J R Army Med Corps 1985; 131: 164-166
Case Report
Accidental Impalement Injuries of the Intraperitoneal Rectum caused by the Barrel
of the Self Loading Rifle
Major D S Jackson", FRCS, RAMC
Military Wing Musgrave Park Hospital BFPO 801
SUMMARY: Rectal impalement injuries are uncommon. Two cases are described of soldiers who suffered similar
injuries due to accidental impalement on the barrel of a self-loading rifle.
Rectal injuries are the most serious of those which After peritoneal toilet with normal saline tHe ~
involve the large bowel. Only to-15 years ago the abdomen was closed with tube pelvic suction drainage.
mortality ranged from 30 to 60%, though more recent He made a good post-operative recovery and four weeks
reports have substantially improved on these figures'. later the colostomy was closed uneventfully. Two weeks
Impalement of the ano-rectum is unusual and afterwards he rejoined his unit.
accounts for very few of the causes of rectal injury. I
report two similar cases of accidental impalement in CaseB
soldiers on the barrel of the self-loading rifle. Private McG aged 19 was admitted to hospital in
October 1984. Whilst on patrol in the border area of
Case A Northern Ireland he attempted to climb over a fence."
Signalman S, aged 19 was admitted to hospital in July He leant his SLR vertically against the fence and as he ~
1980. Whilst training to carry out an anti-ambush drill climbed up, the fence collapsed. In the fall he stradled
he jumped off the back of an Army 4 ton lorry and the barrel of his weapon and impaled himself. He
impaled himself on the barrel of the SLR (self loading removed the weapon and subsequently defaecated
rifle) of another soldier who was crouched on the ground passing blood and faeces. ~
with his weapon vertical. The victim was disimpaled by Examination revealed the same findings as in Case A
colleagues at the scene of the accident and a penetrating with signs of lower abdominal peritonitis, a small peri-
length of 20 cms was estimated. The barrel of the anal abrasion, intact sphincter ani and a rectum full of
weapon was described as faeculent with 'flesh' attached blood and faeces. After resuscitation and antibiotics he I
to the end. underwent examination under anaesthesia and
On examination he had a tachycardia of 120 per laparotomy. Digital examination demonstrated a tear in
minute with normal blood pressure. He complained of the anterior wall" of the rectum above the prostate
lower abdominal pain and had signs of lower abdominal behind the bladder. Faeces were removed manually and
peritonitis. Examination of the perineum revealed an a catheter inserted which drained blood-stained urine.
abrasion at the anal margin and rectal examination At laparotomy the peritoneum was found to contain j
showed the presence of fresh blood and faeces. blood and faeces. The barrel of the rifle had pierced the
A diagnosis of intraperitoneal rectal perforation was recto-vesical septum, ab raided the left seminal vesicle
made and after resuscitation with intravenous fluids and and in addition had penetrated the sigmoid mesentery
antibiotics, he underwent examination under which was freely bleeding (Fig 1).
anaesthesia. This confirmed a perforation ofthe anterior The rectum was mobilised and the perforation closed,
wall of the rectum above the prostate. A urinary with chromic catgut. The left seminal vesicle and vas
catheter was passed which drained blood stained urine. deferens were intact. A left iliac sigmoid loop colostomy
At laparotomy the peritoneum contained blood and was fashioned over a rod, proximal loop lowermost,
faeces. The rectum was mobilised and the perforation utilizing the defect in the sigmoid mensentery. After
found deep in the pelvis in the recto-vesical pouch. The peritoneal lavage the abdomen was closed with I
seminal vesical on the left was bleeding but relatively extraperitoneal peJvic tube suction drainage.
undamaged. The rectal perforation was closed with silk He made an uneventful recovery and six weeks later
sutures and a defunctioning left iliac sigmoid loop the colostomy was closed. Eight days afterwards he
colostomy fashioned over a rod with a large bore tube developed a local wound infection followed by a faecal
inserted into the proximal loop for complete faecal fistula which subsequently healed spontaneously and in
diversion. March 1985 he returned to his unit. 4
D S l ackson 165
Discussion aeeo mmoua te th e girder. Subse qu e nt removal of th e
Th e <.:ommonest ca uses of rec tal injury a re stab g ird er required the st re ngt h of two me n 3 .
wo unds, gun sho t wounds a nd road traffic acciden ts. The most ha rrowin g ease report of recta l impale me nt
Less common ca uses are iat rogeni c (sig moidoscopy a nd whi ch wi ll of be more than curso ry interest to m a ny
biopsy, co lon oseopy and biopsy, Ba rium e ne ma, readers was publ ished in 1984 . It was subtitled 'An
laceration duri ng o perative procedure. irradiati o n and Unrecogni sed Haza rd for Surgeons' a nd occurred in t he
sel f induced (a no-ero tic stimulat io n byc ne ma ta , fo reig n operati ng thea tre during a neuros urg ica l procedure. A
bodies e tc). Impa le me nt injuri es arc unco mmo n in most junior surgeon. ass isti ng at the time. impaled himself o n
se ries reporti ng large bowe l trau ma a nd in these report s th e ce ntral stee l shaft of a swivel type s!ool. the sca t o f
the mechanism of injury is ofte n no t described::. Usually which had fali en off as the height was being adjusted'.
