Buttock wound and its management.

1. Page 1
Management of penetrating buttock
trauma in a London Major Trauma Centre
Raimundas Lunevicius, Tom König, Joanne Cooke, Avril Chang, Ali Hallal, Dylan Lewis,
Robert Bentley, Klaus Martin Schulte
29-30 Apr 2011, Vilnius, Lithuania
International colorectal cancer conference
7th triennial meeting of the Lithuanian Society of Coloproctologists
South East London Trauma Network

2. Agenda / Aims
Overview of characteristics of patients / penetrating injuries
Buttock injury / KCH
Literature review on buttock injury
Conclusion: one
2

3. Penetrating injury by month, n = 220 Apr – Dec, 2010 3
29
23
9
23
28
34
29
20
25
0
5
10
15
20
25
30
35
40
from 6 Apr May Jun Jul Aug Sep Oct Nov Dec

4. Males: 96% Apr – Dec, 2010 4
4%
96%
Gender & Penetrating Injury
Females, n=8 Males, n=212

5. Stabbing 83%, shooting 16% Apr – Dec, 2010 5
Stabbing, 183, 83%
Shooting, 36, 16%
Stabbing+Shooting, 1, 1%

6. Body regions wounded: mono vs poly-trauma 4:1
Jul – Dec 2010 (* posterior torso includes buttocks) 6
0 10 20 30 40 50 60
Neck, n=11 (6%)
Head & Face, n=11 (6%)
Abdomen, n=29 (15%)
Posterior torso*, n=37 (20%)
Chest, n=45 (24%)
Extremities, n=55 (29%)

7. Penetrating buttock injury 6th Apr - Dec 2010
Case Gender Age Injury
mechanism
ABC Admission
Hb (g/dL)
Other body
regions injuries
CT Bed
1 Male 23 Shooting Stable 14.2 L lower back – (axr) Ward
2 Female 50 Stabbing Stable 13.9 Face, torso + CDU
3 Male 26 Stabbing Stable 16.5 Head, face, hand + Ward
4 Male 19 Stabbing Stable 14.1 Head, face – Ward
5 Male 19 Stabbing Stable 13.9 Abdomen + Ward
6 Male 16 Stabbing Stable – Back + CDU
7 Male 16 Stabbing Stable 14.1 – + Ward
8 Male 18 Stabbing Stable 13.4 Chest, arm + Ward
9 Male 17 Stabbing Stable 16.0 Chest + Ward
7

8. Penetrating buttock injury (continuation)
No Clinical mode of
presentation
Buttock
aspect
CT-scan
finding
Management Transfusio
n
Length
of stay
Outcome
1 Multiple entry sites
of pellets
na na Debridgement,
extraction
– 1 Recovery
2 Wounds na – Observation – < 1 Recovery
3 External
haemorrhage
na – Suturing – < 1 Recovery
4 External
haemorrhage
na na Suturing – 2 Recovery
5 External
haemorrhage
na – Skin suturing – < 1 Recovery
6 Wound na
–
Observation – < 1 Recovery
7 Rectal injury R buttock:
‘Close to
anal region’
Hematoma,
rectal injury
Loop sigmoid
colostomy
–
7 Recovery
8 External recurrent
haemorrhage
R lateral +
L lateral
and medial
Muscles,
hematoma
1: Packing
2: Ligation: bleed
2
3 Recovery
9 External
haemorrage
Seven
lacerations
M sc/ L glut
hematoma
1: Packing
2: Ligation: bleed
4 4 Recovery
8

9. Buttock Injury (case 7)
Axial and Coronal CT showing
right buttock stabbing. Haematoma in the
superficial soft tissues is accompanied by
continued bleeding within the perirectal
soft tissue. At laparotomy : loop sigmoid
colostomy (F502838)

10. Buttock Injury (case 8)
Axial and Sagittal CT showing penetration through the right gluteus
maximus and obturator internus muscles with haematoma but no continued
bleeding. Note the asymmetry of the latter. (D439070)

11. Buttock Injury (case 9)
Axial and Sagittal CT illustrate superficial penetration through the soft tissues
medial aspect of the left gluteus maximus muscle / no bleeding.
( P148728)

12. Summary table on buttock penetrating injury
Criterion Finding Per cent Comment
Male/ female ratio 8:1 89% -
Average age (range) 23 y (16-50) – -
Stabbing / shooting ratio 8:1 89% The usual thing
Penetrating injuries of other
regions
8 89% High rate
Admissions to CDU or ASU 9 100% 6h duration observation is
needed
CT scan
Proctosigmoidoscopy
7
0
78%
0
Very useful
Might have been used more often
Major injuries diagnosed:
Major gluteal vessels
Rectal injury
3
2
1
33%
22%
11%
High rate
Major operations 3 33% Extended gluteal OR laparotomy
Average length of stay (days) 2 days (1-7) – All pts were observed / admitted
Outcomes All survived 100% Survival rate 97-98%
12

13. MDT meeting: issue / buttock injury
What are the best management options?
Literature review
Page 13

14. Search strategy
Databases:
PubMed / Medline, Embase, Cochrane Database,
CINAHL, NICE guidelines
Titles/abstracts/articles: 1021
from 1970 to 2010
Relevant articles - 40
Page 14

15. Relevant articles: 40
Type of publication Level Evidence grade Number
Systematic reviews level IA grade A –
Randomized controlled studies level IB grade A –
Review of literature grade A 4
Prospective studies level IIA grade B 2
Retrospective studies level IIB grade B 14
Case reports level III grade C 18
Commentaries, opinions, guidelines level IV – 2
15

16. Retrospective reviews: key points
Penetrating wounds (Stab / Missile):
• Viscus / major vessel injury – 30%
• Laparotomies – 27%
• Extended gluteal surgery – 6%
• Angioradiological surgery – 2%
• Mortality – 2-3 %
• SW proved to be as damaging as MW
Thorough urgent evaluation
• PR, urine, CT-angio, proctosigmoidoscopy…
Division of buttock:
• upper zone / lower zone
Selective management / clinical findings
16

17. Case reports: key points
Misdiagnosis
• Aggressive evaluation is needed
False gluteal aneurysm / abscess differentiation
Consider CT-scan / CT-angiography
Bullet / pellets migrates (very rare)
• Invasive radiology
17

18. Take – homes
There is no such thing
as a not dangerous
penetrating gluteal injury
• Scan
• Scope (selected cases)
• Observe or treat
Guidelines / Protocols
An academic health sciences center for London
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