Impalement injuries of the shoulder: a case report with literature review.

The management of penetrating skeletal extremity trauma is a clinical challenge even for experienced surgeons. While the treatment of associated vascular injuries should be prioritized, there is still a lack of evidence regarding the management of foreign bodies in case of bone fractures or neurological injuries. Here we present a case of impalement of the right proximal humerus with a construction steel rod. The 54-year-old man was successfully treated without vascular, neurological, and thoracic sequelae. A review of the current literature about the most appropriate extrication sequences and soft tissue reconstruction following massive foreign body injuries was carried out.

Introduction

Penetrating traumas are injuries caused by a body piercing the skin and damaging the underlying tissues. (1) The incidence of such traumas has been rising worldwide (1, 2). Extremities are often involved, with an equal distribution of gunshot and non-gunshot injuries (1, 3-6).

The mortality rate is estimated between 0,5% and 29.1% and death is usually due to major vessel bleeding. Arterial damage is associated with injury of veins in 31%, nerves in 27%, and bones in 26% (6-12).

A delayed diagnosis of associated neurovascular and tendon injuries is not rare, especially in the upper limb and in unconscious patients (2, 13, 14).

The application of advanced trauma life support (ATLS) principles is mandatory to diagnose and treat on-time life and limb-threatening conditions. After airways management, cardiovascular functions should be preserved with manual compression of bleedings or by using a tourniquet. Patients with signs of major arterial bleeding need surgical repair within 6-12 hours, while patients more stable can be further studied. Neurological injuries such as brachial plexus or axillary nerve are uncommon, but a careful neurological exam should be carried out. In penetrating traumas, copious wound irrigation is essential, and appropriate antibiotic prophylaxis helps to prevent deep infections. Close clinical monitoring is required for the early detection of compartment syndrome signs (2, 10).

Few studies are present about the most appropriate management and timing of surgery on bone penetrating trauma.

Here we report a case of impalement of the right proximal humerus with a construction steel rod. Written consent was taken from the patient for publication.

A review of the current literature about the most appropriate extrication sequences and soft tissue reconstruction following massive foreign body injuries was carried out.

Case report

A 54-year-old male patient was transported to the Emergency Department after falling from 1.5 meters on an iron rod that resulted embedded in his right shoulder.

The patient had a history of glomerulonephritis after an allergic reaction to the tetanus vaccine; no other pathologies were reported.

At the first medical examination, the patient was conscious, hemodynamically stable with a normal body temperature. The ATLS protocol was followed, and no signs of life-threatening conditions were found.

The wound with the protruding rod had no significant bleeding (Fig. 1), normal peripheric pulses, and no alteration of the peripheral neurovascular status.

Figure 1.

Clinical appearance at admission (A-B)

The patient immediately started antibiotic prophylaxis with Amoxicillin/Clavulanic acid 2g q8 for 72 hours, according to guidelines for contaminated wounds (15).

At shoulder x-rays and CT scan with contrast, the foreign body was trespassing the proximal humeral epi-physis, leaving a minor intraarticular bony fragment but avoiding any neurovascular structure (Fig. 2). No signs of bleeding from major vessels and no sign of pneumo-thorax were found. A complete panel of blood tests (Table 1) was performed. No abnormalities were present.

Figure 2.

Radiographic imaging: X-rays (A), CT scan (B-C), 3D reconstruction (D-E)

Table 1.

Summary of arterial blood test analysis performed at the emergency room admission

Variable	Arterial Blood Sample (range)
Hemoglobin	148 g/L (135-170)
Hematocrit	0.42 L/L (0.38 — 0.49)
White blood cells	8.91 x 10-9/L (4.30 — 10.00)
Platets	146 x 10-9/L (150 — 400)
Prothrombin time	0.95 INR (0.80 — 1.17)
Activated partial thromboplastin time	0.77 Ratio (0.8 — 1.20)
Ph	7.39 (7.35- 7.45)
Partial pressure of carbon dioxide	38 mmHg (35 — 45)
Partial pressure of oxygen	96 mmHg (80 — 100)
Bicarbonate	26 mmol/L (22 — 26)
Oxygen saturation	97%
Lactate	1.0 mmol/L (0.6 — 2.2)
Sodium	138 mmol/L (135 — 145)
Potassium	3.8 mmol/L (3.5 — 5.0)
Chloride	104 mmol/L (95 — 107)
Ionized calcium	1.16 mmol/L (1.1 — 1.35)
Glucose	108 mg/dl (60 — 99)

