Monday, March 14, 2005

Tales from the Trauma Service VI......
Day job and computer games taking their toll as of late. The gunshot wound to the buttocks is a frequent "comic relief" tool used in war movies such as Forrest Gump or Band of Brothers. But for a forty-ish year old over the weekend it was no laughing matter. He was shot with an entry wound very lateral in his left buttock. The projectile was located subcutaneously at his lateral right thigh. His urine was clear and gross blood on his rectal exam. His films:

The yellow circles mark the entry wound (with paper clip) and some soft tissue air near his scrotum.

And now we see the culprit. A digital rectal exam revealed a wound in his lower rectum or anus. He was too tender to allow for a proctoscopy in the ED. So off to the OR.
Sorry, not enough light for pictures. I will use my Netter atlas:

The black circles represent the areas of tissue damage to his posterior anus.
Here is another view:

The black line is the approximate path of the projectile, the green circles are the areas of severely damaged external sphincter muscle, and the blue circle is the area of posterior attachment.
I tried to piece together things as best as I could. I also placed an end sigmoid colostomy. The usual plan is barium evaluation and anorectal manometry in a few months. The two main worries are incontinence and stricture. This may be a permanent colostomy for him.
He doesn't think its too funny.


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