Ann Thorac Surg 2001;71:1019-1021
© 2001 The Society of Thoracic Surgeons
Case report
Penetrating thoracic trauma in arrow injuries
Nicolas Peloponissios, MDa,
Nermin Halkic, MDa,
Olivier Moeschler, MDb,
Pierre Schnyder, PhDc,
Henri Vuilleumier, MDa
a Department of Surgery, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland
b Department of Anesthesiology, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland
c Department of Radiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
Accepted for publication March 21, 2000.
Address reprint requests to Dr Peloponissios, Department of Surgery, University Hospital, CHUV 1011 Lausanne, Switzerland
e-mail: nicolas.peloponissios{at}chuv.hospvd.ch
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Abstract
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Arrow wounds are very rare. We present herein a case of hilar penetrating thoracic trauma caused by an arrow, and a review of the literature, to clarify the management of these cases and their indications for surgery. Depending on the type of arrowhead, the tissue elasticity can narrow the wound track around the shaft of the arrow, sometimes causing a tamponade effect. In the mediastinal or hilar area, an arrow should not be removed before an injury to the major blood vessels or the heart has been ruled out.
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Introduction
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Arrows have considerable penetrating capacity in soft tissue and flat bones, sufficient to penetrate deeply into large body cavities and to injure the heart or major vessels. Depending on the type of arrowhead, the tissue elasticity can narrow the wound tract around the shaft of the arrow, sometimes realizing a tamponade effect. The extraction of an arrow, especially in the mediastinal or hilar area, can result in severe blood loss requiring an emergency thoracotomy.
A 45-year-old patient who attempted to commit suicide with a crossbow, was admitted to hospital 2 hours after the incident. Upon arrival in the emergency room, he was conscious with stable normal vital signs. The arrow was penetrating the thorax in the fifth left intercostal space on the medial clavicular line (Fig 1). The exterior segment of the arrow’s shaft could be seen beating. No active external bleeding was noted. Chest x-ray film showed only a small pleural effusion in the left diaphragmatic recess. An enhanced spiral computed tomography (CT) did not show any contrast extravasation. The arrow was in close proximity to the left coronary artery, superior pulmonary vein, and inferior lobar artery. A small pneumothorax was also present and a small hemopericard suspected. CT-scan interpretation could not formally rule out any vascular injury and a posterolateral thoracotomy in the fifth intercostal space was performed 2 hours after admission. A 300 mL hemothorax was drained. The arrow was lying in close contact to the ascending aorta and the left pulmonary vein without wall injury. There were lacerations of the apicoposterior segment of the left upper lobe and of the upper segment of the inferior lobe. The arrow was retrieved under direct visual control and a wedge resection of the injured lung segments performed. No hemopericardium was found.
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Fig 1. Patient upon arrival in the emergency room. The arrow can be seen penetrating the chest in the fifth left intercostal space on the medial clavicular line. The inset shows the field tip of this arrow.
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The two-dimensional CT reconstruction (Fig 2), realized the day after the intervention, showed more clearly the track of the arrow which lay in close contact to the left coronary artery, superior pulmonary vein, and inferior lobar artery.
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Fig 2. Three-millimeter computed tomography section showing the aluminum radiolucent arrow. The small black arrow indicates the steel proximal end of the arrow. An ill-defined area of high attenuation value relates to a pulmonary laceration surrounding the proximal end of the arrow. A small left pleural effusion is also displayed. (CA = left coronary artery; SPV = superior pulmonary vein; ILA = inferior lobar artery.)
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There were no immediate postoperative complications, and the patient was referred to a psychiatric hospital after 10 days. A 2-month follow-up did not reveal any delayed complication.
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Comment
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Injuries caused by arrows are usually less destructive than those caused by bullets because of lesser velocity and energy. Barbed arrows are an exception because of the risk of extensive damage to major structures when retrieved [1]. The ballistics of arrows was described in the Karger and associates report of 1998 [2]. Both the excellent exterior ballistic of the arrow and its high sectional density favors a deep penetration of tissue without the need of a great kinetic energy. The morphology of the wound track depends essentially on the arrowhead shape. A broad head causes star-like and sometimes gaping wounds. The field tip (Fig 1) causes incision-like wounds which are sharply cut with no significant bruising or tearing tissue destruction. Movable structures (bowel, vessels) in the trajectory of the injury seem not to be pushed aside but incised. The experimental study of Karger and colleagues [2] showed that for the field tip, the tissue elasticity narrowed or even closed the wound track, with the arrow shaft functioning as a plug.
