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CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 3  |  Page : 201-204

An unusual impalement injury to knee


Department of Orthopaedics, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India

Date of Submission30-May-2020
Date of Acceptance28-Jun-2020
Date of Web Publication30-Sep-2020

Correspondence Address:
Dr. Ashok K Patnala
Department of Orthopaedics, Andhra Medical College, B-98, Dayal Nagar, Visalakshi Nagar, Vishakhapatnam - 530 0432, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_80_20

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  Abstract 


Impalement injuries are one of the severe types of injuries combining effects of both penetrating and blunt trauma leading to crushing injury, wound contamination, and multi-organ damage. These types of injuries are usually a result of falls from a height, vehicular accidents, and slip with strong external force. A 12-year-old boy was involved in a road traffic accident where an auto-rickshaw toppled. A loose rusted iron frame penetrated through his left knee and lower thigh. The impaled rod was removed under direct vision and the fractured lateral femoral condyle was fixed under general anesthesia. Impalement injuries require a multidisciplinary approach. The management of each case has to be individualized. Extensive wound exposure, extraction under direct vision, adequate debridement, and antibiotic coverage are pearls of management.

Keywords: Impalement, penetrating, knee


How to cite this article:
Kodidasu HA, Murugan AK, Siddanathi CS, Patnala AK. An unusual impalement injury to knee. J NTR Univ Health Sci 2020;9:201-4

How to cite this URL:
Kodidasu HA, Murugan AK, Siddanathi CS, Patnala AK. An unusual impalement injury to knee. J NTR Univ Health Sci [serial online] 2020 [cited 2020 Oct 25];9:201-4. Available from: https://www.jdrntruhs.org/text.asp?2020/9/3/201/296831




  Introduction Top


Impalement injuries are rarer presentations in the emergency department and present complex surgical challenges in management. Immediate transfer to a tertiary center, preoperative planning, and multispecialty involvement is crucial in the management of such cases. Impalement injuries have effects of both penetrating and blunt trauma, leading to crush injury, wound contamination, and multi-organ damage.

These injuries are usually due to fall from height and road traffic accidents.[1],[2],[3] These injuries are uncommon,[1],[3],[4],[5],[6] and review of the literature shows only occasional case reports. Management of such injuries requires appropriate prehospital care, transportation, minimal handling, infection prevention, anticipation, and management of potential intraoperative complications. We report a case of impalement injury to the knee, with a review of the literature.


  Case History Top


A 12-year-old boy was involved in a road traffic accident where an auto-rickshaw toppled. A loose rusted iron frame penetrated through his left knee and lower thigh. The patient was first taken to a nearby primary health center where the initial dressing was done and was referred to our hospital [Figure 1] and [Figure 2].
Figure 1: Patient immediately after injury

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Figure 2: Patient at presentation

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On presentation, he was fully conscious, well-oriented and was in hypotension. The patient did not have any other major injury except for abrasions on the left elbow. The entry wound of the object was through the anteromedial aspect of the left knee, with an exit through the anterolateral aspect of the thigh. There was no distal vascular deficit.

Plain X-rays confirmed the trajectory of the rod [Figure 3].
Figure 3: Anteroposterior and lateral views of radiographs

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Fluid management was done with colloids and blood transfusion. The patient was shifted to the operation theater. The patient was given short general anesthesia. As the rod was palpable under the skin, the entry and exit wounds were connected through careful dissection. The rod was manipulated carefully out of the soft tissues. Careful debridement was done. A thorough wash with normal saline was given. There was a fracture of the lateral condyle with a transverse and coronal split. The fracture was fixed with two 4 mm cannulated cancellous (CC) screws. The wound was closed primarily over a negative suction drain [Figure 4].
Figure 4: Fracture reduction and fixation

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Broad-spectrum antibiotics were administered along with tetanus booster dose and anti-tetanus serum. The wound was clean, and suture lines were dry on the 3rd and 6th postoperative days. The patient was discharged on the 10th postoperative day [Figure 5] and [Figure 6].
Figure 5: Postoperative wound

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Figure 6: Patient ambulatory with non weight bearing on injured side

