Case Report

An unusual stab wound to the buttock Ashraf F Hefny1,2, Elnazeer A Salim1, Masoud O Bashir1,2, Fikri M Abu-Zidan2 Departments of Surgery, Al-Rahba Hospital, Abu Dhabi, 2CMHS, UAE University, Al Ain, United Arab Emirates

1

ABSTRACT Stab wounds to the buttock are uncommon injuries that are rarely seen in surgical civilian practice. Although, the wound appears trivial, it may cause major life-threatening visceral and vascular injuries. Failure to detect these injuries may lead to serious morbidity and mortality. Herein, we report a patient with a single gluteal stab wound, which was initially sutured and treated conservatively. Two days later, patient developed fever, lower abdominal pain and tenderness with leakage of fecal material from the wound. Exploratory laparotomy revealed an extraperitoneal rectal perforation for which a Hartmann’s procedure was performed. Computed tomography scanning is recommended as a diagnostic tool for stable patients having buttock stab wounds. Diverging colostomy is the standard surgical procedure for extraperitonal rectal injuries that cannot be properly visualized and repaired during a laparotomy. More evidence is needed to assess the fecal non-diversion approach in the treatment of these patients. Key Words: Buttock, injury, penetrating, stab, wound

INTRODUCTION

CASE REPORT

Stab wounds to the buttock are uncommon injuries that are rarely seen in the surgical civilian practice.[1] The wounds may appear trivial. However, major life-threatening visceral and vascular injuries may occur in about one quarter of these injuries.[2] The management of stab wounds of the gluteal region is challenging. There are no standards of care agreed on for the management of these injuries. The treatment of patients varies according to different trauma centers. Organ injuries related to these wounds may manifest slowly and failure to detect them may lead to death.[3]

A 47-year-old diabetic man had a stab wound to his right buttock inflicted by his roommate using a kitchen knife. On examination, his pulse was 75 beats/min and his blood pressure (BP) was 100/50 mmHg. The abdomen was soft and not tender. A single wound was seen on the medial side of the right gluteal area superior to the intertrochanteric plane [Figure  1]. No neurological deficits were detected. Arterial pulses of the lower limbs were well-felt. The wound was sutured in the Emergency Department and patient was scheduled for discharge. Patient felt dizzy, complained of fresh bleeding per rectum and fainted before being sent home. At this stage, his pulse rate was 105 beats/min and his BP had dropped to 65/40 mmHg. Patient was resuscitated with crystalloids and he became hemodynamically stable. Rigid sigmoidoscopic examination was performed under general anesthesia and showed blood clots in the rectum with no active bleeding. No obvious injury to the rectal wall was seen despite the injection of methylene blue through the gluteal wound. Patient was admitted to the surgical ward for close observation. He was kept fasting, had intravenous fluids and antibiotics were administered. Two days later, patient complained of lower abdominal pain. Fecal matter passed through the gluteal wound. Patient had a temperature of 38°C. There was tenderness and guarding in the lower abdomen. Abdominal computed tomography (CT) scan with oral, rectal and intravenous contrast was performed. It showed contrast leakage from the posterior wall of the rectum, intraperitoneal free air and air in the mesentery

Herein, we report a patient who sustained a single gluteal stab wound that was associated with rectal perforation. This case demonstrates the importance of clinical suspicion for early diagnosis of organ injuries caused by penetrating buttock stab wounds. Address for correspondence: Prof. Fikri Abu-Zidan, E-mail: [email protected] Access this article online Quick Response Code: Website: www.onlinejets.org

DOI: 10.4103/0974-2700.120387

298

Journal of Emergencies, Trauma, and Shock I 6:4 I Oct - Dec 2013

Hefny, et al.: Buttock penetrating wound

around the rectum [Figures 2 and 3]. Exploratory laparotomy was performed. No intraperitoneal fecal soiling was seen. Nevertheless, there was a significant amount of air in the retroperitoneal space and in the bowel mesentery [Figure 4]. The rectum was mobilized, but the extraperitoneal perforation could not be seen. Hartmann’s procedure was performed. Gluteal wound exploration revealed a deep laceration lateral to the edge of the sacrum. Debridement of the necrotic tissue was performed. Post-operatively, patient had slow recovery because of intestinal ileus. The colostomy started to function on the fourth post-operative day. Patient recovered completely at day 10 and was scheduled for reversal of the Hartmann’s procedure 12 weeks after surgery. He decided to travel overseas to his home country to continue his treatment. DISCUSSION The thick fat that covers the gluteal muscle, sacrum and iliac bones gives a false assurance that stab wounds to the buttock do not cause serious injuries.[2]

