On a knife-edge: clinical uncertainty with an extensive knife blade in situ in the craniofacial region

Abstract

A 25-year-old man presented to the trauma department following a penetrating stab wound to his left infraorbital margin with retained knife blade causing superoposterior displacement of the globe. Plain skull X-ray revealed an extensive retained blade with subsequent CT imaging revealing the tip of the blade had reached the right styloid process with no neurovascular compromise. Initial concern was primarily for the left eye leading to ophthalmology being the first specialty requested to review the patient. However, once the extent of the injury was established, ophthalmology requested further review from maxillofacial, ENT and neurosurgery. This resulted in an 84 hours wait between the initial injury and the removal of the knife blade. Incredibly, the patient had no initial sequelae from such an extensive injury and had an unremarkable recovery with no further complications aside from a laceration to the left inferior rectus muscle that was conservatively managed.

Background

Penetrating knife injuries are extremely common among young black men in South Africa. However, extensive penetrating injuries to the orbit and craniofacial region without cerebral involvement or neurovascular sequelae are a rare occurrence in the literature. Penetrating injuries can be deceptive as the entry wound may conceal the extent of the injury or if any foreign bodies remain in situ. Any penetrating wound with evidence of foreign body retention should warrant CT imaging. Further management depends on the structures involved but due to the multiple possible structures involved in these injuries spanning various medical disciplines, a multidisciplinary approach is often necessary. Removal of foreign bodies should be done as soon as possible to avoid secondary complications such as translocation, bleeding and infection. We present the case of a 25-year-old man with an extensive penetrating injury to the orbit and facial structures with a 10.8 cm blade retained in situ with no neurovascular and ophthalmological compromise.

Case presentation

A 25-year-old man presented to the trauma department at Chris Hani Baragwanath Academic Hospital on Sunday morning having been referred from a local clinic in Soweto with a penetrating facial injury with retained knife blade. On questioning, he had been stabbed in the infraorbital region on Saturday evening while under the influence of alcohol. His only complaint was of a headache and painful left eye movements. His local clinic without access to CT, initially performed plain skull X-rays (figures 1 and 2) to determine further management of this case, revealing an obliquely oriented knife blade penetrating extensively into the facial region. He was subsequently referred onwards for further management.

Figure 1.

Anteroposterior skull X-ray.

Figure 2.

Lateral skull X-ray.

On initial assessment, the patient was clinically stable with Glasgow Coma Scale (GCS) 15/15, both pupils equal and reactive to light and a 3×1 cm laceration below the left eye, with the end of the knife blade just visible infraorbitally (figure 3) and causing superoposterior displacement of the globe without any obvious damage to the left eye structures. His vision on gross testing was retained, and eye movements were preserved in the superior and lateral directions, with severe pain on medial and inferior gaze directions. No neurological deficit was noted. The proximity of the blade to the left eye and the patient’s symptoms resulted in ophthalmology being the first point of referral.

Figure 3.

Appearance of blade end on admission.

Review by the ophthalmologist demonstrated 6/9 visual acuity in both eyes. Initially, the ophthalmologists accepted the patient for their management but after reviewing the imaging, they requested further input from neurosurgery, maxillofacial and ENT in order to plan management. With no cranial involvement and no neurological signs, neurosurgery deemed the patient not appropriate for their intervention and likewise ENT stated that this injury was for management by maxillofacial. Maxillofacial accepted the patient on review, requesting a CT angiogram following which a joint operation with ophthalmology input and follow-up was agreed as the course of action. The need for multiple reviews resulted in a 24 hours wait between initial presentation to admission to an inpatient bed. Due to the unpredictable nature of the injury and the delays, a decision was made to escalate the patient to the resus area from the trauma pit for close observation.

Investigations

Plain skull X-ray (figure 1, figure 2) revealed an extensive knife blade retained in situ entering at the inferior orbital rim and travelling in a lateral-inferior-posterior direction.

CT brain and C-spine (figure 4) demonstrated the blade had travelled through the left medial orbital wall, ethmoid air cells, turbinates and right sphenoid bone, with the inner tip lying adjacent to the right styloid process. For ease of visualisation, a three-dimensional reconstruction has been produced in both still (figure 5) and video form (video 1).

Figure 4.

CT brain slice.

Figure 5.

Three-dimensional reconstruction of CT brain with knife blade highlighted.

Video 1.

Download video file ^{(3.9MB, mp4)}

DOI: 10.1136/bcr-2018-226054.video01

360° Three-dimensional reconstruction of CT brain with knife blade highlighted

CT angiography was complicated by the patient having a fish allergy and requiring a desensitisation protocol and as a result was not performed until 48 hours after admission on which it demonstrated no vascular injury, and the patient was deemed suitable for surgical intervention the following day.

