10.16 Minor Impalement Injuries
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agk's Library of Common Simple Emergencies

Presentation
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A sharp metal object such as a needle, heavy 
wire, nail or fork is driven into or through a 
patient's extremity. In some instances, the 
patient may arrive with a large object 
attached; for instance, a child who has stepped 
on a nail going through a board may be brought 
in with the entire board attached. As minor as 
most of these injuries are, they tend to create 
a spectacle and draw a crowd.

What to do:
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- If you are dealing with an impaled object 
    attached to some thing that is acting like 
    a lever and causing pain with movement, 
    either immediately pull the extremity off 
    the sharp object (if it is straight and 
    smooth) or quickly cut through it to 
    release the patient. You can usually cut an 
    exposed nail or metal spike with an 
    orthopedic pin cutter.
- Obtain x rays when pain and further damage 
    from a leveraged object is not a problem, 
    and when there is a suspicion of an 
    underlying fracture, fragmentation, or 
    hooking of the impaled object, as might 
    occur with a heavy wire that has been 
    thrown from under a lawnmower. It is not 
    necessary to x ray a penetrating nail, form 
    or other non-malleable, non-fragile object 
    that will remain intact and is easily 
    removed regardless of its radiographic 
    appearance.
- Examine the extremity for possible 
    neurovascular or tendon injury.
- If surgical debridement is anticipated after 
    removal of the object, then infiltration of 
    an anesthetic should be provided prior to 
    removal. Otherwise, consider whether or not 
    the patient wants the transient discomfort 
    of local anesthetic before the object is 
    quickly pulled out. Local anesthesia will 
    usually not give complete pain relief when 
    a deeply imbedded object is removed; inform 
    the patient of this.
- Objects with small barbs, such as crochet 
    needles and fish spines, can be removed by 
    first anesthetizing the area and then 
    applying firm traction until the barb is 
    revealed through the puncture wound. The 
    fibrils of connective tissue caught over 
    the barb can then be cut with a scalpel 
    blade or fine scissors.
- After removal of the impaled object the wound 
    should be appropriately debrided and 
    irrigated, as described for [puncture 
    wounds]. Tetanus prophylaxis should be 
    provided and, except for contaminated 
    wounds like a fish spine, a prophylactic 
    antibiotic should not be prescribed.

What not to do:
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- Do not send a patient to x ray with a 
    leveraged object impaled. This creates 
    further pain and possible injury with every 
    movement and the x ray seldom provides 
    useful information.
- Do not try to hand-saw off a board attached 
    to an impaled object. The resultant 
    movement will obviously cause unnecessary 
    pain and possibly harm.

Discussion:
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Simple impalement injuries of the extremities 
should not be confused with major impalement 
injuries of the neck and trunk in which the 
foreign object usually should not be 
precipitously removed. With major impalement 
injuries careful localization with x rays is 
required, and full exposure and vascular 
control in the operating room is also a 
necessity to prevent rapid exsanguination when 
the impaled object is removed from the heart or 
a great vessel. Large impalement injuries of 
the extremities also require immediate surgical 
consultation and thorough consideration of 
potential neurovascular and musculoskeletal 
injuries.

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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