Glass table tops: An unusual source of lethal domestic injury

A 42-year-old woman who fell through a glass tabletop had her lower back pierced by a long shard of glass. She rapidly exsanguinated. At autopsy, a single penetrating wound was present in her left lower back, with complete transection of her left kidney and a 3.5 L haematoperitoneum. Death was due to exsanguination following accidental transection of the left kidney by a penetrating glass injury of the lower back. Glass-topped tables are a well-recognised source of injury in a domestic setting There are far more non-lethal than lethal injuries, many of which involve children. Quite long shards may remain undetected in wounds for considerable amounts of time. Non-tempered glass is a particular risk for breakage. Glass-topped tables should not be used as substitutes for chairs, particularly in overweight or obese individuals.

Self-inflicted neck wounds under influence of lysergic acid diethylamide: A case report and literature review

RATIONALE

Lysergic acid diethylamide (LSD) is a highly potent psychedelic drug derived from ergot alkaloids. The available literature data derived from controlled studies or usage in a medical setting seem reassuring; however the literature contains very rare cases of fatal self-inflicted injuries associated with LSD exposure. The behavioral disorder that created the conditions conducive to death is a maladaptive or irrational response to the psychiatric manifestations induced by the substance.

PATIENT CONCERN

Here, we report the case of a 26-year-old man found dead with large neck wounds in a locked house. No medical history other than recreational use of alcohol and narcotics was reported as well as any history of psychotic disease. The entirety of the other investigations carried out did not demonstrate the presence of a third party at the place of death and a dropper bottle containing LSD was found near the body.

DIAGNOSIS

We report the first case of fatal self-inflicted neck wounds with a cutting instrument in the context of acute exposure to LSD in a patient with no psychiatric history and without suicidal symptoms at the time of the self-aggressive act.

INTERVENTION AND OUTCOMES

In the present work, we used a validated method using liquid chromatography coupled with mass spectrometry for simultaneous quantification of LSD and its metabolites (O-H-LSD and Nor-LSD) in whole blood and urine samples. LSD and O-H-LSD were respectively found at 1460 and 182 pg/mL in blood. In the urine, the concentrations of LSD, nor-LSD, O-H-LSD were, respectively, 3670, 201, and 4890 ng/L.

LESSONS

This observation is particularly relevant in view of the resurgence of interest in the therapeutic use of LSD, notwithstanding the fact that the literature has not demonstrated a link between suicidal risk and acute or chronic exposure to LSD.

The Avocado Hand

Accidental self-inflicted knife injuries to digits are a common cause of tendon and nerve injury requiring hand surgery. There has been an apparent increase in avocado related hand injuries. Classically, the patients hold the avocado in their non-dominant hand while using a knife to cut/peel the fruit with their dominant hand. The mechanism of injury is usually a stabbing injury to the non-dominant hand as the knife slips past the stone, through the soft avocado fruit. Despite their apparent increased incidence, we could not find any cases in the literature which describe the "avocado hand". We present a case of a 32-year-old woman who sustained a significant hand injury while preparing an avocado. She required exploration and repair of a digital nerve under regional anaesthesia and has since made a full recovery.

[The morphological characteristic of the skin lesions inflicted by plastic knives with four cutting edges]

The objective of the present work was to study the morphological features of the skin lesions inflicted by the blades of the Fgx Boot Blade I knives having four cutting edges. The study revealed the signs that can be used to distinguish between morphological characteristics of the stab and lacerated wounds having the primary and secondary incisions made by the four-edge blade.

Large piece of wood board removal and long term survival in a patient with stabbed thoracic wound - case report

Stabbed thoracic trauma is quite common in military practice,but they very rarely occur in civilian life, where they are predominantly accidental injuries. Thoracic stabbed wounds are more commonly observed in men than in women and in younger rather than older people. The management and prognosis depend on the composition, size and location of the foreign body. A 28-year-old Caucasian woman presented to the emergency room with hemorrhagic shock, a large stabbed wound and retention of a large piece of wood board.Less than 10 minutes after arriving to the emergency room she underwent open surgical thoracotomies and resection of the spleen rupture without any significant postoperative complications. At the end of the procedure the left breast was reconstructed. The original aspects of this case are the singularity of the foreign body and its relative harmlessness in spite of its large size.

