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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 14  |  Issue : 4  |  Page : 202-204

A case report on the unusual facial injuries: Impalement injuries


1 Department of Plastic Surgery, King George Medical University, Lucknow, Uttar Pradesh, India
2 Department of General Surgery, Mayo Institute of Medical Sciences, Barabanki, Uttar Pradesh, India

Date of Submission22-Jul-2021
Date of Decision09-Aug-2021
Date of Acceptance02-Sep-2021
Date of Web Publication11-Jan-2022

Correspondence Address:
Sandesh Bharat Singh
Department of General Surgery, Mayo Institute of Medical Sciences, Barabanki, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hmj.hmj_51_21

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  Abstract 


Introduction: Impalement injuries are comparatively rarer in nature than other types of injuries. They mostly affect the extremities, whereas the face is rarely involved. They are defined as penetrating injuries, wherein a traumatic object gets impaled in the human body. Impalement injuries of the face present to the emergency. The approach and management of such injuries remain controversial and requires a multi-team approach. We report a case of an impalement injury of the face along with its successful management. Case Report: An interesting case of transorbital penetrating injury is presented. An 8-year-old male child presented in the emergency trauma centre with an alleged history of fall from the first floor of his house resulting in a penetrating injury by a roof tile 'Khaprail' to his face and skull. Conclusions: Impalement injuries to the face and skull require a prompt action, multi-team approach and urgent surgical intervention to prevent damage to salvageable vital tissues. A thorough knowledge of relevant surgical anatomy and a disciplined surgical hand is imperative for optimal results.

Keywords: Facial injuries, foreign body face, impalement injuries


How to cite this article:
Singh SB, Mishra A, Upadhyaya D N. A case report on the unusual facial injuries: Impalement injuries. Hamdan Med J 2021;14:202-4

How to cite this URL:
Singh SB, Mishra A, Upadhyaya D N. A case report on the unusual facial injuries: Impalement injuries. Hamdan Med J [serial online] 2021 [cited 2022 Jan 20];14:202-4. Available from: http://www.hamdanjournal.org/text.asp?2021/14/4/202/335384




  Introduction Top


Hand injuries are the most complex injuries when compared to other bodily injuries.[1] Impalement injuries are defined as injuries resulting from an object that penetrates into the body of a patient. It enters through a puncture on the skin and can be impaled up to variable depths.[2] These injuries are differentiated as: Type I injuries occurring when a moving body strikes an immobile object. Type II injuries in which a mobile object strikes an immobile body.[3] Such objects may be seen on clinical examination or may even go unnoticed.[4]


  Case Report Top


Patient information

An 8-year-old male child presented in the emergency trauma centre with an alleged history of fall from the first floor of his house resulting in a penetrating injury by a roof tile 'Khaprail' to his face and skull [Figure 1].
Figure 1: Pre-operative images

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Clinical findings

A 13 cm tile was impaled damaging the left eye, peri-orbital structures, optic nerve and compressing the contralateral vital structures of the eye, base of skull and brain. The child was immediately stabilised, assessed by our plastic surgery team and was planned for urgent surgical intervention to allay further damages.

Diagnostic assessment

An emergency computed tomography scan was done which revealed the foreign body penetrating through and fracturing nasal bones, ethmoids, medial wall of the right orbit and superolateral and medial wall of the left orbit reaching to the greater wing of sphenoid on the left side. Pneumocephalus was noted, the left globe was displaced inferolaterally and the right globe was compressed.

Therapeutic intervention

The patient was taken under general anaesthesia and a multi-team approach was sought. Lumbar drain was inserted by the neurosurgery team to decompress the frontal lobes and peri-cranial flap was opened through a bicoronal approach. The foreign body was seen penetrating causing damage to the nasal bones and ethmoids. Medial wall of the right orbit and medial and superolateral wall of the left orbit was seen as fractured. The left globe was ruptured and displaced [Figure 2]. The foreign body was detached from adjacent entrapments and removed with utmost surgical precision. Haemostasis was achieved and any dural rupture was ruled out.
Figure 2: Intra-operative images

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Debridement of necrotic tissue and slough was done. The damaged left eye was eviscerated by the ophthalmology team and the right eye was decompressed and secured. The left upper and lower eyelids were reconstructed by local flap from adjoining tissue after ascertaining vascularity of the same. Lacerations were sutured; peri-cranial flap was reposited and sutured. Non-compressive dressing was done and the child was put on broad-spectrum antibiotics. Lumbar drain was removed on the 5th postoperatively day. The rest of the postoperative period was uneventful and lead to the healthy recovery of the patient [Figure 3].
Figure 3: Post-operative images

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Follow-up

The patient is on regular follow-up with plastic surgery, ophthalmology and neurology team and is doing well.


