An Unusual Transorbital Penetrating Injury by House-key (lock): A Case Report with a Small Review of Literature

Penetrating injuries of the brain are quite uncommon, comprising approximately 0.4% of all head injuries. In our case, a four-year-old boy who fell forward on a house-key (lock) accidentally while playing with some other children sustained a left sided penetrating transorbital brain injury. After hospital admission, the patient had a Glasgow Coma Scale (GCS) score of 15/15, no visual loss but restriction of upward gaze (left eye) and profuse bleeding from the wound site. Firstly, the metallic key was removed in emergency operation theatre and haemostasis divured. Next day we did a combined surgical approach with neurosurgeons, Eye-surgeons and general surgeons after having CT scan report. We report this case because penetrating head injury is rare and transorbital penetrating head injury is even rarer and a predicament in emergency surgical practice with controversial management.

A four-year-old boy fell from the bed on his face while playing in home resulting in a penetrating transorbital injury by house key which was kept on the floor inadvertently. While taking admission in casualty ward at midnight, the patient was conscious and completely responsive with GCS score of 15 points. Physical examination revealed a left supraorbital (superolateral aspect) wound [Table/Fig-1a]; but no bony defects were palpated over the superior orbital rim. The eyeball was intact with normal visual acuity but restriction of movement of his left eye was noticed especially in upward gaze. There was no history of vomiting or loss of consciousness.

[Table/Fig-1a,b]:

(a) House-key impacted into the superolateral aspect of left orbit (b) Antero-posterior x-ray of face and cranium showing metallic key in left orbit

X-ray of skull was done immediately (both antero-posterior and lateral view), which revealed a metallic house key impacted into the left orbit [Table/Fig-1b,2a]. The child was immediately shifted into the operation theatre as there was profuse bleeding from wound site. Wound site was explored to remove the key under general anaesthesia. Next day morning CT scan of brain and orbit was done which revealed a fracture of the supero-lateral orbital roof (left) with displacement of the fracture fragments into the anterior cranial fossa [Table/Fig-2b] but surprisingly there was no further clinical deterioration. Considering the consequences of impacted foreign bodies in brain, the patient was shifted to nearest neurosurgical centre where with the help of multidisciplinary team approach including general surgeons, neurosurgeons and eye surgeons an extradural frontal craniotomy was done to explore the bony defect of left orbital roof and to remove bone fragments. Pericranium was then placed over the bony defect for stabilization of the orbital roof and the tear of the left superior rectus muscle was repaired by ophthalmologist. There was a small dural tear which was also repaired. Postoperative period was uneventful where the patient was treated with intravenous 3^rd generation cephalosporin, dexamethasone and regular dressing. The patient was discharged home on 10^th Postoperative day on prophylaxis for seizure for one month and tapering dose of oral steroids. He is under follow-up for last two months without any neurological or ocular complications.

[Table/Fig-2a,b]:

(a) lateral x-ray of face and skull showing intracranial extension of foreign body; (b) Axial CT scan brain showing left orbital roof fracture fragments

Penetrating brain injuries (PBI) are usually caused by relatively high-velocity metal objects i.e. missile, stab knife etc. and also can occur in explosions (splinters), motor vehicle collisions (metallic rod), occupational (screw drivers, nails, pins etc) or household accidents by scissors, glass, sharp-nails etc. Although less prevalent, PBI carries a worse prognosis than closed head trauma [1]. There are different routes for penetrating intracranial injury through the orbit among which the commonest route of entry is through superior orbital roof. The orbital roof is made up of the orbital plate of the frontal bone and the lesser wing of the sphenoid bone. It is very thin than other parts of the cranium and is therefore at particular risk of injury specially in children, because of the lack of a pneumatized frontal sinus [2]. There are certain other areas within the orbit that may provide direct access to the cranial cavity, such as the superior orbital fissure, inferior orbital fissure and the optic canal. Turbin et al., reported the pattern of transorbital intracranial injury and divided the orbital surface into four different zones [3]. The complications of transorbital penetrating cranio-cerebral injury include consequences of extra-ocular muscle injury, Intra-parenchymal brain lesions like cerebral oedema, cerebral contusions, intra-cerebral haematoma, subdural and epidural haematoma, subarachnoid haemorrhage, pneumocephalus, cerebrospinal (CSF) fluid fistulas, etc. Infective complications including brain abscess, encephalitis, meningitis, osteomyelitis and scalp wound sepsis & vascular complications like pseudo-aneurysm, post-traumatic carotico-cavernous fistula rarely also can occur [4]. The risk of postoperative seizure is as high as 30 to 50%, of which 10% appear within first week of trauma [5]. Initially there may be no apparent neurological deficit on examination and therefore a lack of neurological signs does not exclude an associated brain injury [6]. Chibbaro et al., reported 18 cases of orbito-cranial injuries caused by penetrating non-missile foreign bodies where GCS of 14-15 was noticed in 50% of subjects without obvious evidence of intracranial injury [7]. Therefore, even in the presence of a trivial orbital wound, a thorough ophthalmological examination and neurological evaluation is recommended supplemented by imaging studies (CT Scan) whenever necessary. Non-displaced or minimally displaced orbital roof fractures are usually managed by observation [8]. Early surgical exploration is recommended to reduce the morbidity in cases of retained foreign body and displaced fracture. A search of English medical databases, using key words transorbital penetrating injury and brain injury, revealed some interesting case reports, which were compiled in [Table/Fig-3] [9–17].

The principles of treatment for transorbital penetrating injury are removal of bone fragments and foreign body, control of persistent bleeding and intracranial hypertension, prevention of infection through debridement of all contaminated and necrotic tissues and at the same time preservation of as much nervous tissue as possible, and restoration of anatomic structures through accurate closure of the dura and lastly reconstruction of orbital roof. Jin Woo Kim et al., reported successful use of titanium micromesh and micro-screw system for large displaced fracture. These meshes do not interfere with postoperative imaging [18].

In a case of transorbital penetrating injury, high index of suspension for underlying brain injury even in absence of any neurological symptoms is mandatory and appropriate radiological imaging should be considered. Outcome depends upon the type of object, site of entry into the eye globe, its trajectory, involvement of paranasal sinuses, extent of brain parenchymal injury and the septic complications. Furthermore, we also emphasize the importance of a combined team approach involving general surgeons, neurosurgeons and ophthalmologists for surgical intervention in such cases.

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