the cause is a fa ll , with the body playing the acti ve role C hildre n have been th e subj ect of several report s of
a nd th e impaling object th e passive rolc a nd the c xtent impa leme nt trauma suffering injuries due to high jump
of the injury depe nds upo n th e he ight from whic h t he bars. cri cket st umps. cha ir legs and pogo sti cks 1 . In 1976
body falls a nd the sha pe a nd d ime nsio ns of the impa ling an o utbrea k of peritonitis in a nursery was traced to the
object. Sharp objects will impa le at th e site of co ntact in habit of one of the nurse s placing rectal t he rm ometers
t he perin e um wh e reas blunt objccb as in th ese two cases hig h in the rectums of the babie s and thus techni ca lly
wi ll be directed by the bUllocks a nd sacrum to th e apex impaling them !!.
of the perineum in the na tal deft and damage th e a no- J could find no previous re pore of impalement injury
rec tum and uroge nital tract}. o n the barrel o f a rifl e in the literature which is perhaps
Untreated , recta l impal e me nt injuries are le thal , a surprisin g give n th e ovt:ra ll
fact apprecia ted by the Ancie nt C hin ese who used duri ng trainin g. exercises a nd o n ac ti ve service when
impalemen t as a met ho d of executing crimina ls. Kin g th ey are in sepa ra ble from their perso nal wea po ns.
EdwanJ 11 o f England was murd ereu by impa lement , a In the t\VO cases described. the wound tracks were
meth od sekc re d hecausc it le ft no ex ternal marks"_ exactl y simila r with a perianal abrasio n , e ntry thro ugh
There is o nl y o ne co ntempo rary re po rt of mu rder by the a nal sphincter into the ano-rectum. ex it from the
impalement in the literature 5 the victim a me ntal rectu m a nterio rl y ~bove the prostate. through th e fascia
hos pit al inmate. He had been the passive partner in o f De non villi er. skirtin g the poste rior aspect of the
homosexual practices a nd he was kill ed by multiple bladder and se minal vesicles and into the pelvis. I n both
impalcm c nts wi th a sha rpened broom ha ndle . At ca ses it is like ly tha t the firm prostate protected the lower
necro psy o ne track was found to ex te nd from t he a no- rectum. the a nterior poin t o f least res ista nce be in g just
coccygeal raph e through the li ver to the diaphragm ~ . flbove \.,,-herc the anterior rectal wall is suppo rt ed by th e
Th e vast majority of impal e ment injuries are acci de nt a l. recto-vesica l sc ptum . In neith er case was there se rio us
A rece nt report described [he injury and ma nageme nt injury to the hladder or sma ll bowe l tho ugh the a bsence
u f a surviving pa ti e nt wh o impal ed herself from a no- of the for mc r may he due lO bo th bladders being e mpty
rectum to right ni pplt! on a tree branch after jumpin g at th e lime of injury though thi s ca nnot be substantia ted.
fro m a burning building6 . In 1982 a fall fro m scaffo ld ing In the second case th e barrel had perfo rated the
result ed in im pa lement o f the victi m o n a la rge stee l sig moid mesent ery whi ch became a so urce o f
girder. Though the pe netration did not reach th e consid e rahle bleeding. Th e m anagem ent of these
peritoneum the injured m a n had to be a naesth e ti sed a t injuries is rea ll y a ma tt er of adherence to surgical
th e sce ne of th e acciden t and tra nsported to hospital by principles with re pa ir o f the peri neulll, re pair o f t he
ambulan ce with th e doors open at t he back to rectum , perito neal to il et a nd faeca l diversion after
adequate resuscitation and antibiotics. Drainage of the
a rea sho ul d be adequate'mo .
11 is importa nt to kee p th e recta l mobi lisa tion to the
minimum necessary to effec t the repair in orde r not to
damage th e nervi erigentes. Many authors stress the
im porta nce of cleansing the d ista l segme nt o f bowels
per-ope ra ti ve lylU .
Severa l a uthors suggest th at a co lostom y is
unn ccessary in sel ected cases of le ft sided large bowel
colo-rec tal injury' I, depending on such factors as the
degree o f contami na tio n . the size a nd ca use o f the
pe rfo ration , the sec urity of repair and the co lonic faeca l
load . However. most agree th at fa ecal d ive rsio n is
necessary in recta l injuries. Thi s e nta ils a furthe r major
opera ti ve procedure to rc-estab li sh intestin a l continuity
which car ri es a high lll orbidity'2. In Case B a faecal
Fig I. Hol e in Sigmoid Mesentery. fi st ula fo ll owed the colostomy closure whi ch ,
J 66 A ccidental Impalement Injuries of the Intraperitoneal Rectum caused by the Barrel afthe Self Loading Rifle
fortunately, dosed sponta neo usly over a period of six lO GRASDERGF.,R R C AND HI RS('H E F . Recta[ Trauma Am J
wee ks. Surg [983; 145: 795-7Y9.
