Warning: Graphic content
An Albanian farmer who suffered horrific arm injuries from a horse bite required emergency surgery and several reconstructive procedures.
The man’s medical care is described in a case report just published in the Journal of Medical Case Reports.
Hajriz Rudari and his colleagues described the case of the 35-year-old farm worker brought to their emergency room in a state of major hemorrhagic shock with an injury inflicted five hours before admission.
The patient was confused and anxious, and his skin was pale, cold, and sweaty. He was breathing rapidly. The pulse on his left radial artery was weak, rapid, and thready. No pulse could be detected in the radial and ulnar arteries in his damaged right arm.
The arm was heavily deformed, with skin and muscles torn from the humerus bone, which was visible at the bottom of the wound. Major blood vessels were damaged and there was considerable clotting, which meant there was no bleeding at the time of admission.
Arm movement was limited. It was impossible for the doctors to correctly examine nerve function because of difficulties in communication caused by the victim’s state of shock.
Emergency personnel covered the wound and started resuscitation. The patient was stabilized, intubated and taken for emergency surgery.
They described their careful debridement of the injury. They then approached the medial neurovascular bundle in the arm, where they found a complete laceration of the brachial artery, with damage to other vessels.
The surgical team had to harvest a 10cm segment of leg vein to reconstruct the brachial artery.
Muscles were then sewn, with biceps and brachialis muscles reconstructed, and a suction drain put in place. One week after surgery, a skin graft was used to close the wound.
The patient received several units of red blood cells and fresh frozen plasma before and after the surgery, as well as antibiotics and injections to prevent tetanus and rabies.
Infection at the injury site was treated with frequent debridements — removing all non-viable tissue.
Due to postoperative sepsis and hemorrhagic shock at the time of admission, the patient developed acute kidney failure. He underwent several sessions of hemodialysis.
Once the treatment was completed, the renal function, as well as the local and general condition of the patient improved significantly.
After his general condition was stabilized, the patient also underwent several reconstructive surgeries.
He was discharged three weeks after the surgery. Follow-up testing performed 6 months, 1 year, and 5 years after discharge showed no signs of sensory or motor deficit.
The authors said major horse bites require a multidisciplinary approach.
“In the case of our patient, emergency department physicians, vascular and plastic surgeons, intensive care specialists, nephrologists, and infective care specialists were involved.
“In different instances, the inclusion of other specialists may be necessary to save and functionalize the limbs of the patient, or save his/her life.”
Rudari and his colleagues said animal bites are fairly common, comprising almost 2% of all emergency admissions. Dog bites comprise up to 90% of animal bites, followed by cats and humans.
Horses account for only a small portion of animal bites requiring emergency treatment, with the head and neck the most frequent sites, followed by the extremities and trunk. Injuries to the main blood vessels are very rare.
They cautioned about the seriousness of some horse bites. “In the majority of occurrences, horse bite injuries are minor and self-treated. However, in some cases, the injury may be destructive, and limb and life-threatening. In these instances, the patient will require complex surgery and compound perioperative care. This was the case with our patient.”
Horses, they said, could exert a great deal of force in closing their jaws. The resulting wounds are generally contaminated because of the large number of bacteria in the mouth of the horse, and treatment is difficult. The extensive destruction of soft tissues and ischemia can also contribute to problems.
“In certain cases, the combination of these negative factors can lead to severe infection and sepsis, therefore resulting in failure of kidney and other organs.
“To prevent these complications, treatment of horse bite injuries requires extensive debridement of the wound, prompt revascularization, and broad-spectrum intravenous antibiotics.
“Prophylaxis against tetanus and rabies should also be provided.
“Only after the local and general condition of the patient become stable should plastic reconstructive surgery be provided. In case of extensive tissue loss and sepsis, hemodialysis may be required.”
In the case of this farmer, reconstructive plastic surgery helped the appearance of the arm to return to a near-normal state.
The case report team comprised Rudari, Luan Jaha, Adhurim Koshi and Lulzim Vokrri, all with the Department of Vascular Surgery at the University Clinical Center of Kosova, in Pristina, in the Republic of Kosovo.
Rudari, H., Jaha, L., Koshi, A. et al. Severe injury to the brachial neurovascular bundle and muscles due to a horse bite: a case report. J Med Case Reports 15, 271 (2021). https://doi.org/10.1186/s13256-021-02863-w