Gioia, Sara MD; Bacci, Mauro MD; Lancia, Massimo MD; Carlini, Luigi MD; Suadoni, Fabio MD
Penetrating head injuries represent about 0.4% of head injuries.1 Among the penetrating head injuries, the transorbital ones represent about 24% in adults and 45% in children,2 resulting so in a very uncommon type.3
The orbit is the most vulnerable structure of the skull; because of its thin walls, offering only little resistance to the penetrating object, the orbit is a preferential pathway for foreign bodies,4 not usually strong enough to penetrate other regions of the cranium.
Intracranial penetrating transorbital injuries can differ greatly in between each other from a clinical point of view; sometimes they can have a dramatic onset, but sometimes they can be initially occult5 even without clinical neurological findings.6–8
The degree of neurologic damage is related to the impact velocity of the foreign object as well as its size, shape, and trajectory.
By impact velocity, there are 2 classes of projectiles implicated in transorbital penetrating injuries—missile and nonmissile. Missile projectiles are defined as having an impact velocity of more than 100 m/s and cause injuries by tissue laceration and maceration but also via kinetic and thermal energy; nonmissile projectiles have an impact velocity of less than 100 m/s and cause injuries only by tissue laceration and maceration.9
High-velocity injuries usually result in direct fractures of the orbital walls,10–13 whereas low-velocity penetrations may be deflected by the particular configuration of the orbit.14–17
In fact, the orbit is like a horizontal pyramid on a posteromedially directed axis, with a quadrangular base formed by the orbital rim, converging triangular sides formed by the orbital walls and an apex terminating at the superior and inferior orbital fissures and the optic canal. This anatomical structure can lead the low-velocity penetration toward the apex and the anatomical fissures,18 which can provide, in this way, a direct access to the cranial cavity19 even in case of no significant bony fractures.20
In literature, we can find lots of cases of penetrating transorbital injuries with the survival of casualties; death cases caused by this kind of injuries are rare.
On this point, we describe a peculiar autopsy case of a male worker, having a fatal brain stem injury resulting from a transorbital penetration, after an accidental fall onto a screw that was lightly stuck in a wooden board.
On November 21, 2011, at about 4 pm, C.G., a 48-year-old man, was working in a building site. He was lightly hammering some metallic screws on a wooden board laid on the ground and was tightening them up with an electric screwdriver. As reported by some eyewitnesses, while sticking a 13-cm screw on the board, he had accidentally fallen on it, lying prone on the ground. He was helped, but he was dead. He had the screw stuck in his left orbit. Forensic autopsy was performed 48 hours later.
External examination of the body showed the following:
- Presence of the sharp terminal extremity of the screw, protruding 3.5 cm from the inferolateral quadrant of left eye socket, declined from left to right anteroposteriorly at an angle of about 35 degrees and from top to bottom at an angle of about 5 degrees (Fig. 1);
- Ecchymosis and lacerated wounds to the superior and inferior left eyelid and to the upper right eyelid, and scratch on the right cheek;
- Preservation of the left ocular globe.
The subsequent internal examination of the body allowed the following traumatic findings to be identified:
- Emergence of the flat extremity of the screw at the cranial base, on the spheno-occipital synchondrosis level and at the base of the occipital bone, protruding about 2.5 cm in the posterior right cranial cavity, accompanied by a displaced bony fragment (Fig. 2);
- Disruption of the brain stem and part of the right cerebellar hemisphere.
Organ and body fluid samples were taken for further histologic and toxicologic analysis. Results of toxicologic examinations, carried out on central and peripheral blood, were negative for narcotics, psychoactive drugs, and alcohol. The investigations have been completed with a histologic examination of the organs. Samples were embedded in paraffin, and 4-µm thick sections were cut and stained with hematoxylin-eosin. Preparation of samples from the organs only revealed blood infiltration in the brain stem and right cerebellar hemisphere, with morphologically intact red blood cells and no granulocytes. In conclusion, the cause of death was a neurogenic shock due to brain stem injury and right cerebellar hemisphere, in the occasion of an accidental fall.
