Radiology Review

Taking a Stab in the Dark

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Taking a Stab in the Dark

As you arrive for your shift in the emergency department, the outgoing provider asks if you would mind checking a laceration that his student is stapling. “The discharge paperwork is all done,” he says, as he waves goodbye and walks out the door.

You find that the student has just about completed his task: sterilely stapling a 2.5-cm laceration on the left lumbar area of a man in his early 40s.

You ask the student for the basic history, and he informs you that the patient was drinking with friends and “accidentally got cut” when they started roughhousing. You turn your attention to the patient, who appears intoxicated but in no obvious distress; he confirms the story as presented.

A quick review of the chart shows no significant medial history, stable vital signs, and up-to-date tetanus status. The patient can move all extremities well and appears neurovascularly intact. But some instinct prompts you to probe further.

On additional questioning, the patient reveals that he was accidentally stabbed. When you inquire about the object he was stabbed with, he describes it as a knife, “pretty long, sort of like a dagger.”

With this information, you decide to order some laboratory studies and abdominal radiographs (lateral view shown). What is your impression?


 

Taking a Stab in the Dark

ANSWER

The radiograph shows an obvious metallic foreign body that appears to be lodged within the first and second lumbar disc space. This is likely the tip of the knife, which presumably broke off when the patient was stabbed.

The patient was promptly transferred to a trauma center with neurosurgery coverage. Subsequent CT showed that the blade had penetrated the spinal canal, but remarkably, the patient remained neurologically intact. He underwent successful removal without any neurologic compromise.

This case highlights several points for clinicians: First, provider-to-provider sign-out of patients should be complete and detailed. Second, obtaining a thorough history is essential. And third, you should maintain a low threshold for obtaining radiographs of wounds, to rule out a foreign body.

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