Based on this x-ray, what is the diagnosis?
A 52 year-old kiteboarder was kiting at a speed of approximately 18 knots near Biscayne Bay, Florida when he felt a sudden pain in his left thigh. He immediately looked down and saw a small (~1 cm) laceration that was bleeding briskly.
Upon return to shore he called 911 and was transported to an emergency Department where these x-rays were obtained.
Upon arrival in the emergency department the patient’s vital signs were stable. There was a 1 cm puncture wound with minimal bleeding. After plain radiographs were obtained an orthopedic consult was called and they requested a CT scan prior to wound exploration and foreign body removal.
The working diagnosis was stingray barb injury, but the working diagnosis was wrong!
Still stumped?
The intra-operative photographs below reveal the answer.
Credit: Edward Silverman, MD
A careful review of the plain films demonstrates a row of delicate teeth as well as the presence of upper and lower jaws.
After foreign body removal, the patients wound were copiously irrigated and left open. The patient was discharged on Trimethoprim-Sulfamethoxazole (Bactrim) for 1 week and recovered uneventfully.
By some remarkably unfortunate twist of fate, the patient referenced above was kiteboarding in Florida some months later when was bitten by a shark on the same leg! Fortunately, those wounds were neither life or limb threatening. See text message from patient to doctor below:
Discussion
Needlefish (family Belonidae), found in tropical and sub-tropical water’s worldwide are elongated fast surface-swimmers with long, bony, beak-like jaws. These carnivorous fish often travel in schools and leap out of the water at high velocity (up to 60 km/h (37 mph) if startled, escaping predation, or attracted to light. They can be up to 4 feet (1.2m) in length and are capable of flying over 30 feet (10 m) through the air. If a swimmer, surfer, fisherman, or boater happens to be in the flight-path of a flying Needlefish they can get impaled by its bony beak, which often snaps off in the victim.
Injuries from needlefish are uncommon but numerous cases have been reported in the literature. Victims are often canoeists, fishermen, or swimmers who are sometimes uncertain as to the mechanism of injury, as in the case presented. The only visible injury is usually just a small wound and therefore retained fragments of needlefish jaw are commonly missed on initial presentation. Though many injuries are relatively minor, ocular injuries, pneumothorax, and intrabdominal injuries, and even deaths have been reported. Treatment is careful foreign body removal, copious wound irrigation and prophylactic antibiotics which should include coverage for gram-negative marine organisms such as Vibrio.
