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Chapter 261

The evaluation of penetrating injuries to the flank or buttocks is complicated because it can be difficult to identify associated retroperitoneal, intraperitoneal, or vascular injuries that need immediate surgery. Fortunately, an increased armamentarium of diagnostic testing assists in timely diagnosis and allows for selective conservative management. The choice of management, conservative or operative, is based on the emergency evaluation, making the emergency physician’s input essential to a correct decision and a clinically successful outcome.

### Pathophysiology

The flank is the area between the anterior and posterior axillary lines, superiorly bordered by the sixth rib and inferiorly bordered by the iliac crest. Although a penetrating wound to the flank can produce intraperitoneal injury with the associated physical examination findings of peritonitis or hemoperitoneum with shock, it is possible that a penetrating flank wound only injure the retroperitoneal organs. A delay in diagnosis of duodenal, colonic, rectal, renal, pancreatic, or major vascular injuries may result in delayed septic or hemorrhagic shock.

The path of a gunshot or stab wound to the flank may track superiorly. Bullets may ricochet off the bony structures of the spine and produce a unique bullet path and injury pattern. Other intra-abdominal organs may be injured such as the stomach, pancreas, diaphragm, and intrathoracic organs. Inferior tracking will jeopardize the lower GI tract and colon.

### Clinical Features

Obtain information about the mechanism of injury, how much time has passed since the traumatic event, and the nature of the weapon. In the case of a gunshot wound, determine the nature of the gun (e.g., shotgun, handgun, BB gun) and the range between the gun and the patient at time of the gun’s discharge. For gunshot wounds, try to identify an exit wound and reconstruct the bullet path. For stab wounds, determine the nature of the implement and, if possible, estimate a measure of the distance of penetration. Perform a rectal examination because the presence of red blood in the stool indicates bowel injury. Note any blood around the urinary meatus or blood in a Foley catheter drainage, because this suggests bladder or urethral injury.

### Diagnosis

If the primary and secondary surveys reveal penetrating flank trauma, one diagnostic goal is to ascertain injury to the bowel, urinary tract, reproductive system, or vascular structures within the pelvis or abdominal cavity. Table 261-1 lists the diagnostic modalities available (see also Chapter 260, Abdominal Trauma).

Table 261-1 Diagnostic Modalities for Evaluation of Flank Trauma

### CT

In many centers, CT is the diagnostic modality of choice in hemodynamically stable patients with penetrating flank trauma.1–3 Use double [PO diatrizoic acid (Gastrografin) and IV] contrast or triple ...

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