Tech Coloproctol DOI 10.1007/s10151-014-1168-2
REVIEW
Penetrating injury to the buttock: an update R. Lunevicius • D. Lewis • R. G. Ward • A. Chang • N. E. Samalavicius • K. M. Schulte
Received: 5 November 2013 / Accepted: 6 May 2014 Ó Springer-Verlag Italia 2014
Abstract 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 management of penetrating gluteal injuries (PGI). MEDLINE, EMBASE, Cochran, and CINAHL databases were employed. Thirty-seven papers were selected and retrieved for overview from 1,021 records. PGI accounts for 2–3 % of all penetrating injuries, with a mortality rate up to 4 %. Most haemodynamically stable patients will benefit from traditional wound care and selective non-operative management. When gluteal fascia injury is confirmed or suspected, a contrast-enhanced CTscan provides the most accurate injury diagnosis. CT-scanbased angiography and endovascular interventions radically supplement assessment and management of patients
with penetrating injury to the major buttock and adjacent extra-buttock arteries. Immediate life-saving damage-control surgery is indicated for patients with hypovolemic shock and signs of internal bleeding. A universal basic management algorithm is proposed. This overview shows that penetrating injury to the buttock should be regarded as a potential life-threatening injury, and therefore, patients with such injuries should be managed in trauma centres equipped with hybrid operating theatres for emergency endovascular and open surgery for multidisciplinary teams operating 24/7. Keywords Buttock injury Penetrating injury Management Angioembolization Surgery SNOM
Introduction R. Lunevicius (&) R. G. Ward Emergency General Surgery and Major Trauma Units, Cheshire and Merseyside Major Trauma Centre, Aintree University Hospital NHS Foundation Trust, Lower Lane, Liverpool L9 7AL, UK e-mail: [email protected] R. Lunevicius R. G. Ward University Hospital Aintree, Liverpool, UK D. Lewis A. Chang K. M. Schulte Major Trauma Centre for South East London, King’s College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK D. Lewis A. Chang K. M. Schulte King’s Health Partners, London, UK N. E. Samalavicius Medical Faculty, Oncology Institute, Vilnius University, 1 Santariskiu Str., Vilnius 08660, Lithuania
Penetrating injury to the buttock is common as a serious diagnostic and treatment concern in emergency department, general emergency surgery, and trauma centres. However, clinical research on penetrating injury to the buttock is sparse. It began in 1970s in a military trauma centre [1] and only yielded another six retrospective studies from civilian trauma centres [2–7] within 20 years. The first overview of four such studies emphasized a potential danger of any stab wound to the buttock [8]. A new paradigm was up-to-dated in 1997 when it was proved that a selective non-operative management (SNOM) is safe and helps to avoid unnecessary abdominal explorations in patients with gunshot buttock injuries [9]. Nevertheless, a strategy and algorithm for management of penetrating injuries to the buttock has not been established. Furthermore, an education literature is based only on a few research papers. A lack of conceptual overview of the
123
Tech Coloproctol
literature on penetrating injury to the buttock is one of the causes of this phenomenon. We provide a comprehensive conceptual overview of classic and current literature on penetrating injury to the buttock and propose a basic algorithm for management of penetrating gluteal injuries (PGI).
A
Methods MEDLINE, EMBASE, Cochran, and CINAHL databases were employed. The following medical subject heading terms were used for search of records: ‘penetrating buttock injury’, ‘PGI‘, ‘injuries‘, ‘wounds and injuries‘, ‘wound penetrating’in combination with the term ‘Buttocks’. The search was limited to humans, English language, and time for the 1970–2010. This resulted in 1,021 records. Inclusion and exclusion criteria were selected before screening all records for retrieval of the eligible articles for the overview of the literature. Inclusion criteria were as follows: buttock/gluteal stab wounds or injury, and buttock/ gluteal shot, blast, or missile wounds or injury. Exclusion criteria were: the blunt trauma, acupuncture or injection injury, needlestick accidents, iatrogenic injury, wound infection, bone fracture complications, burn injury, gluteal ulcers, chronic gluteal false and true aneurysms, anal and/ or anorectal injury, and rotary lawn mower injury. Each record was screened for retrieval in turn. Thirty-seven papers were selected and retrieved for overview of the literature as systematic review and metaanalysis was not possible. There were no prospective randomized controlled trials. Four articles were brief non-systematic literature overviews [8, 10–12], two were prospectively designed studies from single trauma centre [9, 13], 12 were retrospective reviews [2–5, 7, 14–20], 16 were cases reports [1, 8, 11, 21–33], and three were commentaries [34–36]. No articles reported population-based data on incidence, mortality, and morbidity from penetrating injuries to the buttock. One analytical article was included for this overview [37]. Other references were used for enhancement of key statements of this overview [6, 38–64].
Anatomy The buttock is bordered superiorly by the posterior iliac crest, laterally by the line joining the anterior superior iliac spine and the greater trochanter of the femur (it usually corresponds with the extension of the midaxillary line), inferiorly by the gluteal crease, and medially by the natal cleft (Fig. 1a) [7, 14, 18]. The horizontal division is marked by a line between both greater trochanters that
123
B
Fig. 1 a Drawing showing five landmarks (1–5), contours (bold line) and two zones of the each buttock (6). 1 iliac crest, 2 the anterior superior iliac spine, 3 natal cleft, 4 greater trochanter of the femur, 5 gluteal crease, 6a upper zone of the buttock (above the greater trochanters), 6b lower zone of the buttock (below the greater trochanters). b Drawing showing the lines and points for major buttock vessels and sciatic nerve. 1 posterior superior iliac spine, 2 greater trochanter of the femur, 3 ischial tuberosity, 4 anterior superior iliac spine, 5 coccyx, 6 spine-trochanter line, 7 the imaginary point for the superior gluteal vessels at the suprapiriform foramen on skin, 8: spine-tuberosity line, 9 tuberosity-trochanter line, 10 the imaginary point for the inferior gluteal vessels, internal pudenda, sciatic, and other nerves emerging from infrapiriform foramen on skin
corresponds to the level of the pubic bone anteriorly and the lower sacrum posteriorly. Virtually, all of the major buttock and intrapelvic vessels and organs are situated above the intertrochanteric plane, that is. in the upper zone [7]. The lower zone contains the distal third of the rectum, the lower part of the urinary bladder, urethra, external genitalia and, in females, most of the vagina, and in males, most of the prostate. Injuries to the major buttock or neighbouring extra-buttock vessels, any extraperitoneal or intraperitoneal viscus, bone, or neural structures are defined as major injuries. Features of surgical anatomy of
Tech Coloproctol
the buttock are described in ‘‘Appendix’’ [18, 38–40]. Isolated anorectal injury is not classified as buttock injury.
Clinical epidemiology Incidence Penetrating gluteal injury is a relatively common cause of admission to emergency rooms in large and underprivileged urban areas, accounting for 2–3 % of all penetrating injuries [15, 19]. However, true incidence of penetrating injuries to the buttock is unknown. Over 97 % of the patients consist are males with a mean age of 23–33 year [9, 16–18]. Fifty-five per cent of patients had a positive blood alcohol test on admission, with mean blood alcohol level 162 mg/dL. Involvement of more than a single system is present in many of these injuries [2, 5]. Causative events Stabbing, shooting, blasting, impalement, and transfixion have been reported. Shooting- and stabbing-related injuries to the buttock in civilian environment are most commonly reviewed. Injuries due to impalement and transfixion are, fortunately, uncommon in civilian life [26]. Mortality Mortality rate varies from 0 to 4 % in individual studies from civilian trauma centres [2–5, 7, 9, 13, 14, 17–19]. In a battlefield environment, where missile injuries, either shot or blast, dominate, the mortality rate is 6 % [15]. In a subset of severely injured and haemodynamically unstable patients, mortality of 25 % has been reported [16, 20]. Morbidity Short-term and long-term morbidity for patients with penetrating trauma to the buttock varies from 0 to 33 % [2, 16, 19]. A prospective study demonstrates 15.8 % morbidity rate in survivals [9]. Haemorrhage from injured major vessels, false gluteal aneurysm, gluteal compartment syndrome, perirectal haematoma, injuries to the rectum or small bowel, prolonged ileus or transient obstruction, soft tissue or urinary tract infections, sciatic nerve or lumbosacral plexus injury, impotence, and pressure sores is most common complication. The possibility of such rare injury complication as bullet/pellet migration to the right ventricle of the heart or hepatic veins was highlighted in case reports [23, 29].
Classifications, grading, and scoring The newest update of Abbreviated Injury Scale 2008 indicates that penetrating non-complicated injury of soft tissues of the buttock is regarded as grade 1 [41]. When there is tissue loss [25 cm2, it should be regarded as a grade 2 injury. It has to be regarded as a grade 3 injury if any buttock injury is associated with blood loss [20 % by volume. Buttock injuries should be assigned to the external body region for Injury Severity Score (ISS) calculation if there are no injuries to bony pelvis, intraabdominal, or intrapelvic structures. However, if such underlying anatomical structures are involved, injuries should be assigned to either the lower extremity body region (provided bony pelvis fracture is confirmed) or abdomen when the ISS is calculated. In general, penetrating injuries to the buttock are classified according to the mechanism of injury, functional significance of injured structure (minor vs major), type of injury (major vessel, sciatic nerve, bony pelvis, etc.), penetration zone (upper vs lower), environmental conditions (civilian vs battlefield/military), and severity (Abbreviated Injury Scale).
Patterns of major injuries Data from a prospective study demonstrate that major lifethreatening visceral and vascular injuries occur in 29 % of patients who sustained GSW and were admitted to a level 1 trauma centre [9]. Data from a retrospective study on stab wounds (SW) to the buttock reveal that visceral and vascular injuries occur in 10.5 % of patients admitted to a large trauma centre [19]. The most commonly damaged structures following penetrating injury to the buttock are the superior gluteal artery (SGA), rectum, small bowel, and colon (more than 5 % each). Injury of the iliac artery and/ or vein is diagnosed in 3 % of patients. Injuries to sciatic or lumbosacral nerves are rare—1 % [37]. The patterns of major injuries associated with stabbing and shooting differ. Stabbings are most frequently associated, in descending order, with injuries to gluteal arteries, rectum, and iliac vessels. Gunshot injuries frequently result in wider organ damage involving, in descending order, small bowel, colon, rectum, bony pelvis, and bladder injuries [37]. High-velocity bullets may ricochet off the bony pelvis and can produce an unexpected bullet path in the abdominal cavity or down to the key vessels of the thigh. Injury of the bony ring of the pelvis happens in 5–14 % of shot patients in a civil environment, 35 % in a battlefield environment, and it is associated with a wide spectrum of pelvic and abdominal injuries [9, 14, 15].
123
Tech Coloproctol
Triage All patients with penetrating injuries to the torso should be transported preferentially to the highest level of a care trauma centre within the trauma network [42]. As soon as the patient enters the emergency department of the trauma centre, further in-hospital triage should depend on the haemodynamic status of the patient. Patients in hypovolemic shock and signs of acute internal bleeding need resuscitation and immediate prompt intervention. Consideration should be given to initiation of massive transfusion protocols and angioembolization or damage-control surgery as critical injury to the common, external, or internal iliac vessels is most common cause of shock [10]. The fast track contrast-enhanced CT-scan of the torso has to be performed when a source and type of bleeding is unclear in non-shocked patients.
