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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 26  |  Issue : 1  |  Page : 20-23

Pediatric upper extremity fence-penetrating traumas


1 Clinic of Plastic, Reconstructive and Aesthetic Surgery, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
2 Dr. Ersin Aksam Training and Research Hospital, Clinic of Plastic, Reconstructive and Aesthetic Surgery, Gaziantep, Turkey
3 Department of Plastic, Reconstructive and Aesthetic Surgery, Yildirim Beyazit University, Ankara, Turkey

Date of Web Publication20-Mar-2018

Correspondence Address:
Dr. Ugur Horoz
Dr. Ersin Arslan Training and Research Hospital, Plastik, Rekonstrüktif ve Estetik Cerrahi Kliniği, Eyupoğlu Mah, Hürriyet Cd, 27010 Şahinbey, Gaziantep
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_8_18

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  Abstract 


Purpose: Penetrating hand injuries related to sharp metal or wooden fences are rarely reported in pediatric population. Most of these traumas occur after accidentally falling on the fence. The aim of this study is to evaluate the characteristics of the patients suffering from fence injuries and to present our management. Materials and Methods: In this study, 14 patients admitted to our emergency department with fence postpenetrating traumas between March 2013 and April 2016 were retrospectively examined. Eleven pediatric patients with fence postpenetrating trauma to upper extremity were included. Patient demographics, zone of injury, injury type, surgical intervention, and follow-up results were documented. Statistical analysis was performed using Chi-square test. Results: In the past 4 years, 11 patients aged 4 to 15 years with fence-related upper extremity traumas were treated in our clinic. Preteen age group was the most affected group. The most commonly penetrated region was below the elbow (7 patients). All wounds were surgically explored for accompanying injuries and repaired if any neurovascular or muscle injuries were present. Conclusion: To be able to prevent and appropriately treat these types of injuries in children, it is necessary to surgically explore and understand the mechanism.

Keywords: Hand, penetrating, trauma


How to cite this article:
Keles MK, Horoz U, Ballioglu B, Muratoglu HG, Seven E, Tellioglu AT. Pediatric upper extremity fence-penetrating traumas. Turk J Plast Surg 2018;26:20-3

How to cite this URL:
Keles MK, Horoz U, Ballioglu B, Muratoglu HG, Seven E, Tellioglu AT. Pediatric upper extremity fence-penetrating traumas. Turk J Plast Surg [serial online] 2018 [cited 2019 Jan 16];26:20-3. Available from: http://www.turkjplastsurg.org/text.asp?2018/26/1/20/228010




  Introduction Top


Penetration traumas by fences due to falling, traffic accidents, or battery have been previously reported in the literature.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11] Investigation of the etiology shows that most fence posttraumas are accidental. Accidental self-penetrating traumas by sharp metal or wooden fences generally occur after falling on the fence.[3],[4],[6],[7],[8],[10],[11] These kinds of preventable traumas may sometimes have catastrophic results. Fences were also reported to be an etiological factor in pediatric hand injuries in the USA.[12]

Children are the group most often affected by this type of injury because they are unaware of the dangers these decorative objects can pose. Even death may occur after accidental self-penetration of an object during a child's playtime or daily activities. Such injuries are not a cause of morbidity for the children but also inflict psychological pain on the parents.[13] As a result, parents may also have to stay home to take care of their children, which may lead to financial loss.[13]

Understanding these types of accidental upper extremity injuries is a necessity for preventive approach and surgical management. Like in all traumas in all age groups, etiologies of pediatric hand injuries are undergoing changes with the lifestyle. However, we have relatively low literature knowledge about preventive strategies and the mechanism of formation.[12],[14] In Turkey, decorative fences are widely used to cover buildings. These decorative fences are made of wood or iron and generally feature spear-shaped posts. These sometimes cause serious injuries when people try to jump over them. This study will discuss the pediatric patient characteristics who suffer from fence injuries and the clinical presentation management and treatment of these types of injuries in children.


  Materials and Methods Top


Between March 2013 and April 2016, 14 patients admitted to our emergency room after falling on a fence were evaluated. Only upper extremity traumas in children were included. Two patients with tight and orbital injuries were excluded. One adult patient was also excluded. Patient age, sex, injury zone, type of injury, complications, and surgical intervention were recorded. Follow-up period was minimum 6-month postoperatively. Injuries were classified as below the elbow and above the elbow which are the two affected parts in the upper extremities. All patients admitted to the ER had skin lacerations. In addition, we evaluated the type of injuries as complex and simple. Injuries that involved the nerves, vessels, tendons, and bones were evaluated as complex. If the examination and radiologic evaluation did not indicate involvement of any critical anatomic structures, the injury was evaluated as simple. Partial injuries to muscles were also evaluated as simple.

