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\begin{document}

\title{A case of penetrating buttock trauma and lessons learnt~ on how new
protocols of the Northern Ireland Major Trauma Network can improve~
patient care~~~~~~~~~~~~~}



\author[1]{Dimitrios Angelou}%
\author[1]{Mark McKeever}%
\author[1]{Amy Doran}%
\author[1]{Momin Malik}%
\affil[1]{Affiliation not available}%


\vspace{-1em}



  
  \date{May 17, 2024}


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\textbf{ABSTRACT}

We are reporting a case of a patient who was brought to our emergency
department after having sustained a penetrating buttock trauma and we
are discussing about the importance of good Inter-hospital collaboration
to provide patients with early access to Major Trauma Centres with a
specific focus on Northern Ireland protocols.

Our patient is a 54-year-old lady who fell from a stepladder onto the
metallic base of an artificial Christmas tree causing the stem of the
tree to impale her through her right buttock into her pelvis.

Despite the impressive mechanism of injury, there was no immediate
life-threatening bleed and the patient was subsequently transferred to
the local Major Trauma Centre for expert surgical management but
suffered significant delays due to suboptimal communication and lack of
clear transfer pathways.

Current literature recognises that penetrating gluteal trauma should be
considered a life-threatening injury and this case highlights learning
points around the management of penetrating trauma in terms of
investigations, early transfer and definitive surgical treatment.

We discuss about the initial management, imaging and surgical
considerations for this case.

We also discuss about the current recommendations for early transfer
between smaller centres to Major Trauma Centres and the Northern Ireland
specific protocols that have been introduced by the Northern Ireland
Major Trauma Network. We focus on the Call and Send protocol and on the
NIMTN Major Trauma Triage Tool.

\par\null

\textbf{INTRODUCTION - TRAUMA PROTOCOLS FOR NORTHERN IRELAND}

The Northern Ireland Major Trauma Network (NIMTN) has created regional
protocols in order to guide practice and coordinate trauma services
between the different HSC trusts in Northern Ireland. {[}1{]}

The NIMTN is active on the planning of every aspect of trauma care
ranging from the pre-hospital care to the rehabilitation care but we are
only going to focus on the emergency transfer protocols for major
trauma. A basic principle of the guidance is that the patient should be
receiving the right care in the right place at the right time.

Northern Ireland's Major Trauma Centre is the Royal Victoria Hospital in
Belfast and is receiving patients from all other local hospitals in the
region.

The relevant protocols in action are the Call and Send Protocol and also
the Major Trauma Triage Tool. They aim to define the criteria for direct
transfer to a Major trauma centre versus the nearest district hospital
and also provide a clear guidance on the process for a transfer of major
trauma to the major trauma centre in order to avoid unnecessary delays.

The call and send protocol has been in use since January of 2021 and is
an extension of the major trauma triage tool. It uses the injury
severity score and facilitates transfer from district general hospitals
to the major trauma centre. To be exact, patients with calculated injury
severity score more than 15 qualify for expediated transfer to the MTC.
That indicates that the patient has at least a single system severe
injury or multiple system minor/ moderate injuries. The Local hospital
senior ED doctor contacts the MTC where the patient cannot be refused
and a hyperacute transfer is arranged.

This protocol reduces the clinical debate of accepting the patient
transfer and it provides a direct trauma line for efficient
communication.

The Major Trauma Triage Tool aims to direct all major trauma to the MTC
to avoid unnecessary delays. Decisions are made against set of criteria
for severe injuries including: 1. Vital signs and level of
consciousness, 2. high risk anatomy of the injury, 3. mechanism of
injury.

If the severity criteria are fulfilled and the estimated arrival time to
the major trauma centre is less than 45 minutes then the patient is
transferred directly to the MTC.

Further information and the exact protocols can be found on the NIMTN
website http://www.hscboard.hscni.net/majortrauma/nimtn-contacts/.

Penetrating buttock injuries are rare but potentially life-threatening
injuries {[}2{]} and this case highlights learning points around the
early management of penetrating buttock trauma, the current transfer
protocols and the specific surgical considerations. This report aims to
aid doctors consolidate their knowledge around the subject and improve
their management of similar situations.

We also aim to raise awareness regarding the Northern Ireland Major
Trauma Network transfer protocols that were not available at the time of
the event.