Initial clinical assessment and diagnostic tools for further evaluation Primary and secondary trauma surveys should be completed for all patients regardless of their stability. While doing a physical examination of the whole body, it is advisable to identify and describe the locations of the gun shot entrance and exit wounds, to help understand the bullet trajectory. Palpation of femoral pulses, inspection of external urethral meatus, neurological assessment of lower limbs, and digital rectal examination should be performed. Focused Assessment with Sonography for Trauma (FAST) should be selectively used as the sensitivity and specificity is rather poor for penetrating trauma. Bladder catheterization should be performed. Plain X-ray films of the pelvis, contrast CTscan of the abdomen and pelvis with or without contrastenhanced enema, rigid sigmoidoscopy, urethrogram, cystoscopy, and angiography are other adjunctive diagnostic tests [6, 14, 43].
Management plans and algorithms One plan of management of GSW to the buttock and three algorithms for management of gluteal SW, for management of penetrating gluteal GSW and for management of a suspected gluteal artery (GA) or internal pudendal artery (IPA) injury, have been suggested [5, 9, 14, 18]. Each was based on a particular rationale and logic in order to manage serious challenges presenting in penetrating trauma to the buttock. Management algorithms for patients with transpelvic GSW can be useful tools in decision-making when the bullet enters the buttock and fully passes the pelvis [6, 43]. At least 70 % of patients admitted to the large trauma centre will be managed conservatively. The remaining
123
patients will undergo a surgical, either endovascular or open, procedure. Currently, interventional radiology techniques are increasingly used for patients with injuries to the major buttock or extra-buttock arteries [36]. We propose a universal basic management algorithm for penetrating buttock injuries (Fig. 2).
Indications for emergency surgery Indications for emergency trauma laparotomy are as follows: (1) haemoperitoneum related with haemodynamic instability or shock, (2) injury of common, external, and internal iliac vessels with haemodynamic instability when endovascular treatment methods cannot be applied, (3) generalizing peritonitis, (4) full-thickness injury to the intraperitoneal or extraperitoneal bowel confirmed clinically, endoscopically, or radiologically, and (5) intraperitoneal perforation of the urinary bladder. A hybrid operating room is the best place for acute surgery because both surgical procedures, either endovascular or open, can be performed there [36]. Principles of endovascular and open management of penetrating injuries to the major buttock and adjacent extra-buttock vessels are summarized Table 1. It should be kept in mind that injuries to internal iliac artery (IIA) can be controlled by angioembolization if local resources are beneficial. Endovascular stenting can be effectively applied for some not critical injuries of common or external iliac arteries and veins. Extraperitoneal fullthickness rectal injury is treated by diverting sigmoidostomy with or without endorectal repair of the injured rectal wall. Direct retroperitoneal pelvic packing via a midline incision from the umbilicus to the symphysis and the abdominal musculature division without opening of peritoneum with subsequent therapeutic angiography is the emergency procedure for uncontrollable bleeding from major iliac vessel or vessels, mainly veins. When the patient is in shock due to ongoing external bleeding from the penetrating buttock wound, the wound packing and, if packing is not successful, a balloon catheter tamponade by placing a Foley or Fogarty catheter through the wound track and a radiological embolization of the bleeding artery should be the first direct damage-control gluteal procedure. Emergency gluteal surgery with the aim to stop the haemorrhage from the buttock vessel is indicated for ongoing continuous or recurrent external bleeding from gluteal wound when endovascular modalities of bleeding control are not indicated, failed, or cannot be applied due to particular reasons [36]. The source of this type of bleeding usually is injury of SGA, inferior gluteal artery (IGA), or IPA. In the event of external haemorrhage from the gluteal wound in patients without signs of hypovolemic shock, an attempt to control or temporize bleeding should be made in
Tech Coloproctol Fig. 2 Basic scheme of algorithm for management of penetrating injuries to the buttock
the trauma bay with packing (or balloon tamponade) of the wound track. Contrast CT-scan with angiography should be the next diagnostic tool to assess the potential for endovascular control of injured and bleeding buttock vessel. Timing for local wound debridement, which includes necrotic and/or dirty soft tissue removal, washout, and appropriate dressing, depends on the physiological condition of the individual patient. Other indications for early planned surgery include non-stable bony pelvis fracture, injury of sciatic nerve, and urethra/ureter injury when conservative management cannot be applied.
Technical considerations Positioning of the patient for trauma laparotomy When immediate laparotomy should be done due to intraabdominal bleeding and hypovolemic shock, the patient should be laid down in a routine supine position without consideration for Lloyd-Davies positioning. On the contrary,
trauma laparotomy has to be performed in the Lloyd-Davies position for patient with suspected or proven visceral perforation secondary to buttock trauma. This position is chosen under the stable or controlled circumstances when a thorough intraoperative rectal examination, with/without endorectal repair or with/without laparotomy, is planned. Positioning of the patient for gluteal surgery First of all, the prone (face down) or semiprone (so-called Sims’s) positions with the roll under the pubis and with the thigh laterally rotated is recommended for gluteal or extended gluteal incision [20, 36]. This approach also allows the use of a speculum (Fansler, Pratt, Eisenhammer, etc.) for examination of the rectum. Secondly, other positioning alternatives can be chosen—since colorectal surgeons report that the prone or semiprone position often causes post-operative pain over the pubis and lower backache [44]. The laterolateral position, that is a modified Sim’s position, can be an option for unilateral gluteal or extended gluteal exposure as well as for good exposure of
123
Tech Coloproctol Table 1 Principles of open and endovascular management of penetrating injuries to buttock and adjacent extra-buttock vessels Vessel
Definitive management
Damage-control management
Possible consequences
Arteries Superior gluteal
Ligation/embolize
Packing
Buttock ischaemia/rare
Inferior gluteal
Ligation/embolize
Packing
Buttock ischaemia/rare
Internal pudendal
Ligation/embolize
Packing
Electile dysfunction/rare
Internal iliac
Ligation/embolize
Ligation/oversew/undersew
Buttock ischaemia/rare
External iliac
Repair/stent
Shunta/ligation/oversew/undersew
Lower extremity ischaemia
Common iliac
Repair/stent
Shunta/ligation/oversew/undersew
Lower extremity ischaemia
Common femoral
Repair/stent
Shunta/ligation/oversew/undersew
Lower extremity ischaemia
Gluteal
Ligation
Packing
None
Internal pudendal Internal iliac
Ligation Ligation
Packing Retroperitoneal packingb, ligation
None Should be none/oedema
External iliac
Repair, stent
Retroperitoneal packingb, ligation
Lower extremity oedema
Common iliac
Repair, stent
Retroperitoneal packingb, ligation
Lower extremity oedema
Femoral
Repair, stent
Packing, ligation
Lower extremity oedema
Veins
a
Temporary intravascular shunt for injuries to common, external iliac, and common femoral arteries is the primary damage-control procedure as it eliminates the incidence of ischaemia, fasciotomies and amputation substantially. Ligation as the primary damage-control procedure needs to be avoided
b
Retroperitoneal packing, either unilateral or bilateral, is performed via a midline incision from the umbilicus to the symphysis and the abdominal musculature division without opening of peritoneum
the anorectal canal if needed. If this position is chosen, the patient should be placed with one leg straight and the other leg curled on the pillow. Thirdly, the lithotomic position can be used for exposure and packing of penetrating wounds to the medial or perianal aspect of the lower zone buttock and for the examination of the rectum. Fourthly, in an acute setting, a simple face down is acceptable for buttock exploration. Finally, all these positions can be combined with the addition of a vertical lift, that is with the Trendelenburg or reverse Trendelenburg. Gluteal incisions As acute care surgery is aimed to expose a space beneath gluteus maximus muscle where most gluteal vessels and nerves are located, the incision—longitudinal to gluteus maximus fibres—and the longitudinal division of this muscle should be adequate to clinical problem. Briefly, the gluteal incision should be long. There are two surgical approaches for open buttock trauma surgery (Fig. 3) [20, 36]. The first one, a simple gluteal incision, corresponds partially with the incision of Kocher–Langenbeck through longitudinal splitting of the gluteus maximus muscle in its anterior third [45], however, without tenotomies of the piriform and the obturator internus and gemmelli muscles. The skin incision should be made parallel to the fibres of the gluteus maximus, beginning 2 cm below the posterior superior iliac spine and ending at the posterosuperior angle of the greater
123
Fig. 3 Gluteal incisions. 1 simple gluteal incision, 2 extended gluteal incision (‘‘question mark’’; Henry), 3 gluteus maximus muscle
trochanter. The Kocher–Langenbeck incision runs below the greater trochanter of the femur. The second one, an extended gluteal incision, is another choice in buttock surgery [20, 46]. It is known as the ‘question-mark shape’ incision or Henry incision [47]. It starts a few centimetres (usually up to 6 cm) below the iliac crest medially, runs upwardly towards the posterior superior iliac spine, further curving and running down following the superior border of the gluteus maximus, and ends over the
Tech Coloproctol Fig. 4 Oblique view pelvic arteries: 1 external iliac, 2 internal iliac, 2a anterior trunk (division) of internal iliac, 2b posterior trunk (division) of internal iliac, 3 superior gluteal, 4: middle rectal, 5 internal pudenda, 6 inferior gluteal
greater trochanter of the femur to the level of the inferior gluteal fold. There is, therefore, an impression that this incision consists of two different parts, shorter (or medial longitudinal) and longer (or lateral oblique). A further incision of the fascia, gluteus maximus muscle on upper margin and its fascia laterally, gives a chance to rotate and retract the gluteus maximus muscle medially and, therefore, will expose the superior gluteus, inferior gluteus, and internal pudendal vessels as well as the sciatic, posterior femoral cutaneous, and pudenda nerves. Sections of the piriformis muscle, its tendon, and neighbouring muscles can be made for better exposure of the sciatic nerve or vessels [48]. In addition, an incision can be extended downwards if surgical circumstances require. We therefore recommend the Henry incision for gluteal surgery as it provides a better exposure to main neurovascular structures of the buttock. The following six features of surgery via gluteal incision should be kept in mind: (1) both skin and subcutaneous tissue of the buttock is thick; (2) superficial fascia of the gluteus maximus muscle contains the cutaneous nerves; (3) there is a recommendation in order to prevent gluteal nerve damage that a proximal extension of the transgluteal incision should be limited to 3 cm to the tip of the greater trochanter [49]; (4) the operation might be quite bloody; packed red blood cells should be prepared; (5) 12–18-cmlength incision should be regarded as a surgical introduction to a minimal invasive approach—longer incisions are preferable [50]; (6) both gluteal incisions, either simple or extended, can be also used for emergency fasciotomies for the post-traumatic gluteal compartments [46].
