Case

reports

561

of rupture of these structures, the bone appeared to be weaker leading to a spiral fracture of the proximal phalanx. A spiral fracture of the humerus due to a more or less similar mechanism as a result of violent muscle activity has been reported for throwing sports and arm wrestling (Helm and Stuart, 1986; Marymont et al., 1989; Noack and Rottinger, 19%). Both bony union of such spiral fractures and recovery of function is usually fast because of the indirect nature of the violence and the relatively little soft tissue damage.

Acknowledegment The authors wish to thank Mr Huiser of the Department Medical Photography for the photographs.

of

References

Figure 3. Stable, undisplaced spiral fracture phalanx of the index finger (Case 2).

of the proximal

Discussion These two cases present an uncommon mechanism resulting in a spiral fracture of the proximal phalanx of the index finger, which to our knowledge has not been reported previously in the English literature. This fracture is produced by a rotary force during traction. It clearly demonstrates the strength of the ligamentous structures of the metacarpophalangeal and proximal interphalangeal joints, i.e. instead

Helm R. H. and Stuart P. (1986) Fracture of the humerus during the use of an arm wrestling machine. BY.Med. ]. 293, 1644. Marymont J. V., Coupe K. J. and Clanton T. 0. (1989) Sportsrelated spontaneous fractures of the humerus. Orfhop. Rev. 18, 957. Noack W. and Rottinger H. (1990) Die indirekte Humerusfraktur im Sport. Sporfwrlefz Sporfschaden 450. O’Brien E. T. (1982) Fractures of the metacarpals and phalanges. In: Green D. L. (ed.). Operafive I-land Surgery. New York: Churchill Livingstone, 703. Wray R. C. Jr (1990) Fractures and joint injuries of the hand. In: McCarthy J. G. (ed.). Plarh’c Surgery, Vol. 7, The Hand, Part 1, Philadelphia: W. B. Saunders. 4593. Paper accepted

24 February

1992.

Requests for reprinfs should be addressed to: Professor Dr H. J. Klasen, Department of Traumatology, University Hospital Groningen, Oostersiongel 59, PO Box 30.001, 9700 RB Groningen, The Netherlands.

Venous bullet embolism: a case report and review of the literature Z. Nazir, S. T. Esufali, N. S. Rae* and I. Rimi* Departments

of Surgery and Radiology*,

The Aga Khan University

Introduction Bullet vascular embolism is an uncommon complication of penetrating gunshot injuries. These wandering bullets present multiple problems for the clinicians, including localization of the bullet, determination of its path of travel and decision if and when the bullet needs to be removed. This report describes a case of venous bullet embolism to the heart managed at the Aga Khan University Hospital to demonstrate the difficulties encountered in the diagnosis and management of such cases. 0 1992 Butterworth-Heinemann 0020-1383/92/080561-03

Ltd

Hospital, Karachi, Pakistan

Case report A 35-year-old man was brought to the emergency room for evaluation and management of gunshot injury to the back and left chest. The patient was conscious and alert, complaining of mild pain in the left supraclavicular fossa. His blood pressure was 130/70mmHg, heart rate 90 beats/min, and respiratory rate lB/min. Examination revealed fullness and tenderness in the left supraclavicular fossa. Two wounds of entry were present on the back of the left upper chest and shoulder. No exist wound or other

562

Injury: the British Journal of Accident Surgery (1992)Vol. tb/No.

Figure 1. Radiographs showing location of the bullet along the inferior vena cava. abnormalities were detected on routine examination of the head and neck, abdomen and limbs. Initial radiograph of the chest revealed one bullet in the shoulder region, while the other bullet was missing. In order to locate the missing bullet, whole body fluoroscopy was conducted. This revealed a bullet positioned along the course of the inferior vena cava (WC) (FigureI). This was confirmed on venography. During the procedure the bullet migrated into the right ventricle, but under fluoroscopy it was manipulated into the right saphenous vein by rapidly changing the position of the fluoroscopy table. Retrieval through a right long saphenous cut-down using a Dormia basket was unsuccessful due to migration of the bullet into the right internal iliac vein. An occluding balloon catheter was inserted into the WC via the long saphenous vein to prevent embolization towards the heart and the patient was transferred to the operating room. The right common iliac vein was exposed through a muscle-cutting flank incision. During dissection and isolation of the common iliac vein, the bullet slipped to the left common iliac vein, from which it was finally retrieved through a separate incision. The postoperative course was uneventfuI and the patient has remained well throughout a l-year follow-up.

