Available online at
ScienceDirect www.sciencedirect.com Chirurgie de la main 34 (2015) 145–148
Clinical case
The TASERed finger: A new entity. Case report and review of literature The TASERed finger : une nouvelle entité. Un cas rapporté et revue de la littérature B. Dunet *, A. Erbland, M.-L. Abi-Chahla, C. Tournier, T. Fabre Orthopedic and Traumatologic Unit, hôpital Pellegrin, place Amélie-Raba-Léo, 33076 Bordeaux cedex, France Received 26 January 2015; received in revised form 18 February 2015; accepted 11 April 2015 Available online 6 May 2015
Abstract The TASER1 is a self-defense weapon whose use has now become commonplace among law enforcement agencies. Electronic control weapons were first used in the USA in the 1990s and then adopted in Europe and France. We report a case of an 18-year-old male who presented a penetrating lesion of the middle phalanx of the left index finger. To the best of our knowledge, this is the first complex finger injury due to the TASER1. It highlights the potential major risks to finger vitality and function with use of this electrical weapon. # 2015 Elsevier Masson SAS. All rights reserved. Keywords: TASER1; Injury; Fracture; Finger; Bone
Résumé Le TASER1 est une arme de dissuasion et de neutralisation qui est de plus en plus répandue et d’usage courant pour les forces de l’ordre. Elle a été utilisée en premier aux États-Unis, puis s’est répandue en Europe et en France. Nous rapportons le cas d’un jeune homme de 18 ans ayant été « tasé » et ayant présenté une lésion transfixiante de la phalange intermédiaire de l’index gauche. Il s’agit à notre connaissance du premier cas de lésion osseuse transfixiante d’un doigt avec atteinte pluritissulaire associée dû au TASER1. Elle met en évidence les risques majeurs potentiels pour la vitalité et la fonction digitale d’une atteinte par arme à projection électrique. # 2015 Elsevier Masson SAS. Tous droits réservés. Mots clés : TASER1 ; Lésion ; Fracture ; Doigt ; Os
1. Introduction The TASER1 (Fig. 1) is a self-defense weapon that is now commonly used by law enforcement agencies. As a conductedelectric weapon, it incapacitates threatening subjects. This report describes the case of an 18-year-old male who was tasered and presented with a penetrating lesion of the middle phalanx of the left index finger. We believe this is the first reported case of a penetrating bone injury in a finger where multiple tissues are involved.
* Corresponding author. E-mail address: [email protected] (B. Dunet). http://dx.doi.org/10.1016/j.main.2015.04.001 1297-3203/# 2015 Elsevier Masson SAS. All rights reserved.
2. Case report During police questioning in October 2011, an 18 year-old, right-handed male, manual labourer, who was in France illegally, was tasered by the law enforcement officers to stop him from attempting to escape through a window. When he arrived at the emergency room (ER), the emergency physicians identified the first TASER1 dart in his thoracic area and the second one in his left index finger. The initial clinical examination identified no skin lesions; no sensory and motor deficits or vascular disorders were present in the left upper limb. Neurology, cardiology and respiratory examinations were normal. There were no heart rhythm disorders visible on electrocardiogram. Radiographs taken in
146
B. Dunet et al. / Chirurgie de la main 34 (2015) 145–148
Fig. 1. The TASER1 conducted electric weapon, model X26.
the ER confirmed the thoracic location of the first dart and the absence of associated complications (Fig. 2), along with the presence of a foreign body in the soft tissues over the middle phalanx of the left index finger (Fig. 3). When the patient was referred to us, the first step was to remove any burnt tissue in the area penetrated by the dart (Fig. 4). The patient had no signs of dysesthesia or paresthesia. Active extension of the distal phalanx was possible but not flexion. The finger’s vascularization was intact. Review of the initial radiographs led to the diagnosis of a penetrating injury to the base of the middle phalanx in the left index finger. Surgical exploration was performed under regional anesthesia in the operating room under tourniquet, once the dart had been cut from the skin. Dorsal exploration found no injury to the extensor mechanism and confirmed bone penetration at the level of the base of the middle phalanx over the triangular area between the two lateral slips of the extensor mechanism. The second stage consisted of volar exploration through a Brunnertype incision. The flexor digitorum profundus tendon was found to be partially lacerated and the C2 pulley damaged. The digital palmar neurovascular bundles were intact. A counter-incision was made in the middle palmar crease to carry out extensive prophylactic lavage of the flexor tendon sheath. After removing the barb, abundant lavage of the bone was performed using a catheter; the lacerated tendon was repaired with 4-0 PDS in a
Fig. 3. A/P and lateral radiographs of the left hand with foreign body penetrating into the middle phalanx.
