- Email: [email protected]
Gluteal stab wound is a frequent and potentially dangerous injury
Injury, Int. J. Care Injured (2005) 36, 148—150
Gluteal stab wound is a frequent and potentially dangerous injury Sergio Susmalliana,*, Tiberiu Ezrib, Marina Elisa, Katia Dayana, Ilan Charuzia, Michael Muggia-Sullama a
Department of Surgery B, E. Wolfson Medical Center, Holon, Israel Department of Anaesthesia, E. Wolfson Medical Center, Holon, Israel
b
Accepted 8 October 2003
KEYWORDS Gluteal; Stab wound; Trauma
Summary Background: Stab wounds to the gluteal area are a frequent injury in an urban trauma centre. These injuries may appear innocuous but is potentially life threatening. Therefore they deserve timely evaluation and management. The purpose of this study was to evaluate our experience with this type of injury and to propose a treatment protocol. Methods: During the last 5 years 269 patients with stab injuries, were admitted to our Department of Emergency Medicine (DEM). Thirty-nine patients (14%) who had gluteal penetration were included in this study. Patients’ charts were retrospectively reviewed for demographic data, type of injury and additional injuries, evaluation, management and outcome. Results: Stab wound of the gluteal region was the most frequent injury after chest and abdominal injuries. Thirty patients presented with soft tissue damage only and nine were severely injured. Seven of the severely injured patients had significant bleeding; two of them were treated by embolisation. One patient suffered a rectal injury and one a small bowel perforation, both treated surgically. There was no post-operative complication or mortality. Conclusions: Penetration of the gluteal is a potentially life threatening injury. Meticulous observation and high level of suspicion ensure early treatment and can prevent mortality. ß 2004 Elsevier Ltd. All rights reserved.
Introduction Penetrating injuries of the gluteal area have been seen more frequently in our Department of Emergency Medicine (DEM) in the last few years. Most of the patients have soft tissue injury without major vascular, neurological or visceral involvement. However, about a quarter of the cases may have severe life-treating injuries.4 Injuries reported in the literature include bleeding from the superior and inferior gluteal and the *Corresponding author. Tel.: þ972-35028634; fax: þ972-35016667. E-mail address: [email protected] (S. Susmallian).
iliac vessels,2 damage of the sciatic or gluteal nerve, spinal cord penetration, urethral disruption,6 rectal and visceral perforation. Adoption of protocols in the treatment of trauma patients has been shown to be a safe way to avoid missed major injuries and is applicable to this type of injury. The study was undertaken in our 600 beds, university affiliated, community hospital, which provides medical care (mainly covered by medical insurance) for 500,000 urban area citizens. The aim of this report is to emphasise that a penetrating stab wound in the gluteal area is a frequent and a potential severe injury. We reviewed all the patients admitted to the DEM with a penetrating injury to the gluteal area over the last 5 years.
0020–1383/$ — see front matter ß 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2003.10.002
Stab wound of the gluteal region
Materials and methods We reviewed the records of all 269 patients who arrived at our DEM from June 1997 to June 2002 with penetrating stab wounds. All the patients admitted after penetrating trauma of the gluteal region caused by knives were included, other causes of penetrating injuries were excluded, and superficial lacerations (without fasciae penetration) were also excluded. The gluteal region was defined as the area limited superiorly by the line between the iliac crests, inferiorly by the gluteal fold and laterally by an imaginary line tangential to the greater trochanter.1 All patients were treated according to the protocols of Advanced Trauma Life Support. Local exploration of the wounds was done under local anaesthesia to determine if the penetration included the fascia. Haemodynamically unstable patients were evaluated and treated in the shock room and then diagnostic studies were performed such as computerised tomography, retrograde urethrography or angiography as indicated. Tetanus toxoid was injected intramuscular to un-immunised patients. Patients with only soft tissue damage were discharged after close observation, and wound treatment by debridment and suture. Patients with severe bleeding on admission were diagnosed by angiography and treated successfully by embolisation. Patients with abdominal or rectal injuries were treated surgically. Statistic: results are expressed as mean values and percentage.
