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Open Access

Penetrating gluteal injuries in North West London: a retrospective cohort study and initial management guideline

Gerard Hywel Owen McKnight, Seema Yalamanchili, Natalia Sanchez-Thompson, Nadia Guidozzi, Natasha Dunhill-Turner, Alex Holborow, Nicola Batrick, Shehan Hettiaratchy, Mansoor Khan, Elika Kashef, Chris Aylwin, Dan Frith
DOI: 10.1136/tsaco-2021-000727 Published 23 July 2021
Gerard Hywel Owen McKnight
1Institute of Naval Medicine, Royal Navy, Gosport, UK
2Major Trauma, Imperial College Healthcare NHS Trust, London, UK
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Seema Yalamanchili
2Major Trauma, Imperial College Healthcare NHS Trust, London, UK
3Division of Surgery and Cancer, Imperial College London Faculty of Medicine, London, UK
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Natalia Sanchez-Thompson
2Major Trauma, Imperial College Healthcare NHS Trust, London, UK
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Nadia Guidozzi
2Major Trauma, Imperial College Healthcare NHS Trust, London, UK
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Natasha Dunhill-Turner
2Major Trauma, Imperial College Healthcare NHS Trust, London, UK
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Alex Holborow
4Department of Radiology, Swansea Bay University Health Board, Swansea, UK
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Nicola Batrick
2Major Trauma, Imperial College Healthcare NHS Trust, London, UK
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Shehan Hettiaratchy
2Major Trauma, Imperial College Healthcare NHS Trust, London, UK
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Mansoor Khan
2Major Trauma, Imperial College Healthcare NHS Trust, London, UK
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Elika Kashef
2Major Trauma, Imperial College Healthcare NHS Trust, London, UK
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Chris Aylwin
2Major Trauma, Imperial College Healthcare NHS Trust, London, UK
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Dan Frith
2Major Trauma, Imperial College Healthcare NHS Trust, London, UK
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  • Figure 1
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    Figure 1

    Temporal distribution of penetrating gluteal injuries.

  • Figure 2
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    Figure 2

    Temporal distribution of penetrating gluteal injuries in under 18s (U18).

  • Figure 3
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    Figure 3

    Anatomic distribution of penetrating gluteal injuries (PGI).

  • Figure 4
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    Figure 4

    St Mary’s pathway for penetrating gluteal injuries. Pt; patient, D/W; discuss with, ED; emergency department, CT; computed tomography, PV; portal venous,EUA; examination under anesthetic, GA; general anaesthetic, Gen Surg; general surgery, IR; interventional radiology, Redthread; local violence reduction charity, RS; rigid sigmoidoscopy, TTL; trauma team leader; Vasc; vascular surgery.

Tables

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  • Table 1

    Chronological distribution of PGI and percentage of total penetrating injuries

    YearTotal penetrating traumaPGIPercentage of PGI
    2017640477
    2018634487
    2019559305
    2017–201918331257
    • PGI, penetrating gluteal injury.

  • Table 2

    Comparison with 3 years preceding this study

    2014–20162017–2019% increase
    Total penetrating1272183143
    Total PGI6712587
    % PGI57
    • PGI, penetrating gluteal injury.

  • Table 3

    Absolute risk (AR) of significant structure injury by quadrant of injury

    QuadrantAR (%)
    Upper outer20
    Upper inner14
    Lower outer17
    Lower inner56
    Overall per wound24
    Overall per patient27
  • Table 4

    Clinical examinations performed in the emergency department

    Examinationn (%)
    Digital rectal examination13 (10)
    Rigid sigmoidoscopy11 (9)
    Nil98 (78)
    Refused3 (2)
  • Table 5

    Choice of imaging for penetrating gluteal injuries

    Type of CT scannSensitivity (%)Specificity (%)
    Single-phase combi scan575095
    Dual-phase/triple-phase scan565090
    No CT scan14––
  • Table 6

