A CAJM journal article.Outside South Africa the problem of stab wounds has not received much attention in the African medical literature. This problem has not been studied before in Zimbabwe.
From a review of the literature, supported by the material in this paper, it is clear, that most stab wounds affect the chest and abdomen. Clinicians should therefore be aware of the various management options of such injuries.
This study was carried out to determine the pattern of stab wounds in our practice and to analyze the results of our management of patients with such injuries. The relevant literature is reviewed and suggestions are made to bring our management of stab wounds in line with current management trends

Dube, M.

Muguti, G.I.

Zishiri, C.

Central African Journal of Medicine

English

IDS OpenDocs

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CENTRAL AFRICAN
JOURNAL OF MEDICINE
Vol. 41, No. 12,1995
THE CENTRAL AFRICAN 
JOURNAL OF MEDICINE
ORIGINAL ARTICLES____________
Stab wounds in Bulawayo, 
Zimbabwe: a four year 
audit
GIMUGUTI, C ZISHIRI, M DUBE 
SUMMARY
Between January 1989 and December 1992 a total of 
102 patients (88 pc male and 12 pc female) were treated 
for stab wounds at Mpilo Central Hospital, Bulawayo, 
Zimbabwe. The case records of these patients have 
been studied retrospectively. The mean age of the 
patients was 30 years (Standard Deviation 9). Most of 
the patients, 82 pc (82/102) were residents of the city of 
Bulawayo with only 18 pc (18/102) coming from rural 
areas. The mean delay in presentation was 12 hours 
(SD 11).
A knife was the stabbing instrument in most cases 
(82 pc). Fights, 38 pc (26/68), domestic disputes, 26 pc 
(18/68) and robbery 21 pc (14/68) were the commonest 
motives for stabbing. In most cases stabbing occurred 
in a beer hall, 47 pc (26/55) and at home, 31 pc (17/55).
The majority of stab wounds occurred in the chest, 
51 pc followed by the abdomen, 31 pc. Of the patients 
with stab wounds of the chest 22 pc (14/65) required 
intercostal chest drains. Of the 39 patients with stab 
wounds of the abdomen 20 patients were subjected to
Department of Surgery 
Mpilo Central Hospital 
Bulawayo, Zimbabwe 
Correspondence to:
Professor GI Muguti
Department of Surgery
University of Zimbabwe School of Medicine
P O BoxAI78, Avondale
Harare, Zimbabwe
laparotomy. No abnormality was found at operation in 
50 pc (10/20) of cases.
No major complications or mortality were recorded 
in this series.
Based on the findings in this study, there is need for 
us to adopt a more conservative approach to the 
management of stab wounds, especially those involv­
ing the abdomen. This policy of “selective conserva­
tism” should be based on a thorough physical examina­
tion and appropriate special investigations. Active surgi­
cal intervention should be reserved for specific indica­
tions.
INTRODUCTION
Outside South Africa the problem of stab wounds has 
not received much attention in the African medical 
literature. This problem has not been studied before in 
Zimbabwe.
From a review of the literature, supported by the 
material in this paper, it is clear, that most stab wounds 
affect the chest and abdomen. Clinicians should there­
fore be aware of the various management options of 
such injuries.
This study was carried out to determine the pattern of 
stab wounds in our practice and to analyse the results of 
our management of patients with such injuries. The 
relevant literature is reviewed and suggestions are 
made to bring our management of stab wounds in line 
with current management trends.
MATERIALS AND METHODS
Between January 1989 and December 1992 a total of 
102 patients were treated for stab wounds at Mpilo 
Central Hospital. A retrospective analysis of their case 
records was carried ou t The following information 
was extracted: age, sex, admission details, type of 
stabbing instrument, motive for stabbing, time of day,
380
CENTRAL AFRICAN
JOURNAL OF MEDICINE
Vol. 41, No. 12,1995
place of stabbing, anatomical site, clinical features, 
investigations, treatment, hospital stay and outcome.
RESULTS
Age and sex distribution.
The study included 90 (88 pc) males and 12 (12 pc) 
females). The mean age was 30 years (SD 9).
Figure I: Age and sex distribution.
NO.OF PATIENTS
AGE
■  m ales
H  FEMALES
Admission details.
Most of the patients, 84 (82 pc), were residents of the 
city of Bulawayo. Only 18 patients were from rural 
areas. The delay in presentation was known in 51 
patients. The average delay was 12 hours (SD 11). 
