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 Table of Contents  
Year : 2017  |  Volume : 7  |  Issue : 3  |  Page : 107-110

Penetrating orbitocranial injury in a child secondary to fall on a pencil: Operative technique and review of literature

1 Department of Surgery, Division of Neurological Surgery, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
2 Department of Ophthalmology, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
3 Department of Surgery, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria

Date of Web Publication29-Oct-2018

Correspondence Address:
Dr. David Okon Udoh
Department of Surgery, Division of Neurological Surgery, University of Benin Teaching Hospital, P. M. B. 1111, Benin City, Edo State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ais.ais_25_16

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Orbitocranial penetrating injuries usually present dramatically with the stump of the penetrating object in the wound though occult cases have been reported in which the injury appeared trivial without outward evidence of the penetrating object. We present a child who fell on a pencil and underwent a craniotomy for retrieval of the transorbitocranial penetrating foreign body. A joint neurosurgical and neuroophthalmic evaluation were used in the management. Neuroimaging included computed tomography scan and ocular ultrasound with or without magnetic resonance imaging. In addition, a high index of suspicion is required in seemingly trivial periorbital trauma to prevent devastating and life-threatening complications. Public education on the dangers of children holding potentially harmful schooling and household objects during play is also emphasized.

Keywords: Neuroimaging, orbitocranial injury, pencil, public education

How to cite this article:
Udoh DO, Osaguona V, Obeta EC. Penetrating orbitocranial injury in a child secondary to fall on a pencil: Operative technique and review of literature. Arch Int Surg 2017;7:107-10

How to cite this URL:
Udoh DO, Osaguona V, Obeta EC. Penetrating orbitocranial injury in a child secondary to fall on a pencil: Operative technique and review of literature. Arch Int Surg [serial online] 2017 [cited 2023 Dec 3];7:107-10. Available from:

  Introduction Top

Penetrating orbitocranial injury by a wooden foreign body is relatively uncommon and potentially fatal. Prompt clinical evaluation and computed tomography (CT) scan and/or magnetic resonance imaging and angiography help to exclude major cerebrovascular catastrophe and other potential risks – they also determine the choice of treatment.[1]

Complication rate in transorbitocranial injuries is twice that for penetrating cranial injury not affecting the orbit, with a mortality rate of approximately 12%.[1],[2]

We present a penetrating intracranial injury with a pencil through the orbit in a school-age child highlighting the importance of neuroimaging, interdisciplinary management, and public enlightenment.

  Case Report Top

A six-year-old girl presented at our Emergency Department with a pencil through her right eye. She was referred from a secondary health facility, located about a 110 km away from our teaching hospital. She had tripped while running in school, falling on a pencil held in her right hand. There was right visual loss, but no loss of consciousness, seizure, or cerebrospinal fluid leakage. She presented a day after the injury and surgery was carried out within 24 hours. There was no history of psychiatric illness.

Physical examination showed an acutely ill child, in pain, with a 5 cm broken butt end of a pencil protruding from the right medial canthus and pointing in a posterosuperolateral trajectory [Figure 1].
Figure 1: Broken butt end of the pencil penetrating the orbit at the medial canthus of the right eye

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Glasgow coma scale score was 15. She had a normal mental state, but there was restriction of all eye movements with 4 mm diameter unreactive pupil and absent light perception in the right eye. The left eye was normal. There were no overt long tract signs.

Cardiovascular, respiratory, and abdominal examinations were normal.

A diagnosis of penetrating right orbitocranial pencil injury with unilateral blindness (and ophthalmoplegia) was made.

