Penetrating colored pencil injury with Clostridium bifermentans pre-septal cellulitis: case report, literature review, and treatment algorithm

The incidence of penetrating orbital injuries from writing instruments continues to rise in the pediatric population. Such injuries can cause significant visual morbidity and have a lifelong psychosocial impact. While the description of graphite pencil-related orbital trauma management is well demonstrated with over 40 reported cases, a lack of consistent management protocol for colored pencil-related injuries. Here, we report an inadvertent penetrating orbital colored pencil injury with progressive mechanical ptosis and pre-septal cellulitis necessitating urgent orbitotomy, debridement, and washout to reduce inflammatory and infectious burden. The wooden body serves as a nidus for polymicrobial infection, and the unique composition of colored pencil cores may lead to inflammatory processes that require vigilant multidisciplinary surgical and medical management reflected in our literature review.

Multidisciplinary management of an orbitocranial penetrating injury by a pencil in a paediatric patient - A case report

Rationale:

Orbitocranial penetrating injuries can accidentally occur in children while handling pencils and can cause severe sequelae such as ocular damage, brain lesion, intracranial haemorrhage, and infections.

Patient Concerns:

We report the case of a 7-year-old child with an orbitocranial penetrating injury by a pencil, initially gone undetected, that caused a direct damage to the optic nerve.

Diagnosis:

Computed tomography scan with contrast detected the foreign body and the presence of a lesion of the left internal carotid artery.

Treatment:

Angiography was performed to treat the vascular lesion and to prevent haemorrhage. Subsequently, a craniotomy was performed to assist the extraction of the pencil from the entry wound and to remove residual fragments.

Outcomes:

Left eye vision was lost. The 1-year follow-up was uneventful.

Take-away Lessons:

Operative angiography is mandatory before the surgical extraction of the orbitocranial penetrating injury in case of documented intracranial vessel damage.

Penetrating paediatric neck trauma

Penetrating injuries to the internal carotid artery are infrequent but potentially devastating and can be a significant challenge to the operating surgeon. In this article, we present a case of an 11-year-old girl who suffered a serious vascular injury when she fell on a pencil. We also discuss the most up-to-date recommendations concerning the management of zone II injuries to the neck of a paediatric patient.

Instantaneous death due to transorbital reverse penetration of a screw in an accidental fall: unusual autopsy case report and review of the literature

We present a peculiar autopsy case of a transorbital penetrating head injury, in a male worker, after an accidental fall onto a screw not completely stuck into a wooden board. A 13-cm screw entered the cranium 9.5 cm deep, penetrating with the flat end, a condition defined in literature as "reverse penetration." The death was instantaneous and caused by a neurogenic shock due to injuries to the brain stem and the right cerebellar hemisphere. These injuries, enabled by the length of the screw, are generally described in literature as due to nontransorbital penetrations, frequently associated with posterior entry and a large intracranial injury. The ocular globe has been, furthermore, perfectly preserved thanks to its mobility in the orbit. Even the dynamic of the incident is peculiar because of the stationary nature of the penetrating object, which the victim actively fell on by accident. To the best of our knowledge, the matter is therefore a very peculiar mortal case of transorbital intracranial penetration, whose verified injuries and dynamics are absolutely atypical. The case is now under discussion, and a review of pertinent literature is performed.