Anatomical study of the modified direct posterior gluteal splitting approach for acetabular fractures

BACKGROUND

In this study, we investigated the area that can be addressed with an approach in which the skin incision is made directly above the dorsal column with Thiel cadaveric specimens.

METHODS

Six Thiel cadaveric specimens were prepared. A skin incision was made directly above the dorsal column. The accessible proximal end from the proximal part of the greater sciatic notch to the gluteal ridge and the accessible distal end of the ischium were marked with a flat chisel. A molded 8-hole reconstruction plate was placed from the base of the ischium toward the gluteal ridge and fixed with 3 screws proximally and 2 screws distally. The length of the skin incision and the distance from each reference point on the bone to the reachable markings were assessed after the muscles were removed.

RESULTS

Mean skin incision length was 9.3 ± 0.7 (range, 8.0-10.0) cm. In 3 of 6 cases, proximal screws were inserted through different spaces between muscle fibers. In all cases, we were able to reach at least the greater sciatic notch, the gluteal ridge at the level of superior border of the acetabulum, and the base of the ischial tuberosity. In all cases, an 8-hole plate could be placed from the gluteal ridge to the base of the ischium. There were no superior gluteal artery or sciatic nerve injuries in any of the cases.

CONCLUSION

We anatomically investigated the area that can be addressed with an approach in which the skin incision was made directly above the dorsal column. In all cases, we were able to access the areas needed to reduce the fracture and place the plates necessary to stabilize the fracture through a 9.3 ± 0.7 cm skin incision. This approach can be a useful minimally invasive posterior approach for acetabular fractures.

Penetrating buttock trauma is morbid but rarely fatal - A South African experience

BACKGROUND

Penetrating injuries to the buttock are relatively rare but are associated with significant morbidity. This study aimed to review our experience in managing penetrating trauma to the buttocks to contextualize the injury, document the most common associated injuries, and generate an algorithm to assist with the management of these patients.

METHODS

A retrospective study was conducted at a major trauma center in South Africa over 8 years (January 2012 to January 2020). All patients presenting with a penetrating buttock injury were included.

RESULTS

Our study included 40 patients. Gunshot wounds accounted for 93% (37/40), stab wounds accounted for 5% (2/40), and 1 case was gored by a cow. The majority (98%) underwent further investigation in the form of imaging or endoscopy. Forty percent (16/40) required surgical intervention. Of these 16 cases, 14 required a laparotomy, and 2 required gluteal exploration. Fifty-six percent (9/16) required a stoma. Five percent (2/40) experienced one or more complications, both of whom had stomas. The median length of stay for all patients was 3 days, whereas for the patients with stomas was 7 days. There were no ICU admissions or mortality in this study. Only 3 of the 9 stomas were reversed, and the median time to reversal was 16 months.

CONCLUSION

Penetrating trauma to the buttock may result in injuries to surrounding vital structures, which must be actively excluded. Rectal injury was the most common injury, and most required a defunctioning colostomy as part of the management resulting in significant morbidity.

Angiosomal Vascular Occlusions, Deep-Tissue Pressure Injuries, and Competing Theories: A Case Report

ABSTRACT

Compression of the soft tissue between a support surface and a bony prominence has long been the accepted primary mechanism of pressure injury (PrI) formation, with the belief that said compression leads to capillary occlusion, ischemia, and tissue necrosis. This explanation presupposes an "outside-in" pathophysiologic process of tissue damage originating at the local capillary level. Despite advances in prevention protocols, there remains a stubbornly consistent incidence of severe PrIs including deep-tissue injuries, the latter usually evolving into stage 4 PrIs with exposed bone or tendon. This article presents just such a perioperative case with the aim of providing further evidence that these more severe PrIs may result from ischemic insults of a named vessel within specific vascular territories (labeled as angiosomes). Pressure is indeed a factor in the formation of severe PrIs, but these authors postulate that the occlusion occurred at the level of a named artery proximal to the lesion. This vascular event was likely attributable to low mean arterial pressure. The authors suggest that the terminology proposed three decades ago to call both deep-tissue injuries and stage 4 PrIs "vascular occlusion pressure injuries" should be the topic of further research and expert consensus.