Furthermore, the lesions occurring on the right eyelid and cheek resulted compatible with an impact against the edge of one of the many wooden boards surrounding the scene, on which the worker might have fallen.
The prosecutor, through extensive inquiry and interrogation of the colleagues of the deceased, excluded any possibility of a violent confrontation around the time of the accident.
Transorbital penetrating injuries can be accidental or intentional (inflicted21 or self-inflicted).22–27 Among accidental traumas, many cases of penetrating transorbital intracranial injury caused by unusual objects, including toilet brush handles,28 stems of ferns,29 pencils,30 door keys,31 forks,32 faucets,33 metal shelving bars,34 branches,35 knitting needles,36 toy arrows,37 chopsticks,38 and automobile wiper-control stalks,39 have been published.
In case of transorbital penetrating injury, brain damage is generally limited to the directly affected area and wound tract, so in absence of direct injury to the brain stem or laceration of a major intradural vessel, prognosis is quite good.40
In fact, there have been many survival cases published after such kind of traumas, whereas fatal cases of the same kind are rare.
According to our review of the international literature (Table 1), in the past 5 decades (1960–2013), there were only 11 cases of fatal transorbital penetrating injury.41–50 Among them, 7 cases were accidental, 1 case was a suicide, and 1 case was a homicide. The dynamic of the other 2 cases was unknown. Surgical treatment was performed only in 2 cases. Sudden death, due to penetration, was described in no cases, and the most common sites of intracranial injury were the anterior and middle cranial fossae. Ocular globe rupture was described in only 2 cases.
The case under discussion is about a 13-cm long penetrating screw (Fig. 3). The dynamic of the accident is peculiar because rather than presenting a nonmissile object moving toward the target, it features the victim actively falling onto a stationary penetrating body.
Penetrating screw and nail injuries, according to this dynamic, are rare cases; penetrating injuries by this kind of objects have mostly been reported as nail gun injuries.51
Furthermore, another peculiarity of this case is that the screw pierced the cranium not with the sharp end but with the flat one. In literature, among lots of intracranial penetrating wounds caused by screws, there is only one other case of the same type, described by the authors as a “reverse penetration.”52
The fatal intracranial damage caused by the screw detected in the autopsy is in contrast with the absence of damage to the ocular globe. This is in line with literature where in the case of transorbital penetrating injuries, the ocular globe may be preserved.53 This is possible because the ocular globe, which is suspended within the orbital cavity, is fairly resilient to trauma due to its tough sclera and its relative mobility within the surrounding bed of intraorbital fat.54,55 So, during the penetration, the globe may be pushed aside letting the foreign body traverse the orbit, leaving possible ecchymosis or conjunctival hemorrhage as the only evidence of injury.56
In our case, the fatal injury to the brain stem and to the right cerebellar hemisphere was made possible by the considerable length (13 cm) of the penetrating screw. Wounds caused by penetrating bodies to the posterior cranial fossa are generally linked to nontransorbital penetrations brought about, in most cases, by objects with high impact energy57–59 and more commonly associated with diffuse brain damage.60
Moreover, death due to the neurogenic shock was instantaneous, unlike the reviewed fatal cases, because the screw directly disrupted the brain stem, the site of cardiorespiratory centers.
Therefore, the combination of the aforesaid peculiar features, such as the dynamic of the event, the way of penetration, the kind of injury, and the sudden fatal outcome, makes this case absolutely unique among the pertinent cases in the international literature.
Transorbital penetrating injuries represent a very uncommon subset of head trauma. In such cases, brain damage is generally restricted to the directly affected area, so, in the absence of injury to the brain stem or to a major intradural vessel, prognosis is quite good.
According to our review, there were only 11 case reports of fatal transorbital penetrating injury in the international literature.
With regard to that, we describe a very peculiar autopsy case of a male worker who had a fatal brain stem and cerebellar injury resulting from a transorbital penetration after an accidental fall onto a 13-cm-long screw. The foreign body entered the cranium 9.5 cm deep with its flat end; the death was instantaneous due to the injuries to the brain stem and the cerebellum.
In light of the review, our case shows many atypical features, whose combination makes this case absolutely unique among the pertinent cases in the international literature.
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