Unusual penetrating faciocranial injury caused by a knife: a case report

Penetrating Orbital Trauma by Large Foreign Body: Case Series Study with Treatment Guidelines and Literature Review

Purpose

The present study aims to describe a case study of large penetrating orbital trauma and treatment guidelines associated with a review of English-language literature of large foreign bodies impacting the orbit from 1997 to 2020.

Patients and Methods

Five patients suffered large penetrating orbital trauma and required emergency surgical procedures.

Results

Together with this present study, a total of 33 cases were selected. The present work has data similar to the literature, and emergency surgical treatment was required in the majority of the cases.

Conclusion

Penetrating orbital trauma by large objects is a challenge. The initial assessment and treatment are fundamental to determine the case severity. The large foreign body should be surgically removed by a trained and experienced team in an advanced hospital unit as soon as possible to minimize visual, functional and aesthetic sequelae.

Penetrating Midface Trauma: A Case Report, Review of the Literature, and a Diagnostic and Management Protocol

PURPOSE

Penetrating facial trauma is an uncommon injury, but patients who present with these dramatic situations require special consideration. We describe the case of a young man who had been shot with an arrow that deeply penetrated his midface as well as report the results of a literature review of penetrating midface injuries. The information gathered was used to create a diagnostic protocol for patients who sustain such injuries.

METHODS

A PubMed search up to October 2019 using several key phrases was performed, and 623 unique articles were evaluated. Excluding firearm injuries to the midface, there were 57 unique cases that involved penetrating midface injuries. Clinical and imaging data were compiled and evaluated with descriptive statistical analysis.

RESULTS

The average patient age was 27 years, with a male predilection. The most common reported etiology was accidental trauma (54%), and a knife was the most common weapon of injury (30%). The most common (32%) specific location of trauma was within the orbital region, including the canthus or the eyelid. In all cases where the patient had not died immediately, surgery was used to remove the penetrating object. We found that computed tomography was the most commonly obtained imaging study (39% of cases). Radiographs were the sole imaging in 28% of the cases, with angiography (16%) and magnetic resonance imaging (10%) used less frequently in management. In 28% of the cases, deep structures, such as the carotid artery, sphenoid sinus, or skull base, were involved in the injury. In 25% of the cases, there was injury to the central nervous system. Death occurred in 8.8% of the cases. Postoperative complications occurred in at least 21% of the cases. Statistical analysis also revealed a significant correlation between antibiotic use and full recovery. Penetration of the object posterior to the maxillary sinus was correlated with incomplete recovery or death.

CONCLUSIONS

Based on all case reports collected, a Dartmouth Penetrating Midface Protocol was developed to aid the practitioner who may happen to be responsible for these dramatic life-threatening injuries. The Dartmouth Penetrating Midface Protocol is based on the type of imaging available at the treating facility, the neurologic and hemodynamic stability of the patient, and the depth of penetration beyond the posterior wall of the maxillary sinus.

Occult Orbital Injury with Dagger Fragment with Resulting Pneumocephalus

Penetrating injuries of the cranium are relatively uncommon, only 0.4% of all head injuries. In patients with disturbed conscious level, an extensive examination should be performed in the emergency unit to rule out transorbital penetrating brain injury. A 25-year-old male was attacked with a dagger. He presented with ethylic intoxication and the physical examination demonstrated a small skin injury on the lateral canthus of the left eye with a large periocular hematoma which prevented eyelid opening. Cranial CT scan showed a metallic intraorbital foreign body consisting of a fragment of a dagger which perforated the eyeball, and penetrated through the superomedial wall of the orbit into the anterior cranial fossa. Reconstruction of the eyeball was performed and the fragment was removed. Orbital injuries with a knife in situ are very unusual. Early identification and removal of retained foreign bodies are essential.

Direct traumatic optic neuropathy in a temporal laceration: A case report

Facial lacerations are a common presentation in emergency departments. It is important to appreciate the mechanism of injury and the anatomy of structures involved in penetrating lacerations in the maxillofacial region. A 65-year-old man suffered an accidental penetrating injury with a sharp kitchen knife to the right temporal region. There was a single laceration to the right temporal region. The right eye had no perception to light, a total afferent and efferent pupillary defect and partial ophthalmoplegia. Computerised tomography scan revealed signs of penetration through the skin, temporalis, postero-lateral orbital wall and orbital apex. There was no injury to the globe or either retrobulbar or intracranial haemorrhage. A diagnosis of direct traumatic optic neuropathy was made following consultation with opthalmology and neurosurgery teams. Only two similar cases of penetrating trauma in the temporal region resulting in direct traumatic optic neuropathy have been identified in the literature. This case presentation highlights the structures that are at risk of damage from penetrating trauma in the maxillofacial region.

