An unusual penetrating shoulder injury: a case report

Abstract A 32-year-old male sustained penetrating injury of the right shoulder with an angled iron rod in a road side accident. He presented with the rod in situ in his shoulder. Fortunately there was no neurovascular deficit. The metal rod was carefully removed with success, after cutting the rod with hacksaw to avoid neurovascular damage during removal.     

Transorbital penetrating head injury by a toilet brush handle

Background  Transorbital penetrating brain injuries are rare lesions without defined therapy standards. Clinical presentation and intervention  A male patient presented at our institution with a toilet brush handle in the right cerebral hemisphere. CT imaging identified the object entering the right orbit and having crossed the right hemisphere in the ventricular plane. After performing a medium-sized craniotomy, the object was removed step-by-step under monitoring with an intraoperative CT scan to ensure no involving major hemorrhage. Conclusion  Transorbital penetrating brain injuries are treated best by utilizing all up-to-date technical developments such as intraoperative CT-scanning to increase the safety in the management of such exceptional lesions with increased risk of immediate life-threatening intracranial bleeding.     

Transorbital penetrating injury by a chopstick--case report

A one-year-old boy presented with orbitocranial penetrating injury by a chopstick. Neurological examination did not reveal abnormal findings. Skull radiography did not reveal any sign of fracture and there were no abnormal findings. Initially, computed tomography (CT) of the head did not reveal any intracranial lesions. However, bone window CT showed a well-defined low-density abnormality measuring 2.5 cm in length in the right orbit and parasellar region. Magnetic resonance imaging clearly revealed a low-intensity structure extending from the orbit to the prepontine area. Surgical exploration was emergently performed and the wooden fragment was removed. The postoperative course was uneventful. Transorbital penetrating injury by a wooden foreign body is relatively rare. The wound may be superficial and trivial. Major neurological deficit does not usually manifest immediately, so the penetrating injury may be overlooked. If the foreign body is retained in the orbit and cranium, severe infectious complications may occur later.     

An unusual case of penetrating head injury with excellent recovery

We report the remarkable case of the passage of a heavy metal rod through the head of a 42-year-old man. The patient had an excellent outcome because of prompt and efficient rescue efforts combined with transport to a major neurosurgical trauma center. Reference is made to a somewhat similar case publicized over 130 years ago     

A penetrating dorsal thoracic injury that is lucky from every aspect: A case report

IntroductionPenetrating thoracic trauma management represents a major problem for emergency department staff. In these cases, we reported a patient, who can be deemed very lucky, because of both the trauma mechanism and the provided first aid at scene.Presentation of caseA 30-year-old man was transported to the emergency surgery outpatient clinic after being stabbed from his back. A knife entered thorax from the dorsal region paravertebrally between two scapulae. No vascular and thoracic injuries were detected in the CT. The knife was then pulled and removed, and pressure dressing was applied on the wound. He was discharged with full recovery on the second day of admission.DiscussionThoracic traumas may present as blunt or penetrating traumas. Trauma with penetrating dorsal thoracic injuries is usually in the form of stabbing, sharp penetrating object injuries, or firearm injuries. The aim of a successful trauma management is to determine whether a life-threatening condition exists. The general rules of penetrating trauma management are to avoid in-depth exploration for wound site assessment, to avoid removal of penetrating object without accurate diagnosis, and to keep in mind the possibility of intubation for airway security in every moment.ConclusionDuring the initial care of patients with penetrating trauma, the object should not be removed from its place. Our patient was lucky enough in that no thoracic pathology developed during the accident and he was not subjected to any secondary trauma during ambulance transport.     

Rational design of secondary operation for penetrating head injury: A case report

Penetrating head injury is rare,and thus management of such injuries is non-standard.Early diagnosis and intraoperative comprehensive exploration are necessary considering the complexity and severity of the trauma.However,because of the lack of microsurgical techniques in local hospitals,the possible retained foreign bodies and other postoperative complications such as cerebrospinal fluid(CSF)leak usually require a rational design for a secondary operation to deal with.We present a case of a 15-year-old boy who was stabbed with a bamboo stick in his left eye.The chopsticks passed through the orbit roof and penetrated the skull base.In subsequent days,the patient sustained CSF leak and intracranial infection after an unsatisfied primary treatment in the local hospital and had to request a secondary operation in our department.Computed tomography including plain scan,three dimension recon-struction and computed tomographic angiography are used to determine the course and extent of head injury.A frontal craniotomy was performed.Three pieces of stick were found residual and removed with the comminuted orbit bone fragments.A pedicled temporalis muscle fascia graft was applied to repair the frontier skull base and a free temporalis muscle flap to seal the frontal sinus defect.Aggressive broad-spectrum antibiotics of vancomycin and meropenem were administrated for persistent fever after operation.CSF external drainage system continued for 12 days,and was removed 10 days after tem-perature returned to normal.The Glasgow coma scale score was improved to 15 at postoperative day 7 and the patient was discharged at day 22 uneventfully.We believe that appropriate preoperative surgical plan and thorough surgical exploration by microsurgery is essential for attaining a favorable outcome,especially in secondary operation.Good postoperative recovery depends on successfully management before and after operation for possible complications as well.     

