Ann Thorac Surg 2005;80:1131-1132
© 2005 The Society of Thoracic Surgeons
Case report
Structural Allograft Implantation for Thoracic Spinal Impalement
Chiung-Lun Kao, MD,
Jen-Ping Chang, MD
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Department of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital at Chiayi, and Kaohsiung, Taiwan
Accepted for publication February 18, 2004.
* Address reprint requests to Dr Chang, Department of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital at Kaohsiung, 123, Ta-Pei Rd, Niao Sung Hsiang, Kaohsiung Hsien, Taiwan; (Email: c9112772{at}adm.cgmh.org.tw).
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Abstract
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Impalement injury is uncommon, with only occasional reports. Thoracic impalement injuries from falls are rarely seen in the emergency department, because most patients die at the scene of injury. We present an unusual case in which a patient survived a bilateral thoracic impalement injury and was successfully treated for the bleeding thoracic spinal defect with a method that used a structural ulnar allograft implantation.
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Introduction
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Impalement injuries of the chest are uncommon in civilian life and are rarely seen in the emergency department because most patients die at the scene of injury. Minimal manipulation of the object before and during transport is essential to minimize blood loss by maintaining the tamponade effect and to avoid further injury. We present our experience with a patient who suffered from uncontrollable bleeding from the bone marrow of the impaled thoracic vertebral body after a steel rod was extracted. The bone defect was repaired with an ulnar allograft implantation, and the bleeding was successfully stopped.
A 69-year-old man who had fallen into a construction site was sent to the emergency department. An amputated steel rod (1.5 cm in diameter) was impaled through the right chest at the third intercostal space and anterior axillary line. The patient was short of breath. His vital signs were stable and he was alert neurologically. An anteroposterior chest roentgenogram revealed that the steel rod was impaled across the mediastinum (Fig 1). The patient was sent to the operating room for further treatment.
Because the lesions mostly involved the bilateral posterior mediastinum, we decided to use bilateral thoracotomies. To prevent an unpredictable delayed hemopneumothorax during the procedure, a left intercostal tube was placed before the right thoracotomy incision was made. Exploration of the right side of the chest revealed the rod had passed through the right chest wall and the right upper lobe of the lung, and into the thoracic vertebral body. Under direct vision, the steel rod was removed, after which some dark red blood gushed out from the defect of the vertebral body. Because the bleeding could not be well controlled by the application of Surgicel (Johnson & Johnson Gateway, LLC, Piscataway, NJ) and bone wax, we implanted a segment of an ulnar allograft to repair the defect (Fig 2). The ulnar allograft had been harvested 3 months earlier from a 39-year-old male cadaver and was stored at the bone bank. The lung and the chest wounds were extensively irrigated with aseptic normal saline before closure and placement of an underwater seal drain.
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Fig 2. Photograph shows the ulnar allograft (arrow) that was implanted into the vertebral body defect.
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The patient was repositioned, and a left posterolateral thoracotomy was performed. This revealed the well-fixed allograft in the vertebral body and a lacerated left lower lobe of the lung. We speculated that the steel rod passed through the vertebral body, displaced the descending thoracic aorta forward, and impaled into the left lower lobe. Again, the lesions were repaired after extensive irrigation, a drain was placed, and the thoracotomy wound was closed. Tetanus prophylaxis was routine and the broad-spectrum antibiotics were continued for 1 week. The recovery was uneventful.
At 3-year follow-up, the patient was well and a computed tomographic scan showed that the previously implanted allograft kept the integrity of the vertebral body free from collapse (Fig 3).
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Fig 3. Computed tomographic scan shows that the previously implanted structural allograft restored the vertebral body integrity.
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Comment
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The protocols for the management of an impalement injury are suggested by the literature [1–4]. The impaled object should be left in situ to maintain the tamponade effect and cut at one or both ends to permit rapid transport [1]. Rapid assessment and resuscitation of the patient should be carried out according to the principles of trauma management. If the patient’s condition is in stable, the surgical approach may be guided by selected investigation and tests [2]. An unstable patient should be transported to the operating room without undue delay caused by unnecessary tests. Wide exposure is mandatory, and the object should be extracted only after appropriate vascular control has been achieved [3]. The tissue along the path of impalement will be dirty and contused and needs to be adequately débrided and irrigated to prevent serious infection. Antimicrobial and tetanus prophylaxis are essential components of care, and broad-spectrum antibiotics are recommended [4].
The steel rod was extracted from our patient under direct vision without difficulty, but the active bleeding from the vertebral body defect could not be well controlled by conventional hemostatic methods. Hemostasis for bleeding, cancellous bone is challenging. Bone wax is generally used for this purpose. However, the environment in our patient was contaminated, and the apparent potential of this method to promote infection precluded its use [5]. Instead, we used an ulnar allograft to obliterate and tamponade the vertebral defect to achieve the successful hemostasis.
Orthopedic and plastic surgeons use allografts to fill bone defects or replace missing bone segments to promote the healing of nonunited fractures. Cancellous bone is often used for filling cysts or cavities; cortical bone is optimal for reconstructing defects that require a certain form and strength [6]. Vertebral bodies, which are rich in cancellous bone and marrow, provide greater numbers of osteoprogenitor cells for remodeling a graft than other parts of the spine. At times, if vertebral bodies of the spine are lost, struts of allograft can be effective to restore the stability. Based on these concepts, we fashioned a structural ulnar allograft in the same size of the defect created by the steel rod in our patient. This method achieved satisfactory immediate hemostasis and was effective for late spinal integrity restoration. In conclusion, we advocate this particular method for hemostasis and integrity restoration in the case of impalement injuries that involve vertebral bony structures.
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References
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- Vaslef SN, Dragelin JB, Takla MW, Saliba Jr EJ. Multiple impalement with survival Am J Emerg Med 1997;15:70-72.[Medline]
- Bowley DM, Gordon MP, Boffard KD. Thoracic impalement after ultralight aircraft crash J Thorac Cardiovasc Surg 2003;125:954-955.[Free Full Text]
- Thomson BN, Knight SR. Bilateral thoracoabdominal impalementavoiding pitfalls in the management of impalement injuries. J Trauma 2000;49:1135-1137.[Medline]
- Horowitz MD, Dove DB, Eismont FJ, Green BA. Impalement injuries J Trauma 1985;25:914-916.[Medline]
- Nelson DR, Buxton TB, Luu QN, Rissing JP. The promotional effect of bone wax on experimental Staphylococcus aureus osteomyelitis J Thorac Cardiovasc Surg 1990;99:977-980.[Abstract]
- Chapman MW, Rodrigo JJ. Bone grafting, bone graft substitutes, and growth factorsIn: Chapman MW, editor. Chapman’s orthopaedic surgery. Philadelphia: Lippincott William & Wilkins; 2001. pp. 193-198.
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Abstract
Introduction