Type of stabbing instrument.
The type of stabbing instrument was known in 60 cases. 
In the majority of cases, 82 pc (49/60), a knife was used. 
The other stabbing instruments used included: a screw­
driver 7 pc (4/60), some other sharp object 7 pc (4/60), 
a spear 2 pc (1/60), a pair of scissors 2 pc (1/60) and a 
needle2 pc (1/60).
Motive for stabbing and time of day.
The motive for stabbing was known in 68 cases. Fights, 
38 pc (26/68), domestic disputes, 26 pc (18/68 and 
robbery 21 pc (14/68) were the commonest motives for 
stabbing. The other motives included: assaults by un­
known people, 8 pc (6/68), accidental injury, 4 pc (3/ 
68) and attempted suicide in one case (1 pc).
Most of the stab wounds, 83 pc (71/86), occurred at 
night with only 17 pc (15/68) occurring during the day 
time. (Figure II). The time of day when stabbing 
occurred was not known in 16 cases.
Figure II: Stab wounds by time o f day.
Place of stabbing.
In most of cases stabbing occurred in a beerhall, 47 pc 
(26/55) and at home, 31 pc (17/55). Stab wounds also 
occurred in the street, 16 pc (9/55), at the work place, 
4 pc (2/55) and at school, 2 pc (1/55). The place of 
stabbing was not known in 47 cases.
Anatomical site of stab wound.
Multiple stab wounds (i.e. more than two) were re­
corded in 14 cases (14 pc). In the remaining 88 (86 pc) 
patients 127 stab wounds were recorded. In this group 
the majority of stab wounds occurred in the chest, 51 pc 
(65/127) and in the abdomen, 31 pc (39/127). The 
remainder occurred on the upper limbs 10 pc (13/127), 
the neck, 4 pc (5/127), the head, 2 pc (3/127) and the 
lower limbs 2 pc (2/127).
Clinical features.
Twenty eight pc (29/102) of the patients were drunk at 
the time of admission. The most common clinical 
features were: pain, 48 pc (49/102), active bleeding at 
the stab wound site, 21 pc (21/102) and local swelling, 
17 pc (17/102). The other clinical features recorded 
were: difficulty inbreathing, 8 pc (8/102), evisceration 
of the greater omentum, 5 pc (5/102), abdominal dis­
tension, 5 pc (5/102), peritonitis, 3 pc (3/102), shock, 3 
pc (3/102), evisceration of bowel, 1 pc (1/102) and 
fever, 1 pc (1/102).
Investigations.
A chest X-ray was done in 69 cases. An abnormality 
was seen on chest X-ray in 22 pc (15/69) of cases. 
Haemopneumothorax observed in 14 pc (10/69) of 
cases was the commonest abnormality. The other ab-
381
CENTRAL AFRICAN
JOURNAL OF MEDICINE
Vol. 41, No. 12,1995
Among the under priviledged young adult urban 
men social altercations (64 pc in this series) are fre­
quently resolved with knives or other handy weapons. 
Robbery as a motive for stabbing occurred in 21 pc of 
cases in this series. It is interesting to note that the 
majority of stab wounds in this study occurred at night 
(83 p c ) and most commonly in a beerhall (47 pc).
In another study 66 pc of the patients were under the 
influence of alcohol at the time of injury.3 It would 
appear from this observation that stabbing is a form of 
assault that assailants find easier to inflict on their 
victims under the influence of alcohol and under cover 
of darkness.
The investigations carried out among our patients 
included: chest X-rays, plain abdominal X-rays, uri­
nalysis, haemoglobin and urea and electrolyte mea­
surements. The most useful investigation was a chest 
X-ray in cases of stab wounds of the chest and anterior 
abdominal wall. An important abnormality was de­
tected in 22 pc of cases. No abnormalities were de­
tected in 25 patients in whom urea and electrolyte 
measurements were requested and also in 21 plain 
abdominal X-rays. These investigations should be re­
quested only for specific indications. While a plain 
abdominal X-ray may be useful in cases of stab wounds 
of the back and flank (they may show retroperitoneal 
air suggestive of colonic damage) it is not very useful 
in cases of stab wounds of the anterior abdominal wall.
The clinical impression, despite public conception 
supported by the media, is that the lethality of stab 
wounds is quite low. In the Folsom Prison study (Cali­
fornia, USA), the 3 pc mortality and 25 pc requiring a 
procedure beyond suturing reflects the low injury po­
tential long clinically suspected in stab wounds.9 This 
is the only study of its kind involving a closed popula­
tion to accurately assess the overall morbidity and 
mortality of stab wounds.9 In this study all the mortality 
was associated with major chest injury.9 Other studies 
have also shown that mortality in stab wounds is mainly 
