Gunshot Wounds to the Extremities

Transcription

Bulletin of the NYU Hospital for Joint Diseases • Volume 64, Numbers 3 & 4, 2006
139
Gunshot Wounds to the Extremities
Paul A. Dicpinigaitis, M.D., Kenneth J. Koval, M.D., Nirmal C. Tejwani, M.D., and
Kenneth A. Egol, M.D.
T
he incidences of gunshot wound injuries reported
in the literature are higher than those reported for
motor vehicle accidents, sports injuries, or industrial accidents. Each year, approximately 30,000 to 50,000
Americans are killed secondary to gunshot wounds. This
upper range nearly equals the number of fatalities (59,021)
sustained during the 12 years (1961 to 1973) of the Vietnam
war.1 In 2003, the last year for which these statistics are
available, 30,136 persons were fatally wounded by firearms,
representing 18.4% of all injury-related fatalities.2 Additionally, for every death, it is estimated that there are at least
three nonfatal disabling injuries. This results in as many as
500,000 missile wounds occurring annually.3 In 1992, an
anti-gun study from the Violence Policy Center, a national
nonprofit organization based in Washington, DC, reported
there were more licensed gun dealers (245,000) in the US
than gas stations (210,000).4
Gunshot wounds also are a tremendous cost to society.
Recent studies have provided varying estimates of gunrelated medical costs. One national study, for example, has
estimated the total annual cost at 2.3 billion dollars.5 In a
1994 report, medical spending per hospitalized gunshot
victim averaged $25,000.6 Fifty-six percent of these patients
Paul A. Dicpinigaitis, M.D., was a Chief Resident in the NYU
Hospital for Joint Diseases Department of Orthopaedic Surgery,
NYU Hospital for Joint Diseases, New York, New York. Kenneth J.
Koval, M.D., is Professor of Orthopaedic Surgery at the DartmouthHitchcock Medical Center, Lebanon, New Hampshire. Nirmal C.
Tejwani, M.D., is Associate Professor of Orthopaedic Surgery,
NYU School of Medicine and Attending in the Trauma Service,
NYU Hospital for Joint Diseases Department of Orthopaedic Surgery, New York, New York. Kenneth A. Egol, M.D., is Associate
Professor of Orthopaedic Surgery, NYU School of Medicine and
Chief of Trauma Service, NYU Hospital for Joint Diseases Department of Orthopaedic Surgery, New York, New York.
Correspondence: Kenneth A. Egol, M.D., 301 East 17th Street,
NYU Hospital for Joint Diseases, New York, NY 10003.
were unemployed, 79% uninsured, and 68% were substance
abusers.7
Ballistics
The extent of tissue/organ damage depends on a wide variety
of factors including the bullet’s diameter or caliber, as well
as its shape, velocity, tumbling characteristics, and weight.
Bullets are missiles made of lead alloy. The high specific
gravity of lead gives maximum mass with minimum air resistance. Bullet tips can be manufactured in many different
configurations to enhance their performance, and include
pointed, round, flat, and hollow point types. A pointed bullet
has less air resistance and travels longer in a straight line
than a round-nosed bullet. However, a pointed bullet design
confers poor balance, because the center of gravity is shifted
to the rear of the bullet. These projectiles, usually at high
velocity and in stable flight, will tend to become unstable
upon meeting resistance. Thus, upon passing from air to
tissue, there is an enhanced tendency for the bullet to turn
on its short axis (i.e., yaw).8 This can be likened to a car
hitting a utility pole slightly off center.9 As a bullet tumbles
to 90° of yaw, the size of the wound channel created will
be significantly increased, as its kinetic energy is dissipated
with great intensity. The much more devastating wounds
from a pointed bullet after impact can rival those of expanding bullets and are attributable to this instability. At a given
velocity, the smaller the mass of the bullet, the greater the
tendency for it to yaw, tumble, and fragment.
