J R Coll Surg Edinb, 43, December 1998, 419—421

A non-fatal impalement injury of the thorax

W.H. CHUI, D. L. C. CHEUNG, S. W. CHIU, W. T. LEE AND G. W. HE
Division of Cardiothoracic Surgery, Department of Surgery, The University of Hong Kong, Grantham Hospital, Aberdeen, Hong Kong

Impalement is an uncommon injury with only occasional reports in the literature. There are even fewer reports of impalement injuries limited to the thorax. We report herein the case of a 24-year-old man who survived impalement injury of the left side of the thorax with a steel rod while working at a construction site. The great vessels of the thorax were spared but the second thoracic vertebra was fractured resulting in complete paralysis of the left lower limb. The pi~ecjse nature and extent of the injury were determined pre-operatively by computed tomography and aortography. The important principles of surgical management contributing to the successful outcome are described, these being minimal manipulation of the impalement object before and during transport, careful pre-operative planning and a multidisciplinary approach.

Keywords: impalement, injury, thorax.

Impalement injuries of the thorax which require specific surgical considerations arc uncommon but potentially lethal. We report the case of a patient who sustained such an injury which initially appeared to be inconsistent with survival. The important principles of the management of such patients are also discussed.

CASE REPORT

A 24-year-old man, while working at a construction site, slipped and fell from a slanting platform. He was accidentally impaled by a steel rod, about 1.5cm in diameter, which protruded from a metal gate. The steel bar penetrated through the posterior aspect of his left chest just adjacent to the vertebral column. It was cut short by the fire brigade at the scene, leaving about 20cm still protruding from the back so as to facilitate transferral to a regional hospital.

On arrival, he was found to be alert, co-operative and in stable condition. He complained of excruciating pain in the left chest and he was unable to move his left lower limb entirely. The steel rod entered the left chest at the left side of the second thoracic vertebra (Figure 1). The tip of the rod was palpable at the left anterior chest  wall 3cm lateral to the midline at the second intercostal space. The patient’s breathing was rapid and shallow but the respiratory and  heart sounds were normal. All the central and peripheral pulses palpable. A left-sided chest tube connected to an underwater vat of seal drainage system showed no air leakage. His blood pressure 1995; was 100/70 mmHg and pulse rate 90 beats/min Neurologically, complete paralysis of the left lower limb was noted with absent of knee and ankle jerk reflexes whereas the sensation was intact.

Figure 1 Photograph of the patient’s back in the operating room shows the steel rod traversing the left hemithorax.

Figure 2 Anteroposterior erect chest radiograph shows the position of the steel rod in the mediastinum.

Chest radiograph showed a densely radio-opaque rod in the left thoracic cavity without pneumothorax nor pleural effusion (Figure 2). The steel rod could be seen traversing across the mediastinum lying close to the aortic arch. Computed tomographic (CT) scan-of the thorax showed fracture of the second thoracic vertebral body with intact pedicles with a suspected haematoma around the ascending aorta. Orthopaedic consultation reviewed spinal cord injury with a stable spinal column unnecessary for immediate surgical reduction and fixation. On account of the close proximity of the rod to the aortic arch and the suspected haematoma, an urgent aortography was performed. This revealed an intact aortic arch with the bar situated between the left carotid and left subclavian arteries (Figure 3).

Figure 3 Aortography: anteroposterior (A) and lateral (B) views show the steel rod traversing between the left carotid and left subclavian arteries over the superior aspect of the aortic arch.

(a)

(b)

The patient was taken to the operating room and a left fifth posterolateral thoracotomy was performed. There was a minimal amount of blood in the left pleural cavity. The steel rod, entering just to the left of the spinous process of second thoracic vertebra, went through the posterior mediastinum and the narrow space between the left carotid and left subclavian arteries on the superior aspect of the aortic arch. It traversed the anterior mediastinum passing through the second intercostal space tenting up the skin of the anterior chest wall. The heart and lungs were intact. The rod was pushed posteriorly and removed from the back under dl~cct vision. Inspection of the great vessels was carried out by opening the mediastinal pleura so that integrity of them was reassured. The thoracotomy wound was closed with two drainage tubes after thorough irrigation of the pleural cavity. Both entrar~ce and exit wounds were debrided and lavaged before primary closure.

The post-operative course was uncomplicated and he was discharged to the orthopaedic unit for rehabilitation.

DISCUSSION

Impalement injuries are relatively rare and only a few of such injury limited to the thorax have been reported.^1-9 The degree of damage varies according to the involved organs, with impalement of the heart or great vessels having an extremely high mortality.⁷ From our experiences as well as those reported by others,^1-9 the following specific principles in the surgical management merit emphasis:

• no attempt should be made at the scene to remove the impalement object from the thorax. Instead, the object was carefully reduced to a manageable dimensions in order to render transportation technically feasible,
• usual trauma management principles should be followed, including airway control and fluid resuscitation,
• the patient should be transported rapidly to a medical centre capable of dealing with cardiothoracic trauma,
• although we acknowledge the need to proceed to the operating room with patients in unstable condition, we believe that there is a place for more selective and deliberate approach including radiological investigations directed toward the exact nature and extent of injury in haemodynamically stable patients. The CT scan was valuable in detecting the aortic injury component preoperatively,^8,9 however, suspected vascular injuries of the carotid and subclavian arteries could not be excluded in this case. Thus, aortography was performed to delineate the exact injury because surgical repair of these aortic branches require cardiopulmonary bypass (CPB), circulatory arrest, profound hypothermia with or without continuous retrograde cerebral perfusion via superior vena cava. Understanding the extent of the injury is extremely important to plan the appropriate surgical approach,
• the impalement object must be extracted in the operating room under direct vision to prevent uncontrolled haemorrhage with CPB on standby,
• a skilful anaesthetist should be available for endotracheal intubation as the presence of the thoracic impalement object would preclude proper supine positioning,
• finally, all the necrotic tissues should be removed and wounds R adequately debrided to avoid infection.
• With these measures, impalement injuries can have a successful steel outcome. This case study illustrates the importance of co-ordinated 240 efforts in caring for a patient from the pre-hospital setting through the emergency department and operating room.

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Paper accepted on 23 March 1998

©  1998 The Royal College of Surgeons of Edinburgh J R Coll Surg Edinb, 43, December 1998, 419—421