What is Penetrating Groin Trauma (Stab Wounds in the Groin)?
Penetrating wounds in the groin area can create a difficult situation for doctors because they could harm important organs and structures in the body. Quick assessment and a strong suspicion of injury can help improve the results after a traumatic event. Being aware of how different types of injuries occur can help healthcare professionals concentrate their efforts and manage these injuries effectively.
What Causes Penetrating Groin Trauma (Stab Wounds in the Groin)?
Penetrating trauma refers to injuries that occur when an object pierces the skin, either on purpose or by accident. These injuries often come from guns or knives, but other blunt objects like sticks or metal bars can cause them too, especially in falls and high-speed car accidents.
Although chest and stomach injuries are more common, groin injuries should not be overlooked. Both the digestive system and the urinary and reproductive systems can be harmed. Important blood vessels pass through the groin, and damage to these can cause serious health problems and even death.
Risk Factors and Frequency for Penetrating Groin Trauma (Stab Wounds in the Groin)
Penetrating trauma, which includes things like puncture wounds and gunshot wounds, is common in both military and civilian environments, but the causes and types of these injuries vary. In day-to-day civilian life, most of these injuries come from stabbings or from being hit by low-speed projectiles, such as bullets from a handgun. In the military, on the other hand, these injuries often come from either high-speed projectiles or from explosions.
As body armor has improved, soldiers are more likely to suffer injuries to their extremities (arms and legs), rather than their head or torso. These injuries often involve major blood vessels. In fact, vascular injury rates are now five times higher than they were during the World Wars and now account for 12% of all battlefield injuries. During the Iraq and Afghanistan conflicts, 73% of vascular injuries were caused by blast/explosive injuries, with the rest being mostly gunshot wounds.
In the civilian world, penetrating trauma is a serious issue. Between 2007 and 2014, over 435,000 patients were admitted to hospitals in the United States for these types of injuries. This number doesn’t include people who died before they could receive medical attention. About half of these injuries were caused by gunshots and the other half by stab wounds. Most of these injuries happen to young men. There are also a worrying number of cases where children accidentally hurt themselves.
High-profile mass shootings have become more common and deadly in recent years. The shooters in these incidents tend to use high-speed firearms, which cause injuries similar to those seen in warfare. However, mass shootings often result in more injuries to the head, torso, and abdomen than combat injuries. Most of these injuries (93%) are usually fatal. Therefore, doctors who treat trauma patients need to be prepared to deal with high-speed gunshot wounds to the lower body and to treat any associated vascular trauma, as these are injuries that can potentially be treated to improve chances of survival.
Signs and Symptoms of Penetrating Groin Trauma (Stab Wounds in the Groin)
When a patient comes in with injuries from an accident, doctors use a systematic approach to assess and treat the injuries. This begins with checking the patient’s airway and breathing, followed by an evaluation of their circulation to ensure blood flow is normal. This is particularly important in cases of groin injuries where blood vessels may have been damaged. If there is significant bleeding, doctors will apply pressure to stop the bleeding temporarily while completing the rest of the injury assessment. It’s important to fully expose the injury to accurately assess its extent.
After this initial assessment, a more detailed evaluation is conducted. This could include an abdominal exam to check for signs of inflammation that might indicate an internal injury. Another important step is a rectal exam; this can help identify any blood in the gastrointestinal tract that might signal bowel damage. If there’s blood around the urethra, this suggests the genitourinary system, which includes the kidneys, bladder, and associated tubes, has been affected. Doctors will also closely examine both armpits, both groin areas, and the space between the genitals and the anus to look for any other injuries.
The doctor will also check the pulses in the hurt and unaffected limbs. Ankle-brachial index (ABI) is a quick test that doctors can perform to check blood flow. If the results are less than 0.90, it suggests that further imaging tests might be needed. This test is particularly useful in older patients who may have long-standing arterial disease. Symptoms suggestive of vascular injury that doctors look out for are signs such as growing bruise, pulsating blood flow, abnormal rushing or purring sounds, vibrations, or missing pulses.
An important part of this thorough assessment is a comprehensive neurological exam to look for signs of nerve damage which could either be direct physical damage to the nerve or injury due to the effect of forceful impact of the accident. Assessing motor and sensory function is also essential.
Early on, the doctors will secure a large-bore intravenous (IV) line for fluid administration if necessary. They will also take samples for a complete set of blood tests. If there is ongoing bleeding or signs of reduced blood volume like low blood pressure or rapid heart rate, then blood products like plasma and platelets might be given. Depending on the severity of the injuries and the level of pain, the patient might be intubated – a tube inserted into the throat to help with breathing. This is particularly necessary if surgery is urgently needed.