The patient was taken to the operating room; under general anesthesia, after irrigation with saline mixed with povidone-iodine (50:50 ratio), the iron rod was removed conjunctly with a T-Shirt fragment using a self-locking orthopedic plier. A series of samples for microbiological analysis was carried out. Finally, the wound was irrigated with a total of 6 liters of saline solution. An intraarticular drain was placed, and the wound was left open for a secondary intention healing.

The postoperative CT scan did not show additional fragments (Fig. 3).

Figure 3.

CT scan imaging after foreign body removal: CT scan sections (A-C) and 3D reconstruction (D-F)

The days after the patient was constantly apyretic, with a minimum increase of C-reactive protein (CRP, maximum 36 mg/L). The microbiological analysis of intraoperative samples was negative for bacteria and fungi. At the third postoperative day, pendular exercises were started.

The patient was then discharged at home with an arm sling for fifteen days, with weekly appointments for wound medication.

Two weeks after the patient, presented a satisfactory range of motion (ROM), with a Constant Shoulder Score (CSS) of 60 and an Oxford Shoulder Score (OSS) of 32. There was no alteration in the peripheral neurovascular functions.

After 3 months the ROM significantly improved, reaching a flexion of 180°, abduction of 90°, a complete internal rotation and external rotation. However, moderate pain was present at maximal external rotation and abduction, with a CSS of 85 and OSS of 39. The magnetic resonance (MRI) showed supraspinatus and sub- scapularis tendinopathy without full-thickness breaches. Non-steroidal anti-inflammatory drugs (NSAIDs) and physiotherapy for the rotator cuff were recommended.

Discussion

A correct approach to penetrant trauma (PET) can significantly reduce the mortality ad associated morbidity associated to these events. The key steps are represented by triage, primary evaluation on the field, transfer in a trauma hub, secondary evaluation, and definitive care (4). The ATLS precepts guide the emergency evaluation and treatment throughout all these steps (16).

The orthopedic consultant is often involved in the secondary assessment and definitive care of extremities PET.

Vascular assessment

The evaluation of the vascular damage should be primarily performed. Hard signs of arterial injury include pulsatile bleeding, expanding hematomas, palpable tremor, audible noise, and the “5 Ps” of distal ischemia (pulselessness, pallor, pain, paresthesia/pa-ralysis, poikilothermia). Patients with PET and hard signs often need a surgical repair (2, 17). Soft signs such as diminished pulse, delayed capillary refill and stable hematomas, indicate conditions that often do not require surgical treatment, and 24 hours-observation is recommended in these scenarios (2, 14, 18-21).

However, many studies have shown that peripheral pulses often do not correlate with arterial injury (14, 22, 23, 24). Interestingly, while distal pulses can be maintained in 24% of arterial injuries, pulseless limbs can have no arterial injury in 27% of cases (14, 22, 23, 24.) In addition, arteries with partial-wall lesions are unable to contract and control the bleeding (10).

Angiograms and CT Angiography (CTA) are the gold standards for the diagnosis of PET-associated vascular injuries. However, their universal use in PET has still debated because their cost-effectiveness (2, 25.) API (Arterial Pressure Index) and ABI (AnkleBrachial Index) are two clinical available methods to screen arterial injuries and they have a high predictive value with a range between 0.8 and 0.9 (23). In the clinical cased shown here, in absence of hard signs of vascular injury, we decided to perform a CT angiog-raphy.

