Knife inflicted penetrating injuries of the maxillofacial region: a descriptive, record-based study

Jael's syndrome: Hemostatic management of an impacted knife in the facial site-A case report

Key Clinical Message

It is essential to take a specific multidisciplinary approach in penetrating maxillofacial traumas; securing the airway, completing the hemodynamic stabilization, and systemic evaluation and consideration regarding the beneficial therapeutic regime.

Abstract

Jael's syndrome is defined as a deliberate injury caused by a knife to the skull and facial area. This article describes the case of a young male patient with a penetrating knife on the left side of the face following an assault. Due to the high probability of injury to the descending palatine artery, it was decided to make a femoral pathway for catheter angiography in the operation room and have a standby vascular surgeon for selective embolization of the external carotid artery in case of severe bleeding. The treatment plan included removing the foreign body, exploring the wound, suturing, tetanus immunization, and prescribing antibiotics. There was no significant complication in the postoperative period. However, In the 6-month follow-up, the patient complained of weakness in the left upper lip and hypoesthesia in the pathway of the left infraorbital nerve. Jael's syndrome can be life-threatening, so there is a need for accurate initial management performed by a multidisciplinary team to raise the survival rate of these patients.

Antimicrobial Management of Skin and Soft Tissue Infections among Surgical Wards in South Africa: Findings and Implications

Skin and soft tissue infections (SSTIs) are one of the most common infectious diseases requiring antibiotics. However, complications of SSTIs may lead to the overprescribing of antibiotics and to subsequent antibiotic resistance. Consequently, monitoring the prescribing alignment with the current recommendations from the South African Standard Treatment Guidelines (STG) is necessary in order to improve future care. This study involved reviewing pertinent patients with SSTIs who were prescribed antimicrobials in the surgical ward of a leading South African tertiary public hospital from April to June 2021 using an adapted data collection tool. Sixty-seven patient files were reviewed. Among the patients with SSTIs, hypertension and chronic osteomyelitis were the most frequent co-morbidities at 22.4% and 13.4%, respectively. The most diagnosed SSTIs were surgical site infections (35.1%), wound site infections (23%), and major abscesses (16.2%). Blood cultures were performed on 40.3% of patients, with Staphylococcus aureus (32.7%) and Enterococcus spp. (21.2%) being the most cultured pathogens. Cefazolin was prescribed empirically for 46.3% of patients for their SSTIs. In addition, SSTIs were treated with gentamycin, ciprofloxacin, and rifampicin at 17.5%, 11.3%, and 8.8%, respectively, with treatment fully complying with STG recommendations in 55.2% of cases. Overall, the most common cause of SSTIs was Staphylococcus aureus, and empiric treatment is recommended as the initial management. Subsequently, culture sensitivities should be performed to enhance adherence to STGs and to improve future care.

Brutality of ‘Sword’ Injuries in a Rare Maxillofacial Region: 2 Case Reports

Oral and maxillofacial trauma consists of various injuries but penetrating injuries are very rare and frequently require a multidisciplinary approach to treatment. The primary survey is always the initial step in trauma management before continuing with further evaluation and treatment. The following case reports discuss the clinical strategy of our rare encounter of penetrating injuries at the same time. These cases demonstrate that complex penetrating injuries of the oral and maxillofacial region require a structured and multidisciplinary approach to prevent further side effects and obtain an ideal clinical outcome.

Jael's syndrome: Case report and literature review

Introduction and importance

Jael's syndrome, an intentional injury caused by a knife in the face or skull is a rare encounter in clinical and forensic practice, rarely involving an impacted knife. Clinical and radiographic diagnosis is essential to identify severity of injury and location of the retained knife. To the best of our knowledge, this is the first reported novel case of Jael's syndrome in Tanzania.

Case presentation

We present the case of a 31-year old man admitted at Muhimbili National Hospital following an impacted knife. The stab wound extended to the medial wall of left orbit and ended just before the optic foramen associated with vitreous hemorrhage and the retained knife caused superoposterior displacement of the globe. Multidisciplinary management was instituted including prompt evaluation, imaging and surgical removal of the knife under general anesthesia.

