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| CASE REPORT |
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| Year : 2013 | Volume
: 13
| Issue : 1 | Page : 45-47 |
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Jet Ski perineal injury
Hanan Bousbait, Yasser Al-Jehani, Hazem Zakaria, Hessa Albuainain
Department of Surgery, University of Dammam, Dammam, Saudi Arabia
| Date of Web Publication | 28-May-2013 |
Correspondence Address:
Yasser Al-Jehani
Department of Surgery, University of Dammam- Dammam
Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/1319-6308.112231
Since the introduction of Jet Skis, also known as Peronal Water Crafts, the related injuries are increasing due to the increased popularity and use. Perineal injuries are reported as a result of such Jet Ski injuries. We report a case of perineal injury as a result of a Jet Ski injury. We reviewed the current therapeutic modalities and in conclusion prevention remains the essential part in avoiding these injuries and high index of suspension contribute efficiently in the successful management. Keywords: Jet Ski, perineal injury, Personal watercraft
How to cite this article:
Bousbait H, Al-Jehani Y, Zakaria H, Albuainain H. Jet Ski perineal injury. Saudi J Sports Med 2013;13:45-7 |
| Introduction | |  |
One of the more popular summer water sports involves personal watercraft (PWC) or jet skis. This has lead to their expanding popularity, their accidents resulting in physical injury is increasing consequently. [1] However, the true incidence of PWC accidents is unknown as many of these accidents are not reported. [1] Mechanisms consisted of direct collision with other objects, falls from the PWC, handlebar straddle injuries, axial loading, and encounters with the hydrostatic jet stream. [2] These injuries vary widely in severity and presentation. Our patient had perineal injury following PWC riding. Literature is deficient in articles describing the management issues of sever traumatic perineal injury despite the potential mortality and morbidity from such injuries. [3]
| Case Report | | |
A 23 year old male was referred to our hospital on the same day of his jet skiing accident. He was reported to be a rear riding passenger in high speed at the time when he felt air, water and pressure going forcefully into his perineum from the rush of the high-pressure water which propels the PWC. He was neither wearing the protective suit nor personal floating device (PFD). He fell from the vehicle but had no loss of consciousness and extracted himself from the water. Initially he was conscious, alert and oriented with Glasgow Coma Scale (GCS) 15/15, hemodynamically stable and the examination of the neck, chest and abdomen was unremarkable. No deformities or abnormalities were noted on the extremities. Assessment of the perineum revealed extensive scrotal swelling and linear deep laceration extending from the anal cleft through the anus and the perineum with questionable weak anal tone. Laboratory works were all in normal ranges except for leukocytosis. Cysto-urethrogram was done and showed no urethral injury. Computed Tomography (CT) scan with contrast (Intravenous, oral and rectal) showed extensive perianal injury in which the wound tract extended into the anus with hematoma tract in the right perianal subcutaneous fat [Figure 1]. Extensive surgical emphysema was also seen in the scrotal sac and along the left inguinal canal in addition to the scrotal hematoma. No solid or visceral injuries were detected. The integrity of the testicles and epididymi were confirmed by Doppler ultrasound. Patient was taken immediately to the Operating Room (OR) for exploratory laparatomy, no evidence of perforation into the abdominal cavity; a diverting colostomy was performed in the transverse colon. In lithiotomy position [Figure 2], examination of the perineum revealed; An elliptical lid in the anterior triangle just close to the mid line. The left upper angle was leading to the inside of the scrotal sac which was full of big hematoma. The anal orifice was intact i.e. both mucocutanous and circular musculature. The caudal part of the elliptical wound, which measured (6 × 3 cm) reached to the level of the coccyx, but not compromising the muscle. Sigmoidoscopy was done and no significant findings were seen. Irrigation was done followed by dressing. Five days later, debridement and wound dressing were done. Tunica vaginalis was excised a long with the pyogenic membrane. Three weeks later, split skin grafting was harvested from the left thigh, applied and sutured over the raw area of the perineum. Examination after 12 days showed good taken graft and the sutures were removed. The patient underwent colostomy closure after 6 months from the accident. He had uneventful postoperative course and was discharged in good condition with no residual deficit. | Figure 1: CT scan with contrast (Intravenous, oral and rectal) showing the perianal wound extended to the anus with extensive surgical emphysema in the scrotal sac along the scrotal hematoma
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 | Figure 2: Operative picture Gross picture in lithiotomy position showing scrotal sac full of big hematoma and the elliptical (6 × 3 cm) with its posterior angle at the tip of the coccyx
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| Discussion | | |
