Unusual pediatric thoracic trauma management in a low-resource setting: A case report

INTRODUCTION

Thoracic trauma in the pediatric population is a significant cause of morbidity and mortality, contributing to up to 25% of trauma-related deaths in children.¹ However, penetrating chest injuries in this age group are relatively uncommon when compared to blunt trauma. Most penetrating injuries result from road traffic injuries, violence, or accidental impalements, and only a handful of cases have been reported in the literature where such injuries were caused by falling natural objects.² The pediatric chest wall is more compliant than in adults, offering less protection to internal organs, which increases the risk of internal injuries even with minor external force. Penetrating injuries involving wooden foreign bodies introduce an additional layer of complexity. Due to their porous nature and potential contamination with environmental microorganisms, wooden materials have a higher propensity for causing infections, abscesses, and delayed complications. Furthermore, they may fragment or splinter, making complete removal and wound management challenging. In rural areas, children often engage in outdoor activities without adult supervision, increasing their risk for trauma from environmental hazards. Many times, severe injuries do not give enough time to seek medical care and lead to mortality on the spot. Timely recognition and management of such injuries are crucial to reducing morbidity. Here, we present a rare case of a penetrating thoracic injury in a child caused by a falling coconut tree branch in a rural setting, detailing the clinical presentation, surgical approach, and postoperative course.

CASE REPORT

An 11-year-old male presented to the Emergency Department of our hospital following a penetrating chest injury. The injury occurred while he was lying under a coconut tree, and a sharp-ended branch fell vertically onto him, penetrating his right supraclavicular region. On presentation, the patient was alert and hemodynamically stable but exhibited signs of respiratory distress. Examination revealed a visible penetrating wound at the right supraclavicular region with the distal portion of the wooden branch palpable within the right hemithorax [Figure 1]. Breath sounds were reduced on the right side. There was no external bleeding or signs of other systemic trauma. He had extensive subcutaneous emphysema with tachypnea and reduced depth of respiration, indicating respiratory distress. Chest X-ray (CXR) revealed a right-sided pneumothorax with a foreign body extending into the right hemithorax, with the diaphragm intact [Figure 2]. There was no evidence of significant hemothorax or mediastinal shift. A right-sided intercostal chest drain (ICD) was inserted in the emergency department in the 5^th intercostal space along the anterior axillary line to decompress the pneumothorax. The drainage was minimal, and there was no active bleeding. There was no evidence of sensory or motor deficit in the right upper limb, nor was there vascular compromise in that limb. Pulses were well felt. No attempt was made to remove the impaling object prior to definitive surgical management. As the patients' tetanus immunization status was not known, tetanus immunoglobulin was arranged and administered as per the pediatrician.

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Figure 1:

Site of penetration by wooden piece (yellow arrow)

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Figure 2:

Chest radiograph showing penetration by a wooden piece along with a radiolucent object at its tip (yellow arrow), and subcutaneous emphysema in the chest (black arrow)

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Following stabilization, the patient was taken to the operating theatre for surgical exploration. A right anterior thoracotomy was performed along with exploration of the supraclavicular wound to facilitate safe removal of the foreign body [Figure 3]. The wooden branch was extracted through the supraclavicular wound under direct visualization [Figure 4]. Intraoperative findings included a laceration of the upper lobe of the right lung, which was repaired with absorbable sutures. There were no injuries to the diaphragm, pericardium, or great vessels. Hemostasis was achieved, and a fresh chest tube was inserted. The thoracotomy and supraclavicular wounds were thoroughly washed and closed in layers. The patient was extubated 6 hours after surgery, after ensuring satisfactory oxygenation on arterial blood gas analysis. A CXR prior to extubation also confirmed satisfactory lung expansion. FiO2 was kept at 50% as a part of lung protective ventilation, as oxygenation was satisfactory, with tidal volume as per body weight. No air leak was noted postoperatively. On postoperative day 2, the patient developed a low-grade fever. Blood cultures were sterile, but due to the high risk of infection from organic material, empirical broad-spectrum antibiotics were escalated. The fever resolved within 48 hours. Serial CXRs showed satisfactory lung re-expansion and no residual collection. The chest tube was removed on postoperative day 3. The patient was discharged on day 6 with instructions for follow-up.

