Intravenous injections are an everyday practice in the health-care sector and are also frequently abused among drug abusers. According to a 2019 report published by the Ministry of Social Justice and Empowerment of the Government of India, India has an estimated 8.5 lakh intravenous drug abusers ^[1]. A substantial proportion of them report risky injecting practices. About half reported reusing their needles and syringes, and about a third reported experiencing vein-related complications, ulcers, and abscesses at the injecting sites ^[1]. Intraluminal breaking of the needle is a rare complication that should be taken seriously because it could result in the embolization of needle fragments. We are reporting the case of a young man with a history of intravenous injection of heroin using a reused needle resulting in its breakage inside the lumen of the proximal forearm vein.

A 28-year-old male, right-hand dominant, an intravenous drug abuser for the past 5 years, presented to the orthopedics emergency department of our hospital with a history of pain, redness, and swelling in his left proximal forearm from the past 2 h. The patient admitted to injecting heroin into his left proximal forearm vein with a multiple times reused syringe and that the needle broke while injecting the drug. Immediately, a tourniquet was applied at the level of the midarm by the patient himself to prevent embolization of the needle. Radiographs (AP and Lateral view) of the left forearm confirmed the presence of a broken needle in the mid-left proximal forearm (Fig. 1a and b). The patient was taken to the operation theater with the tourniquet applied. Intraoperative fluoroscopy was used to identify the location of the needle fragment. Wound exploration was done after injecting local anesthesia around the suspected injection site (Fig. 2a), and an intact, slightly bent needle was seen in a superficial vein lumen (Fig. 2b). The needle was removed (Fig. 2c), and the damaged venous segment was suture ligated and resected.

There are several instances reported of intraluminal breakage of the needle in intravenous drug abusers (Table 1). In a few cases, attempts were made to retrieve intraluminal broken needles, but the needles embolized to proximal sites in the body, including the heart and the lung [2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18]. There is not much literature that can be found on the successful retrieval of the needle at the injection site in intravenous drug abusers ^[14]. There is a lack of specific guidelines for needle retrieval. Leaving a needle as such can cause abscess formation ^[14] at the local site and, in extreme cases, can lead to endocarditis ^[8] and purulent pericarditis when embolized ^[10]. An attempt at removing the needle itself can sometimes lead to proximal migration of the needle during manipulation ^[4]. We strongly recommend that IV drug abusers be apprised of the risk of needle breakage, especially after repeated reuse of the needle, and the importance of a tourniquet application as soon as possible to prevent its migration proximally. An important point that needs to be highlighted in our case report is the patient’s presentation time, which was within 2 h of the needle breakage. Early presentation makes the retrieval less complicated for the treating surgeon, as was the case with us. Late presentation risks the broken needle migrating in the body. Another critical point to highlight is the early application of a tourniquet by the patient himself immediately after the needle breakage, which prevented the proximal migration of the needle. Tourniquet use has been reported to be unsuccessful when applied late [4, 14].

Intraluminal intravenous needle breakage should be dealt with like an emergency, as there is a risk of migration of the needle fragment to proximal sites in the body. A tourniquet should be applied as soon as possible to avoid proximal migration of the needle.

Intravenous drug abusers should be educated about safe injection practices and should be sensitized about reporting to the emergency as soon as there is needle breakage.