|Year : 2012 | Volume
| Issue : 1 | Page : 29-32
Penetrating orbito-cranial injury in a child
Abdullahi O Jimoh, Joseph O Obande
Department of Surgery, Division of Neurosurgery, Ahmadu Bello University Teaching Hospital, PMB 06, Shika, Zaria, Nigeria
|Date of Web Publication||22-Sep-2012|
Abdullahi O Jimoh
Department of Surgery, Ahmadu Bello University Teaching Hospital Shika, Zaria
Source of Support: None, Conflict of Interest: None
Introduction: Penetrating brain injury is a very common form of head injury all over the world. It commonly follows missile injury and impalement from assaults and fall on a sharp object. Rarely, however,self-inflicted injury from playing with a sharp object can occur. The objective of this report was to present an unusual injury from a nail that the patient was playing with.
Case Report: A 7 year-old, right-handed primary two pupil presented to our center with a 2-hour history of a 6-inch nail on the head. He fell over a 6-inch nail he was holding while playing. The boy gave an account of what happened at presentation. There was no focal neurological deficit. Skull X-ray showed an orbito-cranial radio-opaque nail through the orbit. He was placed on anticonvulsant, antibiotics, and full course of tetanus prophylaxis. Neither computed tomography scan nor angiography could be done. The nail was removed successfully by craniotomy. He had an 8-week course of intravenous and oral antibiotics and had 2-year course of anticonvulsant. He has been followed up for 2 years without complications.
Conclusion: Although penetrating brain injuries are common worldwide, we present the peculiar accidental injury in a child who was managed with a good outcome.
Keywords: Child, injury, nail, orbito-cranial, penetrating
|How to cite this article:|
Jimoh AO, Obande JO. Penetrating orbito-cranial injury in a child. Arch Int Surg 2012;2:29-32
| Introduction|| |
Penetrating brain injury (PBI) is a very common form of head injury (HI) in the world. It commonly follows missile injury and road traffic accidents; robbery, and military assault. , Injury may also result from impalement following assaults and fall on a sharp object. In children, however, a sharp playing object could be the source of injury during play on their playmates or on themselves. Penetrating orbito-cranial injuries by non-missile low-velocity objects are rare.  Rarely again, self-inflicted injuries from playing with a sharp object can occur in a child.  However, such incidences must be evaluated critically to exclude the possibility of child abuse. In high-income countries, cranio-orbital injuries are promptly evaluated with computed tomography (CT) scan, magnetic resonance imaging (MRI), or angiography. , However, in low-income countries, such facilities are usually not available and the patient may present several hours after injury. We therefore present a case of orbito-cranial injury with a nail, which was successfully managed in our facility.
| Case Report|| |
A 7 year-old, right-handed primary two pupil presented to our center with a 2-hour history of a 6-inch nail on the head through the medial aspect of the right orbit [Figure 1]. He gave a verbal account of falling over the 6-inch nail he was holding on his right hand while playing with his mate. There was no loss of consciousness, no convulsion, and no nasal bleeding. He could see with both eyes. There was no weakness of any part of the body. There was no history of psychiatric illness, previous injury or admission, and no history of child abuse. Examination showed an anxious young boy with about 2-inch rusted nail projecting out of the medial aspect of the right orbit. Glasgow Coma Score was 15. There was no demonstrable focal neurological deficit. There was no leakage of blood or cerebrospinal fluid from the nose, mouth, and ear or around the nail. He was evaluated by maxillo-facial surgeon, the ophthalmologist, and the Ear, Nose, and Throat (ENT) surgeon. Visual acuity was normal in both eyes and fundoscopy was reported as normal. Skull X-ray showed a nail penetrating the right orbit into the middle cranial fossa for a total length of about 10 cm from the skin of the medial side of the eye, penetrating the anterior skull through the orbit [Figure 2] and [Figure 3]. He was immediately commenced on anticonvulsant, antibiotics, and full course of tetanus prophylaxis. Neither CT scan nor angiography could be done immediately due to unavailability.
|Figure 2: Antero-poaterior skull X-ray view showing the radio-opaque nail in the skull|
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|Figure 3: Lateral skull Xray view showing the radio-opaque nail in the skull|
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The patient was resuscitated with intravenous fluid, antibiotics, and commenced on tetanus prophylaxis. Blood chemistry and hematological tests were normal. The patient had emergency surgery after 5 days of presentation. Through a right pterional craniotomy and dissection along the sylvian fissure [Figure 4] for direct assessment of the structural relationship of the nail and the content of the middle cranial fossa, the following observations were noted: The nail was surrounded by about 5 ml of serosanguinous fluid that was immediately aspirated and sent for microscopy culture and sensitivity. Culture was sterile. The full length of the nail was pulled out from the entry point.
