The patient, a 30-year-old male, was admitted to the emergency department of our hospital because of the penetrating injury to his right shoulder and chest wall caused by collision with the roadside fence when he drove a car (Fig. 1A,1B). At the time of admission, he had a clear mind, stable vital signs, a gcs score of 15 points, unbearable pain in his right shoulder and chest wall, and no abnormal breathing. Examination showed that a hollow metal fence of about 13*6*30 cm penetrated from the middle of his right latissimus dorsi (Fig. 1C), and exited above his right clavicle. He couldn’t lift his right upper arm nor move his right elbow, but his right wrist was moving normally and the skin on his right forearm and upper arm was feeling well. The trauma assessment was completed in the emergency department, and his head CT scan demonstrated a fracture of his left occipital condyle (the fracture line involved the ipsilateral atlantooccipital joint surface), but no obvious intracranial hemorrhage was observed. There were no signs of bleeding into thoracic cavity nor of pneumothorax by CT scanning of cervical vertebra and chest in this patient, but a fracture of the left anterior arch of the atlas and a right scapula fracture were found. His right shoulder and chest wall were penetrated by a foreign body (Figs. 2A, 2B). Three-dimensional reconstruction of his right shoulder joint CT prompted a foreign body to come out from the front of his right clavicle (Fig. 2C). His right upper artery angiography showed that the right axillary and brachial arteries were slightly thinner, the right radial artery was unclear, and the right ulnar artery was thin and unclear, suggesting comminuted fractures of the right humeral shaft and scapula. There was no obvious abnormality in the clinical blood test results. After the multi-disciplinary discussion in the emergency department, we planned to perform an emergency operation to take out the foreign body from his right shoulder with the consent of the patient and his family.
Surgical procedure: After being anaesthetized, the patient was placed in the right lateral decubitus position, and his right upper extremity and right side of trunk were routinely disinfected with a drape. During the operation, a foreign body penetration injury on his right shoulder could be seen. A 13 * 4 cm wound on the front and a 13 * 6 cm wound on the back of the body were visible. PVP iodophor solution was used again to sterilize the foreign body and surrounding tissues of the wound. Exploring the anterior wound, we observed that the metal fence penetrated the body from the junction of the right side of platysma, anterior bundle of deltoid and pectoralis major. The cephalic vein had been damaged and formed a traumatic thrombosis. The injured blood vessel was removed and the stump was sutured and ligated. When slowly pulling out the metal fence to the back and outside, we probed again and found that it penetrated from the front of the patient's right clavicle, and touched the axillary artery pulsation on the anterior and lateral sides of the foreign body. There was no obvious bleeding in the axillary artery and vein, and some branches of his right brachial plexus nerve were damaged. After removing the foreign body, we carefully explored on his right thoracicodorsal wound. It was found that his right serratus anterior muscles, teres major muscles, teres minor muscles, infraspinatus muscles, latissimus dorsi muscles and right thoracodorsal nerve were partially injured. Intraoperative fluoroscopy confirmed no obvious foreign body residue (Fig. 3A). The broken end of the right scapular fracture could be touched. The wound area stopped bleeding completely after flushed with PVP, hydrogen peroxide and saline again, and a drainage tube was placed on his right thoracicodorsal wound (Fig. 3B). The wound was covered with iodoform gauze and applied with pressure bandage (Fig. 3C).
The revaluation of the patient’s upper limb function after surgery revealed that his right wrist moved normally, but he had the dermal sensation exceptionally on his right forearm and upper arm. Postoperative MRI examination of his right shoulder joint showed comminuted fractures of the proximal humerus and scapula, injury of glenoid labrum of his articulatio humeri, and partial injury of the tendon of biceps brachii muscle and tator cuff. Multiple muscles and muscle gap were injured around articulatio humeri, and local subcutaneous soft tissues were defected, but the brachial plexus bundle was intact at both injury sites. The patient was transferred to the burn department for flap transplantation two weeks later. His humeral shaft fractures were treated with the standard open reduction and internal fixation techniques, which significantly improved the symptoms of decreased muscle strength and restricted right upper extremity postoperatively.