An image is worth a thousand words

Introduction

This case involved a 15-year-old boy, who slipped and impaled his left hand on a wooden beam. An initial anterior–posterior radiograph was obtained prior to referral to plastic surgery for further management (figure 1).

Figure 1

Clinical photographs and initial X-ray taken of the impalement injury.

Clinical examination was restricted due to access. The patient reported general pain on limited movement of all digits but normal neurology. He received appropriate initial treatment of broad-spectrum antibiotics and tetanus care in the emergency department. His medical and social history were unremarkable.

Question

What is the next most appropriate intervention?

Immediate removal of the impaled structure under tourniquet control in an operating theatre.

Immediate removal of the impaled structure in the emergency department under nerve block.

Further imaging is needed.

Urgent surgical consultation.

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