Chapter 166. Penetrating Trauma to the Flank and Buttocks

Challenges in evaluating penetrating trauma to the flank and buttocks are recognizing peritoneal and retroperitoneal injuries and determining which patients need immediate surgery and which can be managed more conservatively. Mechanism and time of injury, weapon characteristics, and determining the bullet path or stab wound depth may assist in diagnosis.

Clinical Features

Presentation may vary significantly from hemodynamic shock and peritonitis to stable vital signs with an innocuous-appearing wound. Gross blood on rectal examination suggests bowel injury. Blood at the urethral meatus or hematuria suggests genitourinary injury.

Diagnosis and Differential

CT with oral and IV contrast is the diagnostic modality of choice for hemodynamically stable patients. Include rectal contrast if suspicious for rectal or sigmoid injuries. Contrast-enhanced CT can often determine stab wound depth.

Emergency Department Care and Disposition

1. Follow standard trauma resuscitation protocols. Patients who require emergent exploratory laparotomy include those who are hemodynamically unstable, display peritonitis, and have sustained gunshot wounds to the flank.

2. If the patient displays signs of peritonitis, administer broad-spectrum antibiotics (eg, pipercillin/tazobactam 3.375 grams IV).

3. Most patients with stab wounds can be managed conservatively. High-risk patients (stab wounds with penetration beyond deep fascia) require surgical consultation and admission. Low-risk patients (stab wounds superficial to deep fascia) may be discharged if serial examinations are unremarkable throughout an observation period.

Clinical Features

Gunshot wounds are much more likely to require laparotomy than stab wounds. Gunshot wounds above the level of the greater trochanter and gross hematuria predict the need for surgery. Rectal examination to assess for gross blood, assessment of lower extremity pulses, and neurologic examination to assess for sciatic and femoral nerve injury should be performed.

Diagnosis and Differential

Hemodynamically stable patients should undergo CT with oral, IV, and rectal contrast (to avoid missed colon and rectal injuries). Cystourethrogram should be performed with findings of hematuria or wounds near the genitourinary tract. CT angiography or traditional angiography and venography may be indicated if pelvic hematoma is found on CT.

Emergency Department Care and Disposition

1. Follow standard trauma resuscitation protocols. Patients who are hemodynamically unstable, display peritonitis, or have an intrapelvic or transabdominal bullet path require exploratory laparotomy.

2. If the patient displays signs of peritonitis, administer broad-spectrum antibiotics (eg, pipercillin/tazobactam 3.375 grams IV).

3. Interventional angiography may be required to treat extensive intrapelvic bleeding.

4. Wound exploration is of limited value. Only very superficial stab wounds may be managed and discharged from the ED. Most of these patients require admission and observation due to the risk of occult injuries.