Angioembolization The role of interventional radiology within the trauma setting has evolved over the past 20 years to become a well recognized part of the management of injured patients [36, 51–55]. Solid abdominal organ and pelvic visceral arteries are the most frequent targets for embolization because a combination of a minimally invasive and effective way of securing haemostasis makes it ideal in these locations. In the vast majority of cases, the patients with penetrating injuries to buttock will have had a CT (Figs. 4, 5) before considering angiography and embolization. The indication for and timing of endovascular intervention in penetrating buttock trauma requires a case by case discussion. However, there are five accepted indications. Firstly, ‘cardiovasculary unstable’ patient. Many of these patients will need surgery but haemorrhage is the main cause of early trauma death. However, the removal of the tamponade in massive abdomino-pelvic bleeding with a laparotomy may have fatal consequences. The optimal management, therefore, may be the combined laparotomy with proximal artery control, intra-operative angioembolization, and pelvic packing as a last resort because of pelvic nerve damage. However, this requires the availability of a hybrid theatre [36, 56]. Secondly, haemodynamic instability due to injury of a branch of the IIA is evident on the CT. Most often these branches are SGA, IGA, or IPA. Rarely, branches from the femoral arteries (circumflex and profunda) may be involved. The isolated injury of these arteries is the
123
Tech Coloproctol Fig. 5 Three major buttock arteries and external iliac artery (posterior view pelvic arteries): 1 superior gluteal, 2 inferior gluteal, 3 internal pudenda, 4 external iliac
indication for angioembolization. However, decisions are different when injury of buttock artery is associated with rectal injury as the rectum has supply of blood from both the inferior mesenteric and internal iliac arteries. For instance, in rectal injury with perirectal arterial bleeding, surgery is likely to be more appropriate as the resultant haematoma is often confined to the peri-rectal arteries, and definite bowel surgery will be needed without consideration for angiography. On the other hand, if there is a truncation of an artery (it could be a branch of IIA or superior rectal artery) surrounded by haematoma, this is an indication for angiography as these vessels are likely to become a cause of secondary haemorrhage. Thirdly, external haemorrhage from the wound, primarily treated with compression, and packing. If there is a deeper injury that lies in a difficult location for operative intervention, then CT (if not performed already) with a view to embolization could be considered. Fourthly, pseudoaneurysm following buttock injury. This may become evident within a few days or shortly after the haemorrhage. A palpable mass or symptoms of compression to local neural structures (e.g. sciatic nerve) are an indication for endovascular intervention given the possibility of catastrophic haemorrhage [57, 58]. Fifthly, continued bleeding after abdominal or gluteal surgery. The success of angiographic embolization is 80–100 % relating to the nature of the injury, the experience of the interventional radiologist, and the choice of the embolization material [51, 53]. Complications following endovascular embolization are rare and may be difficult to separate
123
from damage due to the initial injury. Necrosis of muscle and skin is very rare. Damage to the artery used for access, almost always the common femoral artery, does occur with pseudoaneurysms and secondary bleeding being less common now due to vascular closure devices.
Selective non-operative management (SNOM) This is a conservative approach to management for haemodynamically stable patients with penetrating abdominal and pelvic wounds who do not have signs of a possible surgical event [9, 42, 59]. It is important to emphasize that if a local wound exploration was performed due to a stab injury to the buttock, and fascia injury was not confirmed, the SNOM concept should not be applicable. Those patients with stab injuries to the buttock can be discharged after primary wound closure. On the other hand, if fascia/ muscle injury is diagnosed on CT-scan or local wound exploration and when there is no sign of surgical events, the SNOM can be started. Patients with penetrating injuries to the buttock selected for non-operative management should be admitted to a high-dependency unit for continuous monitoring and serial clinical examinations. No oral feeding should be employed. Tetanus toxoid vaccine should be given according to general principles of tetanus vaccination. After 24 h, the stable patient can be transferred to general surgery or an acute care surgery ward and oral feeding can be introduced. Discharge should be considered in 24–48 h for shot patients and in 24 h in stabbed patients [12, 43].
Tech Coloproctol Table 2 Penetrating buttock injury clinical follow-up recommendations Treatment
Risks
Comments
Follow-up
SNOM
Gluteal false aneurysm
Differentiate from infection and primary neuropathy
Early: within 3–7 days Symptoms may present later
SGA occlusion
Buttock soft tissue necrosis
Rare, further surgical management is needed
Early: within 1–2 weeks
IGA occlusion
Buttock soft tissue necrosis
Rare, further surgical management is needed
Early Individualized
IPA occlusion Open gluteal surgery IIA occlusion: open or endovascular
IIV ligation
Traumatic electile dysfunction
May contribute to main aetiology
Cavernosal infection
Due to infected embolus
Starts early
Gluteal false aneurysm skin breakdown over the sacrum and buttock Gluteal musculature or perineum necrosis
Differentiate from infection and neurogenic symptoms Early ischaemic complication Early ischaemic complication: surgical management
Early symptoms may present later Starts early and longterm Starts early and long term
Chronic ulcer
Non-healing
Starts early and long term
Gluteal compartment
Post-embolization
Immediate
Ischaemic neuropathy
Sciatic, femoral, sural nerves
Long term: 1–6 months
Lumbosacral plexopathy
Post-bilateral open occlusion
Long term: 1–6 months
Rectal ischaemia
Small/medium-sized particles as emboli
Immediate/early
Bladder partial ischaemia
Small/medium-sized particles as emboli
Immediate/early
Reproductive capacity restriction
May have impact on fertility
Long term: assessment for intrauterine foetal growth
Oedema
Possible
Not emphasized
SNOM selective non-operative management, SGA superior gluteal artery, IGA inferior gluteal artery, IPA internal pudendal artery, IIA internal iliac artery, IIV internal iliac vein
Follow-up Clinical follow-up is not needed for patients with superficial (above fascia) soft tissue injuries to the buttock. We advocate subspeciality clinical follow-up appropriate to the injuries sustained as following penetrating injury to the buttock, the risk of false aneurysm formation needs to be remembered along with other unusual problems such as migration of bullet or pellet to the inferior vena cava and heart [23, 29]. Further radiological follow-up of patients, in order to exclude or confirm gluteal pseudoaneurysms, is guided by early and long-term clinical findings. A fluctuant, warm, and erythematous post-traumatic swelling should be imaged as a possible pseudoaneurysmal haematoma prior to any further intervention (Table 2) [60–64].
Conclusions This comprehensive overview of the literature shows that penetrating injury to the buttock should be regarded as a potential life-threatening injury, and therefore, patients with such injuries should be managed in trauma centres equipped with hybrid operating theatres for emergency endovascular and open surgery for multidisciplinary teams operating 24/7.
An algorithm for management of PGI should be a part of standard operative procedure and an educational tool. Conflict of interest
None.
Appendix: Features of surgical anatomy of the buttock The sciatic foramina The greater and lesser sciatic foramina are paramount in buttock trauma surgery because, firstly, soft tissues covering both foramina are always exposed during the extended gluteal surgery, and, secondly, they are lateral gates to the pelvic organs and other anatomical structures. One muscle, three vessel sets, and seven nerves cover and pass the greater sciatic foramen, which is considered to be the common site of traumatic penetration to the tissues of the buttock. They are as follows: the piriformis muscle, superior gluteal, inferior gluteal, and internal pudendal vessels, sciatic, superior gluteal, inferior gluteal, pudenda, posterior femoral cutaneous nerves, and nerves to the quadratus femoris and obturator externus. Behind the greater sciatic foramen, inside the pelvis, the internal iliac vessels and trunks of the IIA are located. Superior gluteal vessels and
123
Tech Coloproctol
nerve are major transmitting structures of the suprapirifomis foramen. Inferior gluteal, internal pudendal vessels, pudendal, sciatic, and posterior femoral cutaneous nerves are major transmitting structures of the infrapirifomis foramen. Major buttock arteries Soft tissues of the upper buttock including the root of the sciatic nerve are mainly supplied by the superior gluteal artery (SGA), which is the largest branch of the posterior trunk of the IIA. It divides into a superficial branch supplying the gluteus maximus muscle, and deep branches supplying the gluteus medius and minimus, and tensor fasciae lata muscles. Branches of this artery end at the anterior superior iliac spine. The terminal branches of SGA anastomose with the terminal branches of the lateral and deep circumflex femoral, inferior gluteal, and lateral sacral arteries. The lower buttock and the back of the thigh are mainly supplied by the IGA, the branch of the anterior trunk of IIA. It passes the infrapiriform foramen, which is in between the piriformis and the superior gemelli muscles. Multiple branches of this artery reach the gluteus maximus, the coccyx, sciatic and posterior femoral cutaneous nerves, and thigh muscles. SGA and IGA may form a common trunk. Medial tissues of the lower buttock zone, perineum, urethra, and external genitalia are supplied by multiple muscular, coccygeal, nervi ischiadici, anastomotic, articular, cutaneous branches of IPA, which is the branch of the anterior trunk of the IIA. The IPA emerges from the pelvis below the piriformis muscle, medially to the IGA. The artery passes the ischial spine and enters the perineum through the lesser sciatic foramen. This artery gives origin to the inferior rectal artery. SGA, IGA, and IPA are major buttock arteries, as acute external haemorrhage from these vessels can be very heavy and cause an irreversible hypovolemic shock. Projections of major buttock vessels and sciatic nerve on the skin Knowledge about projections of major buttock vessels on the skin can be used for conjecturing what structures of the buttock are possibly injured by the penetrating agent. Lines drawn between three key bony structures of the buttock— the posterior superior iliac spine, the ischial tuberosity, and the greater trochanter—form a triangle (Fig. 1b). The hip joint projects from the middle area of this triangle. The three points on the three sides of the triangle are most important for conjecturing where the major buttock vessels and nerves emerge beneath the gluteus maximus muscle. Firstly, the point between the upper and middle thirds of
123
the line connecting the posterior superior iliac spine with the greater trochanter (the so-called spine-trochanter line) shows the part of the SGA at the suprapiriform foramen. Secondly, the middle of the line connecting the posterior superior iliac spine and the ischial tuberosity (it is the spine-tuberosity line) is the point for the IGA, sciatic and other nerves emerging from the infrapiriform foramen. Thirdly, the sciatic nerve runs downwards and slightly laterally and crosses the tuberosity-trochanter line, which connects the ischial tuberosity and the greater trochanter, at the point between the middle and medial thirds. It should be kept in mind that a projection of the piriformis muscle and the greater portion of the greater sciatic foramen are above the midpoint of the spine-tuberosity line. The midpoint of the line connecting the coccyx and the anterior superior iliac spine would indicate the SGA to be at the level of the suprapiriformis foramen. The segment of this line running upwards from the midpoint would indicate a continuation of the SGA and its branches on the skin of the buttock. Medial tissues from the ischial tuberosity (i.e. a lateral wall of the ischiorectal fossa) is a mark for the IPA.