Nonmissile Penetrating Injury to the Head: Experience with 17 Cases

BACKGROUND

Penetrating nonmissile injuries to the head are far less common than missile penetrating injuries. Here we describe our experience in managing 17 cases of nonmissile injury to the head, likely the largest such series reported to date. We also highlight the surgical steps and techniques used to remove in situ objects (including weapons) in the penetrating wounds that have not been described previously.

METHODS

We conducted a retrospective study of cases of nonmissile, low-velocity penetrating injuries of the head managed in our department. The recorded data of patients with penetrating head injuries were studied for the cause of the injury, type of object, type and extent of penetration, Glasgow Coma Scale score on admission, other clinical issues, evaluation and assessment, interval from penetration to operation, surgical steps and notes, difficulty during the operation, major and minor complications, follow-up, and ultimate outcome.

RESULTS

Our 17 cases included 6 cases of accidental penetration and 11 cases of penetration as the result of violence. Weapons and other foreign objects causing injury included a teta (a pointed metal weapon with a wooden handle and a barb near the tip, used for hunting and fishing) in 4 cases, a dao (a sharp metal cutting instrument with a wooden handle used for cutting vegetables, fish, meat, bamboo, wood, etc.) in 3 cases, a bamboo stick in 3 cases, a metal rod in 2 cases, a knife in 2 cases, a sharp stone in 1 case, a metal steam chamber cover in 1 case, and a long peg in 1 case. GCS on admission was between 13 and 15 in 15 cases. Only 1 patient exhibited limb weakness. Four patients with an orbitocranial penetrating injury had 1-sided vision loss; 2 of these patients had orbital evisceration, and 1 of these patients died. In 14 patients, the foreign object was in situ at presentation and was removed surgically. Computed tomography scan and plain X-ray of the head were obtained in all patients. Postoperatively, 2 patients (11.7%) needed support in the intensive care unit but died early after surgery. One patient developed late osteomyelitis. The remaining patients were doing well at the most recent follow-up.

CONCLUSIONS

The presenting picture of nonmissile penetrating injury to head may be daunting, but these cases can be managed with very good results with proper (clinical and radiologic) evaluation and simple neurosurgical techniques.

Management and outcome of low velocity penetrating head injury caused by impacted foreign bodies

BACKGROUND

Penetrating head injuries with impacted foreign bodies are rare, associated with a high incidence of morbidity and potentially life-threatening. In this study, we aimed at investigating the outcome of these cases as well as analyzing the factors affecting the prognosis.

METHODS

A retrospective study in which the records of 16 patients who had penetrating head injuries caused by low-velocity impacted foreign bodies were revised. All patients were males with a mean age of 28.9 years (range, 18 to 50 years). The follow-up period ranged from 4 to 13 months with a mean of 8.1 months. Causes of injury were construction accidents in 6 (37.5 %) patients, assault in 6 (37.5 %) and road traffic accidents in 4 (25 %). The impacted objects included a bar of iron, a piece of wood, a nail, a sickle and a piece of glass. Diagnostic computerized tomography (CT) of the brain was carried out on admission in all patients. Thirteen (81.3 %) patients were submitted to surgery, and all had the appropriate management in the form of antibiotics and dehydrating measures as required. The primary outcome measure was the Glasgow Outcome Scale (GOS) at the end of follow-up.

RESULTS

At the end of follow-up, ten (62.5 %) patients had a GOS score of 5, two (12.5 %) patients had a score of 4, and four (25 %) patients had a score of 1.

CONCLUSIONS

Low-velocity penetrating head injuries are most common in young adult males. With the appropriate management, a majority of even the most severe cases can have a favorable outcome.

Low velocity penetrating head injury with impacted foreign bodies in situ

Penetrating head injury is a potentially life-threatening condition. Penetrating head injuries with impacted object (weapon) are rare. The mechanism of low velocity injury is different from high velocity missile injury. Impacted object (weapon) in situ poses some technical difficulties in the investigation and management of the victims, and if the anticipated problems are not managed properly, they may give rise to serious consequences. The management practice of eight patients with impacted object in situ in context of earlier reported similar cases in literature is presented.

Migration of tip knife blade through middle-third facial tissues

PURPOSE

The aim of this paper is to report a case of knife aggression with a spontaneous migration of a tip blade lodged in deep tissues 6 months after trauma.

PATIENT

An 18-year-old woman that was a victim of impalement injury with a knife by her boyfriend on the glabella region with a blade fracture and tip lodging into middle-third facial tissues.