Kessler pattern. No immobilization was used during the postoperative phase. A course of standard antibiotics was implemented for 48 hours with amoxicillin and clavulanic acid (500 mg/62.5 mg; 2 tablets 3/day, per os). The patient’s recovery was good. At the first postoperative visit on the 15th day, the patient had already recovered full range of motion and no sensory or motor deficit was noted. 3. Discussion Invented in 1960 by Jack Cover, an American physicist, and commercialized in 1974, the TASER1 is a non-lethal weapon that has been increasingly used since the start of the 2000s. This electric stun gun has a maximum range of 7.6 m (25 feet); it projects two electrodes at 50 m/s (164 feet/s) that are joined by two isolated wires. These two electrodes are similar to two 9-mm barbs. Upon reaching its target, the gun delivers a
Fig. 2. Standard A/P and lateral radiographs of the chest with precardiac foreign body.
B. Dunet et al. / Chirurgie de la main 34 (2015) 145–148
147
Fig. 5. Injury caused by a service weapon in the USA in 2008.
Fig. 4. Photograph of the penetrating injury in the left index caused by the electrode dart.
50,000 V (2 mA) pulse that freezes the nervous system by stimulating the motor neurons until a refractory period is achieved, resulting in loss of muscle control [1]. The TASER1 works either remotely in ‘‘projectile’’ mode or in ‘‘drive stun’’ mode upon direct contact with the subject. Its use has generated some controversy as it is the source of various complications, including death by potentially non-reversible cardiac arrest with atrial or ventricular fibrillation [2]. Other than its tragic lethal consequences, the TASER1 can also cause various lesions, with sequelae that are not insignificant and can be potentially serious. These injuries are the result of the direct impact or the fall caused by pain and temporary paralysis brought on by the electric shock. Direct injuries or fall-related injuries have been reported such as contusions, deep and superficial wounds, burns [3], eye injuries [4], fractures [5–12], head injuries [13], strokes [14] and transient changes in mental capacity [3,15,16]. Direct bone injuries are rare because the electrodes are quickly stopped by superficial skin tissues; they are mainly the indirect consequence of transient muscle paralysis and the resulting fall. In the case described here, the patient presented with a penetrating bone lesion of the middle phalanx with multiple tissue involvement. The fingers may be the most susceptible to penetrating injury by these electrodes as they are superficial and less protected by muscle and/or fat tissue. We found only one reported case of finger injury by TASER1: in 2005, Dearing and Lewis described a dart lodged in the base of the distal phalanx of the index near the deep flexor tendon attachment [17]. Bozeman et al. reported a finger fracture in their 2008 publication but no other details; more importantly they found that the upper limb was affected in 7.9% of cases [5]. In 2007, Kierzek et al. reported a laceration of the flexor sheath in the left index finger of a policeman injured by his own weapon, without associated tendon or bone involvement [3]. Further research
using the Google Images search engine identified two other US cases that were not documented in the scientific literature; one was a distal volar injury of the distal phalanx by two electrodes in 2008 (Fig. 5); the other was a superficial, dorsal lesion of the base of the middle phalanx without tendon or joint involvement in 2009 (Fig. 6). Although this has never been reported in the fingers, the intensity of the electric current delivered by the TASER1 could result in thromboembolic complications as described by Bell et al. [14]. The electric current received by the subject can lead to vascular spasm and a direct endothelial lesion, source of arterial ischemia [14]. Similarly, the TASER1 can lead to neurological complications [3], but to our knowledge, no motor or sensory deficit secondary to peripheral neural lesions has been reported. It is essential to immediately look for neurological or vascular involvement in a patient presenting with TASER1 related trauma. The function or even the viability of the finger could be compromised. As in our case, there is also a risk of tendon injury and a risk of infection that is not insignificant. We believe this justifies rigorous exploration and systematic abundant lavage in cases of damage to the tendon sheath and cases of bone or joint involvement. This lavage must be combined with a short course of antibiotics (48 hours) consistent with an open, ballistic fracture. The patient’s care must be carried out by a specialized team to avoid any delays or diagnostic errors. Moreover, follow-up is essential as deep skin lesions can progress, particularly burns and deep infections of the soft tissues or bone. Our patient had no signs of persistent neurological deficit, likely because the two electrodes were far apart. This case highlights the potential severe risk to function and viability generated by Taser-induced finger injury. This risk of multiple tissue involvement combining skin burns with tendon, joint, bone, nerve and vascular injury should bring into question the use of these devices, said to be self-defense weapons. Given the absence of reliable studies on the potential risks associated with TASER1 use, questions about the ethics of its use [15] and significant health risks (not all of which are known) have
B. Dunet et al. / Chirurgie de la main 34 (2015) 145–148
148
Fig. 6. Non-penetrating, extra-articular injury to the middle phalanx during police questioning in the USA in 2009.
