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Unusual injury caused by a pencil
Unusual Injury Caused by a Pencil By Kenneth Kenigsberg, Richard Ashley, and Filippo DiCarrnine Great Neck, New York e A case involving a 3-yser.old boy w h o sustained a penetrating injury to the perineum is presented.
Copyright ¢ 1995 by W,B. Saunders Company INDEX WORDS: Penetrating injury, perineum.
OST R E P O R T S of pelvic trauma in children
M caused by foreign objects deal with rectal trauma, t The only article we could find that dealt with penetrating pelvic injuries not involving the rectum was one on bull horn injuries. 2 CASE REPORT
A 3-year-old boy was seen in the emergency room with a plastic toy protruding from the perineum. His mother stated that shortly before being brought to the emergency room, he had been playing in the bathtub and had sat on a small plastic toy.
Fig 3. Pencil within bladder next to Foley balloon.
Fig 1. Toy protruding from perinaum.
Fig 2. Pencil lying free in peritoneal cavity. Journal of Pediatric Surgery, Vol 30, No 6 (June), 1995: pp 891-892
On physical examination, the boy was in no particular distress but had a plastic toy protruding from his perineum approximately 6 cm posterior to the anus and slightly to the right of the midline (Fig 1). The toy seemed fixed as if it were deeply embedded. A radiographic film showed a pencil extending from the plastic toy on the perineum slightly to the left of the midline to the level of the third lumbar vertebrae. There was no evidence of free fluid or air. The bladder was catheterized and grossly bloody urine was obtained. A cystogram was performed and showed extravasation of contrast. We were reluctant to perform a contrast enema because it might have introduced another infectious agent into an abdomen already contaminated by urine and a foreign body. The abdomen was explored, and the pencil was seen lying free of the peritoneum superior to the dome of the bladder (Fig 2). There was no obvious
From the Division of Pediatric Surgery, North Shore University Hospital, Great Neck, NY. Address reprint requests to Kenneth Kenigsberg, MD, Division of Pediatric Surgery, North Shore University Hospital, 1000 Northern Blvd, Suite 100, Great Neck, NYl1021. Copyright © 1995 by W..B. Saunders Company 0022-3468/95/3006-0031503. 00/0 891
892
KENIGSBERG, ASHLEY, AND DICARMINE
injury to any part of the large or small bowel, but the pencil had traversed the entire height of the bladder. The pencil had entered the bladder at the trigone somewhat medial to the right ureteral orifice and exited through the left side of the dome (Fig 3). Although there was no obvious perforation of the bowel, the rectum below the peritoneal reflection could not be visualized. Therefore, the child was sigmoidoscopedto the level at which the sigmoidoscope could be palpated from within the abdomen. There was no injury to the retroperitoneal rectum. The bladder perforations were oversewn with interrupted sutures of Vicryl, and the pencil was withdrawn. A Foley catheter was inserted and the cystotomy closed. The patient had an uneventful postoperative course. The catheter was withdrawn 10 days after the procedure. The patient was able to void without difficultythereafter.
a pencil that p e n e t r a t e d the p e r i n e u m , traversed the b l a d d e r , a n d e n t e r e d the p e r i t o n e a l cavity. This m a n e u v e r allowed us to avoid possible extravasation of contrast t h r o u g h a l a c e r a t i o n of intra- or extraperit o n e a l rectum. W e c o n s i d e r e d it useful to r e p o r t this u n u s u a l case. This type of injury c a n be avoided by p r e v e n t i n g small c h i l d r e n from playing with pencils a n d s h a r p - e d g e d toys in the b a t h t u b .
REFERENCES
DISCUSSION
1. Tuggle D, Huber PJ: Management of rectal trauma. Am J Surg 148:806-808, 1984
I n this case, s i m u l t a n e o u s l a p a r o t o m y a n d sigmoidoscopy were p e r f o r m e d to evaluate d a m a g e caused by
2. Idikula J, Moses BV, Sadhu D, et al: Bull horn injuries. Surg Gynecol Obstet 172:220-222, 1991
Copyright ¢ 1995 by W,B. Saunders Company INDEX WORDS: Penetrating injury, perineum.