RESULTS

After conservative management of a knife tip, a spontaneous migration occurred with its exposition on the zygomatic area, possibly due to a functional treatment to improve mouth opening.

CONCLUSION

Fracture of knife blade with a tip retained deeply into the tissues is considered foreign body, and its removal must be considered. Nevertheless, the basis for this removal takes account the cost-benefit ratio, and if a conservative management was chosen, the clinical and radiological accompanying is mandatory to prevent and to treat its possible complications.

Craniofacial Trauma in Adolescents: Incidence, Etiology, and Prevention

BACKGROUND

The lack of a common agreement on the precise meaning of the term "adolescence" makes it difficult to interpret the literature regarding fractures in this age group.

METHODS

The records of all patients with craniofacial trauma admitted to the Division of Maxillo-Facial Surgery of the Rome "La Sapienza" University Hospital between February 2001 and August 2004 were reviewed retrospectively. Besides the anatomical site of the fracture, the authors also reviewed in the group of adolescent fractures the cause, complications, and the safety devices employed and their effectiveness.

RESULTS

Of 601 patients admitted after facial or craniofacial fractures, 96 were between 11 and 19 (15.97%). The most frequent cause of fracture in this age group was motorcycle crash (39/96), followed by car crash (26/96), sporting accident (15/96), attacks (11/96), microcar crash (2/96), accidental fall (2/96), and firearm trauma (1/96). Only three patients wearing a full-face helmet suffered facial fractures; the most severe fractures with neurosurgical complications occurred in patients without a helmet; the majority of facial fractures occurred in patients wearing an open-face helmet.

CONCLUSIONS

It is universally agreed that the primary cause of fracture is road collisions and, although car crashes prevail in all other age groups, motorcycle crashes are more frequent in adolescents. It is necessary to emphasize the need for protective devices capable of avoiding not only neurosurgical complications but also maxillofacial fractures (full-face helmet).

Unusual penetrating orbit injury

Penetrating head and face injuries can cause hemorrhages, neurological lesions, visual acuity loss, fractures and facial deformities. This report discusses an injury caused by a knife that penetrated the left orbit and reached the skull base without damaging any important structures. The knife was removed through the entrance wound and no complications were observed either during or after surgery.

The value of protocol-driven CT scanning in stab wounds to the head

A prospective study involving 179 patients with cranial and orbital stab wounds was undertaken to evaluate the incidence and relationship of clinical findings, radiographs, and computed tomography (CT) findings and treatment decision. Indications for a CT scanning of the head are a of loss of consciousness, convulsions, any neurological deficit, palpable or visible fracture on the skull X-ray film after an attack with a sharp instrument, presence of an impaling weapon. A CT scan and plain radiography were performed in 179 patients. There were pathological CT findings in 128 patients (71.51%). In contrast only 35/179 (19.5%) X-ray films were positive; 11 (6.15%) patients had a palpable fracture. Approximately 80% of all cranial injuries would remain undetected if the diagnosis would be based on a visible fracture. Fifty percent of patients had an admission GCS of 15/15. The importance of a CT scan and the limited benefit of plain radiography alone in stab injuries to the head is discussed.

Penetrating craniofacial injury in a pediatric patient

Penetrating craniofacial injuries are rare especially in the pediatric age group. They are potentially life-threatening and challenging injuries. We describe an unusual trauma in a 30-month-old child who suffered a craniofacial injury caused by TV antenna. Clinical examination and radiological investigation showed the antenna penetrating the hard palate, left posterior nasal choana, sphenoid sinus, and skull base, up to pituitary fossa. There was no evidence of great vessels injury that confirmed by cerebral angiography. Transpalatal approach was used to remove the antenna and repair the skull base defect. There was no neurological or visual activity deficit postoperatively. The child developed diabetes insipidus that is well controlled using desmopressin.

Injury caused by deeply penetrating knife blade lodged in infratemporal fossa

Knife-inflicted, deeply penetrating head and neck trauma is an uncommon life-threatening injury and a challenging problem. An examination of the neurovascular and systemic physical status is a first requirement and the decision as to which approach to adopt for the removal of the blade is of critical importance. Here we report a rare case of a pre-auricular stab wound with the knife blade deeply lodged in the extracranial infratemporal fossa. Radiological investigations showed that the knife blade had entered from the temporomandibular joint and become lodged through the anterior margin of foremen magnum below the petrosal bone. Minimal left vocal cord paresis, left palatal weakness and a slight deviation of the tongue towards the left side were observed. The other neurological and systemic physical evaluations were normal. Simple withdrawal of the blade in the operating room did not cause serious neurovascular injury. Here we discuss and compare the expanded exposure of anatomical structures for blade removal and simple withdrawal in similar injuries.