II J OSI::" A S et al. Primary closure of civili an co[orectal
wounds. Ann Surg 1972 ; 176: 782-786.
REFERENCES 12 Y AJKO RD et al. Morbidity of colostomy closure. Am J
Surg 1976 ; 132: 304-306.
WANEBO H J , H Ul\'T T K ANI.) MAITHI:;WSON C. Rectal
injuries. J Trauma 1969 ; 9: 712-720.
2 CLAYDON C ANn l\·fARTIN T D. Trauma to the rectum ACCIDENTAL IMPALEMENT INJURIES OF THE
AmSurg 1968; 34: 3 17-320. INTRAPERITONEAL RECTUM CAUSED BY THE
3 DAITA P K. Impalement injuricsofthe colon and rectum.
BARREL OF THE SELF LOADING RIFLE.
Pracritioner 1982; 226: 693-696.
4 F URS'I'E W ANlJ KNOERNSCH1L lJ H. Perforations oftht! distal
la rge imestille produced by intraluminal traumas. Am J From Col R SemI, URAMC, Professor of Military
Su'g 1960; 99: 655-675. Surgery
5 T ORRE C Al\' O VARETTO L. A case of murder by The interesting paper by Major D S Jackson on
impalement. Z. Rechtsmed 1983; 91: 83-84. 'Accidenta l Impale me nt Injuries' draws att entio n tu an
6 . LEAR G H, DE K R Ai\""oST J OHN B. Impalement injury by unusual milit ary hazard, Maj or Jackson reports thi s as
a tree branch from rectum to ri ght nipple. Injury 198 1: 12:
495-49H. being due to the self load ing rifle, th e sta ndard NA TO
7 D ENNISON A R , AND BRrlTON D J . Pt!netrating anorectal
SLR .
injury. Dis Col RecTUm 1984; 27: 624-625. For surgeo ns it is importa nt LO e mphaSise tha t the
8 !-I AAS P A AND FoxT A . Civilian injuries of the rectum and co lostom y coveri ng rectal injuries sho uld co mple te ly
anus Vis Colon Recrum 1979; 22: 17·23 divert the faeca l stre a m, T he o ld-fash ion ed loop
9 An cA RIAN H AND LOWE R . Colon and rectal trauma. Sllrg colosto my is unsa ti sfa ctory in this rega rd.
Clin North Am 1978: 58: 5 19-537. R Scon
ACADEMIC ACHIEVEMENTS Honorary Consultants to the Army
MRCP Capta in N A Hoad, RAM C Or R H Phillips, MA , MRC P , FRCR , was appointed
MRCOG Major I J Page, RAMC Honorary Consultant in Radiothe rape utics to the Army
and Queen Elizabeth Military H ospital with effect fro m
MRCGP MajorPJO 'Brien . RAM C J July 1985.
Majo r J Sheardown, RAMC Mr H S Orton, OBE, FOS , RCS Eng, BDS , OOrth ,
Captain TO l effe rson, RAMC was appointed Honorary Cons ultant in Orthodontics to
the Army with effect from 2 July 1985.
Maj o r J E Burgess, RAM C Professor J Vallan ce-Owen , MA , FRCP, FRCPath ,
Captain K Bende low . RAMC FRCPI , has bee n appointed Honora ry Co nsultant in
Maj o r C R Hodgkinson , RA MC Medicine to the Arm y in Hong Kong with effect from 27
September, 19H5 .
Capta in I W L McCulloch , RAM C
Professo r J C K Lee , MB , BS , Phd , FRCP(C), FCAP,
was appointed H o no rary Consultant in Pathology to th e
Army in Hong Kong with effect from 26 June 1985.
Maj o r-Ge nerai1 P Crowdy. CB, LlR AMC(Retd) was
Membershipoflhe Royal Ca ptain L S O'Brion ,
appointed Honorary Co nsultant in Nutrition to the
College of Psychiatrists. RA M C Army with effect from 4 April 1985.
Professor J V G A Durnin , MB e hB , FRC P , DSc,
Diploma of Ophthalmology Major N A Johnson, MA was appointed Hono rary Consultant in Appli ed
Ph ys io logy to the Army with effect from 4 April 1985.
RAMC Mr 0 Wright , FRCS has been appointed Honorary
Consultant in Otorhinolaryngology to the Ca mbridge
Milit ary Hospital with e ffect from 15 March 1985.