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This week in BMJ Case Reports: paintballing injury, black henna tattoos, WW2 solider



IMAGE: This is the outline of black henna tattoo with surrounding soft tissue inflammation. view more

Credit: BMJ Case Reports 2016

Doctors describe the first report of paintball related liver injury

A teenage boy needed surgery after sustaining an injury to his liver during a paintballing game, reveal doctors writing in the online journal BMJ Case Reports.

Paintballing is a popular recreational sport, but there are growing concerns about pellet related injuries. Travelling at velocities of up to 300 feet per second, high-energy rounds are a well recognised cause of blindness and other facial injuries.

More recently though, it has become apparent that deep abdominal organs, such as the kidney, may also be at risk.

In this latest case, an 18-year-old was admitted to hospital with symptoms suggestive of appendicitis.

However, when the surgeons looked into the abdomen with a camera, they found extensive bleeding coming from the liver. This required the abdomen to be opened up with a larger incision and treatment applied locally to stop further bleeding.

After the operation, it became apparent that the patient had been paintballing a couple of days earlier and described being 'hit' twice on his right flank, although no bruising was noted.

"This represents the first report of paintball related traumatic liver injury," write the doctors.

"Organ injuries of this nature have only been documented three times previously," they explain. In some of these cases, operations have been required to correct damage to the kidney, penis and scrotum.

"Participants and physicians must both be aware of the possible dangers associated with this sport," they conclude.

Concerns over use of skin tattoos with black henna

In BMJ Case Reports this week, doctors warn that black henna tattoos should be avoided, especially during foreign travel, after treating a 10-year-old boy for an allergic reaction to a tattoo painted on his arm while on holiday abroad.

The young boy had redness, itching, and small inflammatory irritated spots on his partially crusted skin lesion, which followed the outline of the tattoo on his right upper arm. The surrounding skin was red, hot and painful to touch.

The rash had started 4 days after application of a temporary black henna tattoo while he was on holiday in Spain.

It is believed that the reaction was caused by paraphenylenediamine (PPD), a textile dye that is commonly added to henna to blacken the pigment and speed up drying time. The combination together is called black henna.

PPD is a known contact allergen, and can lead to a reaction based on its concentration and the duration of exposure.

He was treated with antibiotics, and topical corticosteroid and local anesthetic creams and moisturizing creams. An improvement was noted after 48 hour with rapid resolution of surrounding inflammation.

"Skin tattoos with black henna should be avoided, especially during foreign travel, as this can make the tracing of the vendor and any subsequent public health management challenging," the doctors conclude.

Motorcycle racer develops rare injury in arm

A 26-year-old motorcyclist developed a rare injury in his lower arm due to the repeated nature of intense braking manoeuvres on the racing track.

He was diagnosed with chronic exertional compartment syndrome (CECS), a disabling condition, usually found in fanatic sports participants such as rowers, climbers, and swimmers, and most commonly observed in the legs, but rarely in the forearm.

The patient was admitted to a sports medicine department in the Netherlands, where he described progressive weakness of his right index finger, and pain, weakness and swelling of his right forearm, for a period of 1 year.

His symptoms were more prominent towards the end of races, and he noticed that the pain had already started within 5 minutes after the start of a race. He was not able to finish his last few races due to severe discomfort.

Pain intensity appeared to be related to the number of braking manoeuvres. The frequent and intensive braking required on short tracks with multiple curves caused swelling, tightness and tense muscle compartments in his right forearm.

As a result, he could no longer control the hand brake lever, and he was unable to flex his index finger. Moreover, he felt progressive numbness of the palmar portions of his right hand. The swelling and tightness usually disappeared within 1 hour after racing. However, numbness and weakness of the hand was present until the day after.

He tried medication, rest, ointments and physiotherapy, but none of these helped.

Therefore, the patient underwent a fasciotomy, a surgical procedure where the fascia is cut to relieve tension or pressure commonly to treat the resulting loss of circulation to an area muscle, of both lower arm compartments.

After 6 weeks, the patient was able to start training again at the preoperative level, and within 3 months, he was was able to perform at a higher competitive level.

Injuries in a former World War II soldier

In BMJ Case Reports this week, doctors in Germany describe war injuries in the body of a 91-year-old former World War II soldier who donated his body for medical education.

CT scanning revealed various small metallic objects, later identified as shrapnel fragments, in his right and the left legs, as well as bone abnormalities.

A history obtained from the widow and daughter of the donor revealed that he had been seriously wounded on the Eastern Front at the end of World War II, probably by a nearby rocket explosion.

His multiple fractures and lesions had not been surgically treated in the Austrian military hospital where he was taken, or in the French prisoner of war camp where he was subsequently held.

His lesions were not sufficiently treated. There was no surgical removal of the fragments, poor wound care, and no antibiotic therapy. This is a violation of the Geneva Convention of 1864, 1906, and 1929.

As a consequence of these untreated war wounds, the donor experienced pain and stiffness in his left leg for the rest of his life.

He sought surgical interventions due to infections caused by the shrapnel, but in two of these cases, he developed septicaemia, and required treatment in intensive care.

He was limited in mobility, and had to use a walking aid, even for short distances at home.

"In light of current armed conflicts, the present case is an example of how one injustice can result in severe, lifelong medical consequences," explain the doctors, adding that "implementation of the Geneva Convention must be demanded by governments and NGOs whenever civilians and soldiers are wounded."

Furthermore, this case highlights "how, even after death, a wounded thigh can the story behind it can inform young physicians about the cruelties of war and their obligation to treat people regardless of race, religion, and gender."


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