Journal of Clinical Gerontology & Geriatrics 5 (2014) 28e30
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Case report
Management of severe musculoskeletal trauma following a dog mauling attack in a nonagenarian Davida A. Robinson, MD, Melissa L. Whitmill, MD * Department of Surgery, Boonshoft School of Medicine, Wright State University, Dayton, OH, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 18 June 2013 Received in revised form 27 July 2013 Accepted 9 August 2013 Available online 2 October 2013
Dog bites are increasingly common injuries and pose a significant public health concern. We present a case of a 92-year-old woman who sustained severe musculoskeletal trauma to the bilateral upper and lower extremities following a mauling attack by her two pet Boston Terriers. Patterns of injury and risk factors for dog bite-related injuries, as well as important clinical considerations in the medical and surgical management of dog bite injuries are discussed. Copyright Ó 2013, Asia Pacific League of Clinical Gerontology & Geriatrics. Published by Elsevier Taiwan LLC. All rights reserved.
Keywords: Bites Dogs Elderly Extremities
1. Introduction Dog bites and maulings are an increasingly prevalent public health issue in the United States and throughout the world.1,2 These injuries not only result in significant morbidity and mortality, but are also a significant source of psychological stress and personal and societal economic loss.3,4 In fact, dog bites are the second most costly public health problem in the United States.3 Although these injuries predominantly occur in the pediatric population, they are not uncommon in adults, including the elderly population.1,5 In a series by Langley,6 dog bites occurring in persons over 63 years of age accounted for 22.1% of total dog bites. We herein describe the case of a nonagenarian who sustained extensive musculoskeletal trauma to the bilateral upper and lower extremities. Patterns of injury, risk factors, and important clinical considerations in the medical and surgical management of dog bite injuries are discussed. 2. Case report A 92-year-old woman with a history of hypertension, hypothyroidism, gastroesophageal reflux disease, anemia, osteopenia, arthritis, anxiety, depression, and dementia, which was adequately * Corresponding author. Department of Surgery, Boonshoft School of Medicine, Wright State University, 128 East Apple Street, Weber Center for Health Education, Suite 6816, Dayton, OH 45409, USA. E-mail address:
[email protected] (M.L. Whitmill).
managed with donepezil, was found down on the floor of her home following a mauling attack by her two pet Boston Terriers. The patient’s preinjury functional status was good. She was reportedly reasonably functional within the home, was able to perform most activities of daily living, and was able to ambulate around the home independently. She did not have any medical conditions that would predispose her to impaired wound healing. The patient sustained the following injuries: deep puncture wounds of the right upper extremity with full thickness skin loss on the radial aspect of the forearm, hand, and base of the thumb; a palpable step off at the right second metatarsal head; full thickness skin loss of the dorsum of the hand and partial forearm with visible extensor tendons of the left upper extremity; circumferential, full thickness tissue loss of the right lower extremity with tibia and tendons exposed (Fig. 1A and B); and two large medial and lateral wounds of the calf and multiple puncture wounds of the left lower extremity (Fig. 2). Tetanus toxoid was administered, and the patient was admitted to the intensive care unit for wound care and resuscitation. On posttrauma Day 2, the patient underwent a closed reduction and percutaneous pinning of second metacarpal fracture, irrigation and debridement of bilateral upper and left lower extremities with integra graft coverage and vacuum-assisted closure placement, and simple closure of multiple lacerations of the bilateral hand and left foot. Intraoperative examination of the right lower extremity demonstrated extensive damage and it was determined that an attempt of limb salvage was not possible. Therefore, a below-the-
2210-8335/$ e see front matter Copyright Ó 2013, Asia Pacific League of Clinical Gerontology & Geriatrics. Published by Elsevier Taiwan LLC. All rights reserved. http://dx.doi.org/10.1016/j.jcgg.2013.08.002
D.A. Robinson, M.L. Whitmill / Journal of Clinical Gerontology & Geriatrics 5 (2014) 28e30
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Fig. 1. (A and B) Right lower extremity with circumferential, full thickness tissue loss.