Results Two hundred and sixty-nine patients with penetrating trauma caused by stab wounds were admitted to our DEM. Two hundred and sixty-one patients were males (97.02%) and eight were females (2.98%). The mean age was 26.7 years (range13—75 years). Seven female patients were injured by their family relatives. On admission 206 patients (76.57%) presented with one stab wound and 63 (23.43%) had multiple stab wounds with a maximum of 27 stab wounds to one patient. The distribution of the stab wounds per area is shown in graph number one. Thirty-nine patients with 44 penetrating stab wounds to the gluteal region were admitted to the DEM during the study period (July 1997—June 2002). This type of injury accounted for 14% of all penetrating stab wounds. Demographic data of the patients are shown in Table 1. Thirty patients were classified as non-severe trauma lesions, treated in the DEM
149
Table 1 Demographic data of patient with stab wound in the gluteal region Data
Number of Percentage patients
Male 38 Female 1 Severe injuries 9 Multiple wounds 11 Hemo-dynamically unstable 2 Surgical treatment 2 Discharged from ER 30
97.44 2.56 23.07 28.20 5.13 5.13 76.92
and discharged after observation for at least 2 h. Severe trauma was observed in nine patients, seven of whom presented with severe bleeding. Five cases were treated by external compression and suture of the wound followed by observation for at least 24 h (no blood cells transfusion was required), in two patients who were haemodinamically unstable on admission, angiography with successful remobilization of the superior gluteal artery was performed after haemodynamic stabilisation with crystalloid infusion and two units of packed red cells. Surgical intervention was not necessary in these cases, but the last two patients had close follow up in the Department of Surgery. One patient had a rectal injury, suspected during rectal examination and confirmed by anoscopy. The same patient had additional small bowel lacerations caused by a second stab wound that penetrated the abdominal cavity. He was treated by a diverting colostomy, perineal drainage and suture of the small bowel lacerations. The ninth patient had a laparatomy for positive peritoneal signs after negative finding at computerised tomography. Four small perforations were found in the ileum caused
Figure 1
Anatomic distribution of stab wounds.
150
by a penetrating injury from the gluteus through the sacroiliac joint. The lesions were treated by simple suture. No lesion of sciatic or gluteal nerves were seen in our patients. All nine patients were considered as severely injured and were discharged without complications. No mortality occurred in the study group (Fig. 1).
Discussion Penetrating injury of the buttocks is not frequently reported in the literature. Maull et al.5 published one of the first reports about penetrating wound of the buttocks in 1979. Stab wound to the gluteal region was described in the literature as an uncommon lesion,4 but we agree with Feigenberg et al.,2 that there is a false impression that they are a rare type of injury. Penetrating injury caused by stabbing to the gluteal area is usually a minor trauma, especially when considered separately from gun shot wounds, and most of the patients are discharged after local treatment of their wounds. But it should be remembered that they are a potentially severe and lifethreatening injury.2 This is emphasised by the occurrence of severe injuries in our patient group (9/39). The presentation of severe injuries in patients with gluteal stab is about 25%.4 Fallon et al. described 51 cases of penetrating wounds through the gluteus1 and Ivatury et al. described 60 cases of penetrating gluteal injuries, in both reports stab wounds and gun shot wounds
S. Susmallian et al. were considered together.3 We believe that stab wounds need to be considered separately from gun shot wounds to define their different characteristics. Our study shows that stab wound to the gluteal region are less severe than those produced by gun shot wounds. In our study operative treatment was necessary in two cases (2/39) compared with 40% reported by Fallon et al.1 and 26.7% cited by Ivatury et al.3 when gun shot and stab wound are considered together. In summary stab wound of the gluteal area must be considered a potentially serious lesion. Meticulous observation and suspicious of a major injury during examination should prevent mistakes and ensure early treatment.
References 1. Fallon W, Reyna T, Brunner R, Crooms C, Alexander R. Penetrating trauma to the buttock. South Med J 1988;81: 1236—8. 2. Feigenberg Z, Ben-Baruch D, Barak R, Zer M. Penetrating stab wound of the gluteus–—a potentially life-threatening injury: case reports. J Trauma 1992;33:776—8. 3. Ivatury R, Rao P, Nallathambi M, Gaudino J, Stahl W. Penetrating gluteal injuries. J Trauma 1982;22:706—9. 4. Makrim V, Sorene E, Soffer D, Weinbroum A, Oron D, Kluger Y. Stab wounds to the gluteal region: a management strategy. J Trauma 2001;50:707—10. 5. Maull K, Snoddy J, Haynes B. Penetrating wounds of the buttocks. Surg Gynecol Obstet 1979;169:855—7. 6. Rub R, Madeb R, Kluger Y, Chen T, Avigdor Y. Posterior urethral disruption secondary to a penetrating gluteal injury. Urology 2000;56:509.