Testing for Penetrating Groin Trauma (Stab Wounds in the Groin)
If a person comes to a hospital after a trauma, and it’s suspected they have a groin injury, it’s crucial to get a trauma surgeon on the case as soon as possible. Ideally, this surgeon will be there as the patient arrives. It’s also best if the patient can be taken to a special area, called a trauma bay, designed for emergency care.
After the patient arrives at the hospital, doctors must evaluate the severity of the groin injury based on the patient’s overall condition. If the patient’s condition is stable, doctors can use techniques like pelvic X-rays to determine the injury’s extent; external wounds on the body are marked for easy visualization. On the other hand, if the patient is unstable, they should be taken to the operating room as quickly as possible to control any bleeding or address any other injuries.
Regardless of their overall stability, if a patient shows specific serious signs related to blood vessels (like an expanding bruise, visible pulsing blood, unusual sounds or feelings over the blood vessels, uneven heartbeats, or signs of poor blood flow), they need urgent medical attention. Moreover, medical guidelines even recommend skipping time-consuming vascular imaging if these signs are present.
Patients who are stable and do not have these serious signs still need a thorough check-up of their blood vessels. Doctors use a measurement called ABI (Ankle-Brachial Index). If this examination is normal and ABI values are over 0.9, no more imaging related to blood vessels is needed. On the other hand, if there are less severe signs of blood vessel injury or an ABI value under 0.9, more detailed imaging techniques, like CT angiography or conventional arteriography, might be needed.
Also, depending on the injury’s location and possible path, additional imaging like a CT scan could be useful to check for internal injuries. This might involve injecting a dye into the body to highlight possible damage better. Techniques can also evaluate the urinary system if needed. Once the patient is stable and the immediate issues have been addressed, these imaging techniques can further help assess any associated injuries.
Treatment Options for Penetrating Groin Trauma (Stab Wounds in the Groin)
The approach to managing blood vessel injuries in the groin area will depend on a variety of things, including the particular situation, the affected blood vessel, and the patient’s condition. If the patient is stable or responsive to initial efforts to control bleeding, a repair may be needed. However, patients who are unstable or also have major chest or abdomen injuries might be better off initially with attempts to control the injury, followed by a planned repair surgery later. Injuries to the digestive or urinary systems should be addressed to prevent ongoing contamination.
If the patient is unstable, or if they’re showing clear signs of a blood vessel injury, they’ll require urgent or emergency surgery. If the injury shows up on a scan, it’s important that patients get surgery within six hours—after this time, the chance of complications goes up significantly. Ideally, a vascular surgeon would perform this surgery. But if one isn’t available right away, the trauma surgeon on call should be able to provide temporary care.
Before surgery, the patient’s lower abdomen, both groins, and both legs should be prepared. However, for emergencies, the preparation needs to extend from the chest to the feet. Tools and sutures for dealing with blood vessels should be on hand immediately. Sometimes a device to temporarily divert blood flow, known as a vascular shunt, will need to be quickly available. If this isn’t possible, something like a suction catheter could be used as a makeshift shunt.
If the patient is unstable, especially if they have other injuries needing surgery, it might be necessary to temporarily control the bleeding and perform the repair surgery later. Techniques such as using arterial shunts (tubes placed inside the blood vessel to keep blood flowing) or tying off the affected blood vessels might be used, although these can increase the risk of complications and the need for amputation.
For stable patients, or when possible for unstable ones, attempts should be made for definitive repair. The exact approach will depend on the specifics of the injury, with various strategies used for different types and sizes of injuries. The affected blood vessels will need to be debrided (removing dead tissue), careful attention paid to avoid creating blockages, and it’s likely that the area will need to be cleaned out (a thrombectomy). An imaging scan is typically performed after the repair to make sure blood is flowing properly.
If there are any signs of injury within the abdomen, or if these are detected on images, an exploratory surgery will be necessary. After gaining control of any internal bleeding, the small and large intestines should be examined for injuries. Any wounds should be repaired or cut out (resected), with the ends then joined back together. A similar approach is taken for bladder injuries. Bladder injuries within the abdomen typically require repair to prevent urine leakage, while those outside the abdomen can often be managed simply by using a catheter to drain the bladder.
Urethral (tube that carries urine from the bladder out of the body) injuries are managed based on the exact location, the amount of tissue loss, and the patient’s sex. Most of these injuries occur in males, and can often be repaired directly. However, in some cases, parts of the urethra may need to be temporarily opened up into the skin (marsupialized) to allow for later repair. Female urethral injuries are less common, and can usually be primarily repaired.
A single dose of antibiotics is typically given during surgery. However, taking antibiotics after the operation isn’t usually needed unless the patient develops signs of a septic (blood) infection.
What else can Penetrating Groin Trauma (Stab Wounds in the Groin) be?