Symptomatic hepatothorax presenting 25 years after penetrating thoracoabdominal injury

Hepatic herniation through the diaphragm is a rare finding. It generally occurs due to a congenital diaphragmatic abnormality or blunt trauma resulting in a diaphragmatic defect. Making the diagnosis is difficult, as there are few definitive clinical signs and chest radiograph (CXR) findings may be non-specific. To our knowledge, only a single case report exists of penetrating right diaphragm injury leading to hepatic herniation.A 42-year-old man presented to the emergency department of a regional hospital with hyperglycaemia and exertional dyspnoea. He was diagnosed with diabetes mellitus type 2. He gave a history of smoking for 15 pack-years, was negative for retroviral disease and had no history of pulmonary tuberculosis. He had no significant surgical history but reported being stabbed with a knife in 1995. The point of entry was below the level of the nipple in the right anterior axillary line. At the time, he was treated with an intercostal drain and discharged home.CXR showed a right-sided chest mass. We considered a differential diagnosis of pulmonary consolidation, diaphragm eventration or hepatothorax. Computerized tomography of the chest and abdomen demonstrated apparent intrathoracic extension of the right liver lobe and partial attenuation of the superior vena cava and right atrium due to a mass effect. The upper border of the liver abutted the aortic arch. Surgical treatment options were discussed. The patient declined surgery and will be followed up as an outpatient.     

Dysphagia with head injury

This retrospective study was conducted: (1) to establish the incidence of dysphagia with head injury, (2) to demonstrate the capabilities of videofluorography (VFG) in identifying the common areas of swallowing dysfunction, and (3) to demonstrate the dysphagia management advantages of the VFG. Nine patients (30%) were found to have significant swallowing problems among 30 patients admitted to the Head Injury Program, Erie County Medical Center, Buffalo, NY in 9 months. These nine patients represent 4-5% of all head-injured patients admitted. The most common swallowing problems demonstrated by videofluorography barium swallow were prolonged oral transit and delayed swallowing reflex; each occurring in 87-5% of eight cases. The study revealed a high correlation between swallowing dysfunction and prolonged hospitalization. Serial VFGs document improved swallowing function, and indicate when relatively safe cessation of nasogastric tube feedings can be achieved. This may permit shorter hospitalization.     

Delayed presentation of penetrating craniocerebral injury caused by a nail

A 38 year old woman presented after 2 weeks with penetrating craniocerebral injury from a six inch nail. She had aphasia and right hemiplegia. Brain CT scan showed no significant cerebral injury. The nail track was infected. Craniectomy and extraction of the nail along with broad spectrum antibiotics was effective. She had no residual neurologic deficit.     

Non-operative management of penetrating liver injuries: a prospective study

This is a report of a study of 63 cases of penetrating liver injuries. Forty-two patients (67 per cent) who presented with signs of an acute abdomen were operated on. The liver was routinely sutured and drained. There was no incidence of postoperative intra-abdominal sepsis or haematobilia. In the remaining 21 patients (33 per cent) liver involvement was suggested by the fact that the wound was over the liver region, and penetrated the peritoneum, and abdominal paracentesis for blood was positive or the patient was shocked or pale. The patients in this group had a soft abdomen and they were treated conservatively with observation and blood transfusions if necessary. No complications were recorded in this group. It is concluded that many civilian penetrating injuries of the liver may be managed non-surgically. If an operative approach is selected suturing of the liver with drainage is the recommended procedure.     

Traumatic brain injury with a machete penetrating the dura and brain: Case report from southeast Mexico

IntroductionTraumatic Brain Injury (TBI) is a major cause of death and disability in our society, we present the first case report of non-missile penetrating (NMP) cranial trauma with a machete in Mexico, and our objective by presenting this case is to prove the usefulness of recently proposed algorithms in the treatment of NMPPresentation of caseWe present the case of a 47 year old woman who received a machete hit to the right side of her head during an assault., she arrived fully conscious to the emergency department (ED), computed tomography was performed and based on the findings of this study and in accordance to recently proposed algorithms for managing NMP cranial trauma a craniotomy was performed, at follow-up the patient presented wtih minor neurological disability in the form of left hemiparesis.DiscussionNon-missile penetrating (NMP) lesions are defined as having an impact velocity of less than 100 m/s, causing injury by laceration and maceration, An algorithm for treating NMP cranial trauma has been recently published in the Journal World Neurosurgery by De Holanda et al., in this case we followed the algorithm in order to provide best care available for our patient with good results.ConclusionThe use of current algorithms for managing NMP cranial trauma has proved to be very useful when applied on this particular case. GCS on admission is an important prognostic factor in NMP cranial trauma.     