Neurological assessment

Neurological injuries following shoulder traumas are relatively uncommon (26). BPI (Brachial Plexus injuries) occur in 6% of PET and are often associated with vascular damage (27). The nerve injury of the plexus is usually complete (53% of cases) or supraclavicular (39% of cases). Infraclavicular BPI is uncommon and less frequently require surgery (17% vs 52% of the complete and supraclavicular) (27, 28). The axillary nerve is the most common nerve trunk involved but it recovers spontaneously in 80% of the cases (26, 29).

Deep infection prevention

The infection risk in the context of soft tissue damage is mainly related to three major aspects: contamination, tissues vitality, and time from the index trauma.

Systemic antibiotics should be initiated as early as possible following the current protocols for bone and soft tissue open traumas since the risk of infection increases dramatically after 8 hours from the index trauma (1, 3).

The protocol in our Trauma Center includes a beta-lactamase inhibitor in combination with a beta-lactam drug (Amoxicillin/Clavulanic acid 2g q8) (15). With bone or joint injuries or mammalian bites, antibiotics should be continued for 24-72 hours (2, 30, 31).

Fractures near wounds should be considered open fractures and antibiotics should be started as early as possible, while debridement, irrigation, and reduction of the fracture are completed within 24 hours (14, 32, 33).

The immunization for tetanus should be checked and in case the patient is not immunized, immuno-globulin (Ig) administration is highly recommended.

Surgical treatment: foreign body removal, irrigation, and debridement

Foreign body removal and the treatment of bony associated lesions should be performed avoiding iatro-genic injuries (2). A second-level of diagnostics such as a CT scan can help the surgeon to plan the surgical procedure. Although a foreign body should be preferably removed in many cases, this is contraindicated if the procedure is likely to be excessively traumatic (16). In our case, the benefits from the removal of the construction rod were clearly higher than the risk associated with its permanence in the shoulder.

After extraction of visible debris, irrigation should be performed with a high volume of saline under pressure, using a pulsatile lavage or a syringe (2); soap or topical antibiotics are not beneficial (2, 34-36).

There are no guidelines for the surgical management of penetrant intraosseous trauma (1, 12, 37). It is good practice to perform a proper exposition if the foreign body is not visible. An osteotomy could be necessary if a major skeletal segment is involved. Arthros-copy seems to be a safe alternative for intraarticular foreign bodies (1, 38, 39).

In our case, given the absence of neurovascular injuries, the rod was removed by retrograde beating, without further tissues damages.

For skin closure, clean wounds with vital tissues can be primarily closed. In case of treatment after 8 hours from the trauma (5 hours for the hand and 3 hours for the foot), or in case of grossly contamination, delayed closure or secondary intention healing should be considered, packing the wound with saline-soaked gauze, or using negative pressure drainage devices (2, 3, 40). In our case, although we were able to take the patient to the operating room within 4 hours from the trauma, the contamination of the foreign body (soil and rust) required a second intention healing of the wound.

Post-operative care and discharge

In the post-operative time, if the patients are not in critical condition, close monitoring should be performed (2, 4, 10, 38, 41). Compartment syndrome can occur in case of long ischemia times, high energy traumas, and tourniquet usage. Fat embolism with pulmonary failure can occur in patients with long bone involvement. Renal failure could occur for massive myoglobin release secondary to muscular damage. Finally, residual fragments of the foreign body could lead to late-onset infection or metal poisoning.

Patients should be instructed to check for signs such as growing hematomas, increased unexplained pain, hyperthermia, and secreting wounds (2, 10).

A close follow-up of at least 1-2 weeks is suggested to early detect any complications.

Our patient stayed in the Orthopedic department for a week. After discharge, he had an outpatient visit after 2 weeks, 1, 2, and 3 months.

Conclusion

The case shown here suggests that early diagnosis and proper preparation for surgery are required for penetrating trauma. The most important condition to diagnose and treat are vascular injuries since they are the leading cause of death and limb loss.

There is no consensus on modalities of foreign body removal, but wound irrigation and surgical de-bridement of non-vital tissue should be performed. The patient should be closely followed up at least 2 weeks to detect early complications.