A sharp metal object such as a needle, heavy wire, nail or
fork is driven into or through a patient's extremity. In
some instances, the patient may arrive with a large object
attached; for instance, a child who has stepped on a nail
going through a board may be brought in with the entire board attached. As minor as most of these injuries are, they tend to create a spectacle and draw a crowd.
What to do:
If you are dealing with an impaled object attached to some
thing that is acting like a lever and causing pain with
movement, either immediately pull the extremity off the sharp object (if it is straight and smooth) or quickly cut through it to release the patient. You can usually
cut an exposed nail or metal spike with an orthopedic pin cutter.
Obtain x rays when pain and further damage
from a leveraged object is not a problem, and when there
is a suspicion of an underlying fracture, fragmentation,
or hooking of the impaled object, as might occur with a
heavy wire that has been thrown from under a lawnmower. It is not necessary to x ray a penetrating nail, form or other non-malleable, non-fragile object that will remain intact and is easily removed regardless of its radiographic appearance.
Examine the extremity for possible neurovascular or tendon
injury.
If surgical debridement is anticipated after removal of the
object, then infiltration of an anesthetic should be
provided prior to removal. Otherwise, consider whether or
not the patient wants the transient discomfort of local anesthetic before the
object is quickly pulled out. Local anesthesia will usually
not give complete pain relief when a deeply imbedded object
is removed; inform the patient of this.
Objects with small barbs, such as crochet needles and fish
spines, can be removed by first anesthetizing the area and
then applying firm traction until the barb is revealed
through the puncture wound. The fibrils of connective
tissue caught over the barb can then be cut with a scalpel
blade or fine scissors.
After removal of the impaled object the wound should be
appropriately debrided and irrigated, as described for puncture wounds. Tetanus prophylaxis should be provided and, except for contaminated wounds like a fish spine, a prophylactic antibiotic should not be prescribed.
What not to do:
Do not send a patient to x ray with a leveraged object
impaled. This creates further pain and possible injury with
every movement and the x ray seldom provides useful information.
Do not try to hand-saw off a board attached to an impaled
object. The resultant movement will obviously cause
unnecessary pain and possibly harm.
Discussion:
Simple impalement injuries of the extremities should not be
confused with major impalement injuries of the neck and
trunk in which the foreign object usually should not be
precipitously removed. With major impalement injuries
careful localization with x rays is required, and full
exposure and vascular control in the operating room is also
a necessity to prevent rapid exsanguination when the impaled
object is removed from the heart or a great vessel. Large impalement injuries of the extremities also require immediate surgical consultation and thorough consideration of potential neurovascular and musculoskeletal injuries.