Skull radiographs showed a radio-opaque material with surrounding radiolucency projecting intracranially through the roof of the right orbit [Figure 2].
Figure 2: Computerised tomography scans of the brain with bone windows: Note various stages of penetration of the pencil through the right medial canthus, orbit, orbital roof, and the frontal lobe

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CT brain scan showed a foreign body with hyperdense core and surrounding hypodensity projecting through the roof of the orbit into the pars orbitale of the right frontal lobe; there was no hemorrhagic contusion or edema. The ventricles and basal cisterns were normal [Figure 3].
Figure 3: Intraoperative picture showing the scalp flap reflected over the face: Note (a) The frontal lobe is gently lifted with brain retractors to demonstrate the intracranial end of the pencil, the orbital roof and the passage through the dura. (b) The extracranial part of the pencil jutting out from the right eye below

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Ocular ultrasound scan showed echogenic collections within the anterior segment and vitreous humour. The retina and optic nerves were normal.

The full blood counts, electrolytes, urea and creatinine, urinalysis, and random blood glucose were normal.

She underwent a craniotomy with extradural extraction of pencil in a joint session with the ophthalmologist(s).

Details of operative treatment

Under endotracheal anesthesia with muscle relaxation, the child was positioned supine. Intravenous ceftriaxone was administered prophylactically. The head was elevated, minimally extended, and rotated 45° to the left to aid exposure of the right frontal skull base. A right frontoparietal scalp flap was raised and with a low-reaching right frontal craniotomy flap just over the supraorbital ridge, the right subfrontal region was exposed. Using hand-held brain retractors, the right frontal lobe was gently lifted from the skull base to show the pencil penetrating through the superior wall of the orbit into ventral surface of the frontal lobe. Further gentle retraction eased the tip of the pencil out of the frontal lobe. With the entire extraorbital and intracranial extent of the pencil in view, the intracranial part of the pencil was cut sharply flush with the orbital roof and the pencil was retrieved through the medial canthus without resistance. The dural, cranial base and upper eyelid entry wounds of similar diameter were noted [Figure 3] and [Figure 4]. There was no bleeding or abscess collection. The wound was irrigated with ceftriaxone (and gentamycin)-constituted warm saline fluid. Durorapphy was carried out and bone flap replaced with vicryl stitch. Scalp was apposed with interrupted prolene stitch.
Figure 4: Intraoperative picture showing the retrieved pencil. Note pencil entry wound in the right upper eyelid

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Antibiotics were continued for 1 week before removal of stitches. Repeat visual assessment after 1 week of operation showed improved visual acuity of 6/24 and 6/5 on the right and left, respectively. The wound healed satisfactorily and scalp sutures were removed and she was discharged on eighth postoperative day [Figure 5]. She has remained well.
Figure 5: Eighth day post craniotomy and retrieval of pencil. All sutures removed

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Awareness campaign, public education, and prevention

A 1-hour public enlightenment campaign was broadcast on a state-wide television station by the neurosurgical and ophthalmology units and our hospital's management representative-this targeted parents, caregivers, and school teachers with the objective of preventing penetrating cranial injuries from various schooling and household materials during play.

  Discussion Top

Penetrating objects may pass through the orbit into the cranium via the orbital roof, the superior orbital fissure, or the optic canal; penetration directed upward may pierce the orbital roof into the frontal lobe, especially when the fall is on a sharp object held in the hand.[1] Children are particularly prone because the orbital bones offer little resistance.[1],[2]

Retained broken pencil wood and graphite may result in foreign body granuloma, infection (including brain abscess due to the porous structure and the organic consistency of wood which provide a natural reservoir and good culture medium for microbial agents despite antibiotic prophylaxis) or serious neurovascular complications such as hematoma, cerebrospinal fluid cystocoele, and fistula or aneurysm; ocular complications include severe visual impairment (secondary to direct optic nerve damage, globe laceration, or retinal ischemia), extraocular muscle paralysis secondary to direct trauma or nerve damage, proptosis, and macular edema, which were seen in our patient[1],[3],[4],[5],[6]

Though wood is virtually undetectable on routine plain radiographs since its radiodensity is very similar to that of the soft tissue, the graphite component of a pencil might be seen on X-ray.[1] The detection of an intracranial wooden object by CT scan is also difficult because wood absorbs water and attains almost the same density as the brain tissue; it will be seen as a dark area around the graphite core and it may not be easily differentiated from an intracranial air bubble.[7],[8] Coronal views are recommended because the plane of the orbital roof and floor are nearly parallel to the scanning beam.

