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Journal Name: International Journal of Case Reports and Images (IJCRI)

Type of Article: Case Report

Title: Penetrating Injury in the Forearm Caused by Bird’s Beak

Authors: Taran Singh Pall Singh, Thinesh Varan Subramaniam, Thirumurugan Kususamy, Gopi Mathavan,

doi: To be assigned

Early view version published: June, 1st 2015

How to cite the article: Singh TSP, Subramaniam TV, Kususamy T, Mathavan G. Penetrating Injury in the Forearm Caused by Bird’s Beak. International Journal of Case Reports and Images (IJCRI). Forthcoming 2015

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MANUSCRIPT FOR EDITORIAL REVIEW 1

TYPE OF ARTICLE: Case Report

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TITLE: Penetrating Injury in the Forearm Caused by Bird’s Beak

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AUTHORS:

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Taran Singh Pall Singh1, Ms in Ortho, Thinesh Varan Subramaniam2, MBBS,

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Thirumurugan Kususamy3, MBBS, Gopi Mathavan4, Ms in Ortho

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AFFILIATIONS 1

Taran Singh Pall Singh, Lecturer and Orthopedic Surgeon, University Sains

Malaysia, KubangKerian, Kelantan, Malaysia. 2

Thinesh VaranSubramaniam, Medical officer in orthopedic department, Hospital

TuankuJa’afarSeremban,Negeri Sembilan, Malaysia. 3

Thirumurugan Kurusamy, Medical officer in orthopedic department, Hospital

TuankuJa’afar Seremban, Negeri Sembilan, Malaysian. 4

Gopi Mathavan, Orthopedic Surgeon, Hospital TuankuJa’afar Seremban, Negeri

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Sembilan, Malaysia.

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Department of Orthopaedics, University Sains Malaysia, KubangKerian, Kelantan1.

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Department of Orthopaedics, Hospital TuankuJaafar Seremban, Negeri Sembilan. 2

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CORRESPONDING AUTHOR DETAILS

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Dr. Thinesh Varan Subramaniam

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No 18, Jalan Bukit Nuri Indah 1, Taman Bukit Nuri Indah, 70 300, Seremban, Negeri

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Sembilan, Malaysia.

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Phone number: +6012-5884656

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E-mail: [email protected]

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Short Running Title: This case report describes a penetrating injury caused by a

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bird’s beak. The management includes its removal, meticulous wound debridement

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and antibiotic coverage according to animal bite guidelines.

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Guarantor of Submission: The corresponding author is the guarantor of

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submission.

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I, Thinesh Varanis the guarantor of submission and wish to submit a new manuscript

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entitled “Penetrating injury of the forearm caused by bird’s beak” for the

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consideration by the journal of International Journal of Case Reports and Images.

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This work is original and has not been published elsewhere nor is it currently under

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consideration for publication elsewhere.

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TITLE: Penetrating Injury in the Forearm Caused by Bird’s Beak. A case report.

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ABSTRACT

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Introduction:

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Human injuries caused by animals are a relatively common entity in Malaysia.

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However, when the animal involved is a bird and its victim is a motorcyclist, it is

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rather unheard of. To our knowledge, this is the first reported case of a bird breaking

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its beak in the forearm of a motorcyclist resulting in a surgery to remove the deep-

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seated foreign body.

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Case report:

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We are reporting a case of 21 years old man who collided with a bird while riding

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motorbike. He presented with complaint of wound over the left forearm and foreign

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body sensation. It is associated with minimal pain and swelling. X-ray of left forearm

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showed bird’s beak. Intravenous Augmentin was started, wound debridement was

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done and the bird’s beak is removed with the help of image intensifier under

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emergency operation. Puncture wound was left open for dressing.

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Conclusion:

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Presence of bird’s beak in the forearm is more than a foreign body. Antibiotics

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selection should follow the animal bite guidelines in addition to foreign body removal

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and meticulous wound debridement to prevent infection.

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Keywords:

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Beak, Infection, Forearm, Antibiotics

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TITLE: Penetrating injury in the forearm caused by bird’s beak. A case report.

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INTRODUCTION

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Human injuries caused by animals are a relatively common entity in Malaysia. They

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usually arise from dogs, cats, snakes, monkeys and insects like bees and

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centipedes. Although there have been incidences of birds causing injuries to

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humans, it is almost unheard of for a bird to be involved in a motor vehicle accident

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[1,2].

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In this paper, we report a case of an upper limb injury inflicted on a motorcyclist by a

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bird, which resulted in the bird’s beak becoming a foreign body in the patients

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forearm.

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CASE REPORT

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A 21-year-old man was referred to our Orthopedic Department from a peripheral

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hospital for a foreign body in his left forearm. The man was riding his motorcycle in

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his village area in the evening, when suddenly a bird collided into his left forearm. He

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managed to control his motorcycle and stop to the side of the road only to notice a

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puncture wound over the ulna aspect of the forearm with an object protruding from it.

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Only after he pulled out the object did he realize that it was one half of the bird’s

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broken beak. At that point he could still feel something inside the flexor compartment

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of his left forearm. He could not however locate the bird to identify its type.

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The following morning he went to the nearest district hospital for further treatment.

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An x-ray was done and a faint foreign shadow was noted adjacent to the mid-shaft of

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the left ulna (Figure 1). His wound was dressed and he was administered an anti-

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tetanus toxoid (ATT) injection prior to referral.

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On assessment upon arrival at our center, there was a 1cm puncture wound over the

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distal half of the left ulna region (Figure 2). He was able to flex and extend all fingers

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and the wrist, but with significant pain. There was some non-specific numbness on

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the ulna aspect of the forearm and hand distal to the puncture side, but there was no

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significant peripheral nerve deficit. Both the radial and ulna pulses were palpable.