References 1. Knight RJ (1973) Resuscitation of battle casualties in South Vietnam: experiences at the First Australian Field Hospital. Resuscitation 2:17–31 2. Maull KI, Snoddy JW, Haynes BW Jr (1979) Penetrating wounds of the buttock. Surg Gynecol Obstet 149:855–857 3. Ivatury RR, Rao PM, Nallathambi M, Gaudino J, Stahl WM (1982) Penetrating gluteal injuries. J Trauma 22:706–709 4. Vo NM, Russell JC, Becker DR (1983) Gunshot wounds to the buttocks. Am Surg 49:579–581 5. Fallon WF Jr, Reyna TM, Brunner RG, Crooms C, Alexander RH (1988) Penetrating trauma to the buttock. South Med J 81:1236–1238 6. Duncan AO, Philips TF, Scalea TM et al (1989) Management of transpelvic gunshot wounds. J Trauma 29:1335–1340 7. Mercer DW, Buckman RF Jr, Sood R, Kerr TM, Gelman J (1992) Anatomic considerations in penetrating gluteal wounds. Arch Surg 127:407–410 8. Feigenberg Z, Ben-Baruch D, Barak R, Zer M (1992) Penetrating stab wound of the gluteus: a potentially life-threatening injury: case reports. J Trauma 33:776–778 9. Velmahos GC, Demetriades D, Cornwell EE, Asensio J, Belzberg H, Berne TV (1997) Gunshot wounds to the buttocks: predicting the need for operation. Dis Colon Rectum 40:307–311 10. Salim A, Velmahos GC (2002) When to operate on abdominal gunshot wounds. Scand J Surg 91:62–66 11. Aydin A, Lee CC, Schultz E, Ackerman J (2007) Traumatic inferior gluteal artery pseudoaneurysm: case report and review of literature. Am J Emerg Med 25:488e1–488e3 12. Butt MU, Zacharias N, Velmahos GC (2009) Penetrating abdominal injuries: management controversies. Scand J Trauma Resusc Emerg Med 17:19 13. Velmahos GC, Demetriades D, Cornwell EE III (1998) Transpelvic gunshot wounds: routine laparotomy or selective management? World J Surg 22:1034–1038
Tech Coloproctol 14. DiGiacomo JC, Schwab CW, Rotondo MF et al (1994) Gluteal gunshot wounds: who warrants exploration? J Trauma 37:622–628 15. Lesperance K, Martin MJ, Beekley AC, Steele SR (2008) The significance of penetrating gluteal injuries: an analysis of the Operation Iraqi Freedom experience. J Surg Educ 65:61–66 16. Gilroy D, Saadia R, Hide G, Demetriades D (1992) Penetrating injury to the gluteal region. J Trauma 32:294–297 17. Ferraro FJ, Livingston DH, Odom J, Swan KG, McCormack M, Rush BF Jr (1993) The role of sigmoidoscopy in the management of gunshot wounds to the buttocks. Am Surg 59:350–352 18. Makrin V, Sorene ED, Soffer D, Weinbroum A, Oron D, Kluger Y (2001) Stab wounds to the gluteal region: a management strategy. J Trauma 50:707–710 19. Susmallian S, Ezri T, Elis M, Dayan K, Charuzi I, Muggia-Sullam M (2005) Gluteal stab wound is a frequent and potentially dangerous injury. Injury 36:148–150 ¨ zcan N, Tasdemir K (2009) Isolated 20. Ceyran H, Akc¸ali Y, O penetrating gluteal injuries. Perspect Vasc Surg Endovasc Ther 21:253–256 21. Mamode N, Reid AW (1994) Haemorrhage following penetrating gluteal trauma. Br J Surg 81:203–204 22. Rub R, Madeb R, Kluger Y, Chen T, Avidor Y (2000) Posterior urethral disruption secondary to a penetrating gluteal injury. Urology 56:509 23. Obermeyer RJ, Fecher A, Erzurum VZ, DeVito PM (2000) Embolization of bullet to the right ventricle. Am J Surg 179:189 24. Kalimi R, Angus LD, Gerold T, DiGiacomo JC, Weltman D (2002) Bullet embolization from the left internal iliac vein to the right ventricle. J Trauma 52:772–774 25. Carrick MM, Morel AN, Pham HQ (2007) Shotgun wounds to the buttocks, sacrum, and rectum. J Trauma 62:552 26. Napier F, Fountain-Polley S, Kallapa C (2007) Images in paediatrics: ironing board impalement. Arch Dis Child 92:758 27. van Oldenrijk J, Unlu¨ C, van Wagensveld BA (2007) Perforation of the ileum after a stab wound of the gluteal region: a case report. Emerg Med J 24:737–738 28. Ramasamy A, Hinsley DE, Brooks AJ (2008) The use of improvised bullet markers with 3D CT reconstruction in the evaluation of penetrating trauma. J R Army Med Corps 154:239–241 29. Raikar SS, Jureidini SB, Balfour IC, Tinker K (2010) The fantastic journey of a bullet: out with a snare. Pediatr Cardiol 31:108–110 30. Demetriades D, Rabinowitz B, Sofianos C (1988) Gluteal artery aneurysms. Br J Surg 75:494 31. Holland AJ, Ibach EG (1996) False aneurysm of the inferior gluteal artery following penetrating buttock trauma: case report and review of the literature. Cardiovasc Surg 4:841–843 32. Culliford AT, Cukingham RA, Worth MH Jr (1974) Aneurysms of the gluteal vessels: their etiology and management. J Trauma 14:77–81 33. Chappell ET, Pare L, Salepour M (2006) Fluoroscopic image guidance for minimally invasive extraction of a bullet from the gluteus maximus. J Trauma 60:664–667 34. Scalea TM (1998) Invited commentary on Velmahos GC et al: Transpelvic gunshot wounds: routine laparotomy or selective management? World J Surg 22: 1038 35. DiGiacomo JC, Schwab CW, Kauder DR, Rotondo MF, Velmahos GC et al (1999) Transpelvic gunshot wounds: routine laparotomy or selective management? World J Surg 23:619–620 36. Rasmussen TE (2009) Commentary on ‘‘Isolated penetrating gluteal injuries: a potentially life-threatening trauma’’. Perspect Vasc Surg Endovasc Ther 21: 257–258; discussion 258 37. Lunevicius R, Schulte KM (2011) Analytical review of 664 cases of penetrating buttock trauma. World J Emerg Surg 6:33
38. Wheeless CR, III, MD (2008) Wheeless’ textbook of orthopaedics. Greater sciatic foramen. Duke Orthopaedics. http://www. wheelessonline.com/ortho 39. Bergman R, Afifi AK, Miyauchi R (1847) Anatomy Atlases. http://www.anatomyatlases.org/AnatomicVariants/Cardiovas cular/Text/Arteries/GlutealInferior.shtml. URL: http://www.anat omyatlases.org 40. Schunke M, Ross LM, Schulte E, Lamperti ED, Schumacher U (2006) Atlas of anatomy: general anatomy and musculoskeletal system. Thieme, Stuttgart, Germany, p. 494. http://books.google. com 41. Abbreviated Injury Scale Ó2005. Update 2008. Editors: Gennarelli TA, Wodzin E. Association for the Advancement of Automotive Medicine, Barrington, IL, USA 42. Sasser SM, Hunt RC, Sullivent EE et al (2009) Guidelines for field triage of injured patients. Recommendations of the national expert panelon field triage. Morbidity and Mortality Weekly Report. Recommendations and Reports 58: RR-1. Department of health and human services. Centers for Disease Control and Prevention. http://www.cdc.gov/mmwr/PDF/rr/rr5801.pdf 43. Navsaria PH, Edu S, Nicol AJ (2011) Nonoperative management of pelvic gunshot wounds. Am J Surg 201:784–788 44. Nivatvongs S (1980) Alternative positioning of patients for hemorrhoidectomy. Dis Colon Rectum 23:308–309 45. Rommens PM (2004) The kocher-langenbeck approach for the treatment of acetabular fractures. Eur J Trauma 30:265–273 46. Keene R, Froelich JM, Milbrandt JC, Idusuyi OB (2010) Bilateral gluteal compartment syndrome following robotic-assisted prostatectomy. Orthopedics 33:852 47. Henry AK (1987) Extensile exposure. Churchill Livingstone, New York, p 189 48. Kline DG, Kim D, Midha R, Harch C, Tiel R (1998) Management and results of sciatic nerve injuries: a 24-year experience. J Neurosurg 89:13–23 49. Bos JC, Stoeckart R, Klooswijk AI, van Linge B, Bahadoer R (1994) The surgical anatomy of the superior gluteal nerve and anatomical radiologic bases of the direct lateral approach to the hip. Surg Radiol Anat 16:253–258 50. Spagnolo R, Bonalumi M, Pace F, Capitani D (2009) Minimalinvasive posterior approach in the treatment of the posterior wall fractures of the acetabulum. Musculoskeletal surgery 93:9–13 51. Guven K, Rozanes I, Ucara A, Poyanli A, Yanarb H, Acunas B (2010) Pushable springcoil embolization of pseudoaneurysms caused by gluteal stab injuries. Eur J Radiol 73:391–395 52. Mavili E, Donmez H, Ozcan N, Akcali Y (2007) Endovascular treatment of lower limb penetrating arterial traumas. Cardiovasc Intervent Radiol 30:1124–1129 53. Naidoo NM, Corr PD, Robbs JV, Maharaj J, Nair R (2000) Angiographic embolisation in arterial trauma. Eur J Vasc Endovasc Surg 19:77–81 54. Panetta T, Sclafani SJ, Goldstein AS, Phillips TF, Shaftan GW (1985) Percutaneous transcatheter embolization for massive bleeding from pelvic fractures. J Trauma 25:1021–1029 55. Aksoy M, Taviloglu K, Yanar H et al (2005) Percutaneous transcatheter embolization in arterial injuries of the lower limbs. Acta Radiol 46:471–475 56. Cherry RA, Goodspeed DC, Lynch FC, Delgado J, Reid SJ (2011) Intraoperative angioembolization in the management of pelvic-fracture related hemodynamic instability. J Trauma Manag Outcomes 13:6 57. Lee D, Legiehn GM, Munk PL (2007) Pseudoaneurysm of the superior gluteal artery following polytrauma. Skeletal Radiol 36:875–878 58. Agarwal M, Giannoudis PV, Syed AA, Hinsche AF, Matthews SJ, Smith RM (2003) Pseudoaneurysm of the inferior gluteal
123
Tech Coloproctol artery following polytrauma: diverse presentation of a dangerous complication: a report of two cases. J Orthop Trauma 17:70–74 59. Velmahos GC, Constantinou C, Tillou A, Brown CV, Salim A, Demetriades D (2005) Abdominal computed tomographic scan for patients with gunshot wounds to the abdomen selected for nonoperative management. J Trauma 59:1155–1160; discussion 1160–1161 60. Sziller I, Hupuczi P, Papp Z (2007) Hypogastric artery ligation for severe haemorrhage in obstetric patients. J Perinat Med 35:187–192 61. Andriole GL, Sugarbaker PH (1985) Perineal and bladder necrosis following bilateral internal iliac artery ligation. Report of a case. Dis Colon Rectum 28:183–184
123
62. Nandanwar YS, Jhalam L, Mayadeo N, Guttal DR (1993) Ligation of internal iliac arteries for control of pelvic haemorrhage. J Postgrad Med 39:194 63. El Sheikh MAA, El Fadul BH (2000) Bilateral internal artery ligation in obstetric haemorrhage. Yemen Medical Journal 3:106–114 64. Shin RK, Stecker MM, Imbesi SG (2001) Peripheral nerve ischaemia after internal iliac artery ligation. J Neurol Neurosurg Psychiatry 70:411–412
REVIEW
Penetrating injury to the buttock: an update R. Lunevicius • D. Lewis • R. G. Ward • A. Chang • N. E. Samalavicius • K. M. Schulte
Received: 5 November 2013 / Accepted: 6 May 2014 Ó Springer-Verlag Italia 2014
Abstract 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 management of penetrating gluteal injuries (PGI). MEDLINE, EMBASE, Cochran, and CINAHL databases were employed. Thirty-seven papers were selected and retrieved for overview from 1,021 records. PGI accounts for 2–3 % of all penetrating injuries, with a mortality rate up to 4 %. Most haemodynamically stable patients will benefit from traditional wound care and selective non-operative management. When gluteal fascia injury is confirmed or suspected, a contrast-enhanced CTscan provides the most accurate injury diagnosis. CT-scanbased angiography and endovascular interventions radically supplement assessment and management of patients
with penetrating injury to the major buttock and adjacent extra-buttock arteries. Immediate life-saving damage-control surgery is indicated for patients with hypovolemic shock and signs of internal bleeding. A universal basic management algorithm is proposed. This overview shows that penetrating injury to the buttock should be regarded as a potential life-threatening injury, and therefore, patients with such injuries should be managed in trauma centres equipped with hybrid operating theatres for emergency endovascular and open surgery for multidisciplinary teams operating 24/7. Keywords Buttock injury Penetrating injury Management Angioembolization Surgery SNOM
Introduction R. Lunevicius (&) R. G. Ward Emergency General Surgery and Major Trauma Units, Cheshire and Merseyside Major Trauma Centre, Aintree University Hospital NHS Foundation Trust, Lower Lane, Liverpool L9 7AL, UK e-mail: [email protected] R. Lunevicius R. G. Ward University Hospital Aintree, Liverpool, UK D. Lewis A. Chang K. M. Schulte Major Trauma Centre for South East London, King’s College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK D. Lewis A. Chang K. M. Schulte King’s Health Partners, London, UK N. E. Samalavicius Medical Faculty, Oncology Institute, Vilnius University, 1 Santariskiu Str., Vilnius 08660, Lithuania
Penetrating injury to the buttock is common as a serious diagnostic and treatment concern in emergency department, general emergency surgery, and trauma centres. However, clinical research on penetrating injury to the buttock is sparse. It began in 1970s in a military trauma centre [1] and only yielded another six retrospective studies from civilian trauma centres [2–7] within 20 years. The first overview of four such studies emphasized a potential danger of any stab wound to the buttock [8]. A new paradigm was up-to-dated in 1997 when it was proved that a selective non-operative management (SNOM) is safe and helps to avoid unnecessary abdominal explorations in patients with gunshot buttock injuries [9]. Nevertheless, a strategy and algorithm for management of penetrating injuries to the buttock has not been established. Furthermore, an education literature is based only on a few research papers. A lack of conceptual overview of the
123
Tech Coloproctol
literature on penetrating injury to the buttock is one of the causes of this phenomenon. We provide a comprehensive conceptual overview of classic and current literature on penetrating injury to the buttock and propose a basic algorithm for management of penetrating gluteal injuries (PGI).