due to major chest injuries (i.e. injury to the heart and 
major vessels).110 The mortality of non-cardiac pen­
etrating chest wounds is about 0,4 pc.2
The benign nature of thoracic stab wounds in the 
present study is surprising considering the findings in 
other centres.110,11 Because of our less sophisticated 
paramedical support and ambulance service it is pos­
sible that patients with very serious chest injuries 
involving the heart and major vessels are unlikely to 
reach the hospital alive. The long delay in presentation
(mean 12 hours) is also prejudicial to the outcome of 
patients with serious chest injuries. It is also possible 
that assailants in our community are not as vicious as 
those in much larger cities elsewhere in the world. 
Emergency room thoracotomy facilities are not avail­
able at our hospital. It is therefore unlikely that patients 
requiring such facilities would survive even if they 
made it to the hospital.
Stab wounds of the chest may be associated with a 
spectrum of injuries ranging from the lethal to the 
insignificant. An asymptomatic patient with a stab 
wound of the chest that is not precordial, not in proxim­
ity to the subclavian artery and not suspected of dia­
phragmatic penetration should be serially examined 
and have a follow up chest X-ray at six hours.7 If the 
patient remains asymptomatic and the six hour Film is 
normal, delayed complications are rarely, if ever, en­
countered and the patient does not require further 
investigations or hospitalization.7
In some patients thoracotomy may become neces­
sary for the following indications.1
1. Massive bleeding (1L to 1,5L of blood on inser­
tion of ICD) with persistent blood loss (200 mis/ 
hour for three hours).
2. Bronchial injury (massive air leak).
3. Oesophageal injury.
4. Great vessel injury.
5. Significant retained or infected haemothorax.
6. Acute deterioration of the patient’s condition.
In the present study intercostal chest drains were
inserted in 22 pc of the patients with stab wounds of the 
chest. In one series up to 45 pc of patients with stab 
wounds of the chest required a chest drain.10 During the 
course of this study intercostal drains were generally 
removed 24 to 48 hours after insertion, with a check 
chest X-ray and a short period of observation before 
discharge. None of our patients required a thoracotomy 
for evacuation of a haemothorax. It is important to note 
that any significanthaemothorax not adequately drained 
should be evacuated at thoracotomy within seven days, 
as surgery after this time invariably entails some degree 
of decortication.1
Although the management of anterior abdominal 
wall stab wounds remains controversial there is over­
whelming evidence from major centres supporting the 
policy of selective conservatism in the management of 
stab wounds of the anterior abdominal wall.3’5'6'10121314
383
CENTRAL AFRICAN r —
JOURNAL OF MEDICINE j '-1
j
Negative laparotomy is not an innocous procedure with 
reported mortality rates ranging from zero to 6,3 pc4 
and morbidity rates 17 to 19 pc.4 Mandatory laparatomy, 
therefore, is not a satisfactory method of management. 
The main aim of “selective conservatism” is to mini­
mize the incidence of negative exploration of the abdo­
men without increasing morbidity from missed or 
delayed recognition of serious injuries.
Most reports suggest that a thorough initial physical 
examination and subsequent serial physical examina­
tion are the most reliable methods of evaluating pa­
tients with abdom inal stab wounds for 
laparotomy.510'1213,14
Other ancillary measures like peritoneal lavage and 
wound exploration should probably be reserved for the 
small group of patients in whom physical signs cannot 
be relied upon. Most reports using peritoneal lavage 
have agreed that the presence of faeces, bile, food 
material and bacteria seen on Gram’s stain or more than 
20 ml of gross blood returned define a “positive” 
lavage.5 The main drawback of peritoneal lavage is that 
there is no agreement as to the exact values of red cell 
count in the lavage effluent that are indicative of intra­
abdominal injury.12 Injuries have been found from 
1 000 to 100 000 cclls/inm3 in the lavage fluid.12
The following findings on initial examination of the 
patient have been suggested as indications for 
laparotomy.13
1. Peritonitis, or tenderness remote from the stab 
wound site.
2. Unexplained shock.
3. Evisceration.
4. Gross blood from an orifice.
5. Retained stabbing implement.
6. Radiographic studies suggestive of visceral in­
