Jael’s syndrome: knife blade impacted 1 in the facial skeleton: an illustrated case 2 report and a review of literature

Objective : This article focuses on the penetrating trauma of the facial mass caused 22 by the knife with retention of the blade fractured in the facial skeleton. 23 24 Case report : We describe preoperative, intra-operative and post-operative 25 outcomes of the knife stabbing in the face, and of the surgical removal of the broken 26 8cm long blade using two dimensional, and tridimensional computed tomography, 27 and clinical iconography 28 29 Conclusions : We provide the readership with a broader perspective on iatrogenic 30 facial trauma caused by blades with examples from history of medicine, with 31 biomechanical focus, as well as a review of literature on the management, and on the 32 surgical treatment outcomes of such infrequent emergency in maxillofacial surgery. 33

accessibility of this type of weapon in the civilian environment [16]. A higher 92 incidence is observed in countries with strict gun laws [11,18]. Thus, we find that 93 sharp force homicide is more common than firearm homicide in Europe, unlike the 94 United States [19][20][21][22][23][24]. Stabbing is the most common cause of homicide in the UK 95 [25][26][27]. A 2017 report describes 36,598 incidents, a 22% increase in relation to the

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However, specific penetrating trauma of the facial skeleton is not considered a 102 frequent situation, one of the reasons advanced by some authors is mainly as a resu lt 103 of attempts to protect the face with the hands in self-defense [31].

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In cases where the stabbing is intentional to the skull or face, the cases are grouped 105 in the literature under the name of Jael's syndrome [32][33][34][35]. It was Jefferson et al.,

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[32] who first described in 1968 a severe craniofacial lesion in a 16-year-old boy 107 impaled on a tent peg that penetrated the orbit and extended to the midbrain 108 referring to the Jael's syndrome [32]. This syndrome refers to a biblical scene of the 109 murder of Sisera (Canaanite commander) by Jael, which thus allowed to deliver the 110 tribes of Israel from the domination of king Jabin, in Judges, IV, v. 21: "Jael,

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Heber's wife, took a stake from the tent, took the hammer in her hand, came to him 112 gently, and drove the stake into his temple, and it went into the ground. He was 113 sound a sleep and weary; and he died."

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And although they can be life-threatening when the major blood vessels of the face 115 are affected [1,36,37] the mortality from stab wounds in general is known to be 116 relatively low in the medical and forensic literature [17,26,38,39].

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However, trauma where knife blade retained in the maxillofacial skeleton is an 118 unusual and spectacular injury especially in Europe. However, surgeons of the head 119 and neck region, including otolaryngologists, neurosurgeons, maxillofacial 120 surgeons, ophthalmologists, plastic surgeons and also radiologists, interventional 121 radiologists, anesthetists, emergency physicians, intensivists, need to be aware of the 122 management and care of these dramatic injuries because of the trend of increasing 123 incidence of these types of injuries [40].

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The objective of this article is to review the characteristics, and the management of 125 such injuries through a clinical case.

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Clinical report 127 The case report concerns a 17-year-old male (with no particular medical history),

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During the primary investigation the following elements were checked:

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The removal caused minor bleeding that did not require any particular hemostatic 317 procedure.

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Afterwards, a simple closure in 2 planes was performed on the face, and by simple

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The spectacular aspect of injuries with impaction of the blade in the face as well as 388 its rarity often led to concentrate on the management of the retained tool rather t h a n 389 on the initial resuscitation of the patient [42,43]. However, the clinical examination 390 must remain systematic and routine.

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The ATLS® algorithm is recognized as the gold standard in the initial management 392 of polytraumatized patients, and is instructed in more tha n 50 countries worldwide.

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Its simplicity and systematic approach have contributed greatly to improve the 394 quality of care for trauma patients worldwide. It is estimated that the reduction of 395 deaths caused by polytra uma is of 25-30% when a systematic and organized 396 approach is used [44]. The ATLS is based on a two-step approach, primary and 397 secondary.

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During the primary investigation the first priority consists of stabilizing the patient.