[Certain peculiarities of trace formation associated with the infliction of stab wounds]

The objective of the present study was to elucidate the detailed morphological picture of stab injuries taking into consideration the design of the piercing objects, conditions of wound infliction, and properties of the affected tissues. The experimental injuries were inflicted either by an impact action or compression at an angle of 90 and 45-60 degrees using sharp (0.01 mm) and blunt (0.5 mm) piercing cylinder-conical bevel-edged (40 mm) objects 7 mm in diameter. A total of 128 skin injuries were available for the examination. It was shown that the shape, length, and orientation of the wounds depended on the sharpness of the injurious agent, the angle at which and the speed with which it was stabbed into the tissue. The new morphological features were identified associated with plastic deformation of the skin, viz. the shape of the wound opening, smoothness or borderline thickening of its edges, flattening and folding of epidermis; conditions for the formation of these features were investigated. These data are of importance for the individual and intra-group expert identification of the putative traumatic agents and reconstruction of the circumstances of a given event or offence.

[Forensic medical expertise of the stab wounds: the current state-of-the art]

This review of special literature encompasses the publications on the injuries inflicted by piercing objects. The results of analysis of these materials indicate that both the mechanisms of formation and the morphological features of stab wounds and damages to the clothes are studied perfectly well. Their shape and morphological patterns are shown to be dependent on the size, shape, and cross-section area of the great variety of the piercing objects. However, investigations carried out thus far did not take into consideration the formation of the signs of skin plastic deformation, such as edge portions of borderline thickening, stretching of epidermis over the walls, transformation of the epidermal network pattern into longitudinal folding, etc. It is concluded that further studies are necessary to better characterize injuries inflicted by piercing objects differing in the sharpness and the shape of cross section and thereby to obtain a deeper insight in the morphological features. It can be expected that such studies will provide a basis for the development of criteria for the individual and intra-group expert identification of the traumatic agents.

[The morphological features of stab-and-slash skin wounds inflicted by the blades with differently shaped tips through the multilayer barrier]

The objective of the present work was to study the shape, size, and morphological features of stab-and-slash skin wounds inflicted by the blades with differently shaped tips taking into consideration the direction of stab through multiple garments (1, 2, and 3 layers). The injuries were inflicted by kitchen knives having the blades of practically identical length and width but differently shaped tips. A total of 480 skin wounds and 720 damaged cloth specimens were available for the examination. The analysis of the data obtained revealed differences between morphological features of the skin wounds. Injuries to the skin unprotected by the cloths had different shape and length of the edge and end portions depending on the shape of the blade tip and the direction of the stab. The length of all wound inflicted through the barrier decreased as the number of layers increased. The wounds had the linear shape, their contusion collar and flattened area became narrower; the shape of the back edges of the wounds inflicted through a three-layer barrier altered. It is concluded that the result of the present study may be useful for the improvement of diagnostics of stab-and-slash skin wounds.

Endovascular stent-graft treatment for a traumatic vertebrovertebral arteriovenous fistula with pseudoaneurysm

The rarely occurring vertebrovertebral arteriovenous fistula (VVAVF) is characterized by abnormal direct communications between the vertebral artery or its branches and the neighboring venous system. We present our experience using a stent graft to occlude a chronic, traumatic VVAVF. A 40-year-old woman with dizziness and loud bruits from the occiput underwent digital subtraction angiography (DSA), which revealed a VVAVF with pseudoaneurysm at the C5-C6 level, with retrograde flow from the right vertebral artery. A stent graft was placed across the fistula after balloon dilation. The fistula and pseudoaneurysm disappeared immediately. After 9 months, the patient remained asymptomatic with a patent stent.

Aneurysm of the internal carotid artery after minor trauma

We report a rare case of posttraumatic aneurysm of the internal carotid artery. The aneurysm was surgically removed, followed by a simple postoperative course. Such lesions should be highly suspected in cases of penetration into the retroangulomandibular neck region.

[Peculiarities of expert assessment of a wound inflicted by a self-made projectile--a harpoon with the archery broadhead]

An attempt was undertaken to elucidate the concrete mechanism of wound infliction by a self-made projectile, such as a harpoon with the archery broadhead, based on the entire volume of evidence provided by the inquest. The results thus obtained allowed the potential for differential diagnostics of clothes and body damages caused by arrow-headed projectiles to be extended.

[Analysis of stresses developing in the evidence-bearing material affected by a bladed article]

The objective of the present study was to assess the possibility of using the finite element analysis for the elucidation of the mechanism of formation of stab-cutting injuries. Stresses developing in the evidence-bearing material at different stages of penetration of a bladed article are estimated. The three-dimensional modeling program was employed for the purpose. The finite element analysis demonstrated differing stress topography resulting from the prick of the blade and its plunging into the evidence-bearing material.

