Skull, face and neck injuries caused by a beer bottle

Introduction: Penetrating neck injuries are nowadays frequent civilian trauma and the spectrum of injury ranges from minor to life-threatening. This type of injury is particularly challenging to treat because of the complex anatomy of the neck, with vital structures in close proximity to one another and in the lateral part of the head and neck the major blood vessels and nerves are relatively close to the skin surface and incised wounds in this region can be frequently fatal. Stab wounds to the neck account for 40% of all penetrating neck injuries and are usually low velocity injuries and can be produced with minimal force. Glass can be considered sometimes a sharp, pointed, knife-like tool and glass injuries can cause severe penetrating injuries to skin and underlying nerves and vessels, as well as tendons, and result in significant long term disability or death by exsanguinations due to injury of a major vessel, most often the carotid artery. In bars and disco pub beer is normally served in Italy in glass bottle (33cl) that can become formidable impulsive weapons, due to the sharpness of the edges especially on breaking on somebody’s head or face during altercations. Case report: During a dispute between a group of young people outside a disco pub in an early December morning (07:00 AM) a 33-year-old man (190cm, 99Kg) received a blow with a glass bottle in his head by a 32 years-old man, hit shortly before with a fist in the face, as testified by other persons present at the dispute. Immediately after the fact a passer-by found the young man prone on the sidewalks and alerted the emergency medical service that found the man in hemorrhagic shock. At the Emergency Department (07:22 AM) the clinical-instrumental investigation detected an active heavy bleeding injury complex in the left temporal region (auricle helix lacerations, deep laceration of the parotid gland, injury of the internal jugular vein (level mouth floor); bleeding spots in ramification vessels of the external carotid artery; section of the VII nerve with intracranial retraction of the cranial end; complex fracture of the temporal bone (squamous portion); partial dislocation of the left condyloid process). No other wounds were indicated in the medical records. The heart rate was 130 beats/min, blood pressure was 70/40 mmHg, with cool, clammy skin, snoring breathing, the patient was drowsy and not contactable with mid-midriatic pupils and circulation instability (III-IV hemorrhage class; 08:00 AM: oxygen saturation was 50% in room air; Hb 8.6g/dL and Hb nadir: 6.8g/dL). The patient was treated immediately with intravenous fluids, red blood cell transfusions, cardiotonic and sedative agents and intubation (12:00 PM: Hb 9.3g/dL) and the vascular surgery ended with satisfactory recovery and the patient was discharged after two weeks with outpatient controls and care program. After three months the patients presented evident auricular scars and deficit of the VII, XI, XII left cranial nerves. The perpetrator’s injuries were bruises and contusions to the left eye-cheek region, a superficial laceration of the left eyebrow and a pair of superficial wounds between the first and the second finger of the right hand. Results: In this case the crime tool was a glass beer bottle, but no clear information was given about the assailant bottle grip modality, the bottle integrity, the beer brand and the presence of a bottle filling. The complexity of the wound in the left temporal region was characterized by a temporal comminuted fracture, incomplete condyloid mandibular joint dislocation, vessels and nerves discontinuations and parotid gland and auricle lacerations. No defense wounds were on the victim. From a topographical side the injury complex is precisely placed in a circumscribed area, the left temporal region and the wounds were life-threatening until the very beginning of the clinical consequences. Conclusion: It is well known that stab wounds inflicted with a broken bottle tend to occur as clusters of wounds of different sizes, shapes and depths. Colour, weight and thickness of the glass of a beer bottle depend from the beer brand, but in general an empty beer bottle can weigh around 250 grams. With this minimal bottle’s weight the possibility of an empty beer bottle to be broken by a man’s hand on a man’s head is highly likely to happen. The bottle has a cylindrical morphology and a round rim when perfectly cut, but when broken the bottle’s edges are normally irregular in shape, number and depths of the single shards (jagged rim). If the bottle brakes in a blow against the head it can become a complex sharp-edged instrument, that can produce various penetrating injuries and the characteristics of such wounds are of irregular incised-type wounds of variable depths and severity and cover a circumscribed body area, frequently a bow-like shaped wound is visible on the skin. In this case the complexity of the wounds with a bony fracture and the limited injured area support the hypothesis, in the mechanism of injury, of a single blow to the head with a beer bottle that broke by hitting the victim’s left temporal region (personal injury for defence versus attempted homicide).