Discussion Bullet venous embolism is a rare complication of penetrating gunshot injury. Since the first reported case by Davis in 1834, a search of the English literature to March 1990 revealed 156 cases of bullet embolism, out of which only 34 are venous bullet emboli to the heart (Mathox et al., 1979; Michelassi et al., 1990). The most likely explanation of a bullet penetrating the cardiovascular system is that the small bullet with relatively little energy is able to penetrate one but not both sides of the vessel. Such penetration is not always fatal, because a small wound in the vessel wall may close without exsanguination, in view of the elastic property of blood vessel wall and haematoma surrounding it (Matthox et al., 1979; Falkamer et al., 1987).

8

Penetration of the cardiovascular system after ingestion of foreign bodies and erosion from surrounding tissue has been reported (Mathox et al., 1979). Most commonly intravascular migration of a bullet occurs soon after injury. Rarely it may be delayed up to 14 years (Matthox et al., 1979; Michelassi et al., 1990). Bullet emboli to the heart occur mainly from the right side, including the missiles entering the head and neck veins, femoral vein, iliac vein and inferior vena cava (Mathox et al., 1979; Michelassi et al., 1990). Review of the literature disclosed that 14.7 per cent of venous bullets move in a retrograde manner towards the heart. Retrograde embolization occurs because the pattern of embolization is governed by factors other than blood flow, such as body position, gravity, respiratory movement, the missile’s size and weight, and the width of the vessel lumen (Mathox et al., 1979; Falkamer et al., 1987; Michelassi et al., 1990). The existence of a patent foramen ovale or the perforation of the atrioventricular septum by the bullet may account for paradoxical embolization. Five such cases have been reported in the literature (Mathox et al., 1979). In our case the 0.32 revolver bullet most probably entered the left subclavian vein and moved in a retrograde manner to the IVC and heart. Migration of bullets from systemic veins to the right heart appear to occur more commonly than migration into the pulmonary arterial tree, as bullets tend to become trapped beneath the tricuspid valve or within the chordae tendinae, preventing further migration (Ledgerwood, 1977; Way, 1989). The patient with an intravascular migratory bullet presents a confusing picture. The signs and symptoms do not correlate with those expected from the suspected course of the missile on routine radiological investigations, which shows that the missile location deviates from the suspected course of penetration. Sudden disappearance of a peripheral pulse, with or without ischaemic pain, has been reported in two-third of patients with arterial bullet emboli, whereas two-thirds of patients with venous emboli have no symptoms (Ledgerwood, 1977; Falkamer et al., 1987; Way, 198% Michelassi et al., 1990). Most patients with pulmonary arterial bullet emboli are symptomatic (Ledgerwood, 1977). A few have signs of infarction with chest pain, cough and haemoptysis. When a bullet embolism is suspected, it is extremely important to localize the missile before management (Ledgerwood, 1977; Michelassi et al., 1990). Whole body fluoroscopy, venography, echocardiography and pulmonary angiography are helpful. Recently, owing to improvement in image quality, sonography has been recommended in the detection and localization of foreign bodies (Banerjee and Das, 1991). Prophylactic removal of a bullet from systemic veins, heart and pulmonary artery is important to prevent further embolization by foreign body and associated thrombus, to reduce the possibility of bacterial endocarditis, myocardial irritability, interference with the valvular mechanism and to prevent the psychological morbidity associated with the knowledge of a retained bullet (Ledgerwood, 1977; Mathox et al., 1979; Way, 1989; Michelassi et al., 1990). Documentation of morbidity and mortality from bullet emboli in the right heart is lacking, except for the psychological morbidity demonstrated by Bland and Beebe in their 20-year follow-up of 40 World War II veterans with retained intracardiac foreign bodies (Bland and Beebe, 1966). Removal of the bullet from the right heart needs cardiopul-