|Figure 4: Right pterional craniotomy showing the right sylvian fissuere through which the nail was approached|
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The entry point dural defect was closed with peri-cranial patch. He had an 8-week course of intravenous (4 weeks) and oral antibiotics (4 weeks). The patient is still on anticonvulsant with no neurological deficit after 2 years of follow-up [Figure 5]. With critical structures along its tract, the nail did not injure structures of the visual pathway. The globe of the eye, the optic nerve, the internal carotid and the middle cerebral artery, the veins, the extra-ocular muscles, and nerves were all spared, thereby leaving little structural damage.
| Discussion|| |
It is worth noting that in the literature, the weakest part of the orbit is the roof through which the penetrating agent pierces the frontal lobe. The orbit is bounded on four sides by parts of the zygomatic, frontal, sphenoid, ethmoid, and maxillary bones. The lateral wall of the orbit is the strongest, followed by the superior, inferior, and medial walls. The medial and inferior walls are nearly paper thin, and often can be reabsorbed in the elderly, allowing foreign bodies to penetrate through the orbit into the anterior cranial fossa with little force. , This is consistent with the findings in our case. Various injuries can be encountered due to this trauma which can involve any content on the orbit and related parts of the brain. Penetration through the superior orbital fissure may cause III, IV, V, and VI cranial nerve damage or produce a traumatic carotid cavernous fistula. , In the index case, the nail traversed the orbit and entered the cranium through the posterior-superior part and very close to the adjacent cranial nerves and carotid vessels, but not injuring them, although this injury looks ominous looking at the site of entry and the possible critical areas of the brain along the trajectory of the nail.
It is generally recommended that the anatomical location of the penetrating object should be defined before surgery using images such as CT scan and angiography. , Though our patient presented within 2 hours of injury, the need for good imaging of the injury before surgery and unaffordability for the same caused the delay. , However, since the object was totally radio-opaque, plain radiograph was helpful as no vascular injury was suspected because of the trajectory of the nail. ,, MRI, especially T1-weighted imaging, has proved to be superior to CT scan for identifying dry wooden foreign bodies in the brain parenchyma.  In this case, MRI is contraindicated because the nail is made of steel. CT is the best radiologic method for evaluating penetrating injuries to the soft tissues and intracranial components; additional angiography (CT or Digital Subtraction Angiogram (DSA)) is very important in delineating clearly vascular or near vascular injury. CT is the method of investigation of choice for locating most radiolucent intraocular foreign bodies. ,
Significant morbidity and mortality may result from penetrating orbito-cranial injuries, with mortality rates, because of intracranial infection, ranging between 12% and 25%, especially in the presence of a retained foreign body.  However, our patient did not have infection complicating the surgery. Complications can be divided broadly into three groups. The first group has acute ocular and cerebral injuries including extraocular muscle dysfunction, cranial nerve palsy, optic neuropathy, intracerebral hematoma, and intraventricular hemorrhage, which may require emergency intervention to prevent neurologic sequlae.  The second group experiences late vascular complications, including carotid cavernous fistula and false aneurysm formation, which are not influenced by initial management.  The third and most serious group has persistent cerebrospinal fluid leakage and late infective complications including orbital cellulitis, orbital abscess, encephalitis, brain abscess, and tetanus, which are the major causes of death.  Tetanus, in particular, is very common in developing countries, and therefore needs proactive steps.  Organisms present on the foreign object or skin as well as sinus bacteria contaminating it during its impact provide the infective source, with Staphylococcus aureus being the pathogen implicated in 50% of traumatically induced orbito-cranial abscesses. ,
The nature of the material is very important in determining the possible infecting organism. Worse are vegetable objects and, in particular, a rusted old nail as in the case of our own patient. , Another serious complication that could arise is cerebrospinal fluid leakage due to fistula which can be effectively controlled intraoperatively with preicranial patch. , More commonly, it appears as rhinorrhea secondary to associated fractures of the medial orbital wall and cribriform plate, and may require surgical closure. Posttraumatic epilepsy occurs in 30% or more of patients with PBI, so anticonvulsant therapy may be necessary.
The surgical options that are employed were to gently pull out the nail without resorting to craniotomy, but in this case where there was benefit of locating the tip of the nail, we had to do craniotomy to have vascular access if the object was adjacent to or was acting tampon ad to an injured vessel. We were able to manage the early possible complication of fistula and infection.
The possible long-term complication of epilepsy cannot be ruled out and the patient will have to be followed up for a long time on anticonvulsant. In this case, we used phenobarbitone in the dose of 5 mg/kg in three divided doses and the patient has been convulsion free for 2 years. Traumatic pseudoaneurysms are possible as a long-term complication and have to be looked for by cerebral angiography.
| Conclusion|| |
Although PBIs are common worldwide, they are seen in adults following military or civilian assaults with missile and stab wounds. Because of the softness of the skull bone in children and likelihood of playing with sharp objects such as sticks, these injuries can be common. We present the peculiar injury in a child who was managed using the available therapeutic options and support with a good outcome. All possible complications must be borne in mind.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]