Severe Penetrating Craniofacial Stab Injury with Retained Sharp Knife with Rounded Handle: A Very Rare Case

Background: Craniofacial penetrating injuries are unusual but may cause massive injury to facial tissues and severe brain damage if cranium is entered. Because of the very critical anatomical area involved, these injuries can be challenging to the physicians who first receive them as well as the treating team. Prompt evaluation by utilizing the best diagnostic modality available and timely interference to remove foreign objects is the key aspects to avoid damage to vital organs surrounding the injury and to minimize the late complications. Case Report: We report a case of 24 year old male presented in surgical emergency that sustained a severely penetrating craniofacial assault with a 15 centimeter long sharp knife with intact iron handle and retained blade. Patient was adequately resuscitated and x- ray skull and CT of head along with 3 dimensional reconstruction of face was done to assess any injury. CT scan showed no brain parenchymal injury and only undisplaced fracture of the anterior cranial fossa. Methods and Result: Patient was explored surgically on an emergency basis. The debridement of the wound was done, bone fragments and necrotic tissue was excised. The penetrating knife was gradually removed after surgical procedure. The patient recovered well, and there was no neurological deficit on discharge. Conclusion: The management of penetrating craniofacial trauma is a challenging task and should be handled by multidisciplinary team, so that the management and outcome can be favorable

Operacijsko liječenje penetrirajuće rane mozga i pridružene perforirajuće ozljede oka uzrokovane metalnim objektom male brzine kretanja: prikaz slučaja i uvid u literaturu

Penetrating traumatic brain injury accompanied by perforating ocular injury caused by low-velocity foreign bodies is a life-threatening condition, a surgical emergency and a major challenge in surgical practice, representing a severe subtype of non-missile traumatic brain injury, which is a relatively rare pathology among civilians. Optimal management of such an injury remains controversial, requiring full understanding of its pathophysiology and a multidisciplinary expert approach. Herein, we report a case of penetrating brain and associated perforating eye injury and discuss relevant literature providing further insight into this demanding complex multi-organ injury. We present a case of 39-year-old male patient with transorbital penetrating brain and perforating ocular injury undergoing emergency surgery to remove a retained sharp metallic object from the left parietal lobe. Following appropriate and urgent diagnostics, a decompressive left-sided fronto-temporo-parietal craniectomy was immediately performed. A retained sharp metallic object (a slice of a round saw) was successfully removed, while primary left globe repair and palpebral and fornix reconstruction were performed afterwards by an ophthalmologist. A prophylactic administration of broad-spectrum antibiotics was applied to prevent infectious complications. Early postoperative recovery was uneventful. The patient was discharged on day 45 post-injury having moderate right-sided motor weakness, ipsilateral facial nerve central palsy, and light motoric dysphasia. The vision to his left eye was completely and permanently lost. In conclusion, management of non-missile transorbital penetrating brain injury can be satisfactory when proper clinical and radiologic evaluation, and amply, less radical surgical approach is performed early. A multidisciplinary routine is a prerequisite in achieving a favorable management outcome.Penetrirajuća ozljeda mozga i pridružena perforirajuća ozljeda oka uzrokovana stranim tijelima male brzine kretanja po život je opasno, hitno kirurško stanje koje predstavlja veliki izazov u kirurškoj opskrbi, kao i tešku podvrstu mirnodopske ozljede mozga, koja je relativno rijetka u civilnoj populaciji. Optimalno liječenje ovakve ozljede i nadalje je dvojbeno te zahtijeva potpuno razumijevanje patofiziologije njezinog razvoja, kao i multidisciplinarni ekspertni pristup. U ovom radu donosimo prikaz slučaja penetrirajuće ozljede mozga i pridružene perforirajuće ozljede oka te uvid u recentnu literaturu, kako bi podrobno raspravili o ovoj zahtjevnoj i složenoj višeorganskoj ozljedi. Muškarac u dobi od 39 godina zadobio je transorbitalnu penetrirajuću ozljedu mozga i perforirajuću okularnu ozljedu zbog čega je podvrgnut hitnom kirurškom liječenju kako bi se uklonilo oštar metalni objekt zaostalo u području lijevog tjemenog režnja. Nakon provedene žurne dijagnostike, odmah je učinjena dekompresijska ljevostrana fronto-temporo-parijetalna karniektomija te je uspješno uklonjeno zaostalo metalno strano tijelo (odsječak cirkularne pile), nakon čega je po oftalmologu učinjena primarna opskrba ozljede lijeve očne jabučice i rekonstrukcija vjeđa i forniksa kroz slojeve lijevo. Profilaktička primjena antibiotika širokoga spektra provedena je kako bi se spriječio nastanak infekcijskih komplikacija. Rani poslijeoperacijski oporavak bio je zadovoljavajući. Bolesnik je otpušten iz bolnice 45. dan nakon ozljede s umjerenom motoričkom slabošću desnih udova, istostranom centralnom facioparezom i blagom motoričkom disfazijom. Vid na lijevome oku trajno je i potpuno izgubljen. Zaključujemo kako liječenje mirnodopske transorbitalne penetrirajuće ozljede mozga može biti uspješno ako je provedena pravodobna primjerena klinička i radiološka provjera i ako je primijenjen ogovarajući manje radikalan rani kirurški pristup. Multidisciplinarna opskrba preduvjet je postizanju povoljnog učinka liječenja