Case reports

563

monary bypass and occlusion of the main pulmonary artery with a vascular clamp before manipulation to prevent migration into the pulmonary artery (Ledgerwood, 1975). Transvenous removal of the intracardiac and intravascular bullets using a wire basket is possible; however, caution should be used in attempting this procedure since dislodgement may result in embolization of the bullet (Ledgerwood, 1977; Smith, 1982). Precise localization of the migrating bullet using fluoroscopic facilities is mandatory prior to operative removal as migration of the bullet during operative manipulation is a common problem. The use of balloon catheters (e.g. Swan-Ganz) is recommended to prevent migration of the bullet during any operative manipulation (Ledgerwood, 1977; Michelassi et al., 1990). In conclusion intravascular bullet embolism should be suspected in any patient with a huncal gunshot wound that is unaccompanied by an exit wound and in whom routine radiographs of the thorax and abdomen fail to demonstrate the missile. In such cases whole body fluoroscopy is recommended before surgery for the removal of the migratory bullet.

Acknowledgement Thanks to Mr Muradali Bana, Department preparing the manuscript.

of Surgery,

for

References Banerjee B. and Das R. K. (1991) Sonographic detection of foreign bodies of the extremities. BY.1. Rudiol. 64, 107. Bland E. F. and Beebe G. W. (1966) Missiles in the heart -

A twenty-year follow-up report of World War II cases, N. Engl. J Med. 274,1039. Falkamer L., Eriksson A., Arnerloric et al. (1987) Arterial bullet embolism with radiologic demonstration of vessel entrance. World]. Surg. II. 548. Ledger-wood A. M. (1977) The wandering bullet. Surg. Clin. North Am. 57‘97. Mathox K., Beall A. C., Ennix C. L. et al. (1979) Intravascular migratory bullets. Am. 1. Surg. 13 7, 192. Michelassi F., Pictrabissa A., Ferrari M. et al. (1990) Bullet emboli to the systemic and venous circulation. Srqqery 107,239. Smith L. P. (1982) An improved method for intraarterial foreign body retrieval. Radiology 145, 539. Way C. W. V. (1989) Intrathoracic and intravascular migratory foreign bodies. Surg. Clin. North Am. 69, 125. Paper accepted

27 January

1992.

Requests for reprints should be aaihssd too:Dr S. T. Esufali, Assistant of Surgery, The Aga Khan University Hospital, PO Box 3500, Stadium Road, Karachi-74800, Pakistan.

Professor, Department

Retrosternal dislocation of the clavicle: the ‘stealth’ dislocation D. W. Gale, I. D. Dunn, S. McPherson and 0.0. Department

of Orthopaedic

A. Oni

Surgery, Leicester Royal Infirmary, Leicester, UK

Introduction Retrostemal dislocation of the clavicle is a rare injury, with one case reported in 1600 patients with an injured shoulder girdle (Cave, 1961). Diagnosis is often difficult (Tyer et al., 1963), but can have serious consequences if missed. Pressure from the clavicle may put important thoracic structures at risk. Closed reduction may only be possible within the first 48 h of injury. Thus, for retrostemal dislocation of the clavicle, the term ‘stealth dislocation’ is apt. We report a case illustrating the diagnostic difficulties, and the associated thoracic complications as a reminder of the condition in order that the diagnosis is considered in all cases of a shoulder girdle injury without obvious changes on plain radiography.

movements of the arm. He had also developed dysphagia stridor. On inspection of the shoulder girdle there was remarkably deformity (Figure I). Repeated plain radiographic examination unremarkable. A contrast-enhanced CT scan was obtained in

and little was view

Case report While on a rugby tour, a 17-year-old youth injured his right shoulder in a loose strum during a game. No abnormalities were detected on clinical and radiographic review at the local accident and emergency department. On return home, 24 h later, he

attended the Leicester Royal Infirmary complaining of continued pain in the region of the medial end of the clavicle made worse by 0 1992 Butterworth-Heineman 002&1383/92~080563-02

Ltd

Figure 1. Clinical photograph of the patient, change in shoulder girdle contour (arrowed).

showing

subtle

Venous bullet embolism: a case report and review of the literature.

Case reports 561 of rupture of these structures, the bone appeared to be weaker leading to a spiral fracture of the proximal phalanx. A spiral frac...
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