resulted in calls to strengthen laws related to its use. With TASER1 use increasing, it is important to be aware of the potentials risks associated with this weapon, namely to the fingers and to favor fast, specialized care for any such patients. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Kroll MW. Physiology and pathology of TASER electronic control devices. J Forensic Legal Med 2009;16:173–7. [2] Zipes DP. TASER electronic control devices can cause cardiac arrest in humans. Circulation 2014;129:101–11. [3] Kierzek G, Becour B, Rey-Salmon C, Pourriat JL. Implications cliniques de l’utilisation du TASER. Rev SAMU 2007;29:286–9. [4] Kroll MW, Dawes DM, Heegaard WG. TASER electronic control devices and eye injuries. Doc Ophtalmol 2012;124:157–9. [5] Bozeman WP, Hauda 2nd WE, Heck JJ, Graham Jr DD, Martin BP, et al. Safety and injury profile of conducted electrical weapons used by law enforcement officers against criminal suspects. Ann Emerg Med 2009;53: 480–9.
[6] Jauchem JR. TASER1 conducted electrical weapons: misconceptions in the scientific/medical and other literature. Forensic Sci Med Pathol 2015;11:53–4. [7] Peyron PA, Cathala P, Baccino E. Fractures osseuses par électrisations à basse tension : à propos de deux cas. Rev Med Legal 2014;5:170–5. [8] Sinha A, Dholakia M. Thoracic compression fracture caused by TASERinduced injury: a case report. Phys Med Rehabil 2011;3:S220. [9] Sloane CM, Chan TC, Vilke GM. Thoracic spine compression fracture after TASER activation. J Emerg Med 2008;34:283–5. [10] Winslow JE, Bozeman WP, Fortner MC, Alson RL. Thoracic compression fractures as a result of shock from a conducted energy weapon: a case report. Ann Emerg Med 2007;50:584–6. [11] Coad F, Maw G. TASERed during training: an unusual scapular fracture. Emerg Med Australas 2014;26:206–7. [12] de Runz A, Minetti C, Brix M, Simon E. New TASER injuries: lacrimal canaliculus laceration and ethmoid bone fracture. Int J Oral Maxillofac Surg 2014;43:722–4. [13] LeBlanc-Louvry I, Gricourt C, Touré E, Papin F, Proust B. A brain penetration after TASER injury: controversies regarding TASER gun safety. Forensic Sci Int 2012;221:e7–11. [14] Bell N, Moon M, Dross P. Cerebrovascular accident (CVA) in association with a taser-induced electrical injury. Emerg Radiol 2014;21:211–3. [15] Frenette M. TASER : un risque pour la santé contraire à l’éthique. Ethique Sante 2012;9:107–12. [16] O’Brien AJ, Thom K. Police use of TASER devices in mental health emergencies: a review. Int J Law Psychiatry 2014;37:420–6. [17] Dearing M, Lewis TJ. Foreign body lodged in distal phalanx of left index finger-taser dart. Emerg Radiol 2005;11:364–5.