A
Methods MEDLINE, EMBASE, Cochran, and CINAHL databases were employed. The following medical subject heading terms were used for search of records: ‘penetrating buttock injury’, ‘PGI‘, ‘injuries‘, ‘wounds and injuries‘, ‘wound penetrating’in combination with the term ‘Buttocks’. The search was limited to humans, English language, and time for the 1970–2010. This resulted in 1,021 records. Inclusion and exclusion criteria were selected before screening all records for retrieval of the eligible articles for the overview of the literature. Inclusion criteria were as follows: buttock/gluteal stab wounds or injury, and buttock/ gluteal shot, blast, or missile wounds or injury. Exclusion criteria were: the blunt trauma, acupuncture or injection injury, needlestick accidents, iatrogenic injury, wound infection, bone fracture complications, burn injury, gluteal ulcers, chronic gluteal false and true aneurysms, anal and/ or anorectal injury, and rotary lawn mower injury. Each record was screened for retrieval in turn. Thirty-seven papers were selected and retrieved for overview of the literature as systematic review and metaanalysis was not possible. There were no prospective randomized controlled trials. Four articles were brief non-systematic literature overviews [8, 10–12], two were prospectively designed studies from single trauma centre [9, 13], 12 were retrospective reviews [2–5, 7, 14–20], 16 were cases reports [1, 8, 11, 21–33], and three were commentaries [34–36]. No articles reported population-based data on incidence, mortality, and morbidity from penetrating injuries to the buttock. One analytical article was included for this overview [37]. Other references were used for enhancement of key statements of this overview [6, 38–64].
Anatomy The buttock is bordered superiorly by the posterior iliac crest, laterally by the line joining the anterior superior iliac spine and the greater trochanter of the femur (it usually corresponds with the extension of the midaxillary line), inferiorly by the gluteal crease, and medially by the natal cleft (Fig. 1a) [7, 14, 18]. The horizontal division is marked by a line between both greater trochanters that
123
B
Fig. 1 a Drawing showing five landmarks (1–5), contours (bold line) and two zones of the each buttock (6). 1 iliac crest, 2 the anterior superior iliac spine, 3 natal cleft, 4 greater trochanter of the femur, 5 gluteal crease, 6a upper zone of the buttock (above the greater trochanters), 6b lower zone of the buttock (below the greater trochanters). b Drawing showing the lines and points for major buttock vessels and sciatic nerve. 1 posterior superior iliac spine, 2 greater trochanter of the femur, 3 ischial tuberosity, 4 anterior superior iliac spine, 5 coccyx, 6 spine-trochanter line, 7 the imaginary point for the superior gluteal vessels at the suprapiriform foramen on skin, 8: spine-tuberosity line, 9 tuberosity-trochanter line, 10 the imaginary point for the inferior gluteal vessels, internal pudenda, sciatic, and other nerves emerging from infrapiriform foramen on skin
corresponds to the level of the pubic bone anteriorly and the lower sacrum posteriorly. Virtually, all of the major buttock and intrapelvic vessels and organs are situated above the intertrochanteric plane, that is. in the upper zone [7]. The lower zone contains the distal third of the rectum, the lower part of the urinary bladder, urethra, external genitalia and, in females, most of the vagina, and in males, most of the prostate. Injuries to the major buttock or neighbouring extra-buttock vessels, any extraperitoneal or intraperitoneal viscus, bone, or neural structures are defined as major injuries. Features of surgical anatomy of
Tech Coloproctol
the buttock are described in ‘‘Appendix’’ [18, 38–40]. Isolated anorectal injury is not classified as buttock injury.
Clinical epidemiology Incidence Penetrating gluteal injury is a relatively common cause of admission to emergency rooms in large and underprivileged urban areas, accounting for 2–3 % of all penetrating injuries [15, 19]. However, true incidence of penetrating injuries to the buttock is unknown. Over 97 % of the patients consist are males with a mean age of 23–33 year [9, 16–18]. Fifty-five per cent of patients had a positive blood alcohol test on admission, with mean blood alcohol level 162 mg/dL. Involvement of more than a single system is present in many of these injuries [2, 5]. Causative events Stabbing, shooting, blasting, impalement, and transfixion have been reported. Shooting- and stabbing-related injuries to the buttock in civilian environment are most commonly reviewed. Injuries due to impalement and transfixion are, fortunately, uncommon in civilian life [26]. Mortality Mortality rate varies from 0 to 4 % in individual studies from civilian trauma centres [2–5, 7, 9, 13, 14, 17–19]. In a battlefield environment, where missile injuries, either shot or blast, dominate, the mortality rate is 6 % [15]. In a subset of severely injured and haemodynamically unstable patients, mortality of 25 % has been reported [16, 20]. Morbidity Short-term and long-term morbidity for patients with penetrating trauma to the buttock varies from 0 to 33 % [2, 16, 19]. A prospective study demonstrates 15.8 % morbidity rate in survivals [9]. Haemorrhage from injured major vessels, false gluteal aneurysm, gluteal compartment syndrome, perirectal haematoma, injuries to the rectum or small bowel, prolonged ileus or transient obstruction, soft tissue or urinary tract infections, sciatic nerve or lumbosacral plexus injury, impotence, and pressure sores is most common complication. The possibility of such rare injury complication as bullet/pellet migration to the right ventricle of the heart or hepatic veins was highlighted in case reports [23, 29].
Classifications, grading, and scoring The newest update of Abbreviated Injury Scale 2008 indicates that penetrating non-complicated injury of soft tissues of the buttock is regarded as grade 1 [41]. When there is tissue loss [25 cm2, it should be regarded as a grade 2 injury. It has to be regarded as a grade 3 injury if any buttock injury is associated with blood loss [20 % by volume. Buttock injuries should be assigned to the external body region for Injury Severity Score (ISS) calculation if there are no injuries to bony pelvis, intraabdominal, or intrapelvic structures. However, if such underlying anatomical structures are involved, injuries should be assigned to either the lower extremity body region (provided bony pelvis fracture is confirmed) or abdomen when the ISS is calculated. In general, penetrating injuries to the buttock are classified according to the mechanism of injury, functional significance of injured structure (minor vs major), type of injury (major vessel, sciatic nerve, bony pelvis, etc.), penetration zone (upper vs lower), environmental conditions (civilian vs battlefield/military), and severity (Abbreviated Injury Scale).
Patterns of major injuries Data from a prospective study demonstrate that major lifethreatening visceral and vascular injuries occur in 29 % of patients who sustained GSW and were admitted to a level 1 trauma centre [9]. Data from a retrospective study on stab wounds (SW) to the buttock reveal that visceral and vascular injuries occur in 10.5 % of patients admitted to a large trauma centre [19]. The most commonly damaged structures following penetrating injury to the buttock are the superior gluteal artery (SGA), rectum, small bowel, and colon (more than 5 % each). Injury of the iliac artery and/ or vein is diagnosed in 3 % of patients. Injuries to sciatic or lumbosacral nerves are rare—1 % [37]. The patterns of major injuries associated with stabbing and shooting differ. Stabbings are most frequently associated, in descending order, with injuries to gluteal arteries, rectum, and iliac vessels. Gunshot injuries frequently result in wider organ damage involving, in descending order, small bowel, colon, rectum, bony pelvis, and bladder injuries [37]. High-velocity bullets may ricochet off the bony pelvis and can produce an unexpected bullet path in the abdominal cavity or down to the key vessels of the thigh. Injury of the bony ring of the pelvis happens in 5–14 % of shot patients in a civil environment, 35 % in a battlefield environment, and it is associated with a wide spectrum of pelvic and abdominal injuries [9, 14, 15].
123
Tech Coloproctol
Triage All patients with penetrating injuries to the torso should be transported preferentially to the highest level of a care trauma centre within the trauma network [42]. As soon as the patient enters the emergency department of the trauma centre, further in-hospital triage should depend on the haemodynamic status of the patient. Patients in hypovolemic shock and signs of acute internal bleeding need resuscitation and immediate prompt intervention. Consideration should be given to initiation of massive transfusion protocols and angioembolization or damage-control surgery as critical injury to the common, external, or internal iliac vessels is most common cause of shock [10]. The fast track contrast-enhanced CT-scan of the torso has to be performed when a source and type of bleeding is unclear in non-shocked patients.