\par\null

\textbf{CASE PRESENTATION}

A 54-year-old lady, with no significant pre-existing medical
comorbidities, was brought in by ambulance to the emergency department
of our district general hospital after falling from a stepladder onto
the metallic base/ stem of a half dismantled artificial Christmas tree
while removing Christmas decorations in her home.

She arrived lying prone, with approximately 50 cm of the metallic stem
and base-plate (diameter approximately 60 cm) protruding inferiorly and
laterally from her right buttock, near the gluteal fold. She was
conscious, communicating normally and haemodynamically stable.
Intravenous access had been established by the ambulance crew, and
opiate analgesia given. She had her arms around a pillow, and did not
have a cervical collar on. There was a small amount of congealed blood
around the entry wound. A careful abdominal and perineal examination was
performed, including per rectum and per vagina digital exams. Accepting
the limitations due to the patient's prone position, and the desire not
to move or dislodge the foreign body, all examinations were
unremarkable.

\textbf{INVESTIGATIONS}

Trauma X-rays in the emergency department included a pelvic X-ray
(Figure 1), which showed the radiopaque metal pipe's path from the right
buttock entry point, traversing obliquely through the pelvis and lower
abdomen, with the tip lying in the left upper abdominal quadrant. No
bony injury or free air was identified.

In view of the position of the foreign object, the pelvic and abdominal
neurovascular structures, rectum, urinary bladder, uterus, vagina and
bowel were all considered to be at risk of injury. Removal of the object
in theatre under general anaesthesia was considered the safe option,
with colorectal, gynaecological, orthopaedic, vascular and
interventional radiological expertise on standby in case needed.

The case was discussed with the regional Major Trauma Centre for
immediate transfer. Their advice, however, was to perform a Computerised
Tomography (CT) scan locally prior to transfer, in order to fully assess
the extent of the injury. The extracorporeal length of the metal pipe
and base plate were unable to fit through the donut of the CT scanner.
Sawing off the base plate was considered risky in case the movement
exacerbated any internal injuries. Assistance was sought from the local
fire department, who used metal cutters to snap off and shorten the stem
to a manageable length.

The CT scan (3D reconstructed images Figures 2 and 3) demonstrated the
foreign body penetrating the right buttock close to the sciatic nerve,
traversing through the sciatic foramen, crossing the midline in contact
with the sigmoid colon, loops of small bowel within the pelvis and the
left common iliac artery. It terminated in the left upper abdomen
adjacent to multiple small bowel loops. A small volume haematoma within
the pelvis was also noted but no free air or other abdominal visceral
injuries were seen.

The above investigations required a significant amount of time including
one and a half hour for fire brigade to cut off the metal pole for the
patient to fit in the CT scanner, forty minutes for the CT scan and
report and two and a half hours of debating for trauma specialities to
accept the transfer. The total delay of transfer was three hours and
forty minutes.

\textbf{TREATMENT AND OUTCOMES}

The patient remained clinically stable throughout, and was transferred
to the local MTC for definitive management seven hours after
presentation. The foreign body was removed under direct vision in
theatres, during a laparotomy by the vascular surgeons. No major
bleeding or visceral damage was identified and the entry wound was
closed primarily. The patient had an uneventful recovery and was
discharged home after four days. One- and six-month post-operative
out-patient clinic visits raised no further issues.

\textbf{DISCUSSION}

Penetrating buttock trauma is accounts for 2-3\% of penetrating injuries
to the torso; with stab wounds, gunshots and transfixation injuries
being more common than impalement. The mechanisms of injury for
impalement injuries include falls from a height onto a protruding hard
object {[}3,4{]} and high-speed collisions {[}5{]}. They can be
potentially life threatening due to the risk of injury to a number of
critical abdominal and pelvic vessels, with a mortality of 4\%- 11\%
{[}6,7{]}. The severity of the injury should not be underestimated even
if it initially appears innocuous or the entry would small {[}8{]}.

Initial Management should follow ATLS guidelines. During the initial
assessment the foreign body must not be removed from the injury site
{[}4{]} as further bleeding may be caused from the removal process.
Early life saving interventions like major haemorrhage protocol
activation, radiologic embolization or damage control surgery may be
needed {[}6{]}.

In stable patients, the imaging modality of choice to assess visceral
injuries is CT {[}4,6,9{]}. Oral, intravenous and rectal contrast as
well as endoscopy may be used. Visceral and vascular injuries are
common, the frequency of various visceral and vascular injuries reported
in literature are shown in Table 1.

