|Year : 2014 | Volume
| Issue : 2 | Page : 91-93
An unusual impalement injury involving both extremities
TP Elamurugan, GS Sreenath, S Jagdish
Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
|Date of Web Publication||10-Apr-2015|
Dr. T P Elamurugan
Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 003
Source of Support: None, Conflict of Interest: None
Impalement injury occurs due to penetration by sharp objects during road traffic accident, fall or workplace mishaps. They usually involve the trunk, cranium, or isolated extremities. Involvement of upper and lower extremity in the same injury is rare. We report the case of a 48-year-old man who sustained a fall from 25 feet under the influence of alcohol onto a wooden fencing pole. The pole went penetrating posteriorly through the right axilla and anteriorly through the right thigh without involving the trunk.
Keywords: Impalement injury, penetrating trauma, pole
|How to cite this article:|
Elamurugan T P, Sreenath G S, Jagdish S. An unusual impalement injury involving both extremities. Afr J Trauma 2014;3:91-3
| Introduction|| |
Impalement injury is defined as penetration of a body cavity or region by an elongated object which remains in situ.  They can occur following both penetrating and blunt trauma. Mechanism of injury and the velocity of the trauma are the factors that influence the injury severity.  Impalement injuries can involve the trunk, head and neck region, and extremities. There have been several case reports reporting the impalement injuries of various regions. We report a unique case of the impalement injury involving both the upper and lower extremities by a single wooden pole without involvement of the trunk.
| Case Report|| |
A 45-year-old man, farmer by occupation presented to the emergency department with a history of the fall from a height at his residence. The patient complained of sustaining a penetrating injury to his right upper and lower limb by a wooden pole following the fall. He reported that he had fallen from the first floor of his house which was around 25 feet above ground level under the influence of alcohol (re-arranged) onto a wooden fencing (fence) pole which was used to tether the cattle in his house, under the influence of alcohol (remove). There was no history of loss of consciousness or any other injury. On examination, he was conscious, oriented and pale but hemodynamically stable.
A wooden pole of diameter approximately 4 cm and length of around one and a half meter was found penetrating through the right upper limb and right lower limb [Figure 1]. One end of the pole was found projecting out through the posterior aspect of the right axilla behind the shoulder joint and anterior to latissimus dorsi muscle and the other end of the pole was projecting out through the anterior aspect of the right thigh just below the inguinal ligament [Figure 2]. The thoracic and abdominal cavities were however not involved in the injury. The right upper limb was abducted at the shoulder joint, and the right lower limb was abducted and externally rotated at the hip. The pole was found tenting the right adductor longus muscle. There was no evidence of neurovascular injury in both the (remove) extremities.
The patient was shifted (moved) to the operation theater for exploration, removal of the wooden pole and wound lavage. Under general anesthesia, exploration of the wound at the level of the right groin was planned first. The patient was put in the supine position, and the pole was delivered from the thigh anteriorly by incising the skin, subcutaneous tissue, and adductor longus muscle [Figure 3]. There was no underlying neurovascular injury. The pole was stabilized by the assistant and its movement at the shoulder joint was avoided. Wound lavage was given (done) and the wound left open with stay sutures for (on the)?? Adductor longus muscle. Subsequently, the patient was shifted to left lateral position with extreme care for exploration of the pole at the right shoulder joint region. The pole was approached from the posterior aspect of the shoulder joint and was delivered posteriorly by incising the skin, subcutaneous tissue, and teres (major and minor) muscles [Figure 3]. No neurovascular injury was found. Wound lavage was given, and the teres muscles were sutured. The wound was left open and allowed to heal by secondary intention. Postoperatively, the patient was stable, and the wound granulated well. The patient was given (commenced on) physiotherapy and discharged on the 10 th postoperative day.