Facial impaled trauma involving anterior cranial fossa: case report

An extraordinary case of trans-orbital penetrating injury is presented. A 42-year-old male was surprised while he was stealing into an apartment. While he was trying to escape through the window, he fell on a rod of the fence with not severe ocular and cerebral complications. We describe a unique presentation of a trans-orbital penetration injury that had a good outcome and not severe ocular and cerebral complications. After being transported at the S.M. Goretti Hospital in Latina, the rod was removed outside the operating room and the CT scan was performed. Patient underwent urgent surgery after stabilization of vital parameters

Orbitalno-kranijska penetrirajuća ozljeda

A case of a 37-year-old female patient is presented. The patient was admitted to the Surgical Emergency Unit after accidental fall on a metal rod when she had sustained stab injury of the right orbit with penetration into the right frontal brain lobe. Multi-slice computed tomography (MSCT) showed penetrating injury and fracture of the right orbital roof without eyeball damage and endocranial impressed bone fragments into the right frontal brain lobe. Urgent surgical intervention was performed by a maxillofacial surgeon and neurosurgeon, including reposition of bone fragments of the orbital roof and cranioplasty. Reconstruction of Tenon’s capsule of the right eyeball was performed by an ophthalmologist. From the intraoperative wound swab of the orbit, Bacillus cereus was isolated, therefore the patient was administered ciprofloxacin and rifampicin as recommended by an infectious disease (ID) specialist. Follow up brain MSCT at 15 days and magnetic resonance imaging of the brain at 25 days showed brain edema in the right frontal area and signs of local brain abscess. Intravenous administration of the ciprofloxacin and metronidazole antibiotics with corticosteroids for edema suppression were ordered by the ID physician. Fourteen weeks after this therapy, brain MSCT showed complete abscess regression and no neurologic deficit with only mild psychomotor changes.Prikazujemo slučaj 37-godišnje bolesnice primljene na hitni kirurški prijam nakon slučajnog pada na metalnu šipku i posljedične ubodne ozljede desne orbite s probojem u desni frontalni režanj mozga. Svijest nije gubila. MSCT je pokazao penetrirajuću ozljedu i frakturu krova desne orbite bez oštećenja očnog bulbusa i endokranijskim imprimatom fragmenata u desni frontalni režanj mozga. Nije bilo znakova edema mozga, ali je bila prisutna proptoza, ptoza i curenje cerebrospinalnog likvora iz lezije konjunktive. Hitan operativni zahvat su izveli maksilofacijalni kirurg i neurokirurg; učinjena je repozicija koštanih fragmenata krova orbite i kranioplastika. Oftalmolog je izveo rekonstrukciju Tenonove kapsule desnog očnog bulbusa. Iz intraoperacijskog obriska rane orbite izoliran je Bacillus cereus te su prema preporuci infektologa ordinirani antibiotici ciprofloksacin i rifampicin. Kontrolni MSCT mozga nakon 15 dana i MRI mozga nakon 25 dana su pokazali edem mozga desne frontalne regije i znakove lokalnog apscesa mozga. Infektolog je ordinirao intravensku primjenu antibiotika ciprofloksacin i metronidazol s kortikosteroidima radi suzbijanja edema. Nakon 14 tjedana antibiotske terapije MSCT mozga je pokazao potpunu regresiju apscesa bez okolnog edema, a bolesnica je bila bez neurološkog deficita s blagim psihomotornim promjenama