ScienceDirect www.sciencedirect.com Chirurgie de la main 34 (2015) 145–148
Clinical case
The TASERed finger: A new entity. Case report and review of literature The TASERed finger : une nouvelle entité. Un cas rapporté et revue de la littérature B. Dunet *, A. Erbland, M.-L. Abi-Chahla, C. Tournier, T. Fabre Orthopedic and Traumatologic Unit, hôpital Pellegrin, place Amélie-Raba-Léo, 33076 Bordeaux cedex, France Received 26 January 2015; received in revised form 18 February 2015; accepted 11 April 2015 Available online 6 May 2015
Abstract The TASER1 is a self-defense weapon whose use has now become commonplace among law enforcement agencies. Electronic control weapons were first used in the USA in the 1990s and then adopted in Europe and France. We report a case of an 18-year-old male who presented a penetrating lesion of the middle phalanx of the left index finger. To the best of our knowledge, this is the first complex finger injury due to the TASER1. It highlights the potential major risks to finger vitality and function with use of this electrical weapon. # 2015 Elsevier Masson SAS. All rights reserved. Keywords: TASER1; Injury; Fracture; Finger; Bone
Résumé Le TASER1 est une arme de dissuasion et de neutralisation qui est de plus en plus répandue et d’usage courant pour les forces de l’ordre. Elle a été utilisée en premier aux États-Unis, puis s’est répandue en Europe et en France. Nous rapportons le cas d’un jeune homme de 18 ans ayant été « tasé » et ayant présenté une lésion transfixiante de la phalange intermédiaire de l’index gauche. Il s’agit à notre connaissance du premier cas de lésion osseuse transfixiante d’un doigt avec atteinte pluritissulaire associée dû au TASER1. Elle met en évidence les risques majeurs potentiels pour la vitalité et la fonction digitale d’une atteinte par arme à projection électrique. # 2015 Elsevier Masson SAS. Tous droits réservés. Mots clés : TASER1 ; Lésion ; Fracture ; Doigt ; Os
1. Introduction The TASER1 (Fig. 1) is a self-defense weapon that is now commonly used by law enforcement agencies. As a conductedelectric weapon, it incapacitates threatening subjects. This report describes the case of an 18-year-old male who was tasered and presented with a penetrating lesion of the middle phalanx of the left index finger. We believe this is the first reported case of a penetrating bone injury in a finger where multiple tissues are involved.
* Corresponding author. E-mail address: [email protected] (B. Dunet). http://dx.doi.org/10.1016/j.main.2015.04.001 1297-3203/# 2015 Elsevier Masson SAS. All rights reserved.
2. Case report During police questioning in October 2011, an 18 year-old, right-handed male, manual labourer, who was in France illegally, was tasered by the law enforcement officers to stop him from attempting to escape through a window. When he arrived at the emergency room (ER), the emergency physicians identified the first TASER1 dart in his thoracic area and the second one in his left index finger. The initial clinical examination identified no skin lesions; no sensory and motor deficits or vascular disorders were present in the left upper limb. Neurology, cardiology and respiratory examinations were normal. There were no heart rhythm disorders visible on electrocardiogram. Radiographs taken in
146
B. Dunet et al. / Chirurgie de la main 34 (2015) 145–148
Fig. 1. The TASER1 conducted electric weapon, model X26.
the ER confirmed the thoracic location of the first dart and the absence of associated complications (Fig. 2), along with the presence of a foreign body in the soft tissues over the middle phalanx of the left index finger (Fig. 3). When the patient was referred to us, the first step was to remove any burnt tissue in the area penetrated by the dart (Fig. 4). The patient had no signs of dysesthesia or paresthesia. Active extension of the distal phalanx was possible but not flexion. The finger’s vascularization was intact. Review of the initial radiographs led to the diagnosis of a penetrating injury to the base of the middle phalanx in the left index finger. Surgical exploration was performed under regional anesthesia in the operating room under tourniquet, once the dart had been cut from the skin. Dorsal exploration found no injury to the extensor mechanism and confirmed bone penetration at the level of the base of the middle phalanx over the triangular area between the two lateral slips of the extensor mechanism. The second stage consisted of volar exploration through a Brunnertype incision. The flexor digitorum profundus tendon was found to be partially lacerated and the C2 pulley damaged. The digital palmar neurovascular bundles were intact. A counter-incision was made in the middle palmar crease to carry out extensive prophylactic lavage of the flexor tendon sheath. After removing the barb, abundant lavage of the bone was performed using a catheter; the lacerated tendon was repaired with 4-0 PDS in a
Fig. 3. A/P and lateral radiographs of the left hand with foreign body penetrating into the middle phalanx.