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Figure 3:

Intraoperative image showing penetration by a wooden piece (red arrow) and a right thoracotomy access (green arrow)

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Figure 4:

Penetrating piece of wood after successful extraction (metallic chain entangled at its tip)

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DISCUSSION

Penetrating thoracic injuries in children are rare and typically involve man-made objects or projectiles.² Injuries caused by wooden materials are particularly concerning due to the risk of retained fragments, infection, and delayed complications such as empyema or abscess formation.^3,4 The presence of a wooden foreign body necessitates surgical exploration. Computed tomography (CT) scans are typically superior in identifying radiolucent wooden materials and associated complications.⁵, though in this case, initial imaging with CXR was sufficient to identify the foreign body due to its size and radio-opacity caused by metallic fragments stuck to it. While CT is ideal for surgical planning, in this case, the decision to proceed without CT was based on clinical urgency and safety considerations, as the child wasn’t cooperative and we preferred to avoid sedation, considering his borderline hemodynamics. The operative management of penetrating lung injuries depends on the extent of parenchymal damage, the location of injury, and the hemodynamic status of the patient. Pneumonorrhaphy is preferred for limited, peripheral lung lacerations as it allows rapid control of air leaks and bleeding while preserving functional lung tissue. Pulmonary tractotomy is useful for through-and-through injuries with deeper parenchymal involvement, permitting direct visualization and selective ligation of injured bronchi and vessels along the wound tract. Non-anatomical (wedge) resections are reserved for localized but non-repairable injuries, whereas anatomical resections, such as lobectomy, are considered only in cases of extensive destruction or uncontrollable hemorrhage. In the present case, the limited parenchymal injury without major vascular involvement allowed effective management with pneumonorrhaphy, avoiding unnecessary lung resection and associated morbidity.

Thoracotomy remains the standard approach for safe removal of intrathoracic foreign bodies and management of associated injuries.⁶ Anterior thoracotomy provides quick access with satisfactory visualization of the thoracic structures, and the same was employed in this case. Video-Assisted Thoracoscopic Surgery may be considered in cases where the patients are absolutely stable, with the availability of preoperative CT images and expertise. In this case, early surgical intervention and lung repair prevented further complications. The post-operative fever highlighted the risk of infection. Organic materials like wood are associated with polymicrobial infections, including gram-positive, gram-negative, and anaerobic organisms.⁷ Premature removal of impaled objects in prehospital settings is better avoided without the availability of specialized care, as there is potential for catastrophic hemorrhage. Further, pediatric trauma necessitates the availability of a pediatric team, as well as a competent emergency and thoracic surgical team to deliver the best possible resuscitation and care. Intensive care following major surgery also plays a very significant role. Broad-spectrum antibiotics, tailored when necessary, are crucial to prevent sepsis and wound complications. This case also underlines the challenges in managing pediatric trauma, where delays in presentation or lack of specialized care could result in worsened outcomes.⁸

CONCLUSION

This case illustrates the successful management of an unusual pediatric penetrating thoracic injury caused by a falling coconut tree branch in a low-resource setting—an uncommon mechanism of trauma in a village with potentially life-threatening consequences. The case emphasizes the critical importance of rapid assessment and referral, timely surgical intervention, and appropriate post-operative care. Wooden foreign bodies, especially those contaminated from natural environments, pose a high risk of infection and necessitate prompt removal and antibiotic coverage. Injuries of this nature, although rare, must be approached with a high degree of suspicion and preparedness, particularly in low-resource settings where access to immediate specialized care may be limited. Early stabilization, imaging, and intervention can significantly reduce complications and improve outcomes. As outdoor injuries from natural elements continue to be part of the pediatric trauma spectrum in tropical regions, this case highlights the need for awareness and readiness in both emergency and surgical settings.