[Gluteal compartment syndrome after immobilization following opioid abuse]

This article reports the case of a 42-year-old male patient, who sustained a gluteal compartment syndrome after drug-induced immobilization with subsequent rhabdomyolysis and sciatic nerve palsy. Unlike compartment syndrome of the forearm or lower leg, this is a rare condition. After immediate surgical decompression and installation of negative pressure wound treatment, hemofiltration in acute renal failure could be averted using forced diuresis. The sensorimotor function of the lower extremity improved already after the first treatment and secondary wound closure was possible after 1 week. The patient was discharged 11 days after admission with complete recovery of sensorimotor and renal functions.

Gluteal Burns from a Car Seat Heater in a Neurologically Intact Patient: A Case Report

BACKGROUND

Car seat heaters are an increasingly common amenity in vehicles in the United States, but they have been shown to place neurologically impaired patients at risk for significant burns.

CASE REPORT

We discuss the case of a neurologically intact and otherwise healthy 49-year-old man who presented to the Emergency Department with second-degree gluteal and posterior upper thigh burns after using a car seat warmer for 8 consecutive hours. At no point during the course of his drive did he experience discomfort beyond feeling slightly warm. The patient was treated with supportive therapy and standard wound care, and he had a full recovery after 10 days. We review the pathophysiology of burns and discuss how seat heaters can place even neurologically intact patients at risk for significant burn injuries. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our case is the first published report of a neurologically intact patient sustaining significant burns from the use of a car seat heater. This case illustrates that burn injuries can develop after prolonged exposure even at low temperatures. Emergency physicians should perform a careful skin examination on all patients presenting with gluteal discomfort in whom a history of car seat warmer use is obtained.

Environmental buttocks burns in children and adolescents with spina bifida in the Southwestern United States

PURPOSE

Spina Bifida (SB) is a congenital defect of the neural tube resulting in motor and sensory defects and frequently includes insensate skin on the buttocks and feet which are innervated by sacral nerves. For those living in hot climates such as the Southwestern United States, environmental surfaces reach temperatures throughout June-September that cause thermal burns. The objective of this novel case series was to evaluate the circumstances associated with environmental buttocks burns in children with SB who attend the District Medical Group Children's Rehabilitative Services Myelomeningocele (MM) Planning clinic in Phoenix, AZ.

METHODS

Nine children and adolescents with SB and a history of environmental buttocks burns were identified through participation in the National Spina Bifida Patient Registry at District Medical Group Children's Rehabilitative Services Myelomeningocele Planning Clinic. Parents and patients were interviewed about the burn circumstances, charts were reviewed, and information was gathered from the NSBPR including level of function and ambulation status.

RESULTS

Most of the patients were found to be of emerging independent ages (average age 10 years) and were not with their parents at the time of the burn. All had myelomeningocele (MM), almost all were community ambulators, and all had mid lumbar, low lumbar or sacral level function. There were no non-ambulators. In addition, the majority were wearing incontinence products.

CONCLUSIONS

Children and adolescents with MM who are community ambulators, of an emerging independent age, and live in hot climates are at risk of environmental buttocks burns. Enhanced education in environmental thermal burn prevention is important. This education should be particularly focused on the child as they spend more time in settings without their parents. In addition, this enhanced education should extend to those who support the child or teen such as teachers, coaches, family and friends.

