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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 92-94

Dog bite causing open radial neck fracture with posterior interosseous nerve palsy in a child


1 Department of Orthopaedics, PGIMER, Chandigarh, India
2 Department of Orthopaedics, AIIMS, Delhi, India

Date of Submission10-Feb-2020
Date of Acceptance06-Apr-2020
Date of Web Publication10-Sep-2020

Correspondence Address:
Saurabh Vashisht
15 Ground Floor, Department of Orthopaedics, Nehru Hospital, PGIMER, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JODP.JODP_6_20

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  Abstract 


Fractures secondary to dog bites are extremely rare with an incidence of around 1.4%. These are usually reported above the clavicle in children and in the extremities in adolescents and adults. Upper extremity fractures, other than hand fractures, have been reported very infrequently. We report a rare case of a Gustillo-Anderson grade 3b open fracture of the radial neck with associated posterior interosseous nerve palsy following a dog bite in a 12-year-old boy. The fracture was picked up promptly due to thorough history-taking, careful clinical examination and screening with plain radiographs. The wound was debrided aggressively under antibiotic coverage with standard tetanus and rabies prophylaxis and was allowed to heal by secondary intention after immobilizing the fracture in an above-elbow plaster splint. The fracture united uneventfully and neurologic function recovered completely within 12 weeks with excellent functional outcome at the one-year-follow-up visit.

Keywords: Dog bite, fracture, posterior interosseous nerve palsy, radius neck


How to cite this article:
Patel S, Vashisht S, John R, Bansal T, Kumar V. Dog bite causing open radial neck fracture with posterior interosseous nerve palsy in a child. J Orthop Dis Traumatol 2020;3:92-4

How to cite this URL:
Patel S, Vashisht S, John R, Bansal T, Kumar V. Dog bite causing open radial neck fracture with posterior interosseous nerve palsy in a child. J Orthop Dis Traumatol [serial online] 2020 [cited 2020 Sep 22];3:92-4. Available from: http://www.jodt.org/text.asp?2020/3/2/92/294740




  Introduction Top


Dog bite injury is the most common animal bite injury reported in the literature. The Centers for Disease Control and Prevention estimates about 4.7 million dog bites in the U.S. annually, among whom only 333,000 victims visit a hospital for emergency care.[1],[2],[3] Estimates in India, as per a WHO report, suggest that around 17.4 million dog bites occur in India annually, which is about three times more than that seen in the U.S.[4] These injuries can cause significant morbidity and occasional mortality to the patient; they also carry a significant economic burden to society.[2],[3] Dog bite injuries usually lead to superficial soft tissue injuries and very rarely cause fractures.[5] Faciomaxillary and skull fractures are the most common dog bite-related fractures reported in children aged 5 years or less.[5],[6],[7] In older children, adolescents, and adults, extremity fractures are more common.[6],[7] In this report, we present a unique, interesting case of an open fracture of the radial neck with posterior interosseous nerve (PIN) palsy in a 12-year-old male child caused by a dog bite. No such case has been reported in the literature to date.


  Case Report Top


A 12-year-old male child presented to us after sustaining a dog bite injury over his right upper forearm region by a stray dog while playing on the streets. There was no history of an associated fall before, during, or after the injury incident. On examination, the patient had two large wounds over the lateral aspect of the proximal forearm, measuring approximately 8 cm × 6 cm and 6 cm × 3 cm, respectively. The elbow was swollen and tender. The exposed muscles were severely contused and lacerated [Figure 1]. Elbow movements were painful; although he was able to extend his wrist actively, he had a distal neurological deficit in the form of finger and thumb drop. Plain radiographs of the right elbow were taken to rule out fracture (s) as the soft tissue injury was extensive and also because of the neurologic deficit. A minimally displaced radial neck fracture was noted on the radiographs [Figure 2]. Tetanus and rabies vaccinations were given promptly as per standard protocols. He also received 500 IU of intramuscular tetanus immunoglobulin as part of tetanus prophylaxis. The wound was debrided meticulously under empirical antibiotic coverage (cefuroxime, amikacin, and metronidazole) and thoroughly washed with copious amounts of normal saline. The PIN was explored and found to be in continuity. Primary closure was not done due to the notoriously high risk of infection, which has been observed in open fractures secondary to animal bites.[8] An above-elbow plaster splint was given with the limb in 90° flexion and pronation along with a custom-made cock-up extension splint for the wrist, fingers, and thumb; the limb was kept elevated to reduce associated swelling. The dressing was changed daily for 2 weeks with paraffin-soaked gauzes.
Figure 1: Wound status and progression of wound on follow-up. (a) Wound status on presentation, (b) wound after 3 weeks follow-up