In 1974, Kawasaki Motor Corporation introduced the personal watercraft under the name "jet ski". [1],[4] Tremendous increase in popularity has been noted since 1990. The fast speed, the low price compared with other powered watercraft, the ease of launch and recovery, and the maneuverability have contributed to the increasing popularity of PWC. Surprisingly, these watercraft are involved in 55% of all reported collisions between boats even though personal watercraft account for less than 10% of all water vehicles. [4] Mechanisms of injury consisted of direct collision with other objects, falls from the PWC, handlebar straddle injuries, axial loading, and encounters with the hydrostatic jet stream. [2] The majority of injuries are lacerations, contusions, sprains, and fractures. [1] Although fatal injuries including closed head injury, hollow and solid viscus injuries, chest trauma, spinal injuries leading to paralysis and death occur in jet ski accident more than small boats accidents. [5] Haan
et al confirmed that inexperience and reckless behavior were the greatest contributing factors to PWC injuries. [2]
Perineal wounds are often associated with an impact with the water after ejection from the jet ski or by the rush of the high-pressure water which propels the jet ski. [6] Sever perineal injury can present complex diagnostic and management dilemmas because of the close relationship of the genitourinary tract, intestinal tract, and other soft tissue in this area. Early mortality from sever perineal injuries is most commonly the result of exsanguination and shock from associated injuries, including major vessels laceration, and fractures. [7] Hence, life threatening injuries should be excluded before initial wound care. Pelvic x-ray can help the diagnosis of pelvic fractures. Urethrogram and cystogram should be performed whenever there is a suspicion of distal urinary tract injury. Sigmoidoscopy, to exclude any rectal injury, should also be routine in the management of these wounds. CT scan is recommended if the patient is hemodynamically stable to exclude free air and fluid in the peritoneal cavity and retroperitoneal space. Special attention is given to the pelvic portion of the CT scan to rule out suspected rectal injuries. Because most of the injuries associated with complex perineal laceration are isolated below the diaphragm, limited laparatomy is a good modality for diagnosis and management of such injuries. [3] Because only 15% to 20% of patients sustain significant intra abdominal injuries, a limited incision allows adequate exposure for creation of stomas and placement of an enteral feeding tube and suprapubic catheter if needed. [8] For perineal injuries, a formal protocol consisting of initial radical debridement, fecal diversion, feeding jejunostomy, daily debridement and pulsatile irrigation for at least 3 days was instituted in 1989 at the Elvis Presley Memorial Trauma Centre at the University of Tennessee, Memphis. [3] In 2003 Kudsk et al proved this protocol to be successful in a retrospective study of 25 patients over 14 years with severe soft tissue injuries to the perineum. [3] Once a patient has survived the initial injury, the most common cause of morbidity and mortality from massive perineal wounds is pelvic sepsis. [3],[7] Inadequate debridement of necrotic tissue, residual hematoma, and fecal contamination are usually a fatal combination. To decrease the risk of pelvic sepsis, it is recommended to do fecal diversion and distal rectal washout with close observation of the pelvic wound. [3] Daily debridement with irrigation has been proved to contribute in the prevention of pelvic sepsis, and only when there was a deviation from this protocol did pelvic sepsis develop. [3] Granulation tissue is well established around the 4th day. Options for coverage are closure of the wound by flaps, split-thickness skin grafts, or secondary closure. Such early coverage simplifies wound care, decreases the metabolic losses of a large open wound, and helps with early mobility of the patient. Post operative complications include wound infection, abdominal abscess, delayed bleeding, as well as delayed healing, persistent sinuses and fistulae.
In conclusion, PWC related injuries represent a rapidly increasing source of water-sport related trauma. High index of suspicion for serious injuries must be maintained when evaluating patient with such accident. Prevention is essential. All persons on jet skis should wear PFD, take a training course in the use of the equipment, and be over 16 years of age. [9]
| References | | |
| 1. | White MW, Cheatham ML. The underestimated impact of personal watercraft injuries. Am Surg 1999;65:865-9. 
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| 2. | Haan JM, Kramer ME, Scalea TM. Pattern of injury from personal watercraft. Am Surg 2002;68:624-7.
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| 3. | Kudsk KA, Hanna MK. Management of complex perineal injuries. World J Surg 2003;27:895-900.
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| 4. | Tsai A, Rhea JT, Novelline RA. The jet ski open-book pelvic fracture: Diagnosis with multidetector CT. Emerg Radiol 2003;10:96-8.
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| 5. | Beierle EA, Chen MK, Langham MR, Kays DW, Talbert JL. Small watercraft injuries in children. Am Surg 2002;68:535-8.
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| 6. | Ehrman D, Kramer J, Nayduch D. Jet ski incident: Unsuspected contralateral vascular injury. J Trauma Nurs 2000;7:72-4.
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| 7. | Ksminsky RE, Shbeeb I, Makos G, Boland JP. Blunt pelviperineal injuries: An expanded role for the diverting colostomy. Dis Colon Rectum 1982;25:787-90.
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| 8. | Kudsk KA, McQueen MA, Voeller GR, Fox MA, Mangiante EC Jr, Fabian TC. Management of complex perineal soft-tissue injuries. J Trauma 1990;30:1155-60.
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| 9. | Personal watercraft industry association: The personal watercraft story (on- line reference). Washington DC: Personal Watercraft Industry Association; 2000.
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[Figure 1], [Figure 2]
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