A Computer Modeling Study to Assess the Durability of Prophylactic Dressings Subjected to Moisture in Biomechanical Pressure Injury Prevention

The sacral area is the most common site for pressure injuries (PIs) associated with prolonged supine bedrest. In previous studies, an anisotropic multilayer prophylactic dressing was found to reduce the incidence of PIs and redistribute pressure. The purpose of the current study was to further investigate relationships between design features and biomechanical efficacy of sacral prophylactic dressings. Using computer modeling, the anisotropic multilayer dressing and a hypothetical dressing with different mechanical properties were tested under dry and 3 levels of moist/wet conditions. Sixteen (16) finite element model variants representing the buttocks were developed. The model variants utilized slices of the weight-bearing buttocks of a 28-year-old healthy woman for segmentation of the pelvic bones and soft tissues. Effective stresses and maximal shear stresses in a volume of interest of soft tissues surrounding the sacrum were calculated from the simulations, and a protective endurance (PE) index was further calculated. Resistance to deformations along the direction of the spine when wet was determined by rating simulation outcomes (volumetric exposures to effective stress) for the different dressing conditions. Based on this analysis, the anisotropic multilayer prophylactic dressing exhibited superior PE (80%), which was approximately 4 times that of the hypothetical dressing (22%). This study provides additional important insights regarding the optimal design of prophylactic dressings, especially when exposed to moisture. A next step in research would be to optimize the extent of the anisotropy, particularly the property ratio of stiffnesses (elastic moduli).

Deep gluteal grounding pad burn after abdominal aortic aneurysm repair

Although skin burns at the site of grounding pad are a known risk of surgery, their exact incidence is unknown. We first report the case of a patient who presented a deep gluteal burn at the site of the grounding pad after an abdominal aortic aneurism repair, the etiology and the challenging treatment required to overcome this complication.

SCALE wounds: unavoidable pressure injury

Skin Changes at Life's End (SCALE) wounds include wounds of many underlying etiologies that accompany the dying process. These wounds occur due to unmodifiable intrinsic and extrinsic factors unique to each individual. This article describes the case of a dying patient who sustained a skin tear that deteriorated into a SCALE wound that meets the criteria for a National Pressure Ulcer Advisory Panel unavoidable pressure injury.

Management of adult patients with buttock and perineal burns: The Ross Tilley Burn Centre experience

BACKGROUND

Perineal and buttock burns are challenging wounds to heal for several reasons because of the contamination risk and shear stress that is always present. Because of the nature of the wound bed, pathogens can have ready access to create systemic infections and complications. Prolonged healing times also delay the recovery for patients and add to their discomfort and psychological stress from the injury. The ideal treatment approach is not well defined, and the aims of this study were to conduct a literature review of current treatment suggestions and to look at our own patient population to determine how our center treated these challenging patients.

METHODS

This is a retrospective review of all patients treated between 2010 and 2013 at our center. Patients that received care for burns to the perineum or buttocks were evaluated. Mortalities within 24 hours of admission and transfers before completion of their care were excluded. All patients older than 18 years were included in the study. The primary outcome studied was a cause for graft revision. Secondary outcomes included benefits and risks of fecal management devices, risk of infection, and mortality.

RESULTS

The literature review did not show consensus on how to best manage this patient population. Our results however demonstrated that patients treated with the fecal management device Flexi-seal (Convatec, Skillman, NJ) were at increased risk of developing an infection involving an enteric pathogen and requiring revision procedures. The patient population that was treated with this device was also older and had larger burns. The patients within this group that were treated initially with allograft required fewer revisions when compared with patients that received autograft in this group (23% vs. 34%, p > 0.05).

CONCLUSION

After our data and the literature had been reviewed, the lack of evidence-based treatment protocols led us to create recommendations for burn surgeons with regard to the initial management of this complicated area. Certain key features include avoiding autograft at the primary excision if they have an increased revised Baux score and minimizing the amount of liquid stool contaminating the wound bed to increase success.

LEVEL OF EVIDENCE

Epidemiologic study, level IV. Therapeutic study, level V.