Actually, there is a higher mortality from gluteal stab wounds compared with gluteal gunshot wounds.[4] This may be related to the delayed diagnosis of serious injuries caused by the false sense of security of what appears to be a simple wound.[2] Penetrating wounds to the buttock can cause serious vascular injuries (gluteal vessels, iliac vessels), nerve damage (the sciatic nerve, gluteal nerve) or pelvic and abdominal visceral injuries, depending on the direction and depth of the wound.[5-9] Gluteal penetrating wounds that are located superior to the intretrochanteric plane (as in our patient) can be associated with serious injuries.[2] If the gluteal wound has penetrated through the deep fascia, then the patient should be admitted for close and repeated clinical evaluation.[2,8,9] Gunshot penetrating rectal injuries can be destructive, involving more than one quarter of the rectal circumference. Non-destructive wounds involving less than one quarter of the rectal circumference are usually caused by stab wounds. Our patient had a penetrating extraperitoneal non-destructive

Figure 1: A diagram demonstrating the site of a single wound on the medial side of right buttock superior to the intretrochantric plane (line)

Figure 2: Abdominal computed tomography scan showing leakage of rectal contrast and air (arrow) from the posterior wall of rectum

Figure 3: Abdominal computed tomography scan showing air in the mesentery (arrow) and around the intestine

Figure 4: A significant amount of air is seen in the mesentery (arrow)

Journal of Emergencies, Trauma, and Shock I 6:4 I Oct - Dec 2013

299

Hefny, et al.: Buttock penetrating wound

rectal injury. Gunshot and stab wounds of the buttock are two separate clinical entities and require different management approaches.[4] Management of penetrating rectal injury in civilian practice is rare. Most experience in these injuries is gained from managing wartime penetrating destructive rectal injuries.[9] Management includes performing a diverting colostomy, rectal injury repair (when feasible) and presacral drainage. The management of buttock stab wounds depends on the site and direction of the wound and the hemodynamic status of patient.[1,4,6] If patient is in shock and the wound is bleeding externally, then the wound should be packed[6] and focused assessment sonography for trauma (FAST) should be carried out. If FAST is positive, then the patient needs a laparotomy.[4] If FAST is negative then the patient needs an angioembolization.[4] Rectal examination, urine analysis, proctoscopy and sigmoidoscopy are useful diagnostic methods, especially when there is bleeding per rectum.[6,8] The rectal wall injury in our patient was missed by the rigid sigmoidoscopy. Clearly, air leaked through the perforation during this procedure and a significant amount of air was trapped in the retroperitoneal space and bowel mesentery. No intraperitoneal bowel perforation was detected during the laparotomy. Air leakage through the parietal peritoneum may have been the cause of intraperitoneal free air, which was detected by abdominal CT scan.[10] The cornerstone of early diagnostic management for stable patients having buttock stab wounds has become CT scanning.[4] If patient is hemodynamically stable, then the wound should be explored in the Emergency Room and if the muscle fascia is violated then patient should have CT scan of the abdomen and pelvis.[1] If CT scan is negative, then patient should be admitted for observation[1] and if it shows free intraperitoneal air, then patient needs a laparotomy. If there is an arterial blush then angioembolization is indictaed.[1,4] If CT scan shows free intraperitoneal fluid then urethrocystography is indicated to rule out urinary bladder injury. Diagnostic peritoneal lavage will be useful in this case.[9] Laparatomy will be indicated if the hemodynamic status of patient deteriorates or patient develops peritonitis. [7] If CT scan shows an extraperitoneal rectal injury without a major intraabdominal vascular or visceral injury in a hemodynamically stable patient, then conservative management with active close clinical observation can be adopted.[11] Furthermore, presacral drainage may not be indicated for nondestructive penetrating extraperitoneal rectal injury in civilian practice.[12] We have used complete diverging colostomy in our patient because he was septic, diabetic and had an infected gluteal wound and a delayed diagnosis.

300

CONCLUSIONS Stab wound of the buttock must be considered as a potentially serious injury. CT scanning is recommended as a diagnostic tool for stable patients having buttock stab wounds. Diverging colostomy is the standard surgical procedure for extraperitonal rectal injuries that cannot be properly visualized and repaired during a laparotomy. More evidence is needed to assess the fecal non-diversion approach in the treatment of these patients. ACKNOWLEDGMENTS The authors thank Ms. Geraldine Kershaw, Lecturer, Medical Communication and Study Skills, Department of Medical Education, College of Medicine and Health Sciences, UAE University for language and grammar corrections.

REFERENCES 1.

Makrin V, Sorene ED, Soffer D, Weinbroum A, Oron D, Kluger Y. Stab wounds to the gluteal region: A management strategy. J Trauma 2001;50:707-10.

2.

Mercer DW, Buckman RF Jr, Sood R, Kerr TM, Gelman J. Anatomic considerations in penetrating gluteal wounds. Arch Surg 1992;127:407-10.

3.