Exposing the bullet core at its nose creates expanding type
bullets. This core, which is soft and very pliable, rapidly expands on impact. This expansion can be further enhanced by
the use of hollow point bullets, where a depression is made in
the bullet nose. The purpose is to increase the frontal surface
area that the bullet presents to the tissue along its trajectory
following impact.10 For example, as a nonjacketed bullet
“mushrooms,” a .30 caliber bullet can develop a .70 caliber
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Figure 1 Cross-section of a present day Winchester Super-X®
Drylok Super Steel shotgun shell. A, Hull; B, Plastic collar; C,
Shot; D, Wads; E, Sealed gas chamber; F, Ball powder; G, Primer;
H, Brass. (Winchester® is a trademark of Olin Corporation and
is used with permission. Neither the author nor the publisher are
sponsored by or associated with Olin.)
cross section.11 By deforming or expanding up to twice their
original diameter, hollow point bullets can quadruple the
amount of tissue struck.9 The kinetic energy imparted to the
tissue is thus directly related to the cross-sectional area of
the missile.
To compensate for barrel friction at high velocities, bullets
may be coated or jacketed with materials of higher melting
points. Jacketed bullets are primarily utilized in assault
rifles. Being jacketed also prevents a bullet from softening or becoming deformed upon impact. The Hague Peace
Conference of 1899 required that bullets be “jacketed” in
copper to minimize their deformation and resultant tissue
damage.8 Military ammunition has been jacketed ever since.
However, these constraints are not imposed on ammunition
used by private citizens.
Low velocity is defined as less than 2000 ft/s, while high
velocity is equal to or greater than 2000 ft/s.3 Low velocity
weapons include the .45 caliber handgun (869 ft/s), 9 mm
semi-automatic (955 ft/s), and 357-magnum handgun (1393
ft/s). Magnum shells and cartridges contain a heavier than
standard powder charge, which increases projectile energy
by 20% to 60%.12 High velocity weapons include the AK47 military rifle (2993 ft/s) and M-16 military rifle (2850
ft/s). Typically, high-velocity missiles are associated with
greater soft-tissue damage and wound contamination than
low-velocity missiles.13
Shotguns are considered to be the ultimate close-range
weapon, because they are capable of delivering a load that is
considered to be low velocity (i.e., from 1100 to 1350 ft/s)
yet highly destructive. Between 47% and 59% of shotgun
wounds to the extremities are associated with major soft-
B
A
C
Figure 2 A, Powder-Piston shotgun shell opening up upon leaving the shotgun barrel. B, Buckshot shotgun pellets traveling through air,
accompanied by white polyethylene filler. C, Shotgun plastic wad falling behind shot. (From: Di Maio VJM: Gunshot Wounds: Practical
Aspects of Firearms, Ballistics, and Forensic Techniques. Boca Raton: CRC Press, 1999. With permission.)
141
Figure 4 Radiograph of a gelatin block struck by a full metal
jacket M-16 bullet illustrating breakup of the bullet into secondary missiles/fragments. (From: Di Maio VJM: Gunshot Wounds:
Practical Aspects of Firearms, Ballistics, and Forensic Techniques.
Boca Raton: CRC Press, 1999. With permission.)
Figure 3 This plastic jacket was found upon surgical exploration of a shotgun wound. This shot container was not visualized
radiographically and would have resulted in a wound abscess had
it not been removed. Several shot pellets are also seen. (From:
Swan KG, Swan RC: Gunshot Wounds: Pathophysiology and
Management. Chicago: Year Book Medical Publishers, 1989.
With permission.)
tissue injury, 59% with nerve injury, 24% with vascular
damage, and 44% to 47% with bone or joint injury.14,15
The damage caused by shotguns is related to the tremendous kinetic energy that is generated by the increased mass
of pellets found within a shotgun shell (Figs. 1 and 2). Range
is the most critical determinant of the wounding capacity
of a shotgun. Because of the poor aerodynamic shape of a
spherical pellet, shotgun pellets decelerate rapidly, losing
their kinetic energy in a likewise rapid manner.