Fingleton [3] and Jacob [1] reported 63 patients with thoracic or thoracoabdominal arrow injuries. There were 11 patients with a heart injury, 6 with major blood vessel injury (including ascending aorta, arch of aorta, superior vena cava), and 1 with a hilar injury. Eight (44%) of these 18 patients presented with stable vital signs upon arrival, sometimes having been referred more than 24 hours after the injury. In all cases, the arrow was left in the wound. Postoperative data were only reported by Fingleton [3]. Among 10 patients with mediastinal or hilar injury, only two deaths were reported. A case of transfixed heart and descending thoracic aorta was described by Mullan and coworkers [4] in a stable patient with no evidence of hemopneumothorax on the chest x-ray film. Fradet and colleagues [5] reported the case of a patient arriving at the hospital 8 hours after a penetrating thoracoabdominal trauma with a crossbow bolt. Chest roentgenogram showed only a small left pleural effusion and no pneumothorax. CT scan showed that the arrow was indeed crossing the left lobe of the liver and the diaphragm before penetrating the lower thoracic aorta.
In stable patients, if there is any doubt about major injury to the mediastinal or hilar structure, further investigations such as enhanced spiral computed tomography and reformatted 2D images should be performed to clarify the relationships between the arrow and any major structures. Furthermore, subtle hematoma that cannot be pointed out with an angiogram also can be shown on CT. If such lesions are ruled out, a chest tube must be inserted, if not already done so upon arrival, before extraction of the arrow. In case of any suspicion of vascular injury, good operative exposure is mandatory.
Videothoracoscopy has been described as effective and safe for the initial diagnosis, evaluation, and management in stable patients with thoracic trauma including penetrating injury [6, 7]. It remains controversial especially in cases of suspected cardiac or major vessel injury and is usually not recommended in this particular situation. In hemodynamically unstable patients who need an emergency thoracotomy, according to standard advanced trauma life support criteria, the arrow should not be removed to prevent a worsening of the hemorrhage.
In conclusion, an arrow should never be removed from a patient with stable or unstable vital signs, before an injury to the major blood vessels or the heart has been ruled out. Barbed arrows in proximity to major structures need systematic careful exploration and extraction because of the risk of extensive damage during retrieval.
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Acknowledgments
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The authors acknowledge Miss Laura Mathews and Miss Susanne Rouaud, for their contribution in the translation of this article.
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References
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Jacob O.J. Penetrating thoracoabdominal injuries with arrows: experience with 63 patients. Aust N Z J Surg 1995;65:394-397.[Medline]
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Karger B., Sudhues H., Kneubuehl B.P., Brinkmann B. Experimental arrow wounds: ballistics and traumatology. J Trauma 1998;45:495-501.[Medline]
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Fingleton L.J. Arrow wounds to the heart and mediastinum. Br J Surg 1987;74:126-128.[Medline]
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Mullan F.J., O’Kane H.O., Dasmahapatra H.K., Fisher R.B., Gibbons J.R. Mediastinal transfixion with a crossbow bolt. Br J Surg 1991;78:972-973.[Medline]
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Fradet G., Nelems B., Muller N.L. Penetrating injury of the torso with impalement of the thoracic aorta: preoperative value of the computed tomographic scan. Ann Thorac Surg 1988;45:680-681.[Abstract]
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Lang-Lazdunski L., Mouroux J., Pons F., et al. Role of videothoracoscopy in chest trauma. Ann Thorac Surg 1997;63:327-333.[Abstract/Free Full Text]
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Uribe R.A., Pachon C.E., Frame S.B., et al. A prospective evaluation of thoracoscopy for the diagnosis of penetrating thoracoabdominal trauma. J Trauma 1994;37:650-654.[Medline]
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Abstract
Introduction