After a routine tetanus prophylaxis, blood sample, and X-ray evaluation, all patients were evaluated for vital injuries. Next, accompanying nerve, muscle, tendon, and bone injuries were evaluated. Patients with a risk of vessel injury were immediately taken to the operation theater for primary debridement, exploration, and repair. The remaining patients were treated in the emergency room. All wounds were surgically explored for accompanying injuries and were repaired wherever applicable. Primary closure was done if the wound allowed. Antibiotic protocol was applied to all patients. Preoperative intravenous cefazolin was administered, followed by oral ampicillin twice a day. Patients were checked on weekly in the outpatient clinic after being discharged. Complications were also documented during follow-up. The authors were aware of the Code of Ethics of the World Medical Association (Declaration of Helsinki), which has been printed in the British Medical Journal (July 18, 1964). Informed consent was obtained from the parents of each patient before surgery.

The data obtained were evaluated with SPSS software (version 15.0, SPSS Inc., Chicago, IL, USA). Comparisons of sex, age, injury zone, and injury type among the groups were performed using Chi-square test. Statistical significance was set at P < 0.05.


  Results Top


Data of patients who suffered fence injuries were analyzed [Table 1]. Eleven patients with a mean age of 9.09 years (ranging from 6 to 12 years) were included. Of the total 14 patients evaluated at the beginning of the study, male children were injured more frequently (P = 0.007). Children aged 10 to14 years (preteen) were the most commonly injured group (P = 0.029). Although the most common injury site was below the elbow, the difference between the two groups was not statically significant (P = 0.366). Luckily, almost all injuries were simple, and there was a statistically significant difference when compared to the complex injuries (P = 0.007). Of the 11 patients, five arrived at the emergency room together with the penetrating fence [Figure 1] and [Figure 2]. In two patients, fences were removed from the injured areas under general anesthesia with the help of the fire department. The other three were removed under local anesthesia. No infections were observed in the postoperative follow-up period.
Table 1: The data of the patients with preoperative and postoperative examinations and follow-up results

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Figure 1: A 12-year-old patient brought to the emergency department with penetrating fence in the axillar region. Fence was removed under general anesthesia with the help of the fire department

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Figure 2: (a) A 9-year-old patient admitted to emergency service with penetrating fence in forearm. (b) X-ray of 8-year-old patient with foreign body in the web space

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Ten (91%) patients were repaired primarily, and 1 patient required secondary technique (skin grafting) due to skin dehiscence. Difference between two groups was significant (P = 0.007). None of the patients received concomitant fasciotomies.


  Discussion Top


Previous studies on the epidemiology of pediatric hand traumas show many different mechanisms.[12],[15],[16] Although spear-penetrating traumas are not the most common type, they may have serious results.[6],[9] These types of injuries occur accidentally after falling on a fence or after a car crash or intentionally when a child is assaulted.[3],[4],[5],[8],[9] Although children are well protected from traumas by their parents (who may also experience accidental fall injuries), children are more likely than adults to experience spear-penetrating traumas, given their lack of knowledge about the nature and dangers of such items.

Hand, ocular, spinal, and extremity cases related to spear, foreign body, farm instruments, and impalements have previously been reported in the literature.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[17],[18] To the best of our knowledge, this is the first study of pediatric fence-related upper extremity injuries.

As in a previous study, male patients were predominant in our study.[12],[13] The most commonly injured age range was 10–14 years. That outdoor activities and organized sports are very popular among male children of this age group (preteen) may be the reason for this male dominance.

In our study, the most commonly affected region was below the elbow. This may be because children hold onto the fence post to keep from falling down. Injuries to this region may cause severe dysfunction or even the loss of fingers.[3] Luckily, none of our patient had functional lost in long-term follow-up.

In upper limb injuries, the most important preoperative examination is of the vascular circulation of the distal extremity. Capillary refill may sometimes be confounded due to collateral circulation.[17] Direct visualization of the vascular injury or computed tomography angiography is necessary for a precise diagnosis.[17],[18] Preoperative neurological examination is also critical. It should be done while the patient is awake. Direct visualization of the nerve is also very important for a precise diagnosis. Any functional deficits may indicate nerve, tendon, muscle, or bone injuries. In our patients, we mostly encountered simple injuries. In one patient, however, we repaired the superficial sensory branch of the radial nerve.