Gluteal compartment syndrome and superior gluteal artery injury as a result of simple hip dislocation: a case report

Gluteal compartment syndrome as a result of hematoma from a ruptured superior gluteal artery is exceedingly rare; to date, one similar case in a pelvic fracture model has been reported. We report a case of acute gluteal compartment syndrome from a ruptured superior gluteal artery resulting from a simple posterior hip dislocation in an otherwise healthy young male. Timely surgical exploration, evacuation of the hematoma, and achievement of hemostasis allowed for an excellent outcome at follow-up. We review the gluteal compartments as well as treatment protocols for this injury.

A transverse rectus abdominis myocutaneous (TRAM) flap for reconstruction of a large deformity in the buttock: A new indication for a TRAM flap

A rectus abdominis myocutaneous flap has been used to repair the abdominal wall, chest wall, sternum, breast, and groin. We describe a patient in whom a large deformity in the buttock caused by a road crash was repaired with a transverse rectus abdominis myocutaneous (TRAM) flap. Distally-based TRAM flaps provide a good and reliable way of reconstructing the buttock. Its advantages are a long arc of rotation and well-vascularised bulky tissue that serve as a partition and promote quick healing of the defect. However, the flap is not the first choice for traumatic and infected wounds where fatty tissue is not desired.

[Results of using an epineural suture of the sciatic nerve]

The paper presents results of the examinations and surgical treatment of 28 patients with lesions of the sciatic nerve. Sciatic nerve injuries and functional outcomes are described. Recommendations on medical strategy and treatment are given depending on the injury mechanisms, location, time of surgery, surgical techniques.

Scar sarcoidosis with a 50-year interval between an accident and onset of lesions

Cutaneous sarcoidosis has been reported to develop in scars. We report an unusual case of sarcoidal granuloma formation in scars that had been present for 50 years.

Neurologic injuries after total hip arthroplasty

Neurologic injuries are a potentially devastating complication of total hip arthroplasty (THA). Review of the literature reveals that these injuries are uncommon. The reported incidence ranges from 0.08% to 7.6%. The incidence in primary THA ranges from 0.09% to 3.7% and in revision THA from 0% to 7.6%. Reported etiologies include intraoperative direct nerve injury, significant leg lengthening, improper retractor placement, cement extravasation, cement-related thermal damage, patient positioning, manipulation, and postoperative hematoma. Risk factors include developmental dysplasia of the hip, the female sex, posttraumatic arthritis, and revision surgery. However, no single risk factor has been consistently reported to be significant, and many patients with no known risk factors incur neurologic injuries.

The significance of penetrating gluteal injuries: an analysis of the Operation Iraqi Freedom experience

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.

Third-degree burn by tincture of iodine--a case study

It is important that occupational health nurses understand farmers' work and the risks of injury during farm tasks.

Pseudoaneurysm of the superior gluteal artery following polytrauma

Gluteal artery aneurysms are rare and often secondary to pelvic fractures, blunt or penetrating trauma. We describe a case of a superior gluteal artery pseudoaneurysm that presented as back pain with numbness and weakness of the lower extremities. Diagnosis was confirmed by color Doppler sonography and angiography. A proximal and distal control was obtained over the aneurysm neck via coil embolization with excellent hemostasis within the pseudoaneurysm and maintenance of perfusion to the left pelvis.

Traumatic inferior gluteal artery pseudoaneurysm and arteriovenous fistula managed with emergency transcatheter embolization

We present a case of blunt trauma to the buttock resulting in an inferior gluteal artery pseudoaneurysm and arteriovenous fistula. The characteristic diagnostic features on CT angiography and digital subtraction angiography (DSA), along with the emergency percutaneous management of this traumatic vascular injury, are described. A review of the literature demonstrates inferior gluteal artery pseudoaneurysm is a rare condition, while successful treatment with glue embolization is previously unreported.

Minimally invasive anterolateral approach to the hip: risk to the superior gluteal nerve

BACKGROUND

Minimally invasive approaches to the hip show promise of less muscle trauma compared to conventional approaches. What is the risk of damage to the superior gluteal nerve? We studied the course of the superior gluteal nerve.