Gluteal stab wound is a frequent and potentially dangerous injury Sergio Susmalliana,*, Tiberiu Ezrib, Marina Elisa, Katia Dayana, Ilan Charuzia, Michael Muggia-Sullama a
Department of Surgery B, E. Wolfson Medical Center, Holon, Israel Department of Anaesthesia, E. Wolfson Medical Center, Holon, Israel
b
Accepted 8 October 2003
KEYWORDS Gluteal; Stab wound; Trauma
Summary Background: Stab wounds to the gluteal area are a frequent injury in an urban trauma centre. These injuries may appear innocuous but is potentially life threatening. Therefore they deserve timely evaluation and management. The purpose of this study was to evaluate our experience with this type of injury and to propose a treatment protocol. Methods: During the last 5 years 269 patients with stab injuries, were admitted to our Department of Emergency Medicine (DEM). Thirty-nine patients (14%) who had gluteal penetration were included in this study. Patients’ charts were retrospectively reviewed for demographic data, type of injury and additional injuries, evaluation, management and outcome. Results: Stab wound of the gluteal region was the most frequent injury after chest and abdominal injuries. Thirty patients presented with soft tissue damage only and nine were severely injured. Seven of the severely injured patients had significant bleeding; two of them were treated by embolisation. One patient suffered a rectal injury and one a small bowel perforation, both treated surgically. There was no post-operative complication or mortality. Conclusions: Penetration of the gluteal is a potentially life threatening injury. Meticulous observation and high level of suspicion ensure early treatment and can prevent mortality. ß 2004 Elsevier Ltd. All rights reserved.
Introduction Penetrating injuries of the gluteal area have been seen more frequently in our Department of Emergency Medicine (DEM) in the last few years. Most of the patients have soft tissue injury without major vascular, neurological or visceral involvement. However, about a quarter of the cases may have severe life-treating injuries.4 Injuries reported in the literature include bleeding from the superior and inferior gluteal and the *Corresponding author. Tel.: þ972-35028634; fax: þ972-35016667. E-mail address: [email protected] (S. Susmallian).
iliac vessels,2 damage of the sciatic or gluteal nerve, spinal cord penetration, urethral disruption,6 rectal and visceral perforation. Adoption of protocols in the treatment of trauma patients has been shown to be a safe way to avoid missed major injuries and is applicable to this type of injury. The study was undertaken in our 600 beds, university affiliated, community hospital, which provides medical care (mainly covered by medical insurance) for 500,000 urban area citizens. The aim of this report is to emphasise that a penetrating stab wound in the gluteal area is a frequent and a potential severe injury. We reviewed all the patients admitted to the DEM with a penetrating injury to the gluteal area over the last 5 years.
0020–1383/$ — see front matter ß 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2003.10.002
Stab wound of the gluteal region
Materials and methods We reviewed the records of all 269 patients who arrived at our DEM from June 1997 to June 2002 with penetrating stab wounds. All the patients admitted after penetrating trauma of the gluteal region caused by knives were included, other causes of penetrating injuries were excluded, and superficial lacerations (without fasciae penetration) were also excluded. The gluteal region was defined as the area limited superiorly by the line between the iliac crests, inferiorly by the gluteal fold and laterally by an imaginary line tangential to the greater trochanter.1 All patients were treated according to the protocols of Advanced Trauma Life Support. Local exploration of the wounds was done under local anaesthesia to determine if the penetration included the fascia. Haemodynamically unstable patients were evaluated and treated in the shock room and then diagnostic studies were performed such as computerised tomography, retrograde urethrography or angiography as indicated. Tetanus toxoid was injected intramuscular to un-immunised patients. Patients with only soft tissue damage were discharged after close observation, and wound treatment by debridment and suture. Patients with severe bleeding on admission were diagnosed by angiography and treated successfully by embolisation. Patients with abdominal or rectal injuries were treated surgically. Statistic: results are expressed as mean values and percentage.