The contemporary management of penetrating splenic injury

Introduction

Selective non-operative management (NOM) is standard of care for clinically stable patients with blunt splenic trauma and expectant management approaches are increasingly utilised in penetrating abdominal trauma, including in the setting of solid organ injury. Despite this evolution of clinical practice, little is known about the safety and efficacy of NOM in penetrating splenic injury.

Methods

Trauma registry and medical record review identified all consecutive patients presenting to LAC+USC Medical Center with penetrating splenic injury between January 2001 and December 2011. Associated injuries, incidence and nature of operative intervention, local and systemic complications and mortality were determined.

Results

During the study period, 225 patients experienced penetrating splenic trauma. The majority (187/225, 83%) underwent emergent laparotomy. Thirty-eight clinically stable patients underwent a deliberate trial of NOM and 24/38 (63%) were ultimately managed without laparotomy. Amongst patients failing NOM, 3/14 (21%) underwent splenectomy while an additional 6/14 (42%) had splenorrhaphy. Hollow viscus injury (HVI) occurred in 21% of all patients failing NOM. Forty percent of all NOM patients had diaphragmatic injury (DI). All patients undergoing delayed laparotomy for HVI or a splenic procedure presented symptomatically within 24 h of the initial injury. No deaths occurred in patients undergoing NOM.

Conclusions

Although the vast majority of penetrating splenic trauma requires urgent operative management, a group of patients does present without haemodynamic instability, peritonitis or radiologic evidence of hollow viscus injury. Management of these patients is complicated as over half may remain clinically stable and can avoid laparotomy, making them potential candidates for a trial of NOM. HVI is responsible for NOM failure in up to a fifth of these cases and typically presents within 24 h of injury. Delayed laparotomy, within this limited time period, did not appear to increase mortality nor preclude successful splenic salvage. In clinically stable patients, diagnostic laparoscopy remains essential to evaluate and repair occult DI. As NOM for penetrating abdominal trauma becomes more common, multi-centre data is needed to more accurately define the principles of patient selection and the limitations and consequences of this approach in the setting of splenic injury.     

Abdominal vascular injuries: Blunt vs. penetrating

Introduction: Abdominal vascular injuries (AVIs) remain a great challenge since they are associated with significant mortality. Penetrating injury is the most common cause of AVIs; however, some AVI series had more blunt injuries. There is little information regarding differences between penetrating and blunt AVIs. The objective of the present study was to identify the differences between these two mechanisms in civilian AVI patients in terms of patient’s characteristics, injury details, and outcomes.Method: From January 2007 to January 2016, we retrospectively collected the data of AVI patients at King Chulalongkorn Memorial hospital, including demographic data, details of injury, the operative managements, and outcomes in terms of morbidity and mortality. The comparison of the data between blunt and penetrating AVI patients was performed.Results: There were 55 AVI patients (28 blunt and 27 penetrating). Majority (78%) of the patients in both groups were in shock on arrival. Blunt AVI patients had significantly higher injury severity score (mean(SD) ISS, 36(20) vs. 25(9), p?=?0.019) and more internal iliac artery injuries (8 vs. 1, p?=?0.028). On the other hand, penetrating AVI patients had more aortic injuries (5 vs. 0, p?=?0.046), and inferior vena cava injuries (7 vs. 0, p?=?0.009). Damage control surgery (DCS) was performed in 45 patients (82%), 25 in blunt and 20 in penetrating. The overall mortality rate was 40% (50% in blunt vs. 30% in penetrating, p?=?0.205).Conclusions: Blunt AVI patients had higher ISS and more internal iliac artery injuries, while penetrating AVI patients had more aortic injuries and vena cava injuries. Majority of AVI patients in both groups presented with shock and required DCS.     

Hypothermia and severe head injury

Two patients who were deeply unconscious (GCS = 4) following head injuries, sustained whilst intoxicated with alcohol, became hypothermic due to cold exposure. Despite negative prognostic factors both underwent craniotomy and evacuation of large acute subdural haematoma. After intensive postoperative management and rehabilitation both have made satisfactory recoveries. The contribution of hypothermia to their unpredicted favourable outcome is discussed, and the importance of recording temperature in head-injured patients is emphasized.     