Clinical discussion

Plain skull X-ray revealed an extensive retained blade and computerized tomography (CT) showed the tip of the blade adjacent to the right styloid process with no neurovascular compromise. Initial concern was the left eye that was reported to be viable by ophthalmologists. Incredibly, the patient had no initial sequelae from such an extensive injury and had unremarkable recovery with no complications apart from the wound to left inferior rectus muscle that was conservatively managed. Simple withdrawal of the retained knife was successful.

Conclusion

Craniofacial retained knives are rare. Thorough prompt initial evaluation and intervention is vital since improper management can be devastating.

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Impacted knife at the craniofacial region is a very rare encounter.

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Clinical and radiographic diagnosis is essential to identify extent of damage to critical structures.

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Complications such as diplopia, intracranial hemorrhage and acute cerebrospinal fluid leakage have been reported.

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Multidisciplinary management has to be instituted when retained foreign bodies are encountered.

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Simple surgical removal along the path of insertion of retained foreign body seems safe and effective.

A 10-year study of penetrating head and neck injury by assault in the North East of England

Introduction

Assaults inflicting penetrating head and neck trauma have potential for serious morbidity or mortality. This paper studies in-depth all cases treated at a level one trauma centre in the North East of England over 10 years.

Methods

All patients assaulted with sharp implements to the head and neck treated from 2010 to 2019 were identified using clinical codes.

Results

Retrospective data collection were as follows: 214 patients identified (189 male, 25 female). Average age was 31.5 years (range 3–80). The majority presented between 20:00 and 05:00. Knives were the commonest weapon. Fifty-two had scalp, 137 face and 69 neck injuries. Forty-eight percent had additional non-head and neck injuries. Eighty-six percent required admission, 16.6% to intensive care. Oral and maxillofacial and plastic surgeons provided most treatment. One hundred two required treatment under general and 96 local anaesthetic. Sixteen patients had significant vascular injury, 1 brachial plexus injury, 4 facial nerve injuries (of which 3 repaired) and one required parotid duct repair. Mean length of stay was 3.7 days. No mortality was recorded. Incidence significantly increased from 2010 to 2019.

Conclusions

Head and neck penetrating injuries occur frequently, often with other injuries and mainly in young males. Incidence of significant vascular or nerve injury was low. This study provides important data for those planning trauma services.

Outcomes of stab wounds presenting to Kamuzu Central Hospital in Malawi

Introduction

Injuries are a leading cause of morbidity and mortality worldwide, necessitating that we understand the local burden of injury to improve injury-related trauma care and patient outcomes. The characteristics, outcomes, and risk factors for mortality following stab wounds in Malawi are poorly delineated.

Methods

This is a retrospective, descriptive analysis of patients presenting to Kamuzu Central Hospital in Lilongwe, Malawi, with stab wounds from February 2008 to May 2018. Univariate and bivariate analyses were performed to compare patient and injury characteristics based on mortality. We performed Poisson multivariate regression to predict the factors that increase the relative risk of mortality.

Results

During the study, 32,297 patients presented with assault. Of those patients, 2,352 (7.3%) presented with stab wounds resulting in a 3.2% (n=74) overall mortality. The majority of wounds were to the head or cervical spine (n=1,043, 44.6%), while injuries to the chest (n=319, 13.7%) were less frequent. We found an increased relative risk of mortality in patients who presented with an injury to the chest (RR 3.95, 95% CI 1.79-8.72, p=0.001) and who were brought in by the police (RR 33.24, 95% CI 11.23-98.35, p<0.001).

Conclusion

In this study, stab wounds accounted for 7.3% of all assault cases, with a 3.2% mortality. Though the commonest site of stab was the head, wounds to the chest conferred the highest relative risk of mortality. A multifaceted approach to reducing mortality is needed. Incorporating training of first responders in basic life support, including the police, may reduce stab-related mortality.

