What is the management for a penetration injury to the gluteal region?

Management of Penetrating Gluteal Injury

Immediate Assessment: Hemodynamic Status Determines Everything

The first and most critical step is determining hemodynamic stability (systolic BP ≥90 mmHg, heart rate 50-110 bpm), as this dictates whether the patient proceeds directly to surgery or undergoes imaging evaluation. 1

For Hemodynamically Unstable Patients

• Proceed immediately to the operating room for damage-control surgery without imaging if the patient presents with hypovolemic shock and signs of internal bleeding 2
• Portable chest and pelvic radiographs plus FAST (Focused Assessment with Sonography for Trauma) can be performed rapidly at bedside to identify hemopericardium, pneumothorax, and free intraperitoneal fluid, but should not delay surgical intervention 1
• Early and aggressive hemostatic resuscitation must be initiated immediately 1

For Hemodynamically Stable Patients

Perform FAST examination immediately as the initial diagnostic step, as it can rapidly detect life-threatening injuries at bedside with high sensitivity (0.92) and specificity (0.95-1.0) 3

If FAST is Positive or Gluteal Fascia Penetration is Confirmed/Suspected:

• Obtain contrast-enhanced CT scan of the abdomen/pelvis with multiplanar reformations, which is the standard imaging tool providing the most accurate injury diagnosis 2, 1
• CT angiography (CTA) should be included to evaluate for vascular injuries, as the arterial phase improves identification and characterization of bleeding from gluteal arteries 1
• Abort imaging immediately and proceed to the operating room if the patient becomes unstable during or while awaiting CT 3

Understanding the Injury Pattern

High-Risk Nature of Gluteal Injuries

• Penetrating gluteal injuries account for 2-3% of all penetrating trauma but carry a mortality rate up to 6% 2, 4
• These injuries may appear innocuous but are potentially life-threatening and should be managed in trauma centers equipped with hybrid operating rooms for emergency endovascular and open surgery 2
• Gunshot wounds are high-energy injuries causing both direct tissue damage and radial injury from kinetic energy transfer, placing nearby neurovascular structures at significant risk 5
• Stab wounds are typically low-energy injuries with tissue damage only along the wound tract 1

Associated Injuries Are Common

• Associated injuries occur in 57% of patients with penetrating gluteal injuries, including orthopedic (35%), abdominal (29%), rectal (25%), vascular (21%), genitourinary (14%), and sphincter injuries (9%) 6
• Significant bleeding from gluteal artery branches can occur even in hemodynamically stable patients, with damage potentially obscured initially 7
• Gunshot wounds are associated with higher rates of through-and-through injuries (43%), rectal injury (35%), and need for stoma placement (32%) compared to other mechanisms 6

Definitive Management Based on Imaging Findings

Vascular Injuries

• CT angiography-based endovascular interventions (coil embolization) are the preferred treatment for bleeding from gluteal arteries in stable patients 2, 8
• Angiography should be part of the management protocol for penetrating gluteal injuries, as significant vascular damage may be present even without apparent bleeding 7
• Pseudoaneurysms can develop days to years after initial injury; presence of pain, swelling, tenderness, bleeding, thrill, bruit, or pulsating mass should raise suspicion 8

Surgical Indications

• 76% of patients with penetrating gluteal injuries require surgical management 6
• Immediate surgery is indicated for: hemodynamic instability despite resuscitation, peritoneal signs, rectal injury, or significant intra-abdominal injuries identified on imaging 2, 4
• Consider diverting colostomy in patients with rectal injuries or those incontinent of stool to prevent repetitive wound contamination, particularly in patients with paraplegia 1
• Independent predictors for stoma placement include gunshot wounds (odds ratio = 10) and injury severity score >20 (odds ratio = 27) 6

Selective Non-Operative Management

• Most hemodynamically stable patients without confirmed intra-abdominal or significant vascular injuries will benefit from traditional wound care and selective non-operative management 2
• Close observation with continuous hemodynamic monitoring is essential, as any deterioration mandates immediate surgical exploration 3
• Meticulous observation and high level of suspicion ensure early treatment and can prevent mortality 4

Critical Pitfalls to Avoid

• Never assume a gluteal injury is superficial based on external appearance alone - significant vascular or visceral injuries can be obscured 7, 4
• Do not delay imaging in stable patients when gluteal fascia penetration is suspected - CT with angiography provides critical information for management decisions 2
• Every 10-minute delay from admission to laparotomy in unstable patients increases mortality - prioritize rapid decision-making 3
• Maintain high suspicion for delayed complications including pseudoaneurysm formation, which requires patient education and follow-up protocols 8
• Do not discharge patients without ensuring proper follow-up, as complications can develop days after initial injury 8