Five patients were admitted to the emergency room with the fence still penetrating their wounds. In two cases, metal fences were removed with the help of the fire department team in the operation theater. In such cases, it should be kept in mind that the arteries might be injured, in which case, the penetrating object may obstruct bleeding. If the possibility of a vascular injury cannot be eliminated, the object should be removed in an operation theater with a vascular team ready for surgical intervention. The penetrating object may also be located adjacent to critical anatomic structures, in which case harsh manipulation may damage vital structures. The object should be removed gently. Some spear-shaped fence posts are triangular, and the sharp end penetrates the extremity. In such cases, to prevent additional disruptive injuries from the wide base of the triangle, care must be taken that the object is not simply pulled out. In all stages of treating such injuries and removing foreign bodies, forced manipulation should be avoided.

Since children have smaller anatomical structures, it is easier to damage the arteries, nerves, and conjoint anatomical structures. Whereas all patients in this study were children, no vascular or main nerve trunk injuries were recorded. Only one patient experienced superficial sensory nerve damage to a branch of the radial nerve.

In addition to the anatomical repair, debridement and primary closure, if convenient, were done. Early debridement can prevent infection.[11] In the postoperative period, antibiotics should be administered since the material-penetrating deep tissues may be contaminated.[4] We routinely administered one dose of intravenous cefazolin preoperatively and prescribed prophylactic amoxicillin two times daily for at least 5 days. Although all injuries were contaminated, we did not come across any postoperative infections. This may be due to the relatively lower level of soft tissue damage caused by the spear-shaped structures. Furthermore, appropriate tetanus prophylaxis is critical for wound management.[19]

Spear-shaped fences are popular in our country, and penetrating traumas involving decorative barriers may sometimes be catastrophic. To prevent such injuries, spear-tipped fences should not be produced, and the public should be informed about these injuries. Playgrounds for children aged 5–14 years – the most affected group – should be enclosed with chain-link fencing. In addition, one should be very careful to avoid additional injuries while removing the penetrated object since pediatric patients have more delicate anatomy. Finally, children at risk of such injuries and their families should be better informed about the possible dangers of spear-shaped fencing.

Consent

This study involves 11 pediatric age individuals. All patients' parents signed consent forms in their main language.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients' parents have given consent for images and other clinical information to be reported in the journal. The patients' parents understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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3.
Khan M. Fence-post transfixion injury of the chest. Br J Hosp Med (Lond)1990;44:243.  Back to cited text no. 3
    
4.
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O'Neill S, McKinstry CS, Maguire SM. Unusual stab injury of the spinal cord. Spinal Cord 2004;42:429-30.  Back to cited text no. 6
    
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Rose EH. Massive foreign body impalement of the shoulder and chest wall. Ann Plast Surg 1990;24:451-4.  Back to cited text no. 7
    
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Wankhede AG. Patterned injuries caused by wooden plank. J Forensic Leg Med 2008;15:118-23.  Back to cited text no. 9
    
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Wasfi E, Kendrick B, Yasen T, Varma P, Abd-Elsayed AA. Penetrating eyelid injury: A case report and review of literature. Head Face Med 2009;5:2.  Back to cited text no. 10
    
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Ye T, Jia L, Chen A, Yuan W. Brown-Séquard syndrome due to penetrating injury by an iron fence point. Spinal Cord 2010;48:582-4.  Back to cited text no. 11
    
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Shah SS, Rochette LM, Smith GA. Epidemiology of pediatric hand injuries presenting to United States emergency departments, 1990 to 2009. J Trauma Acute Care Surg 2012;72:1688-94.  Back to cited text no. 12
    
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Akşam B, Akşam E, Ceran C, Demirseren ME. An emerging etiological factor for hand injuries in the pediatric population: Public exercise equipment. Acta Orthop Traumatol Turc 2016;50:153-6.  Back to cited text no. 13
    
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Schnitzer PG. Prevention of unintentional childhood injuries. Am Fam Physician 2006;74:1864-9.  Back to cited text no. 14
    
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Ljungberg EM, Steen Carlsson K, Dahlin LB. Risks for, and causes of, injuries to the hand and forearm: A study in children 0 to 6 years old. Scand J Plast Reconstr Surg Hand Surg 2006;40:166-74.  Back to cited text no. 15
    
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Vadivelu R, Dias JJ, Burke FD, Stanton J. Hand injuries in children: A prospective study. J Pediatr Orthop 2006;26:29-35.  Back to cited text no. 16
    
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Bravman JT, Ipaktchi K, Biffl WL, Stahel PF. Vascular injuries after minor blunt upper extremity trauma: Pitfalls in the recognition and diagnosis of potential “near miss” injuries. Scand J Trauma Resusc Emerg Med 2008;16:16.  Back to cited text no. 17
    
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Graves M, Cole PA. Diagnosis of peripheral vascular injury in extremity trauma. Orthopedics 2006;29:35-7.  Back to cited text no. 18
    
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Black KD, Cico SJ, Caglar D. Wound management. Pediatr Rev 2015;36:207-15.  Back to cited text no. 19
    


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