METHOD

20 legs of 11 formalin-fixed Caucasian cadavers were dissected and the course and the distances of the superior gluteal nerve branches from the tip of the greater trochanter were documented.

RESULTS

The branch of the gluteal superior nerve leading to the gluteal minimus muscle was 33 (20-50) mm from the tip of the greater trochanter, within a deeper layer. The nearest point of the superior gluteal nerve branches from the tip of the greater trochanter in the posterior region was 19 (10-30) mm, in the middle region 20 (20-30) mm and in the anterior region 20 (10-35) mm. In half of the cases, a distal intermuscular branch between gluteal medius and tensor fasciae latae muscle could be found, mean 27 (10-40) mm caudal and 38 (25-60) mm ventral to the tip of the greater trochanter. This distal branch is considered to create a loop with upper branches of the superior gluteal nerve within the tensor fasciae muscle.

INTERPRETATION

The safe zone for the superior gluteal nerve was smaller than previously reported. Use of a minimal direct lateral approach puts the inferior branches within the gluteal medius at risk; however, a minimal anterolateral approach to the hip may compromise branches of the superior gluteal nerve to the tensor fasciae latae muscle.

The flaming gypsy skirt injury

On review of admissions over a 12-month period, we noted a significant number of women presenting with gypsy skirt burns. We describe all six cases to highlight the unique distribution of the wounds and the circumstances in which the accidents occurred. Four skirts were ignited by open fire heaters: two skirts ignited whilst the women were standing nearby, distracted with a telephone conversation; one brushed over the flame as she was walking past the heater; other whilst dancing in the lounge. One skirt was ignited by decorative candles placed on the floor during a social gathering. Another skirt was set alight by cigarette ember, whilst smoking in the toilet. Percentage surface area burned, estimated according to the rule of nines, showed that gypsy skirt burns were significant ranging from 7 to 14% total body surface area (TBSA) and averaging 9% TBSA. Two patients required allogenic split-skin grafts. Common sense care with proximity to naked flame is all that is needed to prevent this injury.

MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

Greater trochanteric pain syndrome is commonly due to gluteus minimus or medius injury rather than trochanteric bursitis. Gluteal tendinopathy most frequently occurs in late-middle aged females. In this pictorial review the pertinent MRI and US anatomy of the gluteal tendon insertions on the greater trochanter and the adjacent bursae are reviewed. The direct (peritendinitis, tendinosis, partial and complete tear) and indirect (bursal fluid, bony changes and fatty atrophy) MRI signs of gluteal tendon injury are illustrated. The key sonographic findings of gluteal tendinopathy are also discussed.

Gluteal compartment syndrome

Gluteal compartment syndrome is uncommon and is often diagnosed late, resulting in muscle necrosis and sciatic nerve palsy. The mainstay of treatment is prompt diagnosis and early surgery. A high index of suspicion is essential, especially in the setting of major bleeding and excessive pain. Embolization and hyperbaric oxygen may be considered as adjuncts to surgery.

Soft tissue injury related to choice of entry point in antegrade femoral nailing: piriform fossa or greater trochanter tip

Intramedullary nailing through the piriform fossa results in some cases in loss of abduction strength and persistent pain. Nail insertion at the tip of the greater trochanter may be favourable. The aim of this study was to assess (possible) iatrogenic injury to the abductor and external rotator musculature, branches of the superior gluteal nerve and branches of the MFCA in relation to the two different entry points. In 10 fresh human cadaver femurs, five unreamed femoral nails (UFN) were inserted through the piriform fossa and five AO prototype nails (AFN) through the trochanteric tip. The iatrogenic injury at each nailing procedure was assessed. Various muscles and tendons, branches of the MFCA along with the hip joint capsule were injured or largely at risk during nail insertion through the piriform fossa. Most of these structures were not exposed during insertion through the trochanteric tip. The reported clinical morbidity after nailing through the piriform fossa may find its origin in direct soft tissue injury and may be reduced by choosing a lateral nail entry point.