Treatment

Removal of knife blade was done under general anaesthesia. Corneal protection and tarsorrhaphy suture applied. The infraorbital margin was accessed through a subtarsal extension using the existing wound entry point (figure 6). Orbicularis oculi was incised along the axis of the blade, with care taken not to incise the inferior rectus muscle. The supraperiosteal tissue was mobilised with blunt dissection exposing the periosteum whereby an infraorbital extension of the wound was made followed by an ostectomy around the blade. Once sufficiently exposed with the aid of hand-held retractors, the blade was clamped and removed using traction from a surgical mallet, measuring 10.8 cm on removal. The orbital floor was explored showing no obvious defect. He was noted to have a laceration to the inferior rectus muscle, but it was decided that this would be for conservative management. Haemostasis was achieved with pressure and occasional utilisation of bipolar diathermy. No major vessel was injured and there was no need for any clip ligation. The wound was layer sutured, dressed with Steri-Strips and chloromycetin applied to the eye and laceration.

Figure 6.

Subtarsal extension of wound entry point.

Outcome and follow-up

There were no complications postoperatively. By his first postoperative day, his vision was impaired when looking downwards due to swelling. He was discharged on the second postoperative day for follow-up in 1 month at St. John’s eye clinic.

Discussion

Penetrating knife injuries to the orbit with a retained blade is still a rare occurrence in the literature, and therefore pose a clinical dilemma to clinicians in any trauma or emergency department.^1–3 The need for a multidisciplinary approach is crucial to the management of these injuries in areas where there is a high degree of specialisation overlap such as the craniofacial region. In our case, the methodical assessment of the patient by trauma, then ophthalmology, neurosurgery, maxillofacial and ENT with concurrent input of radiology demonstrated the clinical uncertainty around who should be taking the lead in managing this case.

The majority of similar cases suggest prompt imaging and intervention is key to improving outcomes in these patients.^{2 4} However, clinical uncertainty over who should be managing this case and delays in imaging meant it had been over 84 hours since the patient had been stabbed until the blade was surgically removed. This demonstrates a rare case in the literature where a significant delay in formal imaging and treatment does not necessarily compromise the outcomes.

It has been highlighted in the literature that a number of patients with penetrating intracranial injuries can often present in an innocuous way with stable observations and no neurological or physical deficits,⁵compared with those with neurovascular deficits.^{6 7} This can lead to trivialisation of the injury which may have contributed significantly to the delays in treatment for this case. Although the prevalence of penetrating knife injuries with retained foreign body to the craniofacial region are rare, the propensity for complications or sequelae of such an extensive injury for such a period of time is unknown. Baseline assessment and stabilisation is crucial and continued monitoring of these patients should occur frequently, meaning these patients should be considered for resus or an equivalent clinical area where close monitoring can be achieved.³

It has been reported that there is no region of preference for foreign bodies to penetrate despite variations in the thickness of the bony structures of the face.⁸ The fact the blade penetrated the left medial orbital wall, the inferior concha and the right sphenoid bone cleanly, stabilised the blade reducing the risk of movement and associated morbidity as a result. This also allowed for a relatively straightforward removal of the blade along the axis of its entrance with minimal risk of damage to neighbouring structures.

Patient’s perspective.

“Greetings to you

I’d like to share my story with you I was stubbed in the bottom of my eye when I was trying to help a friend which is good but bad at the end because I was injured but he wasn’t I can’t put blame on him. By sharing my story with you I wanna make sure whenever you are don’t play hero when someone is carrying a knife or a gun imagine if that was a bullet went through my skull I would have been dead on that same day. Shocking news after the fight I went home trying to clean up so I can take a nap my friends showed up they are the ones who took me to the hospital and we had little argument because of I didn’t feel that I was stubbed the only time I realized that’s when they did x-ray at bath nxowa hospital in Germiston. Then the doctor told me he was going to send me to another hospital which is Bara in Soweto where I stayed three full days before the operation. I’d like to thank to team which participate in my operation they have done the most beautiful job in me and care I received from the sisters it excellent

The incident has left me with experiences that I went and still going through which are both positive and negative.

1. Positive

=It has made me to look at life differently in terms of appreciating the gift of life that we are given, i will be grateful for being alive after that incident.

=I have learnt how to forgive and let go.

=I have become a better person that has learnt how to handle situations both bad or good.

2. Negative

=I have developed this fear within me, from that day i fear for my safety and those that live within my neighbourhood.

=I see how we the youths of this neighbourhood are left with no other options but to become criminals as a way of surviving, bright futures are destroyed because all they see is this hard life.”

Learning points.

• A multidisciplinary approach is crucial to managing penetrating injuries to the craniofacial region.

• Any foreign object penetrating into the maxillofacial region should have a maxillofacial review as the priority or in parallel, with further input from other specialties requested subsequently.

• Extensive penetrating injuries with retained foreign bodies should not be trivialised if the patient is clinically stable with no occult complications or sequelae. These patients should be closely monitored in a resus area or equivalent while awaiting definitive management.

• For penetrating injuries with suspicion of retained foreign body with no access to CT imaging, plain skull X-ray is indicated and can be valuable to further management.