Kessler pattern. No immobilization was used during the postoperative phase. A course of standard antibiotics was implemented for 48 hours with amoxicillin and clavulanic acid (500 mg/62.5 mg; 2 tablets 3/day, per os). The patient’s recovery was good. At the first postoperative visit on the 15th day, the patient had already recovered full range of motion and no sensory or motor deficit was noted. 3. Discussion Invented in 1960 by Jack Cover, an American physicist, and commercialized in 1974, the TASER1 is a non-lethal weapon that has been increasingly used since the start of the 2000s. This electric stun gun has a maximum range of 7.6 m (25 feet); it projects two electrodes at 50 m/s (164 feet/s) that are joined by two isolated wires. These two electrodes are similar to two 9-mm barbs. Upon reaching its target, the gun delivers a
Fig. 2. Standard A/P and lateral radiographs of the chest with precardiac foreign body.
B. Dunet et al. / Chirurgie de la main 34 (2015) 145–148
147
Fig. 5. Injury caused by a service weapon in the USA in 2008.
Fig. 4. Photograph of the penetrating injury in the left index caused by the electrode dart.
50,000 V (2 mA) pulse that freezes the nervous system by stimulating the motor neurons until a refractory period is achieved, resulting in loss of muscle control [1]. The TASER1 works either remotely in ‘‘projectile’’ mode or in ‘‘drive stun’’ mode upon direct contact with the subject. Its use has generated some controversy as it is the source of various complications, including death by potentially non-reversible cardiac arrest with atrial or ventricular fibrillation [2]. Other than its tragic lethal consequences, the TASER1 can also cause various lesions, with sequelae that are not insignificant and can be potentially serious. These injuries are the result of the direct impact or the fall caused by pain and temporary paralysis brought on by the electric shock. Direct injuries or fall-related injuries have been reported such as contusions, deep and superficial wounds, burns [3], eye injuries [4], fractures [5–12], head injuries [13], strokes [14] and transient changes in mental capacity [3,15,16]. Direct bone injuries are rare because the electrodes are quickly stopped by superficial skin tissues; they are mainly the indirect consequence of transient muscle paralysis and the resulting fall. In the case described here, the patient presented with a penetrating bone lesion of the middle phalanx with multiple tissue involvement. The fingers may be the most susceptible to penetrating injury by these electrodes as they are superficial and less protected by muscle and/or fat tissue. We found only one reported case of finger injury by TASER1: in 2005, Dearing and Lewis described a dart lodged in the base of the distal phalanx of the index near the deep flexor tendon attachment [17]. Bozeman et al. reported a finger fracture in their 2008 publication but no other details; more importantly they found that the upper limb was affected in 7.9% of cases [5]. In 2007, Kierzek et al. reported a laceration of the flexor sheath in the left index finger of a policeman injured by his own weapon, without associated tendon or bone involvement [3]. Further research
using the Google Images search engine identified two other US cases that were not documented in the scientific literature; one was a distal volar injury of the distal phalanx by two electrodes in 2008 (Fig. 5); the other was a superficial, dorsal lesion of the base of the middle phalanx without tendon or joint involvement in 2009 (Fig. 6). Although this has never been reported in the fingers, the intensity of the electric current delivered by the TASER1 could result in thromboembolic complications as described by Bell et al. [14]. The electric current received by the subject can lead to vascular spasm and a direct endothelial lesion, source of arterial ischemia [14]. Similarly, the TASER1 can lead to neurological complications [3], but to our knowledge, no motor or sensory deficit secondary to peripheral neural lesions has been reported. It is essential to immediately look for neurological or vascular involvement in a patient presenting with TASER1 related trauma. The function or even the viability of the finger could be compromised. As in our case, there is also a risk of tendon injury and a risk of infection that is not insignificant. We believe this justifies rigorous exploration and systematic abundant lavage in cases of damage to the tendon sheath and cases of bone or joint involvement. This lavage must be combined with a short course of antibiotics (48 hours) consistent with an open, ballistic fracture. The patient’s care must be carried out by a specialized team to avoid any delays or diagnostic errors. Moreover, follow-up is essential as deep skin lesions can progress, particularly burns and deep infections of the soft tissues or bone. Our patient had no signs of persistent neurological deficit, likely because the two electrodes were far apart. This case highlights the potential severe risk to function and viability generated by Taser-induced finger injury. This risk of multiple tissue involvement combining skin burns with tendon, joint, bone, nerve and vascular injury should bring into question the use of these devices, said to be self-defense weapons. Given the absence of reliable studies on the potential risks associated with TASER1 use, questions about the ethics of its use [15] and significant health risks (not all of which are known) have
B. Dunet et al. / Chirurgie de la main 34 (2015) 145–148
148
Fig. 6. Non-penetrating, extra-articular injury to the middle phalanx during police questioning in the USA in 2009.
