Thoracoabdominal impalement is one of the most severe types of penetrating trauma, although its incidence is rare. In the history of mankind this kind of injury has been described as occurring during antique and medieval war as well as being used as an extreme method of torture (Figure 1).1,2 The use of impalement has been published in literature especially in the context of the history of the Romanian count Dracul.2,3 Today, impalement injuries often result as a consequence of a patient falling from a height onto a sharp object or vice versa.4–8 Abdominal impalement injuries are usually associated with visceral and vascular injury, causing significant morbidity and mortality. The management of these injuries poses specific challenges in prehospital care, transport, and management strategies. Although case reports of such trauma usually describe single events only, we report two cases of bodies impaled by iron bars, as well as the successful management of the respective patients.
A 25-year-old male construction worker was brought to hospital due to an impalement caused by a steel rod, 2.5-m long and 3.5-cm thick, which had traversed his body after falling from the 25th floor (a 75-m drop). The object entered through his body while he was in a standing position, entering 2 inches from the midline (vertebral column) and the medial border of the left scapula, and exited on the medial side of the left thigh (Figure 2). On laparotomy with a long median incision, the rod was found lying behind the left liver lobe and the tail of the pancreas. It penetrated the small bowel mesentery in five places parallel to the left border of the abdominal aorta, then passed through the sigmoid colon mesentery, missing the colon, and pierced the left lateral pelvic wall (Figure 3), exiting through the greater sciatic foramen to the upper-medial side of the left thigh.
The rod was extracted under vision, protecting the greater vessels and viscera. Only 30-cm of ischemic small bowel was resected, with end-to-end anastomosis. The patient was discharged home two weeks later following an uneventful recovery.
A 39-year-old male construction worker was admitted to the emergency ward following impalement by a steel rod, 3-m long and 3.5-cm thick, which penetrated his body in a standing position after falling from the sixth floor of a building (20-m high). The object entered through his back near the right shoulder and exited from the lateral side of the left gluteal fold. The patient was haemodynamically stable with no neurological deficits in either upper or lower limbs. An immediate stat scan (Figure 4) showed a comminute fracture of the glenoid end of the right scapula. The rod travelled subcutaneously on the back and exited at the left gluteal fold. On examination, no bleeding per rectum was seen, and catheterization of the urinary bladder revealed haematuria.
On laparotomy through a long median incision, the rod was seen to pierce the body through a right costophrenic angle, passing behind the right liver lobe and traversing the retroperitoneal space behind the right colon, leaving a haematoma. It passed underneath the common iliac vessels and, piercing the dome of the urinary bladder (Figure 5), continued to the left lateral pelvic wall, emerging at the left gluteal fold. The rod was extracted under vision, protecting the right common iliac vessels (Figure 6). The ascending colon and terminal ileum showed ischaemic changes that required right hemicolectomy; the urinary bladder, which had been pierced in two places (entry and exit) was refreshed and closed, with no damage to the rectum, leaving a urinary catheter. The abdomen was closed, leaving a right intercostal drain. The glenoid process of the right scapula was stabilized by internal fixation. The patient was discharged three weeks later following an uneventful recovery.
The majority of impalement injuries described in the literature are caused by objects entering via anatomical orifices into the patient's body (mouth, nose, ears and rectum).9–13 Owing to the rare nature of thoracoabdominal impalement, there are currently no clear guidelines for the operative management of these extensive injuries. However, a review of the existing literature gives some evidence to allow a few conclusions and recommendations.
There is uniform agreement that the impaling object should be left in situ and not removed at the site of the primary accident.4–8,14,15 Removal should be performed only at a tertiary trauma centre utilizing a multimodality surgical approach under the guidance of surgeons specialized in the particular anatomical regions affected by the objects.
Such injuries can involve vital organs, compromising the normal physiology of respiration and circulation, and stabilization of the patient can immediately impose a big challenge owing to interference of the object with these anatomical structures. The severity of organ injuries and the extent of blood loss determine the mortality risk. Therefore, these kinds of traumas can be categorized as follows:
Impalement with cardiovascular injury
Impalement with injury of hollow organs (intestinal tract, bladder)
Impalement with injury of parenchymatous organs (liver, spleen, kidney)
Patients experiencing trauma of type (a) have to be regarded as having the worst prognosis and, in general, death has been seen within 30 min of the accident. Only if the penetrating object is able to close the site of the damage sufficiently, thus avoiding unstoppable bleeding, is there a low chance of survival until arrival at the trauma centre is possible. This reconfirms the necessity of avoiding any removal of the impaling object.
Injuries in groups (b) and (c) have a good chance of a positive outcome if patients can be treated at a tertiary trauma centre with the capability of rapid diagnosis in the emergency room as well as the availability of all surgical subspecialities. To assess the complexity of trauma-induced injuries, a computed tomography (CT) scan should be performed in addition to common emergency diagnostics (e.g. chest radiography of the thorax, abdominal ultrasound).
After the impaling object has been removed by a wide access via thoracotomy and/or laparotomy, organ injuries, particularly cardiac and vascular injuries, need to be addressed in order to prevent acute bleeding and peripheral ischaemia. Following this, damage of hollow organs [injury type (b)] will be treated by surgeons specialized for the respective anatomical structure. This will be followed by orthopaedic, as well as soft-tissue, management.