Stab Injury of the Petrosal Bone: Case Report and Literature Review

Penetrating traumas of the head are generally life-threatening injuries, whose management poses a substantial challenge for emergency department teams. These injuries are characteristically violence-associated and frequently accompanied by damage of essential organs including brain, meninges, large vessels, cranial nerves, eyes, viscerocranium, internal ear, and/or labyrinth. Here, we present an exceptional case of head trauma caused by a knife blade, which was stuck deep inside in the petrous bone. After the extraction of the knife, the patient had very few immediate and no long-term post-traumatic complications. In conclusion, high-end technical equipment as well as an interdisciplinary team of specialized physicians is recommended for the management of penetrating head trauma to optimize the outcome.

Maxillofacial injuries in pregnancy following domestic abuse: A challenge in management

Domestic violence against women remains one of the most difficult obstacles in the growth of civilization. The maxillofacial region is commonly involved, and injuries are complex to characterize and manage due to diverse presentations, underlying physiological changes and sometimes an association with pregnancy complications, creating a challenge for the operating surgeon. This case report discusses the clinical presentation of maxillofacial injuries sustained by a pregnant woman who also had obstetric complications. The management of such trauma by a multidisciplinary squad led by the maxillofacial surgery team is outlined. Increasing awareness among oral healthcare providers for the early identification of interpersonal abuse along with timely intervention and adequate referral is important. Close monitoring and follow-up are also mandatory.

Periorbital Trauma: A New Classification

Overlooked injured structures in periorbital trauma could lead to aesthetic and functional deficits. As trauma may affect superficial, middle, and deep components, meticulous survey guided by a structured periorbital trauma classification is needed for proper management. Thus, a new classification for periorbital trauma is proposed to serve this purpose. Periorbital region was defined anatomically by anthropometric landmarks. The periorbital injuries were categorized according to anatomical and clinical basis. The new classification was used to study periorbital trauma cases received at Ain Shams University Hospitals between July 2013 and July 2016 retrospectively. The study included 260 patients: 196 (75.38%) males and 64 (24.62%) females. The type and severity of injury, time of primary intervention, type of surgery performed, and patients' visits to the outpatient clinic were evaluated. The status of the postinjury and postoperative (primary surgery) aesthetic status and functional status were evaluated. The periorbital region was identified. Anatomical categorization of periorbital injuries included periocular, frontal, temporal, and malar regions. Injuries/deficits were categorized into simple, composite, complex, and isolated bony injuries according to the depth and involved tissues. Subsequently, the classification was formulated. In the retrospective study, the incidence of extended simple injuries was the highest, while the least was the extended complex injuries. Functional deficits occurred in 24 patients (9.23%) and aesthetic deficits occurred in 55 patients (21.15%). Required secondary operations for this group included redo of fixation, correction of medial canthal ligament, repair of canalicular system, scar revisions, fat grafting, and creation of natural creases. The results of this study demonstrated that unsatisfactory aesthetic and functional results occurred when injuries of important structures were overlooked, aesthetic units were not respected, and when management was delayed. A three-dimensional, oriented, new classification of periorbital trauma based on anatomical and clinical categorization is proposed to help in identifying injured structures, stimulate the search for other injuries, structure preoperative evaluation, and recommend a surgical plan that would ultimately achieve precise primary repair with best aesthetic and functional outcome.

Multiple foreign bodies in the facial region from a penetrating stab injury

Penetrating injuries can lead to multiple retained foreign bodies. To present a case of a penetrating stab injury on to the right orbital region of a 37-year-old woman which resulted in lacerations on both eyelids, loss of vision in addition to the retention of glass particle and woven artificial hair strands at the anterior end of the floor of the orbit. The woven artificial hair strand, being flexible in nature, was apparently logged in by the penetrating force of the broken glass used as the stab injury object. Under local anaesthesia, a gentle intermittent pull on one hair strand led to the dislodgement of a piece of broken glass particle along with the other end of the hair strand. The resultant wound was repaired. Stab injuries can result in retained multiple foreign bodies. This possibility should be considered during assessment and management of facial injuries to avoid complications of retention.