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Figure 2: Anteroposterior and lateral radiographs at presentation

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The patient was thereafter followed up at weekly intervals until the wounds healed by secondary intention by about 3 weeks; this was followed by monthly visits for the next 3 consecutive months. Fracture united clinically and radiologically by 8 weeks, and there was complete neurologic recovery by 12 weeks. On the latest follow-up at 1-year postinjury, the patient had full range of motion of the elbow with no distal neurologic deficit and had returned to the preinjury activity levels [Figure 3], [Figure 4], [Figure 5].
Figure 3: Anteroposterior and lateral radiographs at 1-year follow-up

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Figure 4: Clinical photograph at 1-year follow-up showing healed wound and full elbow range of motion

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Figure 5: Clinical photograph at 1-year follow-up showing full extension of thumb

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  Discussion Top


Numerous reports have made known that faciomaxillary injuries are the most common dog bite injuries in children aged 5 years or less; various types of facial and skull fractures have been described in different case series.[9],[10] In particular, Wei et al. performed a retrospective review of around 1200 dog bite injuries to the face; they observed that only 17 cases (1.4%) were associated with facial fractures.[9] Among them, around 33% of patients had multiple facial fractures, 24% of patients had associated facial nerve palsy, and 18% of patients sustained a canalicular injury.

In contrast, adolescents and adults more commonly sustain injuries to the lower extremity and the hands.[5] Fractures of the hand after dog bites are very rare; upper limb fractures other than fractures of the hand are even rarer.[5],[11] To date, only two reports have described pediatric upper limb fractures other than hand fractures, secondary to a dog bite injury.[5],[12]

Wass and Goodacre reported two cases of open fracture secondary to dog bite in a 2-year-old children.[5] One child sustained a supracondylar humerus fracture while the other child sustained both bone forearm fracture; there was no associated neurovascular injury in either of the two cases. Both fractures were treated conservatively after through debridement and lavage of wounds under prophylactic antibiotic coverage. Fractures united uneventfully, and a good functional outcome was achieved in both the cases. Dimant et al. reported two cases (aged 12 and 19) of open wrist fractures.[12] They emphasized that such fractures should be treated as high-grade, open fractures due to considerable soft tissue trauma and exposure to canine bacterial flora, particularly Pasteurellamultocida, which is the most common bacterium causing osteomyelitis after dog bites.[12],[13]

A high index of suspicion for fractures should be maintained in dog bite cases in order not to miss fractures caused by dog bites, especially so in children. A detailed history should be elicited from the victim or a reliable witness to understand the mechanism of injury. All victims must be carefully examined for loss of adjacent joint motion, abnormal mobility, excessive swelling/tenderness, and distal neurovascular deficit; a low threshold should be maintained to obtain radiology in doubtful cases. The previous history of tetanus vaccinations must also be recorded. In general, signs and symptoms out of proportion to the skin wound severity may suggest an underlying skeletal and/or neurovascular injury.[5],[11]

These fractures are usually caused due to the crushing effect generated by the jaws of the dog or due to indirect torsional forces applied by the dog if it shakes its head during the bite or usually a combination of both mechanisms. Whatever be the mechanism of injury, it has to be assumed that the open wound is communicating with the fracture; the resultant open fracture should be graded as a highly contaminated, open fracture (Gustillo-Anderson grade 3A/B – irrespective of the size of the wound).[5],[14],[15]

