumulative effects of local and policy environment and structure on performance. PRINCIPAL FINDINGS: Other things equal, the primary predictors of treatment accrual were: (1) the larger policy environment, as measured by the attendance of nurses at research base meetings; and (2) operational structure, as measured by the number and character of components within participating CCOPs and the number of hours per week worked by data managers. These factors explained 73 percent of the total variance in accrual performance. CONCLUSIONS: Findings suggest criteria for selecting the types of organizations to participate in the alliance, as well as for establishing guidelines for managing such alliances. A future challenge is to determine the extent to which factors predicting accrual to cancer treatment clinical trials are equally important as predictors of accrual to cancer prevention and control trials.

Effects of inhibitors of CYP1A and CYP2B on styrene metabolism in mouse liver and lung microsomes.

Much of the toxicity of styrene is associated with its bioactivation to styrene oxide. Both liver and lung have been shown to carry out this metabolic step, but there are differences reported as to which isomers of cytochrome P450 are responsible for this biotransformation in various species and tissues. CYP2E1, CYP2F, CYP2B, CYP1A1/2 and CYP2C11 have all been implicated. In the current study, alpha-naphthoflavone (alphaNF) and alpha-methylbenzylaminobenzotriazole (MBA), selective inhibitors of CYP1A and CYP2B, were used to ascertain the contributions of these isomers to styrene metabolism in mouse hepatic and pulmonary microsomes. AlphaNF did not inhibit styrene metabolism with microsomal preparations from either tissue. This indicates that CYP1A is unimportant in the metabolism of styrene to styrene oxide. MBA at a very low concentration of 1 microM inhibited the hepatic metabolism of benzyloxyresorufin (a CYP2B substrate) by 87% but caused only a 16 to 19% inhibition of R- and S-styrene oxide formation. This demonstrates that CYP2B plays a minor role in styrene metabolism. At 10 microM, MBA caused an even greater inhibition of styrene metabolism but at that level it also inhibited p-nitrophenol hydroxylation, a CYP2E1-dependent reaction, suggesting a loss of selectivity for this inhibitor at higher concentrations.

Trichotillomania: clinical aspects and treatment strategies.

Trichotillomania is a disorder of compulsive hair pulling that often results in alopecia. The clinical features include the pulling of hair from the scalp, eyebrows, and eyelashes, sometimes symmetrically; pubic and other bodily hair may also be plucked. The disorder is present in 0.6% of college students. The majority of sufferers who seek treatment are female, with usual age of onset between 11 and 16 years. Trichotillomania can occur in a wide variety of psychiatric disorders, and patients with the condition may be more likely to have a lifetime diagnosis of depression or an anxiety, eating, or substance abuse disorder. Although empirically derived treatment guidelines are still lacking, the current literature suggests that behavior therapy and pharmacotherapy are the most efficacious treatments for adult trichotillomania. Controlled trials with pharmacotherapy (clomipramine) have shown significant reductions in hair pulling over the short term. Controlled investigations of behavior therapy have not been conducted, but several treatment series suggest efficacy. At least three reports also suggest that behavior therapy and pharmacotherapy bring some improvement in childhood trichotillomania, although this has not been empirically studied. A case illustrating the combination of behavior therapy techniques and pharmacotherapy in the treatment of trichotillomania is presented.

Growth disturbance lines after injury of the distal tibial physis. Their significance in prognosis.

We reviewed 26 fractures involving the distal physis of the tibia to identify the patterns of formation and displacement of the subsequent growth disturbance lines. Twenty-one patients showed a regular "normal" pattern of line and healed with no deformity. Three patients had medical physeal arrest revealed by abnormal lines. Two other cases had a minor central physeal arrest without subsequent deformity. The pattern and character of the growth disturbance line can provide an early warning of potential deformity.

Irreducible dislocation of the fifth metatarsophalangeal joint: a case report.

Metatarsophalangeal joint dislocations are unusual in children and usually occur in the hallux. We are reporting a case of irreducible traumatic dislocation of the fifth metatarsophalangeal joint. At open reduction, the metatarsal head was incarcerated under the flexor digitorum longus. After returning the flexor digitorum longus tendon to its anatomical position, the metatarsophalangeal joint reduced and was stable.

The bicycle spoke injury: an avoidable accident?

A prospective study of the bicycle spoke injury over a 1-year period included a total of 71 spoke injuries. Of these, 67 injuries occurred on an adult bicycle and four occurred on a child's bicycle. All children sustained ankle and foot injuries, which consisted of contusion and superficial abrasion (N = 45), skin loss (N = 10), skin laceration (N = 4), and undisplaced fractures (N = 12). A biomechanical study was conducted to investigate the use of a protective cover over the wheel to prevent the foot from slipping between the spokes. Wind resistance studies showed that a cover with a mesh size of 10 mm hexagonal could prevent this and at the same time stop the cover from acting as a sail if a flat cover without holes was used instead. The mesh cover, however, will prevent the toes from entering between the spokes but will not prevent the foot from becoming jammed between the wheel and the fork. To prevent this, a plastic shield to bridge the gap between the fork and the horizontal upright has been designed. With these modifications, the bicycle spoke injury can become an injury of the past.