jury (e.g. gas under the diaphragm, extravasation 
of contrast material on intravenous pyelogram).
Mandatory laparotomy seems a.sensible approach to 
the management ofpatients with evisceration of bowel: 
However, the management of the patient with eviscera­
tion of the omentum remains controversial. In one 
South African study only 14 of 26 patients (54 pc) with 
only omental evisceration had serious intra-abdominal 
injury.13 Similar observations have also been made by* 
other workers.10 In patients with eviscerated omentum 
and an otherwise unremarkable examination following 
an anterior abdominal wall slab wound oilier workers 
have safely managed such cases by omental replacc-
Vol. 41, No. 12,1995
ment within the.abdominai cavity.6 However, in cases 
of omental evisceration above the subcostal margin a 
laparotomy is necessary for repair of diaphragmatic 
perforation.14
In the present study out of 39 patients with abdomi­
nal wall stab wounds 19 (50 pc) were successfully 
managed conservatively. The remaining 20 patients 
(50 pc) underwent exploratory laparotomy. No signifi­
cant injury was found at laparotomy in 50 pc (10/20) of 
cases. In the light of experience from major trauma 
centres there is a need for us to reduce our rate of 
unnecessary laparotomies by following more stringent 
criteria for abdominal exploration in cases of anterior 
abdominal wall stab wounds. Because of the chronic 
shortage of skilled manpower in our set up it is essential 
that all patients in whom the indications for exploratory 
laparotomy are not clear cut be assessed by the most 
experienced member of the team.
If the decision to manage the patient conservatively 
is taken then serial physical examination at regular 
intervals (e.g. four hourly) is essential to avoid missing 
serious injuries that may become obvious during the 
observation period. In centres practising “selective 
conservatism” unnecessary laparotomies have been 
reduced to between 10 pc and 21 pc.10121314
In conclusion, selective conservatism based on a 
thorough physical examination and appropriate special 
investigations appears to be the preferred approach to 
the management of stab wounds of the chest and 
abdomen. Active surgical intervention should be re­
served for specific indications.
REFERENCES
1. Rosin MD, Cooper DKC, Morgan JA, van der 
Spuy JW. Surgical management of stab wounds 
of die chest. JR Coll Surg Edinb 1988;33:78- 
85.
2. Mandal AK, Oparah SS. Unusually low mortal­
ity of penetrating wounds of the chest. Tliorac 
Cardiovasc Surg 1989;97:119-25.
3. Leppaniem AK, Salo JA, Haapiaincn RK, 
Lcmpinen MJ. Stab wounds of the liver. Acta 
Clur Scand 1988; 154:89-92.
4. Maria Dason JG, Parsa Mil, Ayuyao A, Free­
man HP. Management of stab wounds to the 
thoraeo abdominal region. Ann Surg 1988;207: 
335-40.
384
5. Shorr MR, Gottlieb MM, Webb K, Ishiguro L, 
Berne TV. Selective management of abdominal 
stab wounds. Arch Surg 1988;123:1141-4.
6. de Lacy AM, Garcia-Valdecasas JC, Grande J, 
Fuster J, Cugat E, Lopez-Boado MA, et al. 
Management of penetrating abdominal stab 
wounds. Br J  Surg 1988;75:231-3.
7. Kerr TM, Sood R, Buckman RF„ Gelman J, 
Grosh J. Prospective trial of the six hour rule in 
stab wounds of the chest. Surg Gynaecol Obstet 
1989;169:223-5.
8. Bordon LM. Penetrating abdominal spear inju­
ries. CentAfi J  Med 1992;38:155-61.
9. Walton CB, Blaisdell WF, Jordan GR, Bodai 
BI. The injury potential and lethality of stab 
wounds: a folsom prison study. J  Trauma 1989; 
29:99-101.
10. McCombe AW. Stab wounds of the trunk: a 
review of clinical experience. J R Coll Surg 
Edinb 1988;33:261-2.
11. Wonnald PJ, Knottenbelt JD, Linegar AG. A 
triage system for stab wounds to the chest. S Afr 
Med J  1989;76:211-2.
12. ZubowskiR, Mallathambi M, Ivatury R, Stahl 
W. Selective conservatism in abdominal stab 
wounds: the efficacy of serial physical exami­
nation. J  Trauma 1988;28:1665-8.
13. Robin AP, Andrews JR, Lange DA, Roberts 
RR, Moskal M, Barrett JA. Selective manage­
ment of anterior abdominal stab wounds. J 
Trauma 1989;29:1684-9.
14. Liebenberg ND, Maasch AJT. Penetrating ab­
dominal wounds -  a prospective trial of conser­
vative treatment based on physical signs. S Afr 
Med J  1988;74:231-3.
CENTRAL AFRICAN
JOURNAL OF MEDICINE
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Stab wounds in Bulawayo, Zimbabwe: a four year audit

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Stab wounds in Bulawayo, Zimbabwe: a four year audit

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