[Stab wounds in children]

Injuries are the most serious health risk in children. Injuries are the main cause of death and long term disabilities in children. Fortunately, stab wounds in children are very rare in our country, but they are, in most cases, very serious injuries. Presenting 3 case reports, this article aims to show the danger of stab wounds and how easily sharp objects can penetrate human tissue. In two out of the three case reports, a foreign object was remained inside the wound. When dealing with such injuries, this possibility must be considered the wound must be carefully inspected. When a revision is necessary, it should be carried out using minimally invasive methods in order to save the child from suffering extensive wounding which would result from the classical open approach revision.

Penetrating cardiac trauma in children

BACKGROUND

Penetrating cardiac traumas in children are dramatic and fatal. Many of the patients are admitted to hospital either in a state of shock or they are dead at presentation. In this study, we aimed to present our experience in penetrating cardiac trauma in children.

METHODS

Seventeen pediatric cases of penetrating cardiac trauma were retrospectively evaluated. The effects on the results of the demographic characteristics of patients, etiology of penetrating trauma, time of presentation to the hospital, physical examination findings in the emergency department, diagnostic methods used, and the surgical techniques applied were evaluated.

RESULTS

The male to female ratio of the 17 retrospectively evaluated cases was 16:1, with an age range of 3-15 years. The patients' mean age was 12.94+/-3.52 years. In all patients, the penetrating cardiac trauma was due to incisive/penetrating tools. The mean Ivatury physiologic index score was 8.23+/-0.78, whereas the mean cardiac injury organ scale score was 5.00+/-0.00. The hospital mortality rate was 5.9% due to the loss of one patient.

CONCLUSION

Shock may develop in pediatric penetrating cardiac trauma in a short time due to hemorrhage and/or cardiac tamponade. The prime factors for patient survival are early diagnosis and emergency thoracotomy.

Stab wound of the cervical spinal cord and ipsilateral vertebral artery injury

Stab wound of the cervical spinal cord with ipsilateral vertebral artery injury is rare. We report a case of a penetrating injury by scissors to the cervical spinal cord and right vertebral artery. The management is discussed and literature reviewed.

Pistol crossbow injuries

This article describes the wounding potential of pistol crossbows to prepare nurses who may have to provide immediate care for patients with injuries from these inexpensive and readily available weapons.

[Identification of the mode of stab-and-hack wound infliction to the chest based on wound features]

The objective of this study was to obtain morphological characteristics of stab-and-hack wounds inflicted by falling down on the knife blade. A formula is derived based on the results of discrimination analysis that can be used in combination with wound morphological features to differentiate between chest stabbing modes.

Arrow-chest injuries in north central Nigeria: case series

BACKGROUND

Metal arrows are still used in communal conflicts on the Jos Plateau in the north central region of Nigeria, even at the turn of the 21st Century with yet undetermined pattern and outcome.

OBJECTIVE

To determine the pattern of the injuries and the factors that influence the outcome of this uncommon condition.

METHODS

A prospective study of nine patients managed over a 6-year period. Information obtained on each patient included sex, age, site of and event leading to the injury, treatment offered and its outcome. The data were analyzed using Microsoft Excel Software.

RESULTS

Nine cases of metal tipped arrow chest injuries are reported. They were all males. Six (67%) cases arrived at the Accident & Emergency Department alive with the arrows partly or completely in the chest. Three cases died in the field of combat giving a mortality rate of 33. The other six (66.6%) were received alive. All the six (67%) had emergency thoracotomy and all of them survived with two (22%) morbidities. In five (56%) cases, including the three dead cases, the arrows were partly inside the chest and partly protruding outside while in four (44%) cases the metal arrows were completely inside the chest. The left hemithorax was more commonly involved with 6 (67%) cases, 2 (22%) on the right and the manubrium sterni in one (11%) case. The associated injuries were arrow injury of the thigh in one (11%) patient and Colles fracture in two (22%) patients. Hospitalization period ranged between 10 to 18 day while mortality was 33% and morbidity was 22% as a result of wound infection.

CONCLUSION

Arrow chest injuries on the Jos Plateau result from communal conflicts among young male adults. Emergency thoracotomy resuscitation produce good outcome in majority of the patients. Bow, arrows and crossbows should be banned as weapons, and instruments for hunting and sports.