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The care must be taken to secure the airway, treat active bleeding (especially of the 400 carotid artery system), and exclude neurological or vision damage [45]. Nonetheless,

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On the other hand, it is essential to prevent coughing and any blade and/or head accessible [50][51][52]. At the same time, the diverse nature of penetrating injuries to the 430 face and neck impedes a single method of airway management [53].

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Once the patient is stabilized and the airway is secured, the long-term treatment

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However, advances in cone-beam CT should lead to a reduction in beam hardening 447 artifacts due to metallic objects, and currently catheter angiogra phy and con e -b ea m

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CT can be combined [57]. In the future, these patients will probably be better 449 examined by cone beam CT angiography [1].  [26]. The most dangerous site for stabbing is the chest [36,63,64]. However,

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these results are to be put in balance with the fact that the study does not distinguish 463 between incised and penetrating knife wounds and that the study describes cases that 464 actually arrived at the hospital [26]. One important point is that a knife can be very 465 deadly in the hands of an experienced person [36,63,64]. However, this low fa tality of facial penetrating trauma has been noted by some authors [1,65], and highlights 467 the protective function of the viscerocranium , which through its bony structures acts 468 as a cushioning zone that absorbs the energy of trauma , and protects the intracra n ia l 469 structures [34]. Moreover, in the case of Jael's syndrome, when it affects the face, its 470 laterality is in two thirds cases on the left side. This corresponds to the fact that the 471 majority of the population is right-handed, so the majority of attackers are right-472 handed, and it is easier for them to hit the left side of the victim [36,66,67].

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During an attack with a movement over the shoulder, the axis is often superior-

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inferior, and latero-medial (orientation found in the illustration of the "wounded 475 man" (Figure 1, and in our present case). This orientation has the advantage of bein g 476 an axis that is away from the large vessels [6].  reported that it may require 140 Newton and for the sternum 200 Newton [75]. In a 510 study to determine the force developed during a knife attack with an over-the-shoulder pronated gesture, it was found that volunteers could generate up to 2000 512 Newton of force along the long axis of a blade on impact, and reach impact speeds 513 of 10 to 18 m/s [76]. Note that none of the volunteers were in a state of fear, rage or 514 excitement, which could tend to increase physical performance.

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One tip is to use large forceps and tap the clamp holding the knife with a surgical 526 hammer to minimize iatrogenic damage [77,78]. However, this technique is not

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This feature has been noted by several authors especially with cheap kitchen 533 knives that can easily break with minimal force, and when such a knife tip h its the 534 bone, the tip can break, and remain embedded in the bone [76,80]. This 535 characteristic is more pronounced with the longer blade. The "ideal" weapon is, in 536 fact, a short knife with a thin blade, with a rigid blade of about 7 cm long" [80].

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This tendency to break or twist can complicate the removal of the knife due to the 538 lack of contact surface for forceps and due to the modification of the removal axis. whom presented with subcutaneous swelling, and two with wound abscesses [69].

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As the knife attacks only last a few seconds, the patient may not be a ware of the 560 attack, and the history may be missing [81,82]. Subsequently, the retained blade neurological impairment and compromised aesthetics [85].

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Contraindications to inorganic origin include location posterior to the orbit,

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proximal to vita l structures, lack of imaging studies, risk of iatrogenic injury,

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absence of symptoms or unclear location [36]. However, Grobbelaar et al., [6] 578 showed no adverse effects after simple removal of the retained blades in 11 patients. and can leave large scars [88].
important especially in the "triangle of death" area of the face drained by the angular 597 vein that drains into the cavernous sinus.

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It is interesting to see that our case is close to several characteristics already 599 mentioned by Jett et al., [90] describing the chara cteristics of the typical victim. The probably due to its wide availability [11,21].

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In summary, in cases of Ja el's syndrome effective coordination, communication, and 608 teamwork of emergency medicine, anesthesia, radiology, surgery, and removal 609 services must be carefully implemented. report.

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• Informed consent: a written informed consent was obtained from the mother of 624 the patient. All images were anonymized and no private data were provided 625 allowing the patient's identification.