Initial clinical assessment and diagnostic tools for further evaluation Primary and secondary trauma surveys should be completed for all patients regardless of their stability. While doing a physical examination of the whole body, it is advisable to identify and describe the locations of the gun shot entrance and exit wounds, to help understand the bullet trajectory. Palpation of femoral pulses, inspection of external urethral meatus, neurological assessment of lower limbs, and digital rectal examination should be performed. Focused Assessment with Sonography for Trauma (FAST) should be selectively used as the sensitivity and specificity is rather poor for penetrating trauma. Bladder catheterization should be performed. Plain X-ray films of the pelvis, contrast CTscan of the abdomen and pelvis with or without contrastenhanced enema, rigid sigmoidoscopy, urethrogram, cystoscopy, and angiography are other adjunctive diagnostic tests [6, 14, 43].
Management plans and algorithms One plan of management of GSW to the buttock and three algorithms for management of gluteal SW, for management of penetrating gluteal GSW and for management of a suspected gluteal artery (GA) or internal pudendal artery (IPA) injury, have been suggested [5, 9, 14, 18]. Each was based on a particular rationale and logic in order to manage serious challenges presenting in penetrating trauma to the buttock. Management algorithms for patients with transpelvic GSW can be useful tools in decision-making when the bullet enters the buttock and fully passes the pelvis [6, 43]. At least 70 % of patients admitted to the large trauma centre will be managed conservatively. The remaining
123
patients will undergo a surgical, either endovascular or open, procedure. Currently, interventional radiology techniques are increasingly used for patients with injuries to the major buttock or extra-buttock arteries [36]. We propose a universal basic management algorithm for penetrating buttock injuries (Fig. 2).
Indications for emergency surgery Indications for emergency trauma laparotomy are as follows: (1) haemoperitoneum related with haemodynamic instability or shock, (2) injury of common, external, and internal iliac vessels with haemodynamic instability when endovascular treatment methods cannot be applied, (3) generalizing peritonitis, (4) full-thickness injury to the intraperitoneal or extraperitoneal bowel confirmed clinically, endoscopically, or radiologically, and (5) intraperitoneal perforation of the urinary bladder. A hybrid operating room is the best place for acute surgery because both surgical procedures, either endovascular or open, can be performed there [36]. Principles of endovascular and open management of penetrating injuries to the major buttock and adjacent extra-buttock vessels are summarized Table 1. It should be kept in mind that injuries to internal iliac artery (IIA) can be controlled by angioembolization if local resources are beneficial. Endovascular stenting can be effectively applied for some not critical injuries of common or external iliac arteries and veins. Extraperitoneal fullthickness rectal injury is treated by diverting sigmoidostomy with or without endorectal repair of the injured rectal wall. Direct retroperitoneal pelvic packing via a midline incision from the umbilicus to the symphysis and the abdominal musculature division without opening of peritoneum with subsequent therapeutic angiography is the emergency procedure for uncontrollable bleeding from major iliac vessel or vessels, mainly veins. When the patient is in shock due to ongoing external bleeding from the penetrating buttock wound, the wound packing and, if packing is not successful, a balloon catheter tamponade by placing a Foley or Fogarty catheter through the wound track and a radiological embolization of the bleeding artery should be the first direct damage-control gluteal procedure. Emergency gluteal surgery with the aim to stop the haemorrhage from the buttock vessel is indicated for ongoing continuous or recurrent external bleeding from gluteal wound when endovascular modalities of bleeding control are not indicated, failed, or cannot be applied due to particular reasons [36]. The source of this type of bleeding usually is injury of SGA, inferior gluteal artery (IGA), or IPA. In the event of external haemorrhage from the gluteal wound in patients without signs of hypovolemic shock, an attempt to control or temporize bleeding should be made in
Tech Coloproctol Fig. 2 Basic scheme of algorithm for management of penetrating injuries to the buttock
the trauma bay with packing (or balloon tamponade) of the wound track. Contrast CT-scan with angiography should be the next diagnostic tool to assess the potential for endovascular control of injured and bleeding buttock vessel. Timing for local wound debridement, which includes necrotic and/or dirty soft tissue removal, washout, and appropriate dressing, depends on the physiological condition of the individual patient. Other indications for early planned surgery include non-stable bony pelvis fracture, injury of sciatic nerve, and urethra/ureter injury when conservative management cannot be applied.
Technical considerations Positioning of the patient for trauma laparotomy When immediate laparotomy should be done due to intraabdominal bleeding and hypovolemic shock, the patient should be laid down in a routine supine position without consideration for Lloyd-Davies positioning. On the contrary,
trauma laparotomy has to be performed in the Lloyd-Davies position for patient with suspected or proven visceral perforation secondary to buttock trauma. This position is chosen under the stable or controlled circumstances when a thorough intraoperative rectal examination, with/without endorectal repair or with/without laparotomy, is planned. Positioning of the patient for gluteal surgery First of all, the prone (face down) or semiprone (so-called Sims’s) positions with the roll under the pubis and with the thigh laterally rotated is recommended for gluteal or extended gluteal incision [20, 36]. This approach also allows the use of a speculum (Fansler, Pratt, Eisenhammer, etc.) for examination of the rectum. Secondly, other positioning alternatives can be chosen—since colorectal surgeons report that the prone or semiprone position often causes post-operative pain over the pubis and lower backache [44]. The laterolateral position, that is a modified Sim’s position, can be an option for unilateral gluteal or extended gluteal exposure as well as for good exposure of
123
Tech Coloproctol Table 1 Principles of open and endovascular management of penetrating injuries to buttock and adjacent extra-buttock vessels Vessel
Definitive management
Damage-control management
Possible consequences
Arteries Superior gluteal
Ligation/embolize
Packing
Buttock ischaemia/rare
Inferior gluteal
Ligation/embolize
Packing
Buttock ischaemia/rare
Internal pudendal
Ligation/embolize
Packing
Electile dysfunction/rare
Internal iliac
Ligation/embolize
Ligation/oversew/undersew
Buttock ischaemia/rare
External iliac
Repair/stent
Shunta/ligation/oversew/undersew
Lower extremity ischaemia
Common iliac
Repair/stent
Shunta/ligation/oversew/undersew
Lower extremity ischaemia
Common femoral
Repair/stent
Shunta/ligation/oversew/undersew
Lower extremity ischaemia
Gluteal
Ligation
Packing
None
Internal pudendal Internal iliac
Ligation Ligation
Packing Retroperitoneal packingb, ligation
None Should be none/oedema
External iliac
Repair, stent
Retroperitoneal packingb, ligation
Lower extremity oedema
Common iliac
Repair, stent
Retroperitoneal packingb, ligation
Lower extremity oedema
Femoral
Repair, stent
Packing, ligation
Lower extremity oedema
Veins
a
Temporary intravascular shunt for injuries to common, external iliac, and common femoral arteries is the primary damage-control procedure as it eliminates the incidence of ischaemia, fasciotomies and amputation substantially. Ligation as the primary damage-control procedure needs to be avoided
b
Retroperitoneal packing, either unilateral or bilateral, is performed via a midline incision from the umbilicus to the symphysis and the abdominal musculature division without opening of peritoneum
the anorectal canal if needed. If this position is chosen, the patient should be placed with one leg straight and the other leg curled on the pillow. Thirdly, the lithotomic position can be used for exposure and packing of penetrating wounds to the medial or perianal aspect of the lower zone buttock and for the examination of the rectum. Fourthly, in an acute setting, a simple face down is acceptable for buttock exploration. Finally, all these positions can be combined with the addition of a vertical lift, that is with the Trendelenburg or reverse Trendelenburg. Gluteal incisions As acute care surgery is aimed to expose a space beneath gluteus maximus muscle where most gluteal vessels and nerves are located, the incision—longitudinal to gluteus maximus fibres—and the longitudinal division of this muscle should be adequate to clinical problem. Briefly, the gluteal incision should be long. There are two surgical approaches for open buttock trauma surgery (Fig. 3) [20, 36]. The first one, a simple gluteal incision, corresponds partially with the incision of Kocher–Langenbeck through longitudinal splitting of the gluteus maximus muscle in its anterior third [45], however, without tenotomies of the piriform and the obturator internus and gemmelli muscles. The skin incision should be made parallel to the fibres of the gluteus maximus, beginning 2 cm below the posterior superior iliac spine and ending at the posterosuperior angle of the greater
123
Fig. 3 Gluteal incisions. 1 simple gluteal incision, 2 extended gluteal incision (‘‘question mark’’; Henry), 3 gluteus maximus muscle
trochanter. The Kocher–Langenbeck incision runs below the greater trochanter of the femur. The second one, an extended gluteal incision, is another choice in buttock surgery [20, 46]. It is known as the ‘question-mark shape’ incision or Henry incision [47]. It starts a few centimetres (usually up to 6 cm) below the iliac crest medially, runs upwardly towards the posterior superior iliac spine, further curving and running down following the superior border of the gluteus maximus, and ends over the
Tech Coloproctol Fig. 4 Oblique view pelvic arteries: 1 external iliac, 2 internal iliac, 2a anterior trunk (division) of internal iliac, 2b posterior trunk (division) of internal iliac, 3 superior gluteal, 4: middle rectal, 5 internal pudenda, 6 inferior gluteal
greater trochanter of the femur to the level of the inferior gluteal fold. There is, therefore, an impression that this incision consists of two different parts, shorter (or medial longitudinal) and longer (or lateral oblique). A further incision of the fascia, gluteus maximus muscle on upper margin and its fascia laterally, gives a chance to rotate and retract the gluteus maximus muscle medially and, therefore, will expose the superior gluteus, inferior gluteus, and internal pudendal vessels as well as the sciatic, posterior femoral cutaneous, and pudenda nerves. Sections of the piriformis muscle, its tendon, and neighbouring muscles can be made for better exposure of the sciatic nerve or vessels [48]. In addition, an incision can be extended downwards if surgical circumstances require. We therefore recommend the Henry incision for gluteal surgery as it provides a better exposure to main neurovascular structures of the buttock. The following six features of surgery via gluteal incision should be kept in mind: (1) both skin and subcutaneous tissue of the buttock is thick; (2) superficial fascia of the gluteus maximus muscle contains the cutaneous nerves; (3) there is a recommendation in order to prevent gluteal nerve damage that a proximal extension of the transgluteal incision should be limited to 3 cm to the tip of the greater trochanter [49]; (4) the operation might be quite bloody; packed red blood cells should be prepared; (5) 12–18-cmlength incision should be regarded as a surgical introduction to a minimal invasive approach—longer incisions are preferable [50]; (6) both gluteal incisions, either simple or extended, can be also used for emergency fasciotomies for the post-traumatic gluteal compartments [46].