  Discussion Top


The roof tiles or 'Khaprail' form an important component of roofs in the Indian rural houses. Their hard and protruded ends can cause serious injuries if there is high force impact. Injuries of the face are less common than other bodily injuries due to the smaller target size of the face, and also because of the protective reflex that move's the face away from a thrown or coming object.[5]

There are a series of reports on impalement injuries that have advised that the impaled object be left as it is and reduced to a size or length which can allow the patient being transported to a health facility.[6] This measure aims to prevent severe life-threatening haemorrhage that may ensue if the tamponading effect by the impaling object on a large vessel be suddenly removed and to also avoid breakage of the impaling object.

There are limited reported cases of successful treatment of such injuries. Such injuries require great deal of caution in their management. The foreign object may be left as it is without disturbing it until it can be removed in the operation theatre, also timely transport of the patient to a tertiary care hospital has to be done along with efficient surgical management of the same.[7]

Impalement injuries are difficult injuries with several challenges which include pre-hospital care, careful mobilisation of the patient, along with its good surgical management. Health workers need to keep in mind such injuries and treat them effectively.[8]

A full body detailed trauma evaluation and resuscitation need to be carried out before attending the local injury. Such objects are to undergo minimal manoeuvring, they have to be extracted in operation theatre under direct vision, through wound debridement should be done and antibiotics should be administered to prevent any wound infection.[9]

The patient preceded on to have an acceptable recovery even with the serious nature of such impalement injuries.


  Conclusions Top


Impalement injuries to the face and skull require a prompt action, multi-team approach and urgent surgical intervention to prevent damage to salvageable vital tissues. A thorough knowledge of relevant surgical anatomy and a disciplined surgical hand is imperative for optimal results.

Informed consent

The patient father's informed consent for publication of the case details was taken.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Singh S, Vardhan H, Halageri S, Singh A, Kumar V, Mishra B, et al. Demographic profile of hand injuries in North India: A tertiary care hospital experience. Albanian J Trauma Emerg Surg 2021;5:759-63.  Back to cited text no. 1
    
2.
Singh SB, Vardhan H, Silwal K, Upadhayaya DN. The unusual impalement injuries of the hand. Curr Health Sci J 2021;47:123-5.  Back to cited text no. 2
    
3.
Eachempati SR, Barie PS, Reed RL 2nd. Survival after transabdominal impalement from a construction injury: A review of the management of impalement injuries. J Trauma 1999;47:864-6.  Back to cited text no. 3
    
4.
Mathur RM, Devgarha S, Goyal G, Sharma D. Impalement injury involving both heart and lung: A rare case report. IOSR J Dent Med Sci 2013;9:62-5.  Back to cited text no. 4
    
5.
Eppley BL. Craniofacial impalement injury: A rake in the face. J Craniofac Surg 2002;13:35-7.  Back to cited text no. 5
    
6.
Akhiwu BI, Adoga AS, Binitie OP, Ani CC, Iweagwu M, Adetutu O, et al. Impalement head injury with a spear. J West Afr Coll Surg 2016;6:113-24.  Back to cited text no. 6
    
7.
Basit S, Lone AH, Khursheed O, Rashid S, Arah R. Penetrating injury of right hand due to impalement of a wooden foreign body in a professional wood cutter: A case report. Int J Health Sci Res 2015;5:454-6.  Back to cited text no. 7
    
8.
Salomone JP. More than skin deep: Use caution when treating impalement injuries. JEMS 2011;36:40-3.  Back to cited text no. 8
    
9.
Banshelkikar SN, Sheth BA, Dhake RP, Goregaonkar AB. Impalement injury to thigh: A case report with review of literature. J Orthop Case Rep 2018;8:71-4.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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