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  Discussion Top


Impalement injuries are rare.[1],[3],[4],[5],[6] Ketterhagen and Wassermann[1] published two cases, one impalement to the thigh by a branch of the tree and the other thoracoabdominal impalement in a road traffic accident. Horowitz et al.[4] published successful management of trunk impalement by an iron rod. Bajaj et al.[6] reported a series of four cases stressing the individualization of treatment in every case. Impalement injury has effects of both penetrating and blunt trauma.[1],[2],[3],[4],[5] It causes wound contamination, crushes injury, underlying organ injury, and neurovascular damage.[2] This type of injury is usually due to falls from height or road traffic accidents.[1],[2],[3] In our case, it was due to vehicular accidents. In impalement injury, the amount of damage depends on the organs involved. Higher mortality is seen in thoracoabdominal injuries due to damage to the heart, lungs, or major blood vessels.[3],[5],[6],[7] In impalement to extremity, complications are usually restricted to a particular limb and are nonfatal.[6],[7] Removal of impaling object should never be attempted outside operation theatre,[1],[2],[3],[4],[5],[7] as it may aggravate blood loss due to loss of tamponade effect. On arrival at the tertiary center, initial assessment should be on the principles of basic life support.[1],[4],[7] After initial resuscitation and ruling out injury to vital organs, an impalement site should be examined to determine the extent of the damage. Emergency exploration of patients should be done who remain hemodynamically unstable even after initial fluid resuscitation, without wasting time for radiological investigations.[5] In stable patients, selective radiological investigations are performed to know the extent of injury and trajectory of the impaling objects.[4] Patient position on the operating table is decided by impaling the object's trajectory and dimensions.[1],[4],[7] This is especially relevant with the type of anesthesia to be given. In our case, general anesthesia was given to the patient in supine position on the operating table. Moreover, since organs at multiple anatomic sites are involved, surgical approach under the guidance of a multispecialty surgical team,[4],[7] is essential. A surgical approach should consider entry and exit wounds,[1],[3],[4] so that objects can be removed under direct vision.[1],[4],[5],[7] Ketterhagen and Wassermann[1] recommended a fistulotomy type of incision merging entry and exit wounds being carried down to the object. According to Bajaj et al.,[6] it is unnecessary to open the entire tract made by impaling object in all cases; irrigating the wound with normal saline with a catheter inside the tract is sufficient. The wound should be thoroughly debrided to remove all devitalized tissue, and necessary wash with normal saline should be given.[1],[3],[4],[7] This is a very significant measure that prevents wound infection. Early administration of broad-spectrum antibiotics covering both aerobic and anaerobic organisms is critical.[1],[3],[4] Most of the time, impalement injuries are field injuries and impaling objects are metal rods (iron) with soil contamination; tetanus immunization should also be carried out as per the guidelines, based on patient's immunization status. Regular follow-up is needed to detect postoperative infections. Horowitz et al.[4] cautioned against the development of infections by unusual pathogens found in soil.


  Conclusion Top


Impalement injuries need multidisciplinary approach. The management of each case has to be individualized. Extensive exposure of wound, removal under direct vision, thorough debridement, and antibiotic coverage are keys to management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ketterhagen JP, Wassermann DH. Impalement injuries: The preferred approach. J Trauma 1983;23:258-9.  Back to cited text no. 1
    
2.
Ova S, Miyata K, Yuasa N, Takeuchi E, Goto Y, Miyake H, et al. Impalement injury to the left buttock with massive bleeding: A case report. Nagoya J Med Sci 2013;75:147-52.  Back to cited text no. 2
    
3.
Naito K, Obayashi O, Mogami A, Han C, Kaneko K. Impalement injury of the pelvis due to car brake pedal. Injury Extra 2008;39:11-3.  Back to cited text no. 3
    
4.
Horowitz MD, Dove DB, Eismont FJ, Green BA. Impalement injuries. J Trauma 1985;25:914-6.  Back to cited text no. 4
    
5.
Shikata H, Tsuchishima S, Sakamoto S, Nagavoshi Y, Shono S, Nishizawa H, et al. Recovery of an impalement and transfixion chest injury by a reinforced steel bar. Ann Thorac Cardiovasc Surg 2001;7:304-6.  Back to cited text no. 5
    
6.
Bajaj HN, Rao PS, Kumar B. Impalement injuries. Arch Orthop Trauma Surg 1989;108:58-9.  Back to cited text no. 6
    
7.
Kelly IP, Attwood SE, Quilan W, Fox MJ. The management of impalement injury. Injury 1995;26:191-3.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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