While a selected group of patients with penetrating gluteal injuries may
be managed conservatively {[}6{]}, surgery remains a cornerstone in the
management. Surgery is essential in the presence of haemodynamic
instability, hemoperitoneum or injury to major vessels, full thickness
injury to bowel, peritonitis and perforation of other hollow viscus
organs including the urinary bladder. Surgical exploration can be
challenging due to the potentially lengthy intra corporeal tract, and
the number and nature of viscera involved. An endoscopic alternative to
open exploration, using the spinal endoscope, has been described for use
in relatively uncomplicated cases {[}10{]}. Angioembolisation is another
invaluable tool, either alone or in tandem with surgery, especially in
haemodynamically unstable patients or for failed control of bleeding
after surgery. It is particularly helpful in dealing with injuries to
branches of the internal iliac artery, superior gluteal artery, and for
the treatment of pseudoaneurysms {[}6{]}.

Better survival is reported when the patient is transferred early to a
trauma unit or equivalent {[}4{]}, as there may be need for
multi-speciality approach; including vascular surgery {[}6{]} and
interventional radiology {[}6{]}. Transfer should never be delayed to
carry out investigations which will not affect the transfer decision. A
number of tools, such as the Injury Severity Score, have been formulated
to aid in decision-making (NICE guidelines NG40). Rapid transfer
protocols should be in place in order to facilitate timely transfer to
the trauma centre with a target time for leaving the unit in less than
30 minutes from arrival {[}11{]}. Despite this, inappropriate delays to
transfer are frequently reported in literature {[}12{]}. This is
especially critical in areas like Northern Ireland and Scotland, where
the population is dispersed, and journey times can be affected by
weather and road conditions.

In our case there were significant delays related to investigations and
transfer which is against the current guidelines. The patient was
haemodynamically stable but had a severe enough injury that put them at
risk of acute deterioration due to bleeding. For that reason, imaging
was performed prior to transport.

\textbf{CONCLUSIONS}

* Penetrating buttock trauma is a potentially life-threatening condition
and should be treated as such according to local major trauma protocols.

* Initial management should be according to ATLS guidelines. Do not
remove the foreign body without ensuring availability of resources to
deal with complex abdominal or pelvic haemorrhage.

* Early transfer to a trauma centre is a key management consideration.
Do not delay transfer for the sake of investigations which will not
impact immediate management or transfer.

* Surgical intervention is a cornerstone for the management of
impalement injuries.

* Northern Ireland specific guidance for major trauma transfer include
the Call and Send Protocol and also the Major Trauma Triage Tool to
reduce unnecessary delays in transfer.

\textbf{FIGURES}

\textbf{Figure 1}\selectlanguage{english}
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\includegraphics[width=0.42\columnwidth]{figures/image1/image1}

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\includegraphics[width=0.42\columnwidth]{figures/image2/image2}

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\textbf{Figure 1} - an x ray showing the Christmas tree base penetrating
through the abdomen

\textbf{Figure 2}\selectlanguage{english}
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\begin{center}
\includegraphics[width=0.42\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}\selectlanguage{english}
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\begin{center}
\includegraphics[width=0.42\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.42\columnwidth]{figures/image5/image5}

\end{center}
\end{figure}

\textbf{Figure 2} - 3D reconstructed CT scan Images demonstrating the
path of the foreign body

\textbf{Figure 3}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image6/image6}

\end{center}
\end{figure}

\textbf{Figure 3-} CT scan image demonstrating the relations of the
foreign body to intra-abdominal structures