Results Two hundred and sixty-nine patients with penetrating trauma caused by stab wounds were admitted to our DEM. Two hundred and sixty-one patients were males (97.02%) and eight were females (2.98%). The mean age was 26.7 years (range13—75 years). Seven female patients were injured by their family relatives. On admission 206 patients (76.57%) presented with one stab wound and 63 (23.43%) had multiple stab wounds with a maximum of 27 stab wounds to one patient. The distribution of the stab wounds per area is shown in graph number one. Thirty-nine patients with 44 penetrating stab wounds to the gluteal region were admitted to the DEM during the study period (July 1997—June 2002). This type of injury accounted for 14% of all penetrating stab wounds. Demographic data of the patients are shown in Table 1. Thirty patients were classified as non-severe trauma lesions, treated in the DEM
149
Table 1 Demographic data of patient with stab wound in the gluteal region Data
Number of Percentage patients
Male 38 Female 1 Severe injuries 9 Multiple wounds 11 Hemo-dynamically unstable 2 Surgical treatment 2 Discharged from ER 30
97.44 2.56 23.07 28.20 5.13 5.13 76.92
and discharged after observation for at least 2 h. Severe trauma was observed in nine patients, seven of whom presented with severe bleeding. Five cases were treated by external compression and suture of the wound followed by observation for at least 24 h (no blood cells transfusion was required), in two patients who were haemodinamically unstable on admission, angiography with successful remobilization of the superior gluteal artery was performed after haemodynamic stabilisation with crystalloid infusion and two units of packed red cells. Surgical intervention was not necessary in these cases, but the last two patients had close follow up in the Department of Surgery. One patient had a rectal injury, suspected during rectal examination and confirmed by anoscopy. The same patient had additional small bowel lacerations caused by a second stab wound that penetrated the abdominal cavity. He was treated by a diverting colostomy, perineal drainage and suture of the small bowel lacerations. The ninth patient had a laparatomy for positive peritoneal signs after negative finding at computerised tomography. Four small perforations were found in the ileum caused
Figure 1
Anatomic distribution of stab wounds.
150
by a penetrating injury from the gluteus through the sacroiliac joint. The lesions were treated by simple suture. No lesion of sciatic or gluteal nerves were seen in our patients. All nine patients were considered as severely injured and were discharged without complications. No mortality occurred in the study group (Fig. 1).
Discussion Penetrating injury of the buttocks is not frequently reported in the literature. Maull et al.5 published one of the first reports about penetrating wound of the buttocks in 1979. Stab wound to the gluteal region was described in the literature as an uncommon lesion,4 but we agree with Feigenberg et al.,2 that there is a false impression that they are a rare type of injury. Penetrating injury caused by stabbing to the gluteal area is usually a minor trauma, especially when considered separately from gun shot wounds, and most of the patients are discharged after local treatment of their wounds. But it should be remembered that they are a potentially severe and lifethreatening injury.2 This is emphasised by the occurrence of severe injuries in our patient group (9/39). The presentation of severe injuries in patients with gluteal stab is about 25%.4 Fallon et al. described 51 cases of penetrating wounds through the gluteus1 and Ivatury et al. described 60 cases of penetrating gluteal injuries, in both reports stab wounds and gun shot wounds
S. Susmallian et al. were considered together.3 We believe that stab wounds need to be considered separately from gun shot wounds to define their different characteristics. Our study shows that stab wound to the gluteal region are less severe than those produced by gun shot wounds. In our study operative treatment was necessary in two cases (2/39) compared with 40% reported by Fallon et al.1 and 26.7% cited by Ivatury et al.3 when gun shot and stab wound are considered together. In summary stab wound of the gluteal area must be considered a potentially serious lesion. Meticulous observation and suspicious of a major injury during examination should prevent mistakes and ensure early treatment.
References 1. Fallon W, Reyna T, Brunner R, Crooms C, Alexander R. Penetrating trauma to the buttock. South Med J 1988;81: 1236—8. 2. Feigenberg Z, Ben-Baruch D, Barak R, Zer M. Penetrating stab wound of the gluteus–—a potentially life-threatening injury: case reports. J Trauma 1992;33:776—8. 3. Ivatury R, Rao P, Nallathambi M, Gaudino J, Stahl W. Penetrating gluteal injuries. J Trauma 1982;22:706—9. 4. Makrim V, Sorene E, Soffer D, Weinbroum A, Oron D, Kluger Y. Stab wounds to the gluteal region: a management strategy. J Trauma 2001;50:707—10. 5. Maull K, Snoddy J, Haynes B. Penetrating wounds of the buttocks. Surg Gynecol Obstet 1979;169:855—7. 6. Rub R, Madeb R, Kluger Y, Chen T, Avigdor Y. Posterior urethral disruption secondary to a penetrating gluteal injury. Urology 2000;56:509.