resulted in calls to strengthen laws related to its use. With TASER1 use increasing, it is important to be aware of the potentials risks associated with this weapon, namely to the fingers and to favor fast, specialized care for any such patients. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Kroll MW. Physiology and pathology of TASER electronic control devices. J Forensic Legal Med 2009;16:173–7. [2] Zipes DP. TASER electronic control devices can cause cardiac arrest in humans. Circulation 2014;129:101–11. [3] Kierzek G, Becour B, Rey-Salmon C, Pourriat JL. Implications cliniques de l’utilisation du TASER. Rev SAMU 2007;29:286–9. [4] Kroll MW, Dawes DM, Heegaard WG. TASER electronic control devices and eye injuries. Doc Ophtalmol 2012;124:157–9. [5] Bozeman WP, Hauda 2nd WE, Heck JJ, Graham Jr DD, Martin BP, et al. Safety and injury profile of conducted electrical weapons used by law enforcement officers against criminal suspects. Ann Emerg Med 2009;53: 480–9.
[6] Jauchem JR. TASER1 conducted electrical weapons: misconceptions in the scientific/medical and other literature. Forensic Sci Med Pathol 2015;11:53–4. [7] Peyron PA, Cathala P, Baccino E. Fractures osseuses par électrisations à basse tension : à propos de deux cas. Rev Med Legal 2014;5:170–5. [8] Sinha A, Dholakia M. Thoracic compression fracture caused by TASERinduced injury: a case report. Phys Med Rehabil 2011;3:S220. [9] Sloane CM, Chan TC, Vilke GM. Thoracic spine compression fracture after TASER activation. J Emerg Med 2008;34:283–5. [10] Winslow JE, Bozeman WP, Fortner MC, Alson RL. Thoracic compression fractures as a result of shock from a conducted energy weapon: a case report. Ann Emerg Med 2007;50:584–6. [11] Coad F, Maw G. TASERed during training: an unusual scapular fracture. Emerg Med Australas 2014;26:206–7. [12] de Runz A, Minetti C, Brix M, Simon E. New TASER injuries: lacrimal canaliculus laceration and ethmoid bone fracture. Int J Oral Maxillofac Surg 2014;43:722–4. [13] LeBlanc-Louvry I, Gricourt C, Touré E, Papin F, Proust B. A brain penetration after TASER injury: controversies regarding TASER gun safety. Forensic Sci Int 2012;221:e7–11. [14] Bell N, Moon M, Dross P. Cerebrovascular accident (CVA) in association with a taser-induced electrical injury. Emerg Radiol 2014;21:211–3. [15] Frenette M. TASER : un risque pour la santé contraire à l’éthique. Ethique Sante 2012;9:107–12. [16] O’Brien AJ, Thom K. Police use of TASER devices in mental health emergencies: a review. Int J Law Psychiatry 2014;37:420–6. [17] Dearing M, Lewis TJ. Foreign body lodged in distal phalanx of left index finger-taser dart. Emerg Radiol 2005;11:364–5.