If someone suffers a penetrating wound to the groin, many different organs could be affected. These can include major arteries or veins, which can cause concerning symptoms. For instance, there could be serious bleeding, a growing lump filled with blood (hematoma), or the lack of a detectable pulse. In other cases, the injuries may not be very obvious to start with, but then later turn into a false blood vessel (pseudoaneurysm) or abnormal connection between an artery and vein (traumatic arteriovenous fistulas). The most common blood vessels that get injured are the superficial and common femoral arteries, but injuries can also happen to the iliac artery and vein, femoral vein, deep artery and vein of the thigh, and the large vein in the leg (great saphenous vein). The injury can also affect nerves, which might include the femoral and sciatic nerves. If the wound is closer to the body (proximal), it could damage the small intestine or large intestine (colon), so doctors must always be mindful of these possibilities. Injuries could also occur to the bladder or the tube that carries urine from the bladder (urethra). Lastly, the injury could cause bone damage, such as fractures to the pelvis or thigh bone (femur), as a result of the impact from a projectile, such as a bullet.
What to expect with Penetrating Groin Trauma (Stab Wounds in the Groin)
Damage to the blood vessels in the groin area often results in high rates of associated health complications and death. Among such injuries, those affecting the external iliac vessels tend to be more complex and hazardous than femoral injuries; they have a higher fatality rate (41.4%), a higher chance of permanent disability (13.8%), and higher instances of any complications (48.3%). The rates of deep vein blood clots (0-5%), surgical site infections (4-7%) and hospital stay length (6-9 days) are comparable for external iliac and femoral vessel injuries.
About 34% of patients with a penetrating injury to the colon or rectum will need to be admitted to the ICU, typically for 10 to 14 days. There is also a 3% risk that the repair site will leak. Furthermore, 67% of such patients are likely to endure complications like leaks in the repair, abdominal infections and wound complications. The death rate is estimated to be around 10%.
Bladder injuries are mostly located outside the abdominal cavity (63%) and come with an 8% mortality rate. Damage to the urethra is rarely fatal, but it may lead to long-term issues such as erectile dysfunction and a narrowing of the urethra, known as urethral strictures.
Possible Complications When Diagnosed with Penetrating Groin Trauma (Stab Wounds in the Groin)
Long periods of blocked blood flow and then restoration of it can increase chances of lower leg compartment syndrome. This condition is less likely in injuries around the upper leg compared to those around the knee or lower leg. Still, it’s a concern for any injury above the knee that requires surgical help. To prevent this, doctors may choose to perform a procedure known as a 4-compartment fasciotomy. If they decide not to do this, then they need to closely monitor the patient after surgery. This is because a missed or late detection of compartment syndrome can lead to the necessity of an amputation.
Injuries to the main arteries leading to the leg can cause blood clots (1% chance), the need for amputation (5% to 9% chance, increases to 20% if a thigh bone fracture is also involved), and long-term neurological issues. Injuries to the main veins in the same area can result in blood clots in the leg (22% chance), lung clots (2%5 chance), and lasting leg swelling or vein damage. It can also lead to the formation of pseudoaneurysms and traumatic arteriovenous fistulas.
In terms of gastrointestinal complications, there could be leaks from the reconnected or repaired part of the bowel. To manage this, more surgery can be needed, especially if there’s an abdominal infection from the leak or if there are untreated injuries. Leaks that are contained can be managed with drains placed by a radiology specialist. Narrowing of the reconnected parts of the bowel, a potential long-term issue, may occur after bowel removal. Wound infections and deep space infections are also possibilities.
Bladder leaks could continue after repair or non-surgical management of injuries outside of the bladder. The site of the repair could become a place for stone formation if a suture that does not dissolve is used. Dilation or other interventions might be needed if the part connecting the bladder and urethra becomes narrowed from the surgical process or trauma. Male patients might experience sexual dysfunction after urethral trauma, particularly if there was surgical intervention.
Preventing Penetrating Groin Trauma (Stab Wounds in the Groin)
Gun violence, especially among young people, continues to be a major problem in the United States, significantly more than in other developed countries. Reasons for this include gun crimes, homicides, and suicides involving firearms. Mental health issues are a contributing factor in this and need to be addressed accordingly.
Studies have shown that improving access to mental health services can slightly reduce the rate of suicides involving firearms. This is an area where timely intervention could save lives. Laws that keep guns away from criminals are also needed and provide an avenue for healthcare professionals to advocate for safer communities.
Practices such as safely storing and handling firearms have been proven to lower the chances of accidental injuries. This offers a direct way for healthcare providers to help their patients, by asking them about their gun ownership during routine visits and advising them on how to safely handle and store their guns to reduce the risk of injury.
