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It has been stated that a “missed tertiary survey is a missed injury”.1 A missed injury is especially likely when a patient’s life threatening injuries and imminent transfer are a distraction to the attending doctors.
We hope this case reinforces the importance of a thorough head to toe examination despite distractions.
A middle aged civilian worker with the Ministry of Defence was testing an air driven projectile launcher. A technical error led to an explosion of the gas cylinder causing widespread (about 25%) mixed thickness burns to the patient’s face, torso, both arms, and right hand.
The patient was first seen in a local accident and emergency department and given first aid. Transfer was arranged to a regional burns unit, but this was delayed because of the risk of inhalational injury. No radiographs were taken on admission to the district general hospital and there was no recorded secondary survey. On admission to the burns unit his main complaint was the deep burn to his right hand. A small wound on his left forearm, disguised in a dermal burn, was not thought significant (fig 1). It was not until he was scheduled for surgery, five days after admission to the burns unit, that a radiograph of his left arm revealed a large piece of shrapnel embedded in his forearm (fig 2). The only clue was increasing discomfort in the left forearm.
No neurovascular or tendon injury was noted preoperatively. The metal fragments extracted (fig 3) were located very close to the median nerve. The area needed debriding as there was necrotic tissue. After delayed closure there was some transient cutaneous sensory deficit at the wrist, in the distribution of the medial antebrachial cutaneous nerve.
The burns were treated with split thickness grafting.
In the literature shrapnel has been reported as causing significant morbidity long after its insertion.2 In this case, had the patient been operated on sooner his wound may well have been grafted over leaving behind the dirty metal fragments. This may well have lead to abscess formation adjacent to the median nerve with significant consequences.
This case serves as a reminder that thorough secondary and tertiary surveys with relevant investigations are necessary in all trauma cases,3 especially when other distracting factors are present.
Conflicts of interest: none declared.