|Figure 3: Plane of the pole deep to latissimus dorsi (arrow) in the posterior axilla (left). Plane of the pole deep to adductor longus (arrow) in the thigh (right)|
Click here to view
| Discussion|| |
Impalement injury is defined as penetration of a body cavity or region by an elongated object which remains in situ following the trauma. They usually occur following road traffic accidents (RTAs), fall from height, workplace mishaps, assaults, etc.  It can occur following both penetrating injury, as well as significant blunt force. Based on the mechanism of injury, impalement injuries can be of two types.  Type 1 injury occurs due to contact of a moving body on an immobile object, e.g., fall from height. Type 2 injury occurs due to penetration of a moving object into an immobile body, e.g. RTAs. In the present case, injury occurred due to fall from a significant height under the influence of gravity onto an erect and stationary wooden pole. The gravity, height of fall, and the weight of the person are responsible for the force required to cause the penetration injury. Nature of the penetrating object varies depending on the place and type of injury. In the present case, the penetrating object was a wooden pole. One of the uniqueness of this injury is that the penetrating object is a wooden pole with a blunt end, hard enough to cause the penetration. This signifies the momentum of the fall.
Depending on the site of impalement, these injuries can be classified as torso, head and neck, extremity, and perineal injuries.  Mechanism of injury, extent of the injury and the prognosis are different for these injuries. Impalement injuries are usually more common in the trunk as there is more area for contact. As the area of contact in the extremities is less, the impalement injuries in these areas are by comparatively thinner and sharp objects. The remarkable feature in the present case is that the penetrating object was almost three-fourths (75%) of the diameter of the extremity which it had penetrated. Since extremities are mobile structures, there would have been a high probability that the penetrating rod would have slipped to the side of the extremity rather than penetrating through it. The other uniqueness of this injury is that the same pole has penetrated through both the ipsilateral extremities without involving the trunk. Both the extremities need to have been aligned exactly in the same line at the time of penetration to produce such an injury.
Impalement injuries are usually associated with injuries to vital organs depending on the site of injury.  In injuries involving the extremities, there is usually an associated neurovascular injury. In the present case, even though, the penetration was by a thick object and in a different orientation to the upper and lower limbs, there was no associated neurovascular injury.
Management of the impalement injury involves stabilization of the patient, stabilization of the penetrating object, tetanus prophylaxis, antibiotic coverage, wound debridement with lavage and rehabilitation1. The dictum to be followed in these injuries is that the penetrating object should not be removed without proper planning and adequate exposure under anesthesia.  In the present injury, the patient and the penetrating object were stabilized in such a way that there was no damage to the neurovascular structures. As the pole was more superficial and anterior at the thigh region, the patient was put in the supine position, and the pole was removed from this region first. Subsequently, the patient was put in left lateral position maintaining the pole in a stable position and was removed from the shoulder region.
| Conclusion|| |
The case report presented here is a unique type of injury because the mechanism of injury was out of the ordinary (uncommon), the penetrating injury involves two mobile regions of the body, penetrating the upper limb posteriorly and the lower limb anteriorly without any associated neurovascular injury.
| References|| |
Paul S, Lee CL. Trauma case review: Survival following impalement. Crit Care Nurse 1994;14:55-9.
Asensio JA, Arroyo H Jr, Veloz W, Forno W, Gambaro E, Roldan GA, et al.
Penetrating thoracoabdominal injuries: Ongoing dilemma-which cavity and when? World J Surg 2002;26:539-43.
Murray JA, Berne J, Asensio JA. Penetrating thoracoabdominal trauma. Emerg Med Clin North Am 1998;16:107-28.
Machens C, Lehmann U, Müller M, Schmitt HJ, Uder M, Pohlemann T. Impalement injury by a wooden branch. Eur J Trauma 2002;28:314-7.
Sawhney C, D'souza N, Mishra B, Gupta B, Das S. Management of a massive thoracoabdominal impalement: A case report. Scand J Trauma Resusc Emerg Med 2009;17:50.
[Figure 1], [Figure 2], [Figure 3]