Unusual cranial trauma caused by pencil in teenager: Case report

Introduction: Penetrating lesions by pencil in the temporal lobe in children and adolescents are uncommon. We present the case of a teenager with penetrating injury by strange object in the temporal lobe. Case: Twelve years old male patient, with history of trauma while he was playing with his friends, presents alteration of the consciousness state, weakness in right hemibody and dysphasia. Urgent surgery is practiced employing an incision in "C" form with improvement of the consciousness state during post-operative. Discussion: Penetrating lesions in the skull and brain are classified as missiles and non-missiles depending of their impact velocity. The wood is a porous organic material that provide a natural deposit of microbian agents, making it potentially lethal. Pre-operative radiological evaluation allows check the trajectory of the penetrating object and secondary lesions present guiding de neurosurgical approach. The prognostic depends on penetration site, timely handling and complications associated. Conclusion: Penetrating lesions by pencil are uncommon, an appropriate imaging evaluation is fundamental to determine the neurosurgical approach that allows prevent and/or decrease secondary damage

PRELIMINARY FINDINGS OF A POTENZIATED PIEZOSURGERGICAL DEVICE AT THE RABBIT SKULL

The number of available ultrasonic osteotomes has remarkably increased. In vitro and in vivo studies have revealed differences between conventional osteotomes, such as rotating or sawing devices, and ultrasound-supported osteotomes (Piezosurgery®) regarding the micromorphology and roughness values of osteotomized bone surfaces. Objective: the present study compares the micro-morphologies and roughness values of osteotomized bone surfaces after the application of rotating and sawing devices, Piezosurgery Medical® and Piezosurgery Medical New Generation Powerful Handpiece. Methods: Fresh, standard-sized bony samples were taken from a rabbit skull using the following osteotomes: rotating and sawing devices, Piezosurgery Medical® and a Piezosurgery Medical New Generation Powerful Handpiece. The required duration of time for each osteotomy was recorded. Micromorphologies and roughness values to characterize the bone surfaces following the different osteotomy methods were described. The prepared surfaces were examined via light microscopy, environmental surface electron microscopy (ESEM), transmission electron microscopy (TEM), confocal laser scanning microscopy (CLSM) and atomic force microscopy. The selective cutting of mineralized tissues while preserving adjacent soft tissue (dura mater and nervous tissue) was studied. Bone necrosis of the osteotomy sites and the vitality of the osteocytes near the sectional plane were investigated, as well as the proportion of apoptosis or cell degeneration. Results and Conclusions: The potential positive effects on bone healing and reossification associated with different devices were evaluated and the comparative analysis among the different devices used was performed, in order to determine the best osteotomes to be employed during cranio-facial surgery

Comparative projectile trauma: an examination of the differences in skeletal trauma inflicted by firearms and archery weapons

In recent years, the defining characteristics of cranial projectile trauma have been reported extensively in experimental studies as well as forensic case reports. The existing literature, however, focuses on trauma inflicted by firearms, primarily handguns and rifles. Though firearms are the most common form of projectile weapon used in a forensic context, there are several types of projectile weapons which have not been examined through experimental research. This gap in the literature not only limits the examination of forensic cases, but also inhibits the examination of trauma found within an archaeological context. This study sought to differentiate the skeletal trauma caused by different projectile weapons that are classified as either firearms (handgun, rifle, and shotgun) or archery weapons (recurve hand bow with field tip arrows, compound hand bow with fixed broadhead arrows, and compound crossbow with field tip bolts, fixed broadhead bolts, and mechanical broadhead bolts). Using polyurethane spheres as proxies for human cranial vaults, samples were shot by one of the specified weapons (n=5) and 35 features resulting from projectile impact (both qualitative and quantitative) of the entrance and exit defects were recorded. Using principal component analysis, it was found that the features of trauma which accounted for the highest proportion of variance observed in the subset which included both entry and exit defects were the maximum fracture length on the external table of the entrance site, the minimum fracture length on the external table of the entrance site, the entrance defect diameter, the minimum fragment length of the fragments that originated from the entrance defect, the width of the reconstructed exit defect, the maximum fracture length on the external table of the entrance defect, and the width of the reconstructed entrance defect. These accounted for 96.74% of the variance within this dataset. When only examining the entrance defects, the most distinguishing variables were the maximum fracture length on the external table of the entrance defect, the width of the entrance defect, the minimum fracture length on the external table of the entrance defect, and the width of the reconstructed entrance defect, accounting for 95.89% of the variance within this dataset. Machine learning (linear discriminant analysis) was applied to test the predictive strength of these variables. In testing the accuracy of these predictions, it was found that the program could correctly predict the weapon used for 74.19% of the samples when examining both the entrance and exit defects and 60.87% of the samples when only examining the features of the entrance defect. The findings of this research exhibit the indiscernible qualitative features between trauma inflicted by different projectile weapons, calling to attention the need to change the current methods of weapon identification. This study has established new quantitative methods for projectile trauma analysis which are simple to perform, require minimal equipment, and are easily applied to forensic and archaeological remains