P ediatric head trauma from motor vehicle crashes is unfortunately not uncommon. However, penetrating transcranial injury from intrinsic objects within vehicles is seemingly rare. We report an unusual case of a child who was impaled by the gear shift of the automobile in which she was traveling after a motor vehicle crash. In addition, we describe this child's hospital course and follow-up and offer a brief discussion of the management of impaling head injuries.
CASE REPORTWe report on a 3-year-old, female, unrestrained frontseat passenger who, as the result of a collision with another vehicle, was impaled by the gear shift of the automobile in which she was riding. Before this crash, the child had met appropriate language and motor-skill milestones, was bowel and bladder trained, and had no medical or surgical history. To extricate the child from the vehicle, the entire steering wheel/column assembly was cut free from the dashboard, and the child was transported to our emergency department with this apparatus still intact (Fig. 1).On arrival, she was awake and nonintubated. Her initial vital signs were stable, with a pulse range of 99 to 131 beats/min, a temperature of 99°F, a blood pressure of 95/52 mm Hg, and respiratory rate of 18 to 30 breaths/min. In assessment the Glasgow Coma Scale (GCS) score was 9; she opened her eyes to tactile stimulus, moaned appropriately, and moved all extremities spontaneously with an apparent right hemiparesis. The gear shift entered her head in the midline, approximately 3 to 4 cm above the brow line. It then exited in the left parieto-occipital region. Apart from this dramatic injury, the remainder of the physical examination finding were normal. Plain radiographs of the chest, pelvis, and lateral cervical spine revealed no abnormalities. Initial blood tests revealed a white blood cell count of 17; hemoglobin, 9.6; platelets, 249; and international normalized ratio, 1.3.The patient was then taken to the operating room, where she was intubated with the steering column still attached, and then transported to the computed tomography (CT) scanner. Scans of the abdomen and pelvis were unremarkable. The CT scan of the head demonstrated the above-noted wound with penetrated bone fragments (Fig. 2). At operation, a metalcutting band saw was used to transect the steering column/ wheel assembly from the gear shift. The gear shift assembly was 1.2 cm in diameter, with a bulbous distal end measuring 2.3 cm in diameter. Copious irrigation was used to minimize the conduction of heat to the brain from the process of cutting through the metal. The head was then draped in a sterile fashion, and a scalp incision was performed such that both