At a range of 1 to 2 yards, a single, large, ragged entrance
wound will be created, with associated massive tissue destruction. From a slightly longer range of 3 to 4 yards, a large,
central wound surrounded by several single pellet wounds is
produced. Each of these single pellet wounds, in turn, may be
associated with significant tissue destruction. At a range of
greater than 7 yards, the pattern of pellet dispersion will be
1 to 3 feet in diameter. At these distances, only a few pellets
will hit the target, causing moderate tissue destruction. At a
range of 20 to 50 yards, the wounding capacity of a shotgun
is negligible.16 Shotgun wounds are usually significantly
contaminated by the contents of the shotgun shell itself (Fig.
3). This material must be fully debrided intraoperatively.
There are three principles regarding the extent of injury
to tissue caused by a gunshot wound: dissipation of kinetic
injury, production of secondary missiles, and cavitation.
Understanding these principles will guide the orthopedic
surgeon’s appraisal of the extent of tissue damage, the need
for debridement, potential for infection, and possibilities for
osseous and soft-tissue reconstruction.
By definition, kinetic energy is equal to 1/2 the mass
multiplied by the velocity squared (1/2 MV2). Therefore,
increasing the velocity of the missile exponentially increases
its kinetic energy. For example, although an M-16 round has
approximately the same caliber and weight as a .22 caliber
handgun bullet, it is fired at a velocity three times greater,
resulting in nearly ten times the kinetic energy.17
Secondary missiles are generated when the primary bullet or missile impacts objects such as cortical bone, teeth,
metal buckles, and buttons. Secondary missiles may cause
more damage than the primary missile by taking erratic and
unpredictable courses and spreading the energy exchange
over a wider area. Secondary missiles may also leave several
exit wounds. As the velocity of the primary bullet increases,
secondary missiles are more frequently produced (Fig.
4).17
Wang and colleagues described three zones of injury
secondary to the missile’s projectory.18 The first zone of
injury is the primary wound tract, otherwise known as the
permanent cavity (Fig. 5). This cavity results from the actual
crushing of tissue directly in the bullet’s path. The second
zone of injury is a contusion zone of muscle adjacent to the
bullet track. Finally, the concussion zone is the area where
the shock waves produced during cavitation have caused
damage distant from the immediate bullet contact area.
When a missile enters tissue, a temporary cavity is created along the primary wound tract through the process of
cavitation (Fig. 5).17 Cavitation occurs when energy distribution from one point spreads into adjacent tissue; the energy
of the moving bullet pushes tissue particles away from the
impact point, producing a cavity. The resultant stretching,
compressing, and shearing of tissue may produce damage
extending several centimeters lateral to the bullet tract.
This temporary cavity lasts only milliseconds after bullet
impact, expanding and collapsing at a rate that is dependent
on the tissue characteristic and the amount of energy transferred by the missile. In low velocity missiles, this temporary
cavity is only slightly larger than the remaining permanent
cavity. High velocity missiles, on the other hand, produce a
142
Figure 5 Wound profiles generated by bullets are variable and
depend on the bullet’s shape, construction, mass, and velocity. Note
the permanent cavity and the large temporary cavity produced when
the bullet begins to yaw. (From: Mandracchia VJ, Buddecke DE,
Statlet TK, Nelson SC. Gunshot wounds to the lower extremity:
A comprehensive review. Clin Podiatr Med Surg. 1999;16(4):601.
With permission. Source: modified from Fackler ML. Civilian
gunshot wounds and ballistics: Dispelling the myths. Emerg Med
Clin North Am. 1998;16:1. Copyright © 1998 WB Saunders, with
permission from Elsevier).
large temporary cavity that is much wider than the permanent
cavity. Furthermore, this large temporary cavity is usually
filled with water vapor that has a low atmospheric pressure.
