BACKGROUND: A rectal impalement injury is a rare type of penetrating injury that involves a solid object being forcefully inserted through anal opening. The removal of such injuries should be planned carefully with preparedness to assess and manage associated injuries in the pelvis and peri-anal region.
METHODS: An elderly female, around 65 years old, had a history of accidental penetration of an iron rod into her anal orifice. The patient was hemodynamically stable, and the distal end of the penetrated rod was visible in the anal verge on arrival. On evaluation, we found that the object had perforated the posterior wall of the middle 1/3rd of the rectum and had traversed retroperitoneally, bypassing all major vessels and viscera.
CONCLUSIONS: We performed exploratory laparotomy, and the iron rod was extracted from the anal canal under vision, and a diversion colostomy of the sigmoid colon was performed. The patient had an uneventful recovery, and the reversal of the sigmoid colostomy was done after 3 months.
CONCLUSIONS: Rectal impalement injuries are rare and serious. It requires a multidisciplinary approach involving a general surgeon, a vascular surgeon, and a urologist since it is associated with a higher incidence of involving major pelvic organs and vessels. In our case, the penetrating object had bypassed all major vessels, which is a rare occurrence.

BACKGROUND: Although vascular anatomy of the rectum is complex, pseudoaneurysm followed by massive hemoperitoneum after rectal impalement injury is extremely rare.
METHODS: A 43-year-old man presented with abdominal distension. One day earlier, he had undergone sigmoid loop colostomy for rectal implement injury at a local hospital. After the operation, he had become hemodynamically unstable. Digital rectal examination showed a penny-sized anterior rectal wall defect 6 cm from the anal verge. Computed tomography (CT) revealed a hematoma (12 × 10 × 15 cm) with bleeding in the pelvic cavity and an adjacent pseudoaneurysm in the rectum. A large amount of blood and massive hematoma were evacuated by surgery. The Hartmann procedure was performed, but the pseudoaneurysm was not resected. On the 11th postoperative day, hemoglobin decreased (11.6 g/dL-7.9 g/dL), and CT revealed a recurrent hematoma (6.0 × 4.2 cm) in the pelvic cavity, with a residual pseudoaneurysm. Angiography failed to localize the pseudoaneurysm. Consequently, prophylactic embolization at the anterior branch of both the internal iliac arteries was performed. The subsequent hospitalization course was uneventful.
CONCLUSIONS: Rectal impalement injury may result in pseudoaneurysm of the rectal arteries. However, pseudoaneurysm rupture of the mid rectal artery, followed by massive hemoperitoneum, has not been reported in the English literature. From our experience, preoperative diagnosis of a pseudoaneurysm is crucial for definite surgical management. When surgical resection is indicated, it should include the underlying pseudoaneurysm.
CONCLUSIONS: Although pseudoaneurysm rupture causing hemoperitoneum after a rectal impalement injury is extremely rare, meticulous preoperative evaluation is necessary for correct management.

Penetrating foreign bodies of different origins in the head and neck are rare and potentially dangerous injuries, which might pose problems for their detection, primary care, and final treatment. Depending on the severity of the underlying trauma, some injuries present a higher risk for the presence of foreign bodies. Minor wounds, including common lacerations, are likely to be contaminated with loose gravel debris or dental fragments, and need to be distinguished from severe wounds caused by impalement, shootings, stabbings, and explosions. Blast injuries resulting from terror attacks are challenging recent therapeutic concepts. Even though these injury patterns are uncommon, they carry the risk of impacted objects with dramatic consequences. Despite improving medical imaging techniques, detection remains a challenge as it is dependent on the material of the foreign body, the affected anatomical site, and the injury severity. Therefore, a detailed history of the circumstances leading to trauma is essential when foreign objects are not visible during clinical examination. Precise detection of the foreign body, its anatomical position, and the affected surrounding structures are vital, especially for impalement injuries of the head and neck area. Therefore, an interdisciplinary planning approach is essential prior to removal of the foreign object. Finally, tension-free anatomical adaptation of the corresponding structures is crucial for maintaining and restoring aesthetic and function. Here, we give an overview of the diagnosis and treatment of cases of foreign body injuries encountered in our department.

This is the 42nd installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at http://www.erad.org/page/CCIP_TOC.

Toothbrushes are the most common cause of foreign body injury to the oral cavity in children, but complete impalement by a toothbrush is an extremely rare occurrence and has not been reported previously. This report describes a 28-month-old girl who fell from a 1m ledge while brushing her teeth. Her toothbrush penetrated the oral cavity and could not be removed, and so she was rushed to the hospital with the toothbrush in place. Contrast-enhanced computed tomography showed penetration of the toothbrush from the oral cavity into and through the right posterior neck at the level of the bifurcation of the common carotid artery. Angiography was performed under general anesthesia, and the toothbrush was removed. In consultation with pediatricians, antibiotic infusion therapy was started, and the patient was extubated on the 5th post-operative day. There were no complications even after eating was resumed, and the patient was discharged on the 13th post-operative day. A toothbrush is an essential item in daily life, but it can cause serious injuries in children in some circumstances.

Impalement injuries result when a hard elongated object penetrates the body cavity or any body part and remains in place. A rare and unusual case of impalement by a bamboo stick in the thoracic cavity through the oropharynx is described. Injury resulted when a man tried to pole-vault with a bamboo stick, which slipped and entered his mouth. Impalement injury through the natural orifice of the oropharynx is discussed, along with the mechanism of the trauma and subsequent death.

A 48-eight-year-old female patient came with prolapse of small intestines per rectum (Fig. 1) due to impalement injury with iron rod at a construction site. As the patient was hemodynamically unstable, she was taken for emergency laparotomy. A large rent in the intraperitoneal rectum was found (Fig. 2), with prolapse of intestines. Luckily for the patient, there was no other intra-abdominal organ injury. As there was no fecal contamination at all, a decision against proximal colostomy was made. The rent was closed in two layers after re-placing the small bowel contents with thorough lavage. Patient made a swift recovery thereafter.