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.