Crossbow injury in a developed country

Abstract

Crossbow injuries are not common in developed countries such as Australia and New Zealand. Despite this, there have been a number of crossbow injuries in New Zealand mainly related to hunting exercises. When such incidents occur, it is important for the surgeons involved in the emergency care of the patient to have some background in the management of these injuries. A 24-year-oldmanpresented to the emergency department (ED) with a crossbow bolt penetrating his left supraclavicular fossa. A broad head arrow was accidentally fired with a high powered crossbow during a hunting exercise and travelled approximately 30 m before striking the jaw (resulting in a superficial laceration) and the left supraclavicular fossa (Fig. 1a). Theaccident occurred in a rugged terrain resulting in 4-h delay in transfer to ED. Vital signs on arrival were: pulse 88 beats/min, systolic blood pressure 140mmHg (after 1 l of normal saline), oxygen saturation 100% (trauma mask) and respiratory rate 32 breaths/min. Chest X-ray (CXR) showeda left haemothoraxwith the arrow traversing through the left supraclavicular fossa into the thoracic cavity (Fig. 1b). Insertionofan intercostal chestdrain immediatelydrained600 mlof bloodwith resolution of the haemothorax on repeat CXR. Therewas minimal chest drain output with no air leak and the patient remained haemodynamically stable. He was then transferred for a computerised tomography (CT) scan. The shaft of the bolt had to be carefully shortened in order for the patient to fit into the scanner. The CT scan (Fig. 2) showed that the bolt lodged posterior to the left carotid sheath, trackingmedially across the left first intercostal space, directing downwards and posterior across the vertebral processes with its tip at the right erector spinae muscle. There was no obvious vital vascular injury or residual pneumothorax. In the operating theatre, an incision was made in the back where the tip of the bolt was expected to be located based on the CT scan and approximation by gentle manipulation of the bolt (Fig. 3). After the identification of the tip, the bolt was carefully advanced forward