Paediatric head injury: incidence, aetiology and management

Trauma is the commonest cause of hospital admission in children. Head injuries are present in 75% of children with trauma and 70% of all traumatic deaths are due to the head injury. The mechanism of brain injury is examined, resulting from the effects of the primary insult and secondary ischaemic damage. Therapeutic interventions will be discussed with specific emphasis on outcome studies. However, institution of adequate oxygen delivery and haemodynamic stability in the child at the earliest moment remains the most important aspect of the management plan.     

Fatal gunshot wounds to the head: a critical appraisal of organ donation rates

Background

Patients sustaining fatal gunshot wounds to the head are often young, without associated comorbidities, and are potentially ideal transplantation candidates.

Methods

A 5-year review of a level I trauma center's prospective database was performed for all patients sustaining fatal gunshot wounds to the head. Demographic, physiologic, anatomic, and laboratory variables were collected.

Results

Sixty-eight patients were identified, of whom 10 (14.7%) were organ donors. Of 25 admitted to the intensive care unit who eventually did not become donors, 15 (60%) were due to lack of consent.

Conclusions

Despite frequent intensive care unit admissions, organ donation is infrequent following fatal gunshot wounds to the head, primarily because of lack of consent. Improved communication with next of kin could improve organ recovery and reduce futile care in this group.     

Jugular bulb venous thrombosis caused by mild head injury: a case report

BACKGROUND: We present here the first report of a jugular bulb venous thrombosis after mild head injury, which lacked either a skull fracture or abnormal findings on CT scan. CASE DESCRIPTION: An 8-year-old boy was hit on the back of the head and experienced headache and vomiting beginning the next morning. A CT scan and cranial x-ray examination failed to reveal any abnormal findings. The patient was treated conservatively; however, his headache and vomiting persisted. At 13 days after the injury, he began to show double vision due to left VIth nerve palsy and bilateral papilloedemas, suggesting an increased ICP. Although repeated CT scan failed to detect abnormal findings in both the supra- and infra-tentorial regions, MRI clearly visualized a thrombus which was situated within the right jugular bulb. Furthermore, MRV demonstrated disruption of venous flow at the jugular bulb. The patient was administered heparin continuously. His symptoms improved and the CSF pressure on lumbar puncture returned to a normal level at 20 days after admission. Magnetic resonance imaging showed resolution of the clot, and MRV appeared to demonstrate partial recanalization simultaneously. The patient was discharged without any neurologic deficits. The clot in the jugular bulb disappeared completely after 4 months, and he could be followed up for 1 year. CONCLUSION: This case underscores the fact that MRI may represent the exclusive screening examination in cases of sinus thrombosis when it occurs within the jugular bulb, as CT scan fails to reveal any findings suggestive of venous thrombosis.     

Delayed recognition of diaphragmatic injury caused by penetrating thoraco-abdominal trauma

INTRODUCTIONPenetrating trauma to the thoraco-abdomen may cause diaphragmatic injury (DI). We present a case which highlights the difficulties of recognizing DI and the limited role of multimodal diagnostic imaging.PRESENTATION OF CASEA 19 year old male presented with stab wounds to his left lateral chest wall. CT was suspicious for diaphragmatic injury but this could not be confirmed despite ultrasound and serial plain radiographs. He was discharged but re-presented with respiratory compromise and diaphragmatic herniation.DISCUSSIONWe review the clinical features of diaphragmatic injury after penetrating thoraco-abdominal trauma and the various imaging modalities available to clinicians.CONCLUSIONA high index of suspicion must be employed for DI in the context of penetrating thoraco-abdominal trauma. Inpatient observation and laparoscopy/thoracoscopy should be considered when radiological findings are ambiguous. Front line physicians should also consider diaphragmatic herniation in stab victims who re-present with respiratory, circulatory, or gastrointestinal symptomology.     

Artistic assault: an unusual penetrating head injury reported as a trivial facial trauma

Summary The authors report a case of penetrating head injury that presented with a deceptively mild complaint. To our knowledge, it is the first report of a paintbrush penetrating the brain. The patient reported being punched in the left eye and presented with a minor headache, swelling around the left orbit, a small cut on the cheek and slightly reduced left eye abduction. After radiological evaluation, a penetrating head injury was diagnosed. Under general anesthesia, through a lateral eyelid incision a 10.5cm long paintbrush, which had penetrated from the left orbit to the right thalamus, was removed. No post-operative infection was seen at six months follow-up. This brief report serves to highlight that penetrating brain injury can occur without neurological deficit and that a minimally invasive surgical approach was successful in avoiding any complications.