\textbf{Table 1.} Frequency of Reported Major Injuries in 615 Patients

Adapted from: (Figure 1. Types of major injury in 615 patients with
penetrating trauma to the buttock.) Lunevicius R, Schulte K-M.
Analytical review of 664 cases of penetrating buttock trauma. World J
Emerg Surg {[}Internet{]}. 2011;6(2):33. Available from:
http://www.wjes.org/content/6/1/33\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
Small Bowel & 8.3\% & Inferior Gluteal Artery & 0.7\%\tabularnewline
\midrule
\endhead
Colon & 6.3\% & Testis & 0.5\%\tabularnewline
Superior Gluteal Artery & 5.4\% & Hypogastric Artery &
0.5\%\tabularnewline
Rectum & 4.9\% & Femoral Vein & 0.5\%\tabularnewline
Bony Pelvis & 4.4\% & Prostate & 0.3\%\tabularnewline
Urinary Bladder & 3.7\% & Liver & 0.3\%\tabularnewline
Iliac Artery & 2\% & Internal Pudendal Artery & 0.3\%\tabularnewline
Major Vessel & 1.6\% & Ureter & 0.2\%\tabularnewline
Urethra & 1.5\% & Ovaries & 0.2\%\tabularnewline
Corpora Cavernosa/ Scrotum & 1\% & Iliac Vessel & 0.2\%\tabularnewline
Retroperitoneal Hematoma & 1\% & Sacroiliac Joint capsule &
0.2\%\tabularnewline
Sciatic Nerve & 0.8\% & Sacrospinous Ligament & 0.2\%\tabularnewline
Femoral Artery & 0.8\% & Popliteal Artery & 0.2\%\tabularnewline
Iliac Vein & 0.8\% & Inferior Vena Cava & 0.2\%\tabularnewline
Lumbosacral Plexus & 0.7\% & Superior Mesenteric Artery &
0.2\%\tabularnewline
\bottomrule
\end{longtable}

\textbf{PATIENT'S PERSPECTIVE}

The patient kindly replied to us with her feedback in writing:

``Just want to add that I received excellent care and attention from
ambulance to hospital. All staff at hospital were extremely kind and
supportive and simply owe my life toto them.

The aftercare from my local community was incredible also.

The whole accident was a very worrying time for my family but
fortunately I've recovered fully.

Thank you so much''

\textbf{REFERENCES}

1. D Redmill, E Giddings. Call \& Send Protocol for Major Trauma.
Northern Ireland Major Trauma Network Standard Operating procedure.
January 2021.

2. Lunevicius R, Schulte K-M. Analytical review of 664 cases of
penetrating buttock trauma. World J Emerg Surg {[}Internet{]}.
2011;6(1):33. Available from: http://www.wjes.org/content/6/1/33

3. Oya S, Miyata K, Yuasa N, Takeuchi E, Goto Y, Miyake H, et al.
Impalement injury to the left buttock with massive bleeding: A case
report. Nagoya J Med Sci. 2014;76(1--2):147--52.

4. Ugoletti L, Zizzo M, Castro Ruiz C, Pavesi E, Biolchini F, Annessi V.
Gluteal, abdominal, and thoracic multiple impalement injuries: A case
report on management of a complex polytrauma. Medicine (Baltimore).
2019;98(22):e15824.

5. Weymann A, Matter P. {[}Penetrating injury{]}. Zeitschrift fur
Unfallchirurgie und Versicherungsmedizin Off Organ der Schweizerischen
Gesellschaft fur Unfallmedizin und Berufskrankheiten = Rev Traumatol
d'assicurologie organe Off la Soc suisse . 1993;Suppl 1:247--51.

6. Lunevicius R, Lewis D, Ward RG, Chang A, Samalavicius NE, Schulte KM.
Penetrating injury to the buttock: an update. Tech Coloproctol.
2014;18(11):981--92.

7. Ceyran H, Ak\selectlanguage{ngerman}çali Y, Özcan N, Tasdemir K. Isolated penetrating gluteal
injuries. Perspect Vasc Surg Endovasc Ther. 2009;21(4):253--6.

8. Hefny AF, Salim EA, Bashir MO, Abu-Zidan FM. An unusual stab wound to
the buttock. J Emergencies, Trauma Shock. 2013;6(4):298--300.

9. Heller MT, Oto A, Allen BC, Akin O, Alexander LF, Chong J, et al. ACR
Appropriateness Criteria® Penetrating Trauma--Lower Abdomen and Pelvis.
J Am Coll Radiol {[}Internet{]}. 2019;16(11):S392--8. Available from:
https://doi.org/10.1016/j.jacr.2019.05.023

10. Long ZS, Nie XY, Zhang YW. Treatment of penetrating trauma to the
buttock assisted by spinal endoscopy. J Int Med Res. 2019;48(1).

11. National Clinical Guideline Centre. Major Trauma: Service Delivery.
Natl Inst Heal Care Excell {[}Internet{]}. 2020;(February):1--8.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/26913313

12. Harrington DT, Connolly M, Biffl WL, Majercik SD, Cioffi WG, Britt
LD, et al. Transfer times to definitive care facilities are too long: A
consequence of an immature trauma system. Ann Surg. 2005;241(6):961--8.

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