Angioembolization The role of interventional radiology within the trauma setting has evolved over the past 20 years to become a well recognized part of the management of injured patients [36, 51–55]. Solid abdominal organ and pelvic visceral arteries are the most frequent targets for embolization because a combination of a minimally invasive and effective way of securing haemostasis makes it ideal in these locations. In the vast majority of cases, the patients with penetrating injuries to buttock will have had a CT (Figs. 4, 5) before considering angiography and embolization. The indication for and timing of endovascular intervention in penetrating buttock trauma requires a case by case discussion. However, there are five accepted indications. Firstly, ‘cardiovasculary unstable’ patient. Many of these patients will need surgery but haemorrhage is the main cause of early trauma death. However, the removal of the tamponade in massive abdomino-pelvic bleeding with a laparotomy may have fatal consequences. The optimal management, therefore, may be the combined laparotomy with proximal artery control, intra-operative angioembolization, and pelvic packing as a last resort because of pelvic nerve damage. However, this requires the availability of a hybrid theatre [36, 56]. Secondly, haemodynamic instability due to injury of a branch of the IIA is evident on the CT. Most often these branches are SGA, IGA, or IPA. Rarely, branches from the femoral arteries (circumflex and profunda) may be involved. The isolated injury of these arteries is the
123
Tech Coloproctol Fig. 5 Three major buttock arteries and external iliac artery (posterior view pelvic arteries): 1 superior gluteal, 2 inferior gluteal, 3 internal pudenda, 4 external iliac
indication for angioembolization. However, decisions are different when injury of buttock artery is associated with rectal injury as the rectum has supply of blood from both the inferior mesenteric and internal iliac arteries. For instance, in rectal injury with perirectal arterial bleeding, surgery is likely to be more appropriate as the resultant haematoma is often confined to the peri-rectal arteries, and definite bowel surgery will be needed without consideration for angiography. On the other hand, if there is a truncation of an artery (it could be a branch of IIA or superior rectal artery) surrounded by haematoma, this is an indication for angiography as these vessels are likely to become a cause of secondary haemorrhage. Thirdly, external haemorrhage from the wound, primarily treated with compression, and packing. If there is a deeper injury that lies in a difficult location for operative intervention, then CT (if not performed already) with a view to embolization could be considered. Fourthly, pseudoaneurysm following buttock injury. This may become evident within a few days or shortly after the haemorrhage. A palpable mass or symptoms of compression to local neural structures (e.g. sciatic nerve) are an indication for endovascular intervention given the possibility of catastrophic haemorrhage [57, 58]. Fifthly, continued bleeding after abdominal or gluteal surgery. The success of angiographic embolization is 80–100 % relating to the nature of the injury, the experience of the interventional radiologist, and the choice of the embolization material [51, 53]. Complications following endovascular embolization are rare and may be difficult to separate
123
from damage due to the initial injury. Necrosis of muscle and skin is very rare. Damage to the artery used for access, almost always the common femoral artery, does occur with pseudoaneurysms and secondary bleeding being less common now due to vascular closure devices.
Selective non-operative management (SNOM) This is a conservative approach to management for haemodynamically stable patients with penetrating abdominal and pelvic wounds who do not have signs of a possible surgical event [9, 42, 59]. It is important to emphasize that if a local wound exploration was performed due to a stab injury to the buttock, and fascia injury was not confirmed, the SNOM concept should not be applicable. Those patients with stab injuries to the buttock can be discharged after primary wound closure. On the other hand, if fascia/ muscle injury is diagnosed on CT-scan or local wound exploration and when there is no sign of surgical events, the SNOM can be started. Patients with penetrating injuries to the buttock selected for non-operative management should be admitted to a high-dependency unit for continuous monitoring and serial clinical examinations. No oral feeding should be employed. Tetanus toxoid vaccine should be given according to general principles of tetanus vaccination. After 24 h, the stable patient can be transferred to general surgery or an acute care surgery ward and oral feeding can be introduced. Discharge should be considered in 24–48 h for shot patients and in 24 h in stabbed patients [12, 43].
Tech Coloproctol Table 2 Penetrating buttock injury clinical follow-up recommendations Treatment
Risks
Comments
Follow-up
SNOM
Gluteal false aneurysm
Differentiate from infection and primary neuropathy
Early: within 3–7 days Symptoms may present later
SGA occlusion
Buttock soft tissue necrosis
Rare, further surgical management is needed
Early: within 1–2 weeks
IGA occlusion
Buttock soft tissue necrosis
Rare, further surgical management is needed
Early Individualized
IPA occlusion Open gluteal surgery IIA occlusion: open or endovascular
IIV ligation
Traumatic electile dysfunction
May contribute to main aetiology
Cavernosal infection
Due to infected embolus
Starts early
Gluteal false aneurysm skin breakdown over the sacrum and buttock Gluteal musculature or perineum necrosis
Differentiate from infection and neurogenic symptoms Early ischaemic complication Early ischaemic complication: surgical management
Early symptoms may present later Starts early and longterm Starts early and long term
Chronic ulcer
Non-healing
Starts early and long term
Gluteal compartment
Post-embolization
Immediate
Ischaemic neuropathy
Sciatic, femoral, sural nerves
Long term: 1–6 months
Lumbosacral plexopathy
Post-bilateral open occlusion
Long term: 1–6 months
Rectal ischaemia
Small/medium-sized particles as emboli
Immediate/early
Bladder partial ischaemia
Small/medium-sized particles as emboli
Immediate/early
Reproductive capacity restriction
May have impact on fertility
Long term: assessment for intrauterine foetal growth
Oedema
Possible
Not emphasized
SNOM selective non-operative management, SGA superior gluteal artery, IGA inferior gluteal artery, IPA internal pudendal artery, IIA internal iliac artery, IIV internal iliac vein
Follow-up Clinical follow-up is not needed for patients with superficial (above fascia) soft tissue injuries to the buttock. We advocate subspeciality clinical follow-up appropriate to the injuries sustained as following penetrating injury to the buttock, the risk of false aneurysm formation needs to be remembered along with other unusual problems such as migration of bullet or pellet to the inferior vena cava and heart [23, 29]. Further radiological follow-up of patients, in order to exclude or confirm gluteal pseudoaneurysms, is guided by early and long-term clinical findings. A fluctuant, warm, and erythematous post-traumatic swelling should be imaged as a possible pseudoaneurysmal haematoma prior to any further intervention (Table 2) [60–64].
Conclusions This comprehensive overview of the literature shows that penetrating injury to the buttock should be regarded as a potential life-threatening injury, and therefore, patients with such injuries should be managed in trauma centres equipped with hybrid operating theatres for emergency endovascular and open surgery for multidisciplinary teams operating 24/7.
An algorithm for management of PGI should be a part of standard operative procedure and an educational tool. Conflict of interest
None.
Appendix: Features of surgical anatomy of the buttock The sciatic foramina The greater and lesser sciatic foramina are paramount in buttock trauma surgery because, firstly, soft tissues covering both foramina are always exposed during the extended gluteal surgery, and, secondly, they are lateral gates to the pelvic organs and other anatomical structures. One muscle, three vessel sets, and seven nerves cover and pass the greater sciatic foramen, which is considered to be the common site of traumatic penetration to the tissues of the buttock. They are as follows: the piriformis muscle, superior gluteal, inferior gluteal, and internal pudendal vessels, sciatic, superior gluteal, inferior gluteal, pudenda, posterior femoral cutaneous nerves, and nerves to the quadratus femoris and obturator externus. Behind the greater sciatic foramen, inside the pelvis, the internal iliac vessels and trunks of the IIA are located. Superior gluteal vessels and
123
Tech Coloproctol
nerve are major transmitting structures of the suprapirifomis foramen. Inferior gluteal, internal pudendal vessels, pudendal, sciatic, and posterior femoral cutaneous nerves are major transmitting structures of the infrapirifomis foramen. Major buttock arteries Soft tissues of the upper buttock including the root of the sciatic nerve are mainly supplied by the superior gluteal artery (SGA), which is the largest branch of the posterior trunk of the IIA. It divides into a superficial branch supplying the gluteus maximus muscle, and deep branches supplying the gluteus medius and minimus, and tensor fasciae lata muscles. Branches of this artery end at the anterior superior iliac spine. The terminal branches of SGA anastomose with the terminal branches of the lateral and deep circumflex femoral, inferior gluteal, and lateral sacral arteries. The lower buttock and the back of the thigh are mainly supplied by the IGA, the branch of the anterior trunk of IIA. It passes the infrapiriform foramen, which is in between the piriformis and the superior gemelli muscles. Multiple branches of this artery reach the gluteus maximus, the coccyx, sciatic and posterior femoral cutaneous nerves, and thigh muscles. SGA and IGA may form a common trunk. Medial tissues of the lower buttock zone, perineum, urethra, and external genitalia are supplied by multiple muscular, coccygeal, nervi ischiadici, anastomotic, articular, cutaneous branches of IPA, which is the branch of the anterior trunk of the IIA. The IPA emerges from the pelvis below the piriformis muscle, medially to the IGA. The artery passes the ischial spine and enters the perineum through the lesser sciatic foramen. This artery gives origin to the inferior rectal artery. SGA, IGA, and IPA are major buttock arteries, as acute external haemorrhage from these vessels can be very heavy and cause an irreversible hypovolemic shock. Projections of major buttock vessels and sciatic nerve on the skin Knowledge about projections of major buttock vessels on the skin can be used for conjecturing what structures of the buttock are possibly injured by the penetrating agent. Lines drawn between three key bony structures of the buttock— the posterior superior iliac spine, the ischial tuberosity, and the greater trochanter—form a triangle (Fig. 1b). The hip joint projects from the middle area of this triangle. The three points on the three sides of the triangle are most important for conjecturing where the major buttock vessels and nerves emerge beneath the gluteus maximus muscle. Firstly, the point between the upper and middle thirds of
123
the line connecting the posterior superior iliac spine with the greater trochanter (the so-called spine-trochanter line) shows the part of the SGA at the suprapiriform foramen. Secondly, the middle of the line connecting the posterior superior iliac spine and the ischial tuberosity (it is the spine-tuberosity line) is the point for the IGA, sciatic and other nerves emerging from the infrapiriform foramen. Thirdly, the sciatic nerve runs downwards and slightly laterally and crosses the tuberosity-trochanter line, which connects the ischial tuberosity and the greater trochanter, at the point between the middle and medial thirds. It should be kept in mind that a projection of the piriformis muscle and the greater portion of the greater sciatic foramen are above the midpoint of the spine-tuberosity line. The midpoint of the line connecting the coccyx and the anterior superior iliac spine would indicate the SGA to be at the level of the suprapiriformis foramen. The segment of this line running upwards from the midpoint would indicate a continuation of the SGA and its branches on the skin of the buttock. Medial tissues from the ischial tuberosity (i.e. a lateral wall of the ischiorectal fossa) is a mark for the IPA.