knee amputation was performed. On postoperative Day 7, the patient underwent split thickness skin coverage of the remaining distal extremities, in addition to a percutaneous endoscopic gastrostomy tube placement for nutritional support. On post-trauma Day 11, the patient developed progressive respiratory distress following presumed aspiration, with acute respiratory failure and asystole. No attempts at resuscitation were made according to the patient’s advanced directives, and the patient died. 3. Discussion Dog bites and maulings remain a significant cause of preventable injury globally. Approximately 1.5% of the US population alone (4.7 million people) are involved in dog bite injuries annually,2,3 which result in significant morbidity and mortality with 885,000 persons/year requiring medical attention; 31,000 persons/year requiring reconstructive surgery; and an average of 19 deaths being reported annually, with a range of 11e33 deaths/year.3 The reported incidence is increasing in the United States by an average of 1.7% annually.1 The increase in dog-related injuries is projected to be even greater secondary to a significant underestimation of cases because many of these injuries go unreported.1,2 Interestingly, dog bites occur most commonly with dogs that are household pets and with persons with whom the dog is most familiar with.1,3 This is epidemiologically significant when one considers that not only is dog ownership in the United States increasing, but also this increased incidence is proportionate to the number of dogs in the household.2
Fig. 2. Multiple puncture wounds of the left lower extremity.
Risk factors for dog attacks are variable and include the breed, sex, and reproductive status of the dog, and personal history of aggression of the dog, with the highest incidence among Bull Terriers, reproductively intact male dogs, and dogs with a history of aggression.1,7 The presence of multiple dogs rather than a solitary dog may also increase the risk of attack secondary to triggering of a natural pack instinct to display territorial behavior and exert social dominance, particularly when involving an unaccompanied child or elderly female.8 Chained dogs, living in a low-income neighborhood, and certain occupations with inherent hazards have also been associated with increased risks.1,3 The presence of mental disorders, particularly anxiety, dissociation, and somatoform disorders, are also associated with an increased risk for dog bite injuries.9 In addition to nonmodifiable behaviors, modifiable behaviors, including teasing, provoking, or disturbing a sleeping or feeding dog, or running away from a dog, have also been identified as risk factors, although many victims have been involved in normal nonprovoking activities prior to the attack.1 Breed type, presence of multiple dogs, personal history of aggression by the dogs, behavior that possibly may have been interpreted as provocative, and dementia may be contributory factors to the mauling attack sustained by our patient. According to the patient report, the patient had fallen and was unable to get up. It is unclear whether the patient’s attempt to get the attention of the household member present in the house at the time of the incident was interpreted by the dogs as provocative behavior, or if her unusual presence on the floor was thought to be an infringement of the dogs’ territorial space, thereby initiating the mauling attack. In addition, the dogs were known to have a personal history of aggression. According to her family report, “when [the dogs] get excited, they bite.” Another possible risk factor specific to our patient is that two dogs were present in her house. The behavior of dogs within a pack has been reported to be more aggressive than that of solitary dogs related to innate instincts that are adaptive to the survival of the pack. The sex and reproductive status of these Boston Terriers are not known. Dog bites are capable of inflicting extensive musculoskeletal and neurovascular injury. A dog’s canine teeth are designed to rip and tear.4 In addition, a large dog’s jaw can exert a crushing force of 50 100 kg/cm2.10 Consequently, dog bites are capable of having both penetrating, blunt, traction, and torsional shearing components to the injury, and typically cause longitudinal lacerations, which are more likely to inflict direct structural damage to nerves, tendons, blood vessels, and joint structures.4,11 These injuries may also be exacerbated by the victim struggling against or being shaken by the dog.11 Operative intervention is frequently required. In a series by Benfield et al,11 interventions included wound irrigation and debridement (51.2%), orthopedic (25.6%) and vascular interventions (10.5%), including tendon and/or nerve repair, and/or bone debridement, and amputation (2.3%). The patterns of injury