Rarely, penetrating orbital injuries may not cause any clinically relevant damage to the globe (as it is pushed aside into the orbital fat), extraocular muscles, intraorbital neurovascular structures, or intracranial.[1],[3],[9] In most other instances, because the orbit is pyramidal in shape, fine pointed objects at low velocity tend to be directed toward the orbital apex causing damage to the optic nerve, extraocular muscles, and ocular nerves.[3]

Management of these patients should be multidisciplinary with adequate conventional neuroimaging. The operation for retrieval of the foreign body should be through an open cranial procedure permitting exposure of the whole intracranial pencil length, hematoma, or abscess evacuation and visualization of vascular structures as well as avoidance of further injury, which is an important goal of intervention.[10]

However, Nigerian cases of penetrated pencil injuries may be underreported though these injuries are common in the developing world.[11],[12]

  Conclusion Top

Childhood penetrating orbitocranial injuries with writing materials, such as pencils, and common household items, such as screw drivers, though relatively uncommon, may be fatal or result in lifelong disabilities. Efforts should be made at preventing them and management of cases presenting to the hospital should be multidisciplinary.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Gazzaz M, Lmejjati M, Akhaddar A, Derraz S, Aghzadi, El Khamlichi A. Paediatric penetrating orbitocranial injury with a pencil - a report of two cases. Pan Arab J Neurosurg 2000;4:2 [ [Last accessed on 2006 Feb 21].  Back to cited text no. 1
Oğuz M, Aksungur EH, Atilla E, Altay M, Soyupak SK, Ildan F, et al. Orbitocranial penetration of a pencil: Extraction under CT control. Eur J Radiol 1993;17:85-7.  Back to cited text no. 2
De Villiers JC, Sevel D. Intracranial complications of transorbital stab wounds. Br J Ophthalmol 1975;59:52-6.  Back to cited text no. 3
Potapov AA, Eropkin SV, Kornienko VN, Arutyunov NV, Yeolchiyan SA, Serova NK, et al. Late diagnosis and removal of a large wooden foreign body in the cranio-orbital region. J Craniofac Surg 1996;7:311-4.  Back to cited text no. 4
Al-Otaibi F, Baeesa S. Occult orbitocranial penetrating pencil injury in a child. Case Rep Surg 2012;2012:716791.  Back to cited text no. 5
Mutlukan E, Fleck BW, Cullen JF, Whittle IR. Case of penetrating orbitocranial injury caused by wood. Br J Ophthalmol 1991;75:374-6.  Back to cited text no. 6
Matsumoto S, Hasuo K, Mizushima A, Mihara F, Fukui M, Shirouzu T, et al. Intracranial penetrating injuries via the optic canal. AJNR Am J Neuroradiol 1998;19:1163-5.  Back to cited text no. 7
Zentner J, Hassler W, Petersen D. A wooden foreign body penetrating the superior orbital fissure. Neurochirurgia (Stuttg) 1991;34:188-90.  Back to cited text no. 8
Bulbula A, Roux P, Asholi A, Bulbulia N. An unusual case of penetrating wound of the orbit. S Afr Ophthalmol 2006;65:75-7.  Back to cited text no. 9
Litvack ZN, Hunt MA, Weinstein JS, West GA. Self-inflicted nail-gun injury with 12 cranial penetrations and associated cerebral trauma. Case report and review of the literature. J Neurosurg 2006;104:828-34.  Back to cited text no. 10
Oluyemi F. Epidemiology of penetrating eye injury in Ibadan: A 10-year hospital-based review. Middle East Afr J Ophthalmol 2011;18:159-63.  Back to cited text no. 11
[PUBMED]  [Full text]  
Aremu SK, Makusid MM, Ibe IC. Oro-cranial penetrating pencil injury. Ann Saudi Med 2012;32:534-6.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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