ABSTRACT

CORRESPONDING AUTHOR:
Dr. Siddharth Dubey,
# 64, Tarini Colony,
AB Road, Dewas,
Madhya Pradesh.
E-mail: siddharthdube0905@gmail.com

ABSTRACT: Arrow injuries are frequently seen in tribal areas of Malwa region with homemade bows and arrow. The patients are usually tribal who are drawn from a large, densely populated tribal belt which is referred from periphery and received at trauma center and managed by the surgical team on emergency duty. The aim of study is documentation of cases and statistics for morbidity and mortality, to study various modes of presentation and management, to study complication associated with arrow injuries and the incidence of arrow injury. A retrospective review and analysis of patient records over a period a period of 15 years from April 2000 to May 2015. The injuries sustained are divided into four groups for the purpose of study. The management depended on the group of the patient. Of the 64 patients of arrow injury treated at our hospital, there was mortality in 3 patients (4.68%). The causes of mortality were found to be haemorrhagic shock, septicaemia, pneumonia with respiratory failure. The commonest complication was wound infection seen in 12 patients.

KEYWORDS: Arrow injury, Penetrating injury, Emergency.

INTRODUCTION: Arrow injuries are frequently seen in tribal areas of Malwa region with homemade bows and arrow. The patients are usually tribal who are drawn from a large, densely populated tribal belt which is referred from periphery and received at trauma center and managed by the surgical team on emergency duty. Patients present with various mode and clinical presentation as chest, thoracic abdominal and limb injury. The mechanism of injury is a combination of two sharp forces penetrating action and peripheral sharp cutting action of knife. The treatment depends on site of injury, general condition of patient, presence of arrow in situ and depth of penetration.

Arrow injury and its astute management is still relevant in this century. With the limited hospital setup, managing patient is challenging to surgeon. A poor TRISS score reflects adversely on the survival. Optimal exploration, adequate mobilization of structure, minimizing hemorrhage, prevention of additional injuries and repair remain the building blocks of a successful management.

MATERIAL & METHODS: A retrospective review and analysis of patient record extending over a period of 15 years from April 2000 to May 2015.

All consecutive patients with arrow injury treated after admission at Maharaja Yashwant Rao Hospital and Mahatma Gandhi Memorial Medical College Indore M.P. were studied. A total 64 patients with penetrating arrow injury were managed. The mean age of patients was 35.Majority were males with exception of 2 females.

For purpose of analysis of data the patients were segregated into four groups:

1. 1.      Group I: Chest arrow injury.
2. 2.      Group II: Abdominal injury.
3. 3.      Group III: Thoraco abdominal injury.
4. 4.      Group IV: Limb & head and neck injury.

STATISTICS:

Management in Group I:

Management in Group II:

Management in Group III:

Management in Group IV:

TRISS⁴ (percentage of survival):

DISCUSSION: A majority of tribes in Malwa region India belong to the poor socio-economic group depending on farming or hunting for livelihood. The tribes are vengeful clan fighting over limited resources.

The mechanism⁵ of injury by arrow is a combination of two sharp forces, penetrating action of a dagger and peripheral sharp cutting action of knife. Laceration of tissues is minimal. Because of the sharp margins and pointed ends of the arrowhead the injury is localized to the tissue in direct contact. The external ballistic performance of an arrow is excellent due to the elongated shape and high sectional density. This enhances the arrow’s capability to penetrate deeper.

The quantum of tissue injury and the rate of haemorrage from arrow injury is generally less. Hence unless vital structure most patients with arrow wounds survive for longer period without treatment.

The diagnostic investigations⁶ used were X-ray Chest and abdomen, USG chest and abdomen, CT Scan (spiral), MRI. Intestine, lungs and diaphragm were the organs most frequently injured.

The treatment depends on the site of injury, general condition of patient, presence of arrow in situ and depth of penetration. Those with arrow in situ require additional care and skill in removing the arrow without causing further injury to internal organs. If neurovascular injury is suspected proximal and distal mobilization and control is required before arrow can be extracted. For abdominal injuries, laparotomy is essential.

Stomach, duodenum, jejunum and ileum perforations need to be repaired in two layers. Patients with multiple perforations in small bowel undergo resection and anastomosis.

All colonic perforations need to be primarily except if there is loaded colon with gross contamination or with gross contamination of peritoneal cavity. Liver wounds are sutured with absorbable gelatin sponge. Retroperitoneal haematomas are not to be disturbed unless an active bleed is present. Mesentric and omental tears are repaired with silk suture. Postoperative drainage of the peritoneal cavity is done in all the patients. Early postoperative mobilization is encouraged and chest physiotherapy provided.

CONCLUSION: Of the 64 patients of arrow injury treated at our hospital, there was mortality in 3 patients (4.68%). The causes of mortality were found to be haemorrhagic shock, septicaemia, pneumonia with respiratory failure. The commonest complication was wound infection seen in 12 patients.

Those with penetrating thoracic wounds were managed conservatively with intercoastal drainage. In patients with abdominal wound, stomach was the most frequently penetrated organ (11/20 i.e. 50%) Exploratory Laparotomy was done in all the patients with abdominal wound.

The management⁷ of arrow injury should be along the lines of standard principles of trauma management. Few patients who presented in a state of shock, shock management were the first priority. Simple investigations like X- ray and USG usually suffice for workup and planning of management. The indications of aspiration were very clear as mentioned earlier. Trauma and Injury Severity Score (TRISS) reflects the morbidity and mortality.

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