Applications of digital subtraction angiography in the management of penetrating injuries of the maxillofacial region: A case report

This report presents a clinical case of trauma due to assault with a knife, and describes the importance of using the correct imaging modality in cases of facial penetrating trauma involving the superficial and deep anatomical planes. Penetrating wounds in the maxillofacial region are rare and poorly reported, but can result in serious complications that are difficult to resolve and may compromise the patient's quality of life, especially when large blood vessels or other vital structures are involved. Thus, it is essential to determine the extent of the affected blood vessels and the proximity of the retained object to the anatomical structures. In this case, digital subtraction angiography was the imaging modality chosen. The use of appropriate imaging examinations allows a proper map of the surgical field, reducing the chances of vascular damage during the surgical procedure.

Undiagnosed impacted knife blade from a penetrative orbital injury: A case report

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The mode of entry of the foreign body was unique as well as the force required to impale and break a knife blade in bone.

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The authors present a minimally invasive technique for dealing with this type of injury and highlight its challenges.

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This case report emphasis the need for baseline radiology in cases of traumatology especially those with vague history.

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The patient was examined by multiple physicians who did not detect the foreign body which could raise medico-legal issues.

Introduction

Impacted foreign bodies in the complex maxillofacial region is uncommon and their safe removal is a challenge.

Case presentation

The authors report an unusual case of a 41 year old male patient who suffered from violence-related orbital trauma with a knife. The presence of this foreign body was not diagnosed for a period of 20 months. After proper clinical and radiologic examination it was localized and extracted in the theater in a safe controlled manner. Although the tip of the blade was left in situ, the patient had a rapid uneventful recovery and follow up.

Discussion

The path of penetration of the foreign body in presented case didn't follow the predicted patterns of orbital injury described in literature. A dilemma exists as to how aggressive such injuries should be managed. Thus the surgical approach implemented for retrieving the current foreign body was highlighted.

Conclusion

Radiographs are a crucial element for early diagnosis and proper management of foreign body injuries. Rapid postoperative recovery can be achieved with simple safe surgical retrieval maneuvers.

Aggression Using a Knife or Other Sharp Instruments and Oral-Maxillofacial Trauma: Incidence, Risk Factors, and Epidemiologic Trends

PURPOSE

The aim of the present study was to characterize the profile of victims of interpersonal physical violence (IPV) caused by a knife or other sharp instrument, identify the factors associated with maxillofacial trauma, and examine the incidence of maxillofacial trauma over time.

PATIENTS AND METHODS

In a retrospective cohort study, we evaluated 569 medicolegal and social records of IPV victims by knife or other sharp instruments treated at a forensic medicine and dentistry center in Brazil during a 4-year consecutive period. The variables investigated were related to the sociodemographic characteristics of the victims, circumstances of the aggression, and trauma patterns. Descriptive and multivariate statistics through Poisson regression and trend analysis with the creation of polynomial regression models were used.

RESULTS

The cumulative incidence of oral-maxillofacial trauma was 19.3%. The mean age of the victims was 31.29 ± 13.82 years. Cases of trauma affecting more than one region of the face prevailed (45.5%). Based on the final Poisson regression model, unemployed people were more likely to exhibit maxillofacial trauma (relative risk [RR] 1.86; 95% confidence interval [CI] 1.03-3.35; P = .039). In addition, individuals were more likely to experience maxillofacial trauma on Wednesdays (RR 1.85; 95% CI 1.01-3.37; P = .045). The trend analysis revealed a significant increase in oral-maxillofacial injuries over time (P < .05).

CONCLUSIONS

The incidence of oral-maxillofacial trauma was high, and the main factors associated with trauma were the victim's employment status and day of occurrence. Future studies will focus on assessing the effect of maxillofacial trauma on the quality of life and well-being of violence victims.

Transverse Fracture of the Mandible: Report of a Rare Case of Domestic Violence and its Management

Domestic violence, a grave violation of basic human rights, remains one of the most challenging problems of our society. Though commonly involving the facial region, these injuries are difficult to characterize and treat due to varied and unique presentations. Cases of violent weapon injuries can often be a challenge for the treating surgeon due to nonbiomechanical pattern of the presentation. The purpose of this report is to discuss the presentation and management of a brutal case of domestic violence with a rare “chop” injury pattern caused by an “axe.” Only two previous reports of sharp weapon injury resulting in horizontal fracture of mandible have been found in literature, of which only one was caused by an axe. The important social issue of significance of health care personnel, who are in a unique position and can contribute toward raising the awareness to the plight of silent sufferers of domestic violence for whom home is often the most dangerous place, is also raised.