The estimated risk of infection after a dog bite varies from 5% to as high as 25% in the literature.[14] A formal, thorough debridement of all devitalized tissue, wound wash with large amounts of saline, prompt tetanus and rabies prophylaxis, and intravenous empirical antibiotic coverage are a must in all cases. The bite wounds are usually allowed to heal by secondary intention as primary closure increases the chances of wound infection and/or osteomyelitis.[5],[14],[15] Surgical fixation of fractures with hardware in the initial sitting is also avoided for the same reason, especially in children, due to the additional advantage of remodeling potential.[16]


  Conclusion Top


Although extremely uncommon, the chances of bony injuries must be considered in the upper extremity dog bite injuries. Debridement, wound wash with large amount of saline, prompt tetanus and rabies prophylaxis, and intravenous empirical antibiotic coverage are a must in all cases. The bite wounds are allowed to heal by secondary intention as primary closure increases the chances of wound infection and/or osteomyelitis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Centre for Disease Control and Prevention (U. S.). Dog bite prevention. Available from: http://www.cdc.gov/homeandrecreationalsafety/dog-bites/biteprevention.html. [Last accessed on 2011 Sep 27].  Back to cited text no. 1
    
2.
Anonymous. Nonfatal Dog Bite-Related Injuries Treated in Hospital Emergency Departments-United States, 2001. Morb Mortal Wkly Rep 2003;52: 605-10.  Back to cited text no. 2
    
3.
Weiss HB, Friedman DI, Coben JH. Incidence of dog bite injuries treated in emergency departments. JAMA 1998;279:51-3.  Back to cited text no. 3
    
4.
Gongal G, Wright AE. Human rabies in the WHO Southeast Asia Region: Forward steps for elimination. Adv Prev Med 2011;2011:383870.  Back to cited text no. 4
    
5.
Wass AR, Goodacre S. Dog bites causing upper-limb fractures in children. Injury 1996;27:433-5.  Back to cited text no. 5
    
6.
Avner JR, Baker MD. Dog bites in urban children. Pediatrics 1991;88:55-7.  Back to cited text no. 6
    
7.
Zook EG, Miller M, Van Beek AL, Wavak P. Successful treatment protocol for canine fang injuries. J Trauma 1980;20:243-7.  Back to cited text no. 7
    
8.
Maimaris C, Quinton DN. Dog-bite lacerations: a controlled trial of primary wound closure. Arch Emerg Med 1988;5:156-61.  Back to cited text no. 8
    
9.
Wei LA, Chen HH, Hink EM, Durairaj VD. Pediatric facial fractures from dog bites. Ophthalmic Plast Reconstr Surg 2013;29:179-82.  Back to cited text no. 9
    
10.
Tu AH, Girotto JA, Singh N, Dufresne CR, Robertson BC, Seyfer AE, et al. Facial fractures from dog bite injuries. Plast Reconstr Surg 2002;109:1259-65.  Back to cited text no. 10
    
11.
Aslam A, Dickinson JC. Dogs bite bones too-A tale of fractures in adult hands. Injury 1999;30:374-6.  Back to cited text no. 11
    
12.
Dimant A, Liebergall M, Porat S, Mosheiff R. Treatment of open fractures due to dog bite. Harefuah 1997;132:461-3, 527.  Back to cited text no. 12
    
13.
Talan DA, Citron DM, Abrahamian FM, Moran GJ, Goldstein EJ. Bacteriologic analysis of infected dog and cat bites. Emergency Medicine Animal Bite Infection Study Group. N Engl J Med 1999;340:85-92.  Back to cited text no. 13
    
14.
Abrahamian FM, Goldstein EJ. Microbiology of animal bite wound infections. Clin Microbiol Rev 2011;24:231-46.  Back to cited text no. 14
    
15.
Cummings P. Antibiotics to prevent infection in patients with dog bite wounds: a meta-analysis of randomised trials. Ann Emerg Med 1994;23:535.  Back to cited text no. 15
    
16.
Evgeniou E, Markeson D, Iyer S, Armstrong A. The management of animal bites in the United kingdom. Eplasty 2013;13:e27.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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