Severe injury to the brachial neurovascular bundle and muscles due to a horse bite: a case report

Abstract

Introduction: Only a small portion of horse injuries are related to horse bites. In the majority of these occurrences, 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 requires complex surgery and compound perioperative care.

Case report: We present the case of a 35-year-old Albanian male farm-worker in whom a horse bite caused an extensive lacero-contusive and avulsive wound to the arm. The wound resulted in injury to the brachial artery, brachial and basilic vein, and biceps and brachialis muscles. Nerve structures and underlying humerus remained intact. The initial management of the severe hemorrhagic shock caused by the bleeding at the site of injury included reconstruction of the brachial artery by interposing saphenous graft and that of the brachial vein by termino-terminal anastomosis. Basilic vein was ligated. The wound was extensively debrided, and after a drain was placed in the wound, biceps and brachialis muscles were reconstructed. The patient received several units of red blood cells and fresh frozen plasma before and after surgery, as well as antibiotic, antitetanic, and antirabies prophylaxes. He had several consecutive necrectomies in the following days. However, due to postoperative sepsis and hemorrhagic shock at time of admission, the patient developed acute renal failure, therefore requiring several hemodialysis sessions. After his general and local condition was stabilized, the patient also underwent several reconstructive surgeries.

Conclusion: Horse bites of large extent require a multidisciplinary approach. The composition of the team of physicians needed for treatment varies depending on the degree of the injury and eventual complications. 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.

Keywords: Arterial injury; Hemodialysis; Horse bite; Sepsis.

Fig. 1.

Horse bite injury of right upper extremity: lateral (a) and medial (b) aspects

Fig. 2.

Injured and clamped blood vessels of the arm, brachial artery, and brachial vein

Fig. 3.

Brachial artery reconstructed with autologous saphenous vein

Fig. 4.

Hand 6 weeks after injury (a) and 2 years after operation (b)