References 1. Knight RJ (1973) Resuscitation of battle casualties in South Vietnam: experiences at the First Australian Field Hospital. Resuscitation 2:17–31 2. Maull KI, Snoddy JW, Haynes BW Jr (1979) Penetrating wounds of the buttock. Surg Gynecol Obstet 149:855–857 3. Ivatury RR, Rao PM, Nallathambi M, Gaudino J, Stahl WM (1982) Penetrating gluteal injuries. J Trauma 22:706–709 4. Vo NM, Russell JC, Becker DR (1983) Gunshot wounds to the buttocks. Am Surg 49:579–581 5. Fallon WF Jr, Reyna TM, Brunner RG, Crooms C, Alexander RH (1988) Penetrating trauma to the buttock. South Med J 81:1236–1238 6. Duncan AO, Philips TF, Scalea TM et al (1989) Management of transpelvic gunshot wounds. J Trauma 29:1335–1340 7. Mercer DW, Buckman RF Jr, Sood R, Kerr TM, Gelman J (1992) Anatomic considerations in penetrating gluteal wounds. Arch Surg 127:407–410 8. Feigenberg Z, Ben-Baruch D, Barak R, Zer M (1992) Penetrating stab wound of the gluteus: a potentially life-threatening injury: case reports. J Trauma 33:776–778 9. Velmahos GC, Demetriades D, Cornwell EE, Asensio J, Belzberg H, Berne TV (1997) Gunshot wounds to the buttocks: predicting the need for operation. Dis Colon Rectum 40:307–311 10. Salim A, Velmahos GC (2002) When to operate on abdominal gunshot wounds. Scand J Surg 91:62–66 11. Aydin A, Lee CC, Schultz E, Ackerman J (2007) Traumatic inferior gluteal artery pseudoaneurysm: case report and review of literature. Am J Emerg Med 25:488e1–488e3 12. Butt MU, Zacharias N, Velmahos GC (2009) Penetrating abdominal injuries: management controversies. Scand J Trauma Resusc Emerg Med 17:19 13. Velmahos GC, Demetriades D, Cornwell EE III (1998) Transpelvic gunshot wounds: routine laparotomy or selective management? World J Surg 22:1034–1038
Tech Coloproctol 14. DiGiacomo JC, Schwab CW, Rotondo MF et al (1994) Gluteal gunshot wounds: who warrants exploration? J Trauma 37:622–628 15. Lesperance K, Martin MJ, Beekley AC, Steele SR (2008) The significance of penetrating gluteal injuries: an analysis of the Operation Iraqi Freedom experience. J Surg Educ 65:61–66 16. Gilroy D, Saadia R, Hide G, Demetriades D (1992) Penetrating injury to the gluteal region. J Trauma 32:294–297 17. Ferraro FJ, Livingston DH, Odom J, Swan KG, McCormack M, Rush BF Jr (1993) The role of sigmoidoscopy in the management of gunshot wounds to the buttocks. Am Surg 59:350–352 18. Makrin V, Sorene ED, Soffer D, Weinbroum A, Oron D, Kluger Y (2001) Stab wounds to the gluteal region: a management strategy. J Trauma 50:707–710 19. Susmallian S, Ezri T, Elis M, Dayan K, Charuzi I, Muggia-Sullam M (2005) Gluteal stab wound is a frequent and potentially dangerous injury. Injury 36:148–150 ¨ zcan N, Tasdemir K (2009) Isolated 20. Ceyran H, Akc¸ali Y, O penetrating gluteal injuries. Perspect Vasc Surg Endovasc Ther 21:253–256 21. Mamode N, Reid AW (1994) Haemorrhage following penetrating gluteal trauma. Br J Surg 81:203–204 22. Rub R, Madeb R, Kluger Y, Chen T, Avidor Y (2000) Posterior urethral disruption secondary to a penetrating gluteal injury. Urology 56:509 23. Obermeyer RJ, Fecher A, Erzurum VZ, DeVito PM (2000) Embolization of bullet to the right ventricle. Am J Surg 179:189 24. Kalimi R, Angus LD, Gerold T, DiGiacomo JC, Weltman D (2002) Bullet embolization from the left internal iliac vein to the right ventricle. J Trauma 52:772–774 25. Carrick MM, Morel AN, Pham HQ (2007) Shotgun wounds to the buttocks, sacrum, and rectum. J Trauma 62:552 26. Napier F, Fountain-Polley S, Kallapa C (2007) Images in paediatrics: ironing board impalement. Arch Dis Child 92:758 27. van Oldenrijk J, Unlu¨ C, van Wagensveld BA (2007) Perforation of the ileum after a stab wound of the gluteal region: a case report. Emerg Med J 24:737–738 28. Ramasamy A, Hinsley DE, Brooks AJ (2008) The use of improvised bullet markers with 3D CT reconstruction in the evaluation of penetrating trauma. J R Army Med Corps 154:239–241 29. Raikar SS, Jureidini SB, Balfour IC, Tinker K (2010) The fantastic journey of a bullet: out with a snare. Pediatr Cardiol 31:108–110 30. Demetriades D, Rabinowitz B, Sofianos C (1988) Gluteal artery aneurysms. Br J Surg 75:494 31. Holland AJ, Ibach EG (1996) False aneurysm of the inferior gluteal artery following penetrating buttock trauma: case report and review of the literature. Cardiovasc Surg 4:841–843 32. Culliford AT, Cukingham RA, Worth MH Jr (1974) Aneurysms of the gluteal vessels: their etiology and management. J Trauma 14:77–81 33. Chappell ET, Pare L, Salepour M (2006) Fluoroscopic image guidance for minimally invasive extraction of a bullet from the gluteus maximus. J Trauma 60:664–667 34. Scalea TM (1998) Invited commentary on Velmahos GC et al: Transpelvic gunshot wounds: routine laparotomy or selective management? World J Surg 22: 1038 35. DiGiacomo JC, Schwab CW, Kauder DR, Rotondo MF, Velmahos GC et al (1999) Transpelvic gunshot wounds: routine laparotomy or selective management? World J Surg 23:619–620 36. Rasmussen TE (2009) Commentary on ‘‘Isolated penetrating gluteal injuries: a potentially life-threatening trauma’’. Perspect Vasc Surg Endovasc Ther 21: 257–258; discussion 258 37. Lunevicius R, Schulte KM (2011) Analytical review of 664 cases of penetrating buttock trauma. World J Emerg Surg 6:33
38. Wheeless CR, III, MD (2008) Wheeless’ textbook of orthopaedics. Greater sciatic foramen. Duke Orthopaedics. http://www. wheelessonline.com/ortho 39. Bergman R, Afifi AK, Miyauchi R (1847) Anatomy Atlases. http://www.anatomyatlases.org/AnatomicVariants/Cardiovas cular/Text/Arteries/GlutealInferior.shtml. URL: http://www.anat omyatlases.org 40. Schunke M, Ross LM, Schulte E, Lamperti ED, Schumacher U (2006) Atlas of anatomy: general anatomy and musculoskeletal system. Thieme, Stuttgart, Germany, p. 494. http://books.google. com 41. Abbreviated Injury Scale Ó2005. Update 2008. Editors: Gennarelli TA, Wodzin E. Association for the Advancement of Automotive Medicine, Barrington, IL, USA 42. Sasser SM, Hunt RC, Sullivent EE et al (2009) Guidelines for field triage of injured patients. Recommendations of the national expert panelon field triage. Morbidity and Mortality Weekly Report. Recommendations and Reports 58: RR-1. Department of health and human services. Centers for Disease Control and Prevention. http://www.cdc.gov/mmwr/PDF/rr/rr5801.pdf 43. Navsaria PH, Edu S, Nicol AJ (2011) Nonoperative management of pelvic gunshot wounds. Am J Surg 201:784–788 44. Nivatvongs S (1980) Alternative positioning of patients for hemorrhoidectomy. Dis Colon Rectum 23:308–309 45. Rommens PM (2004) The kocher-langenbeck approach for the treatment of acetabular fractures. Eur J Trauma 30:265–273 46. Keene R, Froelich JM, Milbrandt JC, Idusuyi OB (2010) Bilateral gluteal compartment syndrome following robotic-assisted prostatectomy. Orthopedics 33:852 47. Henry AK (1987) Extensile exposure. Churchill Livingstone, New York, p 189 48. Kline DG, Kim D, Midha R, Harch C, Tiel R (1998) Management and results of sciatic nerve injuries: a 24-year experience. J Neurosurg 89:13–23 49. Bos JC, Stoeckart R, Klooswijk AI, van Linge B, Bahadoer R (1994) The surgical anatomy of the superior gluteal nerve and anatomical radiologic bases of the direct lateral approach to the hip. Surg Radiol Anat 16:253–258 50. Spagnolo R, Bonalumi M, Pace F, Capitani D (2009) Minimalinvasive posterior approach in the treatment of the posterior wall fractures of the acetabulum. Musculoskeletal surgery 93:9–13 51. Guven K, Rozanes I, Ucara A, Poyanli A, Yanarb H, Acunas B (2010) Pushable springcoil embolization of pseudoaneurysms caused by gluteal stab injuries. Eur J Radiol 73:391–395 52. Mavili E, Donmez H, Ozcan N, Akcali Y (2007) Endovascular treatment of lower limb penetrating arterial traumas. Cardiovasc Intervent Radiol 30:1124–1129 53. Naidoo NM, Corr PD, Robbs JV, Maharaj J, Nair R (2000) Angiographic embolisation in arterial trauma. Eur J Vasc Endovasc Surg 19:77–81 54. Panetta T, Sclafani SJ, Goldstein AS, Phillips TF, Shaftan GW (1985) Percutaneous transcatheter embolization for massive bleeding from pelvic fractures. J Trauma 25:1021–1029 55. Aksoy M, Taviloglu K, Yanar H et al (2005) Percutaneous transcatheter embolization in arterial injuries of the lower limbs. Acta Radiol 46:471–475 56. Cherry RA, Goodspeed DC, Lynch FC, Delgado J, Reid SJ (2011) Intraoperative angioembolization in the management of pelvic-fracture related hemodynamic instability. J Trauma Manag Outcomes 13:6 57. Lee D, Legiehn GM, Munk PL (2007) Pseudoaneurysm of the superior gluteal artery following polytrauma. Skeletal Radiol 36:875–878 58. Agarwal M, Giannoudis PV, Syed AA, Hinsche AF, Matthews SJ, Smith RM (2003) Pseudoaneurysm of the inferior gluteal
123
Tech Coloproctol artery following polytrauma: diverse presentation of a dangerous complication: a report of two cases. J Orthop Trauma 17:70–74 59. Velmahos GC, Constantinou C, Tillou A, Brown CV, Salim A, Demetriades D (2005) Abdominal computed tomographic scan for patients with gunshot wounds to the abdomen selected for nonoperative management. J Trauma 59:1155–1160; discussion 1160–1161 60. Sziller I, Hupuczi P, Papp Z (2007) Hypogastric artery ligation for severe haemorrhage in obstetric patients. J Perinat Med 35:187–192 61. Andriole GL, Sugarbaker PH (1985) Perineal and bladder necrosis following bilateral internal iliac artery ligation. Report of a case. Dis Colon Rectum 28:183–184
123
62. Nandanwar YS, Jhalam L, Mayadeo N, Guttal DR (1993) Ligation of internal iliac arteries for control of pelvic haemorrhage. J Postgrad Med 39:194 63. El Sheikh MAA, El Fadul BH (2000) Bilateral internal artery ligation in obstetric haemorrhage. Yemen Medical Journal 3:106–114 64. Shin RK, Stecker MM, Imbesi SG (2001) Peripheral nerve ischaemia after internal iliac artery ligation. J Neurol Neurosurg Psychiatry 70:411–412