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The patient was started on intravenous Augmentin and prepared for emergency

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wound debridement and removal of bird’s beak.

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With the help of an image intensifier, the beak was localized and removed some 5cm

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away from the entry point (Figure 3). The puncture wound was debrided and a

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separate incision was made to remove the beak (figure 2). There was no major

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neurovascular damage noted. The puncture wound was left open for dressing.

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Patient completed the antibiotics for total duration of 7 days, intravenous for 2 days

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and oral for 5 days. The patient was discharged well with no early complications.

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DISCUSSION

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While it is relatively common for a foreign body to be retained following animal bites,

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especially with dogs, there has been no literature reporting this condition in relation

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to birds [3].

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This case highlights a retained foreign body following a puncture wound, which is

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uncommon [4]. This is further complicated by the fact that the foreign body is a bird’s

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beak, equating the wound to an animal bite. Hence, the management we used was

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based on established guidelines for animal bites. The patient was also very fortunate

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not to suffer a neurovascular injury as the wound and foreign body were very near

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the course of the ulnar nerve and artery.

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The role of radiographs and other imaging modalities e.g. ultrasound and image

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intensifier (although not pivotal in this case as the patient knew the remaining half of

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the beak was in situ), are essential in investigating and localizing a foreign body [4].

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No specific guidelines exist recommending the culture of bite wounds [5]; however, it

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would have been interesting to find out the isolated organism/s, although it would

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have not been conclusive. Unfortunately, no samples were sent for culture in this

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case.

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The patient was given an ATT injection as he was unsure of his tetanus

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immunization and the wound condition did not warrant tetanus immunoglobulin. The

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empirical antibiotics given were to cover gram positive, gram negative and anaerobic

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bacteria, as there is no established data on the microbiologic analysis for bird related

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injuries, unlike in dog and cat bites where Pasteurella, Staphylococcus and

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Streptococcus Species are the most prevalent organisms [5]. The usage of 6

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prophylactic antibiotics was in view of the deep animal bite related puncture wound

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and the delayed duration in the patient’s presentation.

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In this case, the original wound (entry point of foreign body) was left open for

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dressing post debridement. Although data are limited, animal bite related wounds are

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almost always managed by delayed primary or secondary closure [5]. A review

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article by Garbutt et.al. concluded that animal bite wounds in the hand should be left

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open always, while non-puncture wounds elsewhere may be safely treated with

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primary closure after thorough debridement[6].

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Unprovoked bird related injuries are almost unheard of. The sheer velocity

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(motorcycle and flying bird) and nature of the injury managed to completely break the

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beak from its base and propel deep into the forearm. Hence, although not routinely

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practiced, protective motorcycle riding gear usage is essential to avoid such injuries,

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as the effects may be even more devastating when riding at high speeds.

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Conclusion:

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Penetrating injury by bird’s beak should be taken seriously and requires urgent

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removal. The adjunct usage of image intensifier is recommended to reduce operating

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time and soft tissue injury. A prophylactic broad spectrum coverage based on the

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local antibiotic guidelines is required to prevent infection.

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CONFLICT OF INTEREST

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All the authors declare no conflict of interest

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AUTHOR’S CONTRIBUTIONS

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Taran Singh Pall Singh

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Group1 - Conception and design, Acquisition of data, Analysis and interpretation of

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data

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Group 2 - Drafting the article, Critical revision of the article

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Group 3 - Final approval of the version to be published

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Thinesh Varan Subramaniam

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data 7

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Thirumurugan Kurusamy

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data

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Gopi Mathavan

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data

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ACKNOWLEDGEMENTS

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None

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REFERENCES

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1.

Tripathi AK, Erdmann MWH. Bird-bite infection and pyoderma gangrenosum:

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A rare combination? Journal of Plastic, Reconstructive & Aesthetic Surgery

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2008;61(11):1409-11.

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2.

Pediatric Neurosurgery 2006;42(5):308-10.

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3.

4.

5.

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Ball V, Younggren BN. Emergency management of difficult wounds: part 1. Emergency Medicine Clinics of North America 2007;25(1):101-21.

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Halass GW. Management of foreign bodies in the skin. American Family Physician 2007;76(5): 683-8.

219 220

Prokop A, Holzmüller W, Sommer B et al. Dog bite injuries with foreign body incorporation. Handchir Mikrochir Plastische Chirurgie 1993;25(2):90-4.

217 218

Khan MA, Olumide AA. Head injury caused by an ostrich: A rare entity.

6.

Garbutt F, Jenner R. Wound closure in animal bites. Emergency Medicine Journal 2004;21(5):589-590. 8

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FIGURE LEGENDS

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Figure 1: The AP and lateral radiographs of the left forearm showing a faint outline of

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the beak (circled in red) along the ulna bone.

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Figure 2: A photograph of the patient’s left forearm showing the original puncture

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wound and the surgical wound to remove the foreign body.

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Figure 3: A photograph showing the removed half of the broken beak in a container.

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It measures 3.5cm in length.

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FIGURE

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Figure 1: The AP and lateral radiographs of the left forearm showing a faint outline of

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the beak (circled in red) along the ulna bone.

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MANUSCRIPT FOR EDITORIAL REVIEW

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Figure 2: A photograph of the patient’s left forearm showing the original puncture

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wound and the surgical wound to remove the foreign body.

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Figure 3: A photograph showing the removed half of the broken beak in a container.

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It measures 3.5cm in length.

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