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D.A. Robinson, M.L. Whitmill / Journal of Clinical Gerontology & Geriatrics 5 (2014) 28e30
vary with age. Unlike children where the overwhelming majority of bites occur in the head, neck, and face,3,5,11 adult wounds typically occur in the extremities, accounting for 86.2% of injuries in persons over the age of 14.3 Bites involving the hand may be associated with small bone fractures.10 Infection risks and possible transmission of zoonotic infections are also significant concerns to be addressed during treatment. Infections tend to be polymicrobial, involving both aerobic and anaerobic bacteria; however, use of prophylactic antibiotics remains controversial.12 Death following dog attacks has been reported in both the pediatric and elderly populations. In fact, the most severe and fatal dog bite cases have generally occurred in young children or the elderly population.1 The study by Langley1 found that children in the age group of 1e4 years have the highest number of deaths, and infants less than 1 year of age have the highest death rate, with victims less than 10 years of age accounting for 55.6% of total deaths, while persons 65 years or older accounting for 24.0% of deaths. The high death rate in children is predictable, given the usual pattern of injury in this population and potential for exsanguination and death from penetrating wounds to the neck, as well as the risk for cervical spine injury and meningitis following fracture of thin cranial bones.5 However, elderly victims have been found to have a higher in-hospital fatality rate compared with younger persons.1 This is most likely related to the presence of comorbid conditions, preinjury medications, reduced physiologic reserve, and the physical changes of aging compounding the traumatic injury sustained by the attack.1 In conclusion, dog bites remain a growing public health problem, with possible long-lasting physical and psychological impairment, economic loss, and death. The elderly and the very young populations are disproportionately adversely affected by severe dog bite injuries. Public service awareness programs targeting children have been shown to positively impact the prevention of dog bite-related injury in the pediatric population. Perhaps greater research is needed to identify specific risk factors for dog bite-
related injuries in the elderly population, with implementation of public service awareness programs targeting this vulnerable population. Conflicts of interest The authors have no conflicts of interest relevant to this article. Acknowledgments The authors thank Ms Kathy Eubank for her assistance in retrieving articles. References 1. Langley RL. Human fatalities resulting from dog attacks in the United States, 1979e2005. Wilderness Environ Med 2009;20:19e25. 2. Gilchrist J, Sacks JJ, White D, Kresnow MJ. Dog bites: still a problem? Inj Prev 2008;14:296e301. 3. Bini JK, Cohn SM, Acosta SM, McFarland MJ, Muir MT, Michalek JE, et al. Mortality, mauling, and maiming by vicious dogs. Ann Surg 2011;253:791e7. 4. Benson LS, Edwards SL, Schiff AP, Williams CS, Visotsky JL. Dog and cat bites to the hand: treatment and cost assessment. J Hand Surg Am 2006;31A:468e73. 5. Monroy A, Behar P, Nagy M, Poje C, Pizzuto M, Brodsky L. Head and neck dog bites in children. Otolaryngol Head Neck Surg 2009;140:354e7. 6. Langley RL. Animal-related fatalities in the United Statesdan update. Wilderness Environ Med 2005;16:67e74. 7. Wright JC. Severe attacks by dogs: characteristics of the dogs, the victims, and the attack settings. Public Health Rep 1985;100:55e61. 8. Kneafsey B, Condon KC. Severe dog-bite injuries, introducing the concept of pack attack: a literature review and seven case reports. Injury 1995;26:37e41. 9. Yeh CC, Liao CC, Muo CH, Chang SN, Hsieh CH, Chen FN, et al. Mental disorder as a risk factor for dog bites and post-bite cellulitis. Injury 2012;43:1903e7. 10. Aslam A, Dickinson JC. Dogs bite bones tooda tale of fractures in adult hands. Injury 1999;30:374e6. 11. Benfield R, Plurad DS, Lam L, Talving P, Green DJ, Putty B, et al. The epidemiology of dog attacks in an urban environment and the risk of vascular injury. Am Surg 2010;76:203e5. 12. Jaindl M, Grünauer J, Platzer P, Endler G, Thallinger C, Leitgeb J, et al. The management of bite wounds in childrenda retrospective analysis at a level I trauma centre. Injury 2012;43:2117e21.