As a result, contaminating foreign material is more likely to
be sucked into the entrance and exit wounds created by the
vacuum of these high-velocity missiles.17
A narrow 1 mm to 2 mm zone of abraded skin, called
the “abrasion ring,” characterizes entrance wounds. This
ring is produced when the surface of the skin is damaged by
the rubbing or scraping action of one’s clothes as the bullet
penetrates the garments and underlying skin. The resulting
abrasions are oval or circular “punched-out” lesions. On the
palms and soles, they may be stellate in appearance. Ovalshaped wounds imply a more tangential trajectory, whereas
a round wound indicates a more direct, perpendicular path
toward the extremity.19
There are four categories of entrance bullet wounds based
on the target range. These include contact, near contact,
intermediate, and distant wounds.20 Contact wounds are
created when the muzzle of the gun is held against the body
surface at the time of discharge (Fig. 6). These wounds are
characterized by blackened, seared margins. Near-contact
wounds are created when the muzzle of the gun is a short
distance away from the skin at the time of discharge (Fig. 7).
These wounds are characterized by a wide zone of powder
soot deposited in a zone overlying the area of seared, blackened skin. However, the powder grains emerging from the
muzzle blast do not have a chance to disperse and “powder
tattoo” the skin. Angled near-contact wounds occur when
the gun barrel is held at an acute angle to the skin (Fig. 8).
As a result, the complete circumference of the muzzle is
Figure 6 Hard-contact wound with blackened seared margins.
(From: Di Maio VJM: Gunshot Wounds: Practical Aspects of
Firearms, Ballistics, and Forensic Techniques. Boca Raton: CRC
Press, 1999. With permission.)
Figure 7 Near-contact wound with wide zone of powder soot
overlying seared blackened skin. (From: Di Maio VJM: Gunshot
Wounds: Practical Aspects of Firearms, Ballistics, and Forensic
Techniques. Boca Raton: CRC Press, 1999. With permission.)
Figure 8 Angled near-contact wound with blackened seared zone
on same side as muzzle, i.e., pointing toward the weapon. (From:
Di Maio VJM: Gunshot Wounds: Practical Aspects of Firearms,
Ballistics, and Forensic Techniques. Boca Raton: CRC Press, 1999.
With permission.)
not in contact with the skin. The gas and soot emerging
from this gap radiate outward, producing an eccentrically
arranged pattern. A blackened, seared zone will be located
on the same side as the gun’s muzzle. Not only does this
identify the site as the point of entrance, but it also identifies
the bullet’s direction of travel. A third category of wounds
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Figure 9 Representative exit wounds. (From: Di Maio VJM: Gunshot Wounds: Practical Aspects of Firearms, Ballistics, and Forensic
Techniques. Boca Raton: CRC Press, 1999. With permission.)
is described as intermediate. Gunpowder tattooing of skin
is the sine qua non of these wounds. Finally, distant wounds
may still have carried significant velocity or may just be a
“spent” round.
Exit wounds are larger in size than entrance wounds and
more irregular in shape (e.g., stellate, slit-like, or crescent)
(Fig. 9). There is no abrasion ring present in exit wounds.
High velocity missiles may create very large exit wounds.
When a bullet enters the body, its path is unpredictable. A
bullet deflected by bone can exit in an unexpected location.
As a result, it is important to do a secondary survey in these
patients ensuring that all of the patient’s skin is visualized
and examined. If there is no exit wound, then all of the kinetic
energy has been dissipated into the tissue.17
It is important to remember that the missile is not sterilized from the combustion of the charge or from friction
with the gun barrel. Bullets can therefore be vectors of
infection. Wolf and coworkers fired sterile bullets painted
with Staphylococcus aureus into a sterile gelatin block. This
block subsequently grew out S. aureus.21 Gonyea reported
the case of a man who was shot through his tannery work
clothes