[Unusual open craniocerebral injury caused by sickle's tip]

A nine years old girl suffered an unusual penetrating injury to the head caused by a sickle's tip sticked into the skull bones during a lavender harvest on island of Hvar. GCS score was 15. A sickle's blade and its handle were clearly seen coming out of the frontal bone, hanging free, while its tip was firmly sitting in the skull bones! After a neuroradiological diagnostical work up (skull x rays and CT scans) that confirmed intracranial penetration she was operated as an emergency. An osteoclastic craniotomy was done, a and a sickle thereafter easily extracted. Lacerated and contused brain and the penetrating canal were debrided and dura defect covered with a patch. Broad spectrum antibiotics were administered after antitetanic prophylaxis. Postoperative course was uneventful especially regarding infection. One year after the accident she goes normaly to school.

Swordfish Attack—Death by Penetrating Head Injury

There have been very few reports of swordfish attacks on humans and none have resulted in death. Although there are no reports of unprovoked attacks on humans, swordfish can be very dangerous when provoked and they can jump and use their swords to pierce their target. We describe here an unusual case of death that resulted from intracranial penetrating injury caused by a swordfish.

[Cranial wounds of the skull caused by a fencing-foil]

Penetrating stab cranial wounds of the skull by fencing-foil are rare in western countries.

CASE REPORT

This 46-year-old man suffered a penetrating stab wound of the skull through the right orbital region. As a consequence he developed an intracranial hematoma requiring surgical evacuation.

DISCUSSION AND CONCLUSIONS

Damage of intracranial contents due to transorbital penetrating objects other than missiles is a rare event.

[Bull horn wounds in Castellon General Hospital. A study of 387 patients]

Bull horn lesions are frequent in the Latin world due to spectacles involving these animals. These wounds have special characteristics that distinguish them from all other lesions.

MATERIAL AND METHOD

A retrospective analysis of the medical records of patients with bull horn lesions admitted to our service between January 1978 and October 2005 was performed.

RESULTS

A total of 387 patients with bull horn lesions were admitted to our service. There were 12 readmissions due to a new wound in a previously treated patient. Twenty-seven patients had two or more lesions. The location of the wounds was: head and neck in 12 (3.1%), thorax in 21 (5.4%), upper extremities in 19 (4.9%), abdomen in 44 (11.3%), perineum in 41 (10.5%), back and lumbar region in 6 (1.5%), and lower extremities in 244 (63%). Thirty-one laparotomies were performed and there were 23 visceral lesions. Surgical treatment in addition to specific procedures consisted of irrigation with antiseptic solution, Friedreich, and primary closure over drains. Antibiotic and antitetanus vaccinations were administered in all patients. The most frequent early complications were: wound devitalization (7 patients) and infection (6 patients). The most frequent late complication was incisional hernia. Three patients died as a result of hypovolemic shock, septic shock and gas gangrene.

CONCLUSION

Bull horn wounds have special characteristics. Familiarity with these lesions is important in areas where bullfighting is practiced. Although bull horn wounds are severe, their prognosis is good, with few complications and a mortality rate of less than 1%.

Deep sternal wire infection resulting in severe pulmonary valve endocarditis

Right-sided infective endocarditis is uncommon, comprising less than 5% of all cases of endocarditis. This is primarily seen in patients with drug abuse, long-term intravenous catheters, and congenital malformations, or a combination of these. Isolated pulmonary valve endocarditis is difficult to recognize due to its rarity, minimal cardiac manifestations, and predominance of pulmonary infections secondary to embolization of the vegetations. We describe an unusual case of chronic sternal wound infection and migration of an infected braided sternal wire causing right ventricular outflow tract and pulmonary valve endocarditis, which necessitated a complicated reoperation including pulmonary valve replacement with a homograft.

Sharp force injuries in clinical forensic medicine—Findings in victims and perpetrators

The injury findings in 58 perpetrators and 158 victims surviving bodily injuries due to sharp force are presented here. Defence injuries were found in 45.9% of the victims without any significant differences between males and females. There was no clear predominance of defence injuries on the left forearm and hand, as is known from autopsy studies; the right and the left hands were affected with an almost identical frequency. Regarding other parts of the victims' bodies, the topographic distribution of injuries showed a marked concentration on the left side (63.7%). The thorax, head and neck were frequently affected (45.9%, 15.3% and 15.3%, respectively), and less often the abdomen (11.1%), the lumbar and gluteal region (6.3%) and the lower extremities (6.1%). In surviving victims with only one singular stab apart from the upper limbs, the incidence of additional defence injuries on the hands and/or forearms was significantly higher (28.3%) than in fatalities. When the perpetrators had unintentionally cut their own hands, the frequency of these injuries on the right and left hands was almost equal.