OST R E P O R T S of pelvic trauma in children
M caused by foreign objects deal with rectal trauma, t The only article we could find that dealt with penetrating pelvic injuries not involving the rectum was one on bull horn injuries. 2 CASE REPORT
A 3-year-old boy was seen in the emergency room with a plastic toy protruding from the perineum. His mother stated that shortly before being brought to the emergency room, he had been playing in the bathtub and had sat on a small plastic toy.
Fig 3. Pencil within bladder next to Foley balloon.
Fig 1. Toy protruding from perinaum.
Fig 2. Pencil lying free in peritoneal cavity. Journal of Pediatric Surgery, Vol 30, No 6 (June), 1995: pp 891-892
On physical examination, the boy was in no particular distress but had a plastic toy protruding from his perineum approximately 6 cm posterior to the anus and slightly to the right of the midline (Fig 1). The toy seemed fixed as if it were deeply embedded. A radiographic film showed a pencil extending from the plastic toy on the perineum slightly to the left of the midline to the level of the third lumbar vertebrae. There was no evidence of free fluid or air. The bladder was catheterized and grossly bloody urine was obtained. A cystogram was performed and showed extravasation of contrast. We were reluctant to perform a contrast enema because it might have introduced another infectious agent into an abdomen already contaminated by urine and a foreign body. The abdomen was explored, and the pencil was seen lying free of the peritoneum superior to the dome of the bladder (Fig 2). There was no obvious
From the Division of Pediatric Surgery, North Shore University Hospital, Great Neck, NY. Address reprint requests to Kenneth Kenigsberg, MD, Division of Pediatric Surgery, North Shore University Hospital, 1000 Northern Blvd, Suite 100, Great Neck, NYl1021. Copyright © 1995 by W..B. Saunders Company 0022-3468/95/3006-0031503. 00/0 891
892
KENIGSBERG, ASHLEY, AND DICARMINE
injury to any part of the large or small bowel, but the pencil had traversed the entire height of the bladder. The pencil had entered the bladder at the trigone somewhat medial to the right ureteral orifice and exited through the left side of the dome (Fig 3). Although there was no obvious perforation of the bowel, the rectum below the peritoneal reflection could not be visualized. Therefore, the child was sigmoidoscopedto the level at which the sigmoidoscope could be palpated from within the abdomen. There was no injury to the retroperitoneal rectum. The bladder perforations were oversewn with interrupted sutures of Vicryl, and the pencil was withdrawn. A Foley catheter was inserted and the cystotomy closed. The patient had an uneventful postoperative course. The catheter was withdrawn 10 days after the procedure. The patient was able to void without difficultythereafter.
a pencil that p e n e t r a t e d the p e r i n e u m , traversed the b l a d d e r , a n d e n t e r e d the p e r i t o n e a l cavity. This m a n e u v e r allowed us to avoid possible extravasation of contrast t h r o u g h a l a c e r a t i o n of intra- or extraperit o n e a l rectum. W e c o n s i d e r e d it useful to r e p o r t this u n u s u a l case. This type of injury c a n be avoided by p r e v e n t i n g small c h i l d r e n from playing with pencils a n d s h a r p - e d g e d toys in the b a t h t u b .
REFERENCES
DISCUSSION
1. Tuggle D, Huber PJ: Management of rectal trauma. Am J Surg 148:806-808, 1984
I n this case, s i m u l t a n e o u s l a p a r o t o m y a n d sigmoidoscopy were p e r f o r m e d to evaluate d a m a g e caused by
2. Idikula J, Moses BV, Sadhu D, et al: Bull horn injuries. Surg Gynecol Obstet 172:220-222, 1991