Sheathed goring: The paradox of combined blunt and penetrating trauma. Clinical case

García-Rayo, C.; Tejido Sánchez, Á.; Rodríguez Antolín, A.; Téigell Tobar, J.

doi:10.1016/j.acuroe.2024.09.001

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Clinical case" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "683" "paginaFinal" => "684" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "C. García-Rayo, Á. Tejido Sánchez, A. Rodríguez Antolín, J. Téigell Tobar" "autores" => array:4 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "García-Rayo" "email" => array:1 [ 0 => "clara.gre.105@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Á." "apellidos" => "Tejido Sánchez" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Rodríguez Antolín" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Téigell Tobar" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Hospital Universitario Doce de Octubre, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cornada envainada: la paradoja de un trauma contuso-penetrante. Caso clínico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 367 "Ancho" => 1000 "Tamanyo" => 33866 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "(A) Evisceration contained within the left flank. (B) Blockage of left renal arterial flow with associated infarction and perirenal hemorrhage." ] ] ] "textoCompleto" => "Bull horn injuries are frequent in Spain, especially during the summer season, when events involving bulls are mostly celebrated.Any patient with a bull horn injury should be considered a polytraumatized patient and receive the corresponding treatment.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a>In certain cases, the severity of injuries caused by these accidents is not evident on initial evaluation. Sheathed goring is one of these cases. It is a subtype of goring in which the horn hits and penetrates deep tissues – possibly leading to eventrations and severe visceral injuries – without perforating the skin.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>A 45-year-old male with no relevant medical history was transferred to our center after receiving a bull horn goring during a bull run (encierro). He was conscious, oriented and hemodynamically stable on arrival. He presented multiple abrasions and hematomas on the face, thorax and four limbs. Abdominal examination revealed a circular, swollen hematoma on the left flank (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), accompanied by signs of peritoneal irritation.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Given the patient’s stable condition, an emergency computed tomography (CT) scan was performed (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The CT scan ruled out cranial and cervical abnormalities but revealed fractures of five bilateral costal arches and a sternal fracture. At the abdominal area, there was intestinal evisceration contained in the left flank with no evidence of affected bowel loops, a renal vascular injury with associated renal infarction, and evidence of active perirenal hemorrhage.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>In face of these CT findings, immediate surgical exploration was performed through a midline xiphopubic laparotomy. The left abdominal wall presented severe evisceration with dehiscence of the parietal peritoneum, muscle fibers and anterior aponeurosis. The integrity of the intestinal loops contained in the evisceration was verified. A left nephrectomy was performed through a transperitoneal transmesocolic approach with early control of the renal vessels. A large hematoma contained within the Gerota’s fascia was revealed. A preperitoneal polypropylene mesh was placed to repair the abdominal wall defect.Postoperative recovery was uneventful and the patient was discharged on the fifth day.Bull horn injuries are common in regions with a bullfighting tradition. These injuries have unique characteristics such as a large area of tissue damage, multiple paths of injuries, inoculation of anaerobic germs and transmission of tetanus.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a>There are several types of injuries resulting from bull horn wounds.Sheathed goring is characterized by the absence of skin dehiscence, as the elasticity of the skin prevents tearing when the horn penetrates the body, resulting in minor injuries.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> This particularity may lead to underestimate these wounds during examination, as their penetrating mechanism is not evident. However, such injuries are often serious and frequently require emergency surgery.Focusing on the renal vascular injury and its treatment, it was classified as grade V according to the AAST (American Association for the Surgery of Trauma) classification. There is an increasing tendency towards conservative management of renal trauma, even in cases of high-grade injuries in hemodynamically stable patients.<a class="elsevierStyleCrossRefs" href="#bib0015">3–5</a> Keihani et al. developed a nomogram that predicts the need for surgical intervention in cases of high-grade renal trauma, evaluating factors such as the mechanism of injury (penetrating or not), hemodynamic stability and presence of contrast extravasation, among others.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> In this case, despite the hemodynamic stability of the patient, several factors such as the presence of active bleeding foci in the perirenal area, the mechanism of trauma, and the need for surgery to address bowel evisceration led to an emergency laparotomy. According to the nomogram, the patient’s likelihood of needing emergency surgery due to bleeding was estimated to be between 40% and 50%, considering that the mechanism of injury was penetrating. Although there was no solution of continuity of the skin tissue, this type of injury produces characteristics typical of penetrating wounds and tears, thus it falls into this category.The anterior transperitoneal approach to reach the renal pedicle through the mesentery allows faster control of the main renal vessels, which contributes to a safer management of the patient. This approach subsequently allows exploration of the kidney and retroperitoneal region with vascular control. The decision to perform total or partial nephrectomy or renorrhaphy – in cases where the lesions allow for a more conservative approach –<a class="elsevierStyleCrossRefs" href="#bib0020">4,7</a> depends on the findings.Although sheathed goring is uncommon, this injury deserves special attention as it can mask underlying lesions that are more significant than they initially appear. When these involve the kidney, despite the current trend towards conservative management of renal trauma, there are still situations in which surgery is imperative. Surgical intervention can be critical in preventing further complications and even preserving the patient’s life." 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ISSN: 2173-5786

Actas Urológicas Españolas is an international journal dedicated to urological diseases and renal transplant. It has been the official publication of the Spanish Urology Association since 1974 and of the American Urology Confederation since 2008. Its articles cover all aspects related to urology. Actas Urológicas Españolas, governed by the peer review system (double blinded), is published online in Spanish and English. Consequently, manuscripts may be sent in Spanish or English and bidirectional free cost translation will be provided. It has high visibility and accessibility and is found in the most important data bases, Medline/Pubmed, Emabase, JCR, Ïndice Médico Español, Índice bibliográfico Español en Ciencias de la Salud (IBECS), Cuiden, Dialnet, Hinari, Scopus, Google Scholar.

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