    Vascular injuries

    Quadrant of injuryMajor bleedingVessel injuredManagement
    Not recordedYesBranch of the right inferior gluteal artery.Embolization.
    LIYesArterial bleeding within the left bulbocavernosus muscle, arterial bleeding within the left obturator externus muscle, extending into the left prostate peripheral/central zone.
    Arterial/venous bleeding into the rectal lumen.
    Conservative.
    LIYesRight internal pudendal artery.Conservative.
    Not recordedNoIntramuscular branch (gluteal).Conservative.
    UONoIntramuscular branch (gluteal).Conservative.
    UONoBranch of the right superior gluteal artery.Embolization.
    LO+LINoActive venous and arterial bleeding from the small branches of the left deep artery and vein of the thigh.Embolization.
    LINoBleeding from profunda femoris+arteriovenous fistula.Embolization+endovascular repair of arteriovenous fistula.
    LONoIntramuscular branch (gluteal).Conservative.
    UI+LONoSmall branch of profunda femoris.Conservative.
    LONoBranch of the left superior gluteal artery.Conservative.
    UO+LINoIntramuscular branch (gluteal).Conservative.
    UONoPerforating gluteal artery.Conservative.
    • LI, lower inner; LO, lower outer; UI, upper inner; UO, upper outer.

  • Table 7

    Rectal injuries

    QuadrantInjuryManagement
    LIExtraperitoneal, anterior+posterior rectal injury, >25% circumference.Diagnostic laparoscopy+defunctioning ileostomy. Reversed 5 months later.
    LIExtraperitoneal injury at 5 o’clock position, <25% circumference, some division of sphincter.Rectum sutured+drain inserted. Diagnostic laparoscopy normal.
    LISuspected extraperitoneal rectal injury <25% circumference.
    Intramural blood, blood, and feces obscuring view on RS, large mesorectal hematoma on diagnostic laparoscopy.
    Laparoscopic loop colostomy, reversed 3 months later.
    LIAnal sphincter injury, <25% circumference.Washout+packing.
    UIExtraperitoneal injury, 25% of circumference, 6–9 o’clock 8 cm from anal verge.Laparoscopic loop colostomy. Reversed 6 months later.
    LIExtraperitoneal, laceration 2 cm from anal verge extending radially to around 4 cm, <25% circumference. External anal sphincter fibers seen.EUA+packing of rectum+RS+second look EUA.
    • EUA, examination under anesthetic; LI, lower inner; RS, rigid sigmoidoscopy; UI, upper inner.

Supplementary Materials

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  • Supplementary data

    [tsaco-2021-000727supp001.rtf]

Additional Files

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  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    • Data supplement 1
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Penetrating gluteal injuries in North West London: a retrospective cohort study and initial management guideline
Gerard Hywel Owen McKnight, Seema Yalamanchili, Natalia Sanchez-Thompson, Nadia Guidozzi, Natasha Dunhill-Turner, Alex Holborow, Nicola Batrick, Shehan Hettiaratchy, Mansoor Khan, Elika Kashef, Chris Aylwin, Dan Frith
Trauma Surg Acute Care Open Jul 2021, 6 (1) e000727; DOI: 10.1136/tsaco-2021-000727

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Penetrating gluteal injuries in North West London: a retrospective cohort study and initial management guideline
Gerard Hywel Owen McKnight, Seema Yalamanchili, Natalia Sanchez-Thompson, Nadia Guidozzi, Natasha Dunhill-Turner, Alex Holborow, Nicola Batrick, Shehan Hettiaratchy, Mansoor Khan, Elika Kashef, Chris Aylwin, Dan Frith
Trauma Surg Acute Care Open Jul 2021, 6 (1) e000727; DOI: 10.1136/tsaco-2021-000727
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Penetrating gluteal injuries in North West London: a retrospective cohort study and initial management guideline
Gerard Hywel Owen McKnight, Seema Yalamanchili, Natalia Sanchez-Thompson, Nadia Guidozzi, Natasha Dunhill-Turner, Alex Holborow, Nicola Batrick, Shehan Hettiaratchy, Mansoor Khan, Elika Kashef, Chris Aylwin, Dan Frith
Trauma Surgery & Acute Care Open Jul 2021, 6 (1) e000727; DOI: 10.1136/tsaco-2021-000727
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