Hx: A 25 yo male presents after falling at work. EMS reports that he fell approximately 8 ft from a ladder landing on his right side but without head injury. He complained of severe right hip pain at the scene and was unable to ambulate. EMS vitals signs are significant for tachycardia at 130, sinus. IV placed and normal saline bolus initiated prior to arrival. On arrival in the ED, he also reports one week of chills, fever, and right lower quadrant pain, with vomiting for 24 hours. No diarrhea.
SocHx: occasional alcohol, no tobacco or drugs.
- Vital Signs: Pulse 125 regular, BP 122/90, Resp 20, O2 sat 100% room air, Temp 103.2F (39.5C)
- General: Awake, alert, in severe pain in the right hip area.
- Head: normal, without trauma
- EENT: normal TM’s bilaterally, normal exam
- Neck: supple, normal motion, no tenderness
- Chest: normal without abrasions or contusions
- Res: clear to auscultation, no wheezes, tachypneic
- Cardiovascular: Tachycardic, regular
- Abdomen: tender to palpation in the RLQ without rebound. No tenderness LLQ, or upper abdomen.
- Back: no deformity or tenderness
- Extremities: Right leg with severe pain with internal/extrenal rotation at hip, or with flexion at hip. Normal right knee and ankle. Normal Left leg and bilateral upper extremities. Normal pulses.
- GU: normal genitalia, large area of erythema and induration to medial right gluteus, very tender.
- Hip Fracture
- Pelvic Fracture
- Gluteal hematoma
- Gluteal Abscess
- Intra-abdominal trauma
- Bladder rupture
- Ruptured hollow viscus
- Inflammatory bowel disease (crohn’s)
- Septic arthritis
- IV x 2 and fluid boluses of normal saline are initiated.
- Blood is drawn for cultures, CBC, and chemistry. Demonstrates a leukocytosis (17,000).
- Urine is obtained by catheter and is normal.
- Pain medication is administered
- Plain films of pelvis and right hip are obtained and do not demonstrate any traumatic injuries.
- Screening chest xray is obtained and is normal
- CT of the abdomen and pelvis with IV contrast is obtained and demonstrates a large air containing peri-rectal abscess tracking into the soft tissues of the right gluteus.
- Antibiotics are administered IV and surgery is consulted.
- The patient is taken to the operating room for surgical evacuation and debridement of the peri-rectal abscess. A total of 200 cc of purulent fluid is drained from the abscess.
- A drain is placed and antibiotics are continued.
- The patient’s fever and leukocytosis resolve by post operative day 3 and no further surgical intervention is required.
- He is discharged home in a much improved condition to continue oral antibiotics and wound packing.
It is often the case in emergency medicine that patients present with common problems in uncommon ways. In this case a patient presented with concerns for traumatic injury but has unusual physician exam findings in the right gluteus and a fever. Further history widened the differential to include infectious etiologies. Ultimately his presentation after trauma was attributed to sepsis. The presence of right hip pain though initially attributed to a traumatic injury, was actually due to irritation of the iliopsoas muscle group (psoas sign) and obturator internis muscle (obturator sign).
Treatment of peri-rectal abscesses includes intra-operative surgical drainage and antibiotics. Altough abscesses may be seen in the peri-anal area, peri-rectal abscess may involve the ischiorectal or supralevator areas complicating debridement. These abscesses require general anesthesia for adequate drainage. Attempt at bedside drainage of these complex accesses is exceedingly painful and often requires prolonged procedural sedation and post-procedural analgesia, therefore it is recommended that it be performed in the operative setting.