PALM TREE THORN INJURY: AN UNUSUAL AND UNDERESTIMATED CELLULITIS WITH RISK FOR NEAR MISS EVENT

Case Presentation: A 60-year-old male presented with a 4-day complaint of left forearm pain after a palm tree frond fell on his mid-arm resulting in a lump to the area. He was seen in the emergency room (ER) on the day of injury and x-ray of the arm showed no fracture. He was discharged with orthopedic referral. The patient reported that the area became more painful. Attempts at pain relief with ice application and elevation was unsuccessful, and he was unable to get an urgent outpatient orthopedic evaluation. He endorsed numbness around the area but denied fever, drainage or pus. He had no history of gout or diabetes mellitus, smoking or drug use.He was afebrile. Laboratory findings included WBC 9.73 k/uL, lactate 1.0 mmol/L , and C-reactive protein 2.0 mg/dL. He received cefazolin, colchicine and prednisone in the ER, and was admitted for cellulitis and injury due to palm tree frond.On exam, there was a large raised circumferential area to mid left upper extremity that was tender, with mild tingling. No drainage or open wound was observed. He was able to move the extremity, had bounding radial pulse, and normal capillary refill. His antibiotic was changed to ceftriaxone, as literature indicated better susceptibility than cefazolin to a dominant cause of palm tree injury, Pantoea agglomerans (formerly Enterobactor agglomerans) (1, 2). An ultrasound of the extremity was done to evaluate for retained palm particles, and revealed a small linear foreign body. Incision and drainage procedure was performed with significant findings of pus and a long spike foreign object approximately 2 inches long. Tissue culture and stain report revealed Enterobacter cloacae and enterococcus casseliflavus. Both bacteria are found on plants (2, 3, 4, 5). He was discharged with doxycycline and cefdinir, as recommended by infectious disease. At follow-up outpatient visit, he had recovered.

Discussion: The dangers of palm tree injury are often unknown and underestimated by patients and healthcare providers. This patient developed cellulitis and abscess related to palm tree injury and associated retained foreign body. A delayed or missed diagnosis could be detrimental to limb and life.Palm tree thorn injury may cause serious complications from retained foreign body including septic arthritis, synovitis, osteomyelitis, infected hematoma, sepsis and bacteremia as the thorns may penetrate deep soft tissue and bone (2,3,4,5). The retained thorn may migrate causing distant inflammatory processes (6). This injury may go unrecognized due to unfamiliarity with managing this type of injury. A key component of management is finding and removing the foreign body. This becomes very pertinent when a patient is unresponsive to antibiotic therapy. Clinicians should be aware that x-ray is insufficient to detect foreign bodies in these injuries, as thorns are radiolucent and thus difficult for x-ray to locate (3,5). Consideration should be made for ultrasound or magnetic resonance imaging to facilitate rapid detection of foreign bodies and ensuing drainage of the abscess, which is an essential part of treatment (5).

Conclusions: It is vital that clinicians and patients are aware of palm tree injury and its complications and best methods for prevention. Rapidly identifying foreign objects along with its removal prevents missed diagnosis and delayed diagnosis. Additionally, it prevents patient suffering and repeated healthcare system contact that increases healthcare and patient costs. Importantly, x-ray is not the gold standard for detecting palm tree thorns.