Lesperance K, Martin MJ, Beekley AC, Steele SR. The significance of penetrating gluteal injuries: An analysis of the operation Iraqi freedom experience. J Surg Educ 2008;65:61-6.

4.

Lunevicius R, Schulte KM. Analytical review of 664 cases of penetrating buttock trauma. World J Emerg Surg 2011;6:33.

5.

Susmallian S, Ezri T, Elis M, Dayan K, Charuzi I, Muggia-Sullam M. Gluteal stab wound is a frequent and potentially dangerous injury. Injury 2005;36:148-50.

6.

Ceyran H, Akçali Y, Ozcan N, Tasdemir K. Isolated penetrating gluteal injuries. Perspect Vasc Surg Endovasc Ther 2009;21:253-6.

7.

van Oldenrijk J, Unlü C, van Wagensveld BA. Perforation of the ileum after a stab wound of the gluteal region: A case report. Emerg Med J 2007;24:737-8.

8.

Fallon WF Jr, Reyna TM, Brunner RG, Crooms C, Alexander RH. Penetrating trauma to the buttock. South Med J 1988;81:1236-8.

9.

Ivatury RR, Rao PM, Nallathambi M, Gaudino J, Stahl WM. Penetrating gluteal injuries. J Trauma 1982;22:706-9.

10. Ferrara F, Luigiano C, Billi P, Jovine E, Cinquantini F, D’Imperio N. Pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and subcutaneous emphysema after ERCP. Gastrointest Endosc 2009;69:1398-401. 11. Gonzalez RP, Phelan H 3rd, Hassan M, Ellis CN, Rodning CB. Is fecal diversion necessary for nondestructive penetrating extraperitoneal rectal injuries? J Trauma 2006;61:815-9. 12. Gonzalez RP, Falimirski ME, Holevar MR. The role of presacral drainage in the management of penetrating rectal injuries. J Trauma 1998;45:656-61. How to cite this article: Hefny AF, Salim EA, Bashir MO, Abu- Zidan FM. An unusual stab wound to the buttock. J Emerg Trauma Shock 2013;6:298-300. Received: 22.11.12. Accepted: 21.05.13. Source of Support: Nil. Conflict of Interest: None declared.

Journal of Emergencies, Trauma, and Shock I 6:4 I Oct - Dec 2013

Copyright of Journal of Emergencies, Trauma & Shock is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

An unusual stab wound to the buttock.

Stab wounds to the buttock are uncommon injuries that are rarely seen in surgical civilian practice. Although, the wound appears trivial, it may cause...
1MB Sizes 1 Downloads 0 Views

Recommend Documents


Unusual sequela from a pencil stab wound reveals a retained graphite foreign body.
Penetrating pencil-tip injuries are common among children and usually resolve without long-term sequelae. However, failure to detect and remove embedded pencil fragments can result in increased morbidity or misdiagnoses of other, more serious, condit

Candida albicans spondylodiscitis following an abdominal stab wound: forensic considerations.
Candida albicans spondylodiscitis is a fungal infection of the spine which is still unusual in spite of the increasing frequency of predisposing factors. A 22-year-old man received an abdominal stab wound during a physical assault. Initial medical ca

Comparison of stab wound probing versus radiological stab wound channel depiction with contrast medium.
Instillation of contrast medium into stab wounds has shown promising results regarding visibility and assessment of general stab direction with computed tomography. However, the accuracy of this method--and, incidentally also probing of stab wounds--

Brown-Sequard syndrome associated with unusual spinal cord injury by a screwdriver stab wound.
Stab wounds resulting in spinal cord injuries are very rare. In direct central back stabbings, the layers of muscles and the spinal column tends to deflect blades, rarely causing injuries to the spinal cord. We report an unusual case of traumatic spi

Penetrating injury to the buttock: an update.
Clinical research on penetrating injury to the buttock is sparse and largely limited to case reports and clinical series. The purpose of this paper is to provide a detailed overview of literature of the topic and to propose a basic algorithm for mana

Retained foreign body after chest stab wound.
Foreign bodies may occur after a thoracic trauma, but foreign bodies retained after stab wounds are rare. This paper reports the case of a 20-year-old man who was admitted with the diagnosis of haemothorax following a single stab wound on the chest.

Delayed myelopathy secondary to stab wound with a retained blade tip within the laminae: case report.
Delayed neurologic deficit after a stab wound with a retained foreign body near the spinal canal is unusual, adequate radiological examination is fundamental in detecting retained foreign bodies, especially the CT scan, surgical extraction of the for

An unusual homicidal stab wound of the cervical spinal cord: A single case examined by post-mortem computed tomography angiography (PMCTA).
We report an unusual case of homicidal stab wound of the cervical spinal cord, which illustrates the value of post-mortem computed tomography angiography (PMCTA) in cases of vascular injury. First, we noted a posterior and horizontal trajectory to th