Unusual case of self-inflicted thoracic knife wounds with five knives embedded in the left thoracic cavity

Suicide by chest stabbing is a rare cause of penetrating chest trauma. We hereby report a unique case of suicide attempt with multiple thoracic stab wounds and five embedded knives. Although the long kitchen knives were entirely embedded into the left hemithorax no fatal injury occurred. Emergency thoracotomy was performed to remove the knives and repair the lung laceration. Uneventful recovery followed.

Prevention of pressure-induced skin ischemia and impending skin penetration in a displaced clavicle fracture

This article presents a quick and effective method using adhesive tapes to prevent ischemia or penetration of the skin in clavicle fractures.

[Injury pattern on the hand after slipping onto the blade during a knife attack--a contribution to the differential diagnostic classification of sharp force injuries of the upper extremities]

Differential diagnosis of injuries caused by accidental slipping of the hand onto the blade of a knife includes self-inflicted injuries (e.g. to simulate an offense) as well as active and passive defense injuries indicative of the involvement of another party. The injury pattern on the hands of five perpetrators who suffered accidental cuts during knife attacks, as seen by the authors during the clinical forensic examination, is presented. The injuries were localized on the ulnar aspect of the thumb facing the index finger, the radial aspect of the index finger facing the thumb and variable sites on the flexor or extensor side of the middle and ring fingers. Especially in those cases in which the injuries of the victim (e.g. involvement of bony structures) and the dominant hand of the perpetrator are known, additional information for the reconstruction of the course of events may be derived from the cut wounds occurring during the knife attack as the hand slipped onto the blade.

An uncommon peripheral nerve injury after penetrating injury of the forearm: the importance of clinical examination

A 22 year old woman presented to the accident and emergency department with a self inflicted stab wound to the radial side of the volar aspect of the left forearm caused by a pen knife. Her wounds were sutured on the day of injury. Over the course of next three weeks her wounds healed well but she noticed difficulty in using the hand. She therefore attended her general practitioner who suspected a possible nerve injury and referred the patient back to the A&E department. On follow up examination, she was noticed to have a loss of finger and thumb extension and weakness of thumb abduction. Active extension of the wrist (with radial deviation) was intact. There was no sensory deficit. Posterior interosseous nerve (PIN) palsy was diagnosed and the patient was referred to the regional hand surgery unit where she underwent exploration of the wound. A complete transection of the PIN in the supinator canal was found and repaired with good functional outcome. This case reflects the importance of clinical examination in uncommon peripheral nerve injuries and appropriate referral to a specialist department in case of doubtful penetrating wound that pose a threat to an underlying important structure.

Suicide attempts in HIV/AIDS patients: report of two cases presenting with penetrating abdominal injuries

BACKGROUND

We present two patients to highlight an emerging trend of suicide attempts presenting to the surgeons with penetrating abdominal injuries found to be HIV/AIDS related.

METHODS

The two patients were managed at the University of Maiduguri Teaching Hospital in the year 2003. Both patients presented as emergencies with penetrating abdominal injuries and were resuscitated followed by clinical evaluation and laparotomy.

RESULTS

Both patients had visceral injuries that were repaired at laparotomy and were both confirmed HIV positive.

CONCLUSION

There is an emerging trend of suicide attempts in HIV/AIDS patients and the need to determine the suicide pattern that will enable all stakeholders workout a formidable HIV/AIDS and suicide prevention programmes.

The safety of pumpkin carving tools

BACKGROUND

Even with optimal treatment, injuries from pumpkin carving accidents may leave people with compromised hand function. Pumpkin carving tools may reduce the incidence and/or magnitude of these injuries. However, evidence that they are safer is required before these knives can be recommended.

METHODS

Two pumpkin carving knives were compared to a serrated and a plain kitchen knife. The forces required to cut and pierce a pumpkin were determined and then applied by a servo-hydraulic machine to each knife placed against cadaver hands in a manner designed to either lacerate Zone 2 of the finger (six tests for each knife) or to puncture the hand. Inspection and dissection determined the extent of injury.

RESULTS

The pumpkin knives produced some injuries, however, they were fewer and less severe than those caused by the kitchen knives.

CONCLUSIONS

Tools designed specifically for pumpkin carving may indeed be safer. Use of these products, and increased overall awareness of the risks of pumpkin carving in general, which clinicians could help promote, might reduce the frequency and severity of pumpkin carving injuries.