Effect of dry needling of gluteal muscles on straight leg raise: a randomised, placebo controlled, double blind trial

OBJECTIVES

To use a randomised, double blind, placebo controlled trial to establish the effect on straight leg raise, hip internal rotation, and muscle pain of dry needling treatment to the gluteal muscles in athletes with posterior thigh pain referred from gluteal trigger points.

METHODS

A randomised, double blind, placebo controlled trial of 59 male runners was performed during the 2002 Australian Rules football season. Subjects were thoroughly screened and had magnetic resonance imaging of their hamstring muscles to exclude local pathology. The inclusion criterion was reproduction of recognisable posterior thigh pain with the application of digital pressure to the gluteal trigger points. Subjects randomly received either therapeutic or placebo needle treatment on one occasion at their gluteal trigger points. Range of motion and visual analogue scale data were collected immediately before, immediately after, 24 hours after, and 72 hours after the intervention. Range of motion was measured with passive straight leg raise and hip internal rotation. Visual analogue scales were completed for hamstring and gluteal pain and tightness at rest and during a running task.

RESULTS

Magnetic resonance imaging scans revealed normal hamstring musculature in most subjects. Straight leg raise and hip internal rotation remained unchanged in both groups at all times. Visual analogue scale assessment of hamstring pain and tightness and gluteal tightness after running showed improvements immediately after the intervention in both groups (p = 0.001), which were maintained at 24 and 72 hours. The magnitude of this improvement was the same for therapeutic and placebo interventions. Resting muscle pain and tightness were unaffected.

CONCLUSIONS

Neither dry needling nor placebo needling of the gluteal muscles resulted in any change in straight leg raise or hip internal rotation. Both interventions resulted in subjective improvement in activity related muscle pain and tightness. Despite being commonly used clinical tests in this situation, straight leg raise and hip internal rotation are not likely to help the therapist assess response to treatment. Patient reports of response to such treatment are better indicators of its success. The mechanisms by which these responses occur and the reasons for the success of the placebo needling treatment are areas for further investigation.

An unusual case of suicide by broken glass pierced through the buttocks: a case report

Suicidal stabbing to the back and buttocks is very unusual due to the limited accessibility of that region to the victim's hand. The following case report describes a 38-year-old man, known for depression and suicidal ideation, who was found deceased in his home after tearing his right internal iliac artery by stabbing himself through the buttock with a piece of glass from a broken beer bottle. The literature on suicidal stabbing, particularly focusing on the type of weapon and localisation of wounds, is reviewed.

Gluteal stab wound is a frequent and potentially dangerous injury

BACKGROUND

Stab wounds to the gluteal area are a frequent injury in an urban trauma centre. These injuries may appear innocuous but is potentially life threatening. Therefore they deserve timely evaluation and management. The purpose of this study was to evaluate our experience with this type of injury and to propose a treatment protocol.

METHODS

During the last 5 years 269 patients with stab injuries, were admitted to our Department of Emergency Medicine (DEM). Thirty-nine patients (14%) who had gluteal penetration were included in this study. Patients' charts were retrospectively reviewed for demographic data, type of injury and additional injuries, evaluation, management and outcome.

RESULTS

Stab wound of the gluteal region was the most frequent injury after chest and abdominal injuries. Thirty patients presented with soft tissue damage only and nine were severely injured. Seven of the severely injured patients had significant bleeding; two of them were treated by embolisation. One patient suffered a rectal injury and one a small bowel perforation, both treated surgically. There was no post-operative complication or mortality.

CONCLUSIONS

Penetration of the gluteal is a potentially life threatening injury. Meticulous observation and high level of suspicion ensure early treatment and can prevent mortality.