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.