Elsevier

Journal of Surgical Education

Volume 65, Issue 1, January–February 2008, Pages 61-66
Journal of Surgical Education

Original report
The Significance of Penetrating Gluteal Injuries: An Analysis of the Operation Iraqi Freedom Experience

Presented at the 2007 Gary P. Wratten Surgical Conference, Honolulu, Hawaii.
https://doi.org/10.1016/j.jsurg.2007.08.004Get rights and content

Background

Although penetrating gluteal injuries rarely are life-threatening, the risk for concomitant injury to regional anatomic structures warrants additional evaluation. We analyzed factors affecting the management and outcomes of these injuries.

Methods

Retrospective analysis of prospectively collected data from the 31st Combat Support Hospital during Operation Iraqi Freedom over a 16 month period.

Results

From 3442 patients, 115 patients (3.3%) suffered penetrating gluteal injuries. They were predominately male (98%) with a mean injury severity score of 13. Mortality was 6% (n = 7). Primary mechanisms of injury were improvised explosive devices (41%) and gunshot wounds (59%). Associated injuries were present in 57% of patients [orthopedic (35%), abdominal (29%), rectal (25%), vascular (21%), genitourinary (14%), pulmonary (11%), sphincter (9%)]. Overall, 76% required surgical management, with 14% developing postoperative complications. In total, 27 patients (24%) required stoma placement. Gunshot wounds were associated with through and through injuries (43% vs 6%, p < 0.01), rectal injury (35% vs 11%, p < 0.05), and stoma placement (32% vs 11%, p < 0.05). Blast injuries were associated with a higher mean transfusion requirement (11 vs 6 units, p < 0.05), increased length of stay (14 vs 9 days, p < 0.05), and traumatic brain injury (24% vs 6%, p < 0.05). Independent predictors of a need for stoma placement were gunshot wounds (odds ratio = 10, p < 0.05) and injury severity score greater than 20 (odds ratio = 27, p < 0.01).

Conclusions

Penetrating gluteal injuries are associated with significant damage to local structures. Gunshot wounds carry a higher risk of injury to the rectum and stoma placement, whereas blast injuries are associated with less local injury and more multisystem trauma.

Introduction

Penetrating gluteal injuries are an uncommon source of trauma in both civilian trauma centers and battlefield environments, accounting for approximately 2% to 3% of all traumatic injuries.1, 2 They have not been well studied in the surgical literature or documented in past wars, with most series consisting of retrospective reviews and small case series.3, 4 With a wide variety of mechanisms ranging from gunshot and stab wounds to impalement or blast injuries, these injuries present a diagnostic difficulty, as they may often falsely appear benign on initial evaluation or have an ambiguous depth or trajectory.4, 5, 6 Yet, adjacent visceral and vascular structures located in close proximity to one another in the fixed pelvis and abdominal cavity are at significant risk for concomitant injury from either the inciting object or the pelvic injury causing secondary damage. Failure of the physician to appreciate their potential for accompanying injury can therefore result in serious morbidity and mortality. The purpose of this study is to identify and analyze the clinical outcomes and factors affecting the management from a cohort of patients suffering penetrating gluteal injury in the modern combat environment.

Section snippets

Methods

After approval by the Joint Theatre Trauma Registry institutional review board, we queried the prospectively collected data from all US, coalition, and local national patients injured and treated at a combat support hospital during Operation Iraqi Freedom over a 16 month period and identified all patients sustaining penetrating gluteal injuries. Patients with cutaneous or superficial tangential abrasion injuries were excluded. We collected data pertaining to patient demographics, injury

Results

From the 3442 patients treated, 115 (3.3%) sustained penetrating gluteal injuries. See Table 1 for patient demographics. The cohort included 59 (51%) US and coalition forces and 56 (49%) Iraqi national and enemy troops. They were predominantly young men (n = 113, 98%), 28 ± 10.9 years (range, 6-70). They presented with moderate-to-severe physical insult as evidenced by an injury severity score (ISS) of 13 ± 15 (range, 1-75), and 15% (n = 17) having an ISS greater than 20 on arrival. They had a

Discussion

Our study sought to identify factors affecting the management and outcome of patients sustaining penetrating gluteal trauma in a population injured during our most recent wartime conflict. Our data revealed a high rate of associated injuries, including injuries to major vascular and visceral structures in the pelvis and abdomen, in patients presenting with penetrating gluteal injury. By examining demographics, methods of evaluation and treatment, as well as incidence and types of associated

Conclusion

In sum, associated injuries sustained with penetrating gluteal trauma are a consequence of the proximity and fixed nature of vital organs in the pelvis, with those in the trajectory path at greatest risk. Our study identified a high rate of concomitant injuries with associated morbidity and mortality in patients presenting with wounds to the gluteal region. In addition to significant damage to local structures, gunshot wounds carry a higher risk of injury to the rectum while blast injuries are

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