WHO WARRANTS EXPLORATION FOR A GLUTEAL GUNSHOT WOUND?

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Abstract

Objective: It is difficult to determine which stable patients with gluteal gunshot wounds warrant exploration since only 22–32% have major injuries. The ability of pre-operative studies to identify major injuries was evaluated to determine which studies accurately identify the presence or absence of injury.

Methods: The hospital records of all patients with gunshot injuries to the gluteal region from 1 Jan 90 to 31 May 93 were retrospectively reviewed. Patients with concomitant nongluteal wounds between the nipple line and knees were excluded.

Results: 52 patients were identified, 19 of whom underwent surgery. 15 had therapeutic laparotomies and 3 had nontherapeutic laparotomies. 33 patients were managed nonoperatively, but 1 required laparotomy for a retroperitoneal colon injury on his second hospital day. The mean age and presenting vital signs for the 2 groups were similar. The only mortality occurred in a patient with a concomitant gunshot wound to the head, and was excluded from further analysis. The presence or absence of gross blood in the urine or on rectal exam was 100% accurate in identifying GU and rectosigmoid injuries respectively. Rigid proctosigmoidoscopy was falsely negative in I of 4 cases, but 100% accurate when positive. The abdominal exam and the location of the wound above or below the inter-trochanteric line was not predictive of the presence or absence of major injury. X-rays which demonstrated a transpelvic trajectory or a bullet within the pelvis correlated with major injury in 14 of 16 patients. No patients whose pelvic x-rays lacked bony injury or trajectory across the ring of the pelvis had major injuries.

Conclusions: 1) Gross blood in the urine, on digital rectal exam, or on proctosigmoidoscopy is 100% predictive' of an injury warranting exploration. There were no false negative urine or digital rectal exams, but proctosigmoidoscopy had a false negative rate of 25%. 2) Trajectory across the bony ring of the pelvis is of utmost importance, correctly identifying 14 of 16 patients requiring exploration, with 2 false positives and no false negatives. Gluteal wound location is not predictive of injuries requiring exploration. 3) The combination of physical and rectal exam, pelvic x-ray, and urinalysis identified all major injuries warranting exploration, with no false negatives and a false positive rate of 5.9%.

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