The Transcranial Stab Wound and the Life-Saving Zygomatic Arch Clinical Report

A 58-year-old man presented to the neurosurgical emergencies for a transzygomatic transcranial stab wound with a retained broken knife. The patient was neurologically intact. After radiographic evaluation the knife was found to be penetrating the temporal lobe, neighboring the intracavernous portion of the carotid artery. The patient was successfully managed in a conservative way. No abnormalities were seen at 12 months of follow-up. Dealing with penetrating head injuries is a usual condition in neurosurgical practice. Some situations are though really challenging, especially when the offending object is still in place, with a close connection to vital structures. This clinical reports an unusual penetrating head injury, highlighting the importance of careful radiographic evaluation and trying to discuss clear management options.

Management of Self-Harm Injuries in the Maxillofacial Region: A Report of 2 Cases and Review of the Literature

Clinicians face numerous challenges when managing psychiatric patients who self-inflict injuries within the maxillofacial region. In addition to a complex clinical examination, there are both surgical and psychiatric factors to consider, such as the risk of damaging vital structures, the exacerbation of the patient's psychiatric status, and the long-term psychosocial and esthetic sequelae. We present 2 cases of adolescents who repeatedly self-inflicted wounds and/or inserted foreign bodies (FBs) into the face, scalp, and neck. The different treatment modalities were based on full evaluation of the patient's clinical, medical, and diagnostic test findings coupled with a psychiatric assessment. The decision for conservative management or surgical intervention was made according to the presence and location of the FBs, degree of hemorrhage, signs and symptoms of infection, and unpleasant scars that could lead to long-term psychological impairment. In most cases, the FBs were removed and the wounds were toileted and closed under local or general anesthesia. We advocate a holistic approach via a multidisciplinary team, which is deemed essential to provide the highest quality of care for patients to reduce the risk of further relapses. Lastly, a satisfactory esthetic outcome is always paramount to achieve long-term psychological and physical welfare.

Life-threatening expansive sublingual hematoma: a stab wound with lingual artery injury

Vascular injuries are a constant risk in facial trauma, although bone and soft tissues of the face have provided some protection to the larger blood vessels. However, penetrating injuries usually do not have this type of protection and can damage significant vascular arteries. This article presents a case of a stab wound, which led to airway obstruction arising to a large sublingual hematoma due to lingual artery injury. A healthy 44-year-old man was stabbed in the submandibular region and admitted with an airway obstruction. He was subjected to an emergency tracheotomy and evolved with progressive sublingual edema. Computed tomography (CT) angiography showed a left lingual artery injury with the formation of an expansive hematoma. The CT angiography findings helped to identify the cause of the hematoma and guided the surgery to drain the hematoma after ligation of the lingual artery. The treatment was safely performed as planned and evolved uneventfully. The patient recovered fast and well and presented normal functions 6 months after the treatment. This surgical technique is an effective method for treating such injuries because it can be safely performed when guided by CT angiography. The authors argue that the demand for vascular lesions should be routine in patients who have facial trauma.

Jael syndrome: removal of a knife blade impacted in the maxillofacial region under local anaesthesia

The presence of retained foreign bodies in the maxillofacial region as a consequence of penetrating injuries from knives is poorly documented in the scientific literature. This manuscript reports the case of a 30-year-old Caucasian with a knife blade lodged in the maxillofacial skeleton. Following clinical and radiographic exams, it was determined that the object had penetrated through the left nostril and nasal septum, in the direction of the right maxillary sinus, and remained impacted without causing injury to important anatomical structures. After systemic assessment and determination of the exact location of the knife blade, the object was removed in an outpatient setting under local anaesthesia. This manuscript aims to report a rare case of a transfacial penetrating injury involving a knife blade that was removed in an outpatient setting while also discussing the proper conduct and treatment options for similar cases in the context of a brief literature review.