Although none of the editors of InsideSurgery.com are participating in the care of the revelers injured in the running of the bulls in Pamplona, we have reviewed with interest the reports and video clips of the bulls goring the runners.
This type of injury in the surgical trauma world would have components of both penetrating and blunt injury, making them potentially serious and deadly. It is surprising that only 13 runners have been killed in the bull runs since 1924. No doubt the serious injuries are in the hundreds if not thousands during that stretch.
Please see below for the descriptions of the gorings that occurred in specific body areas and the possible trauma injuries that could result:
Lateral (outside) upper leg – this was the injury reportedly sustained by Michael Lenahan, one of two brothers simultaneously gored by one bull. Fortunately for this runner, there are no important vascular structures in this part of the leg; the important arteries and veins all run medially on the leg (on the inside part).
There is a significant muscle mass (tensor fascia lata and lateral part of vastus lateralis) that could become first lacerated (penetrating injury) and then macerated (blunt injury) if the runner was lifted into the air. There could be significant blood loss but since it would be difficult to injury the medial arteries and veins (and if there were no orthopedic injuries) it most likely would not be life-threatening.
There are no major nerves in the area. The force of being gored by a 1200 lb bull would be enough possibly to fracture the femur. If this were to occur, by definition, it would be an open fracture, which has a very serious risk of infection.
Goring in this area would most likely be taken to the operating room for inspection for bleeding muscular arteries and washout.
Lateral (outside) lower leg – this injury was sustained by Christopher Neiff , 24, of Norway. As with the lateral upper leg, this is not a life-threatening injury but can result in a limb-threatening injury.
In the mid upper thigh, the arterial supply of the leg moves to the midline and then travels in three separate arteries after an area of trifurcation just below the knee. The anterior tibia artery runs between the fibula and tibia and the peroneal artery runs on the outside of the leg, along with the peroneal nerve.
The injury suffered by Neiff was described as a 5 inch gash/slash running under the shin bone (tibia) up towards the knee joint. This puts both the anterior tibial and peroneal arteries as described above in jeopardy. Injury to either one of these arteries would bear strong consideration for operative repair in a young male who probably lacked collateral (alternate) blood flow.
However, even if successfully repaired initially, these vessels tend to clot off due to the ruptured inner arterial layer (intima). If there was signficant time before repair when the leg had decreased blood flow, a four compartment fasciotomy would likely performed. This entails making two incisions – one of each side of the leg- and incising the fascial layer (connective tissue layer) around the four muscle bundles in the leg.
Gorings in the lower leg would also have a high risk of bone fracture (particularly the fibula on the lateral lower leg), even in a young man. In addition, there is likely to be damage to the peroneal nerve, which is a structure so easily damaged that it can occur with incorrect positioning in the operating room. Injury to this nerve results in foot-drop and inability to turn the foot out.
Gorings in the lower leg would most likely be taken to the operating room.
Buttock – this is the reported area of injury to Air Force Capt. Lawrence Lenahan. There are no major vascular structures in the buttock. By design of nature, there is usually a large amount of soft tissue between the skin and the sacrum and alar wings (part of the pelvic bone structures).
The only significant nerve structure in the buttock is the obturator nerve that exits the obturator fossa. Damage to this nerve would cause significant motor and sensory dysfunction to the leg, but would likely not be injured due to the overlying tissue. There would be significant soft-tissue injury with bleeding but it would not be life-threatening.
If one could choose where to be deeply gored by a bull, this would be the best anatomic area.
Anterior chest – this was also a reported site of a goring. The severity of this injury depends on whether the bony structures of the sternum (breastbone) and/or ribs were penetrated. Again, by design of nature, it is diffult for injuries that have a low velocity blunt component to penetrate to the inside of the thoracic cavity.
Generally, injuries that cause damage to the lungs, heart, esophagus, and aorta and vena cava have either a high velocity blunt mechanism or a penetrating mechanism. It is likely that being gored in the ribs would cause multiple rib fractures and possibly a pneumothorax (punctured lung). There would not be enough soft tissue in the chest area for a bull to gore and then “snag” a runner causing impalement, as with being gored int he the leg or buttocks. Generally, being gored in the chest would result in being tossed and thrown off the horns.
It is likely that a goring that results only in broken ribs and a pneumothorax without significant hemothorax (blood in the chest cavity) would be managed non-operatively.
Abdomen – this was the area of injury reported in a 24 year-old man from Mexico. Being gored by a bull in the abdomen is a most likely devastating and possibly fatal injury. These are the ultimate “snag” injuries that usually result in the runner being impaled with the weight of the body causing the horn to penetrate deeper into the tissues.
The real danger comes if the horn penetrates through the abdominal wall and goes into the peritoneal or retroperitoneal cavities. The peritoneal cavity contains the liver, gallbladder, stomach, spleen, small bowel, and part of the colon.
The most dangerous injury would be to the highly vascularized, anterior lying liver. A 4 inch-in-diameter bull’s horn lacerating the liver tissue would likely cause a grade 3 or grade 4 liver injury. Injuries to the hollow, viscus organs of the colon, stomach, and small bowel would be serious but well within the repair capabilities of a competent surgeon.
The most devastating area of injury would be to the retroperitoneal structures – duodenum, kidneys, aorta, vena cava, and pancreas. An injury to the aorta or vena cava would be immediately life-threatening in the field.
Injury to the duodenum and/or pancreas would require extensive surgery to staple off and resect (remove) injured tissue and to reconnect the bowel. Trauma surgery to the duodenum and pancreas often results in many drainage tubes, repeat surgeries, and significant morbidity.
This is probably the worst place on the body to be gored. All gorings to the anterior abdomen would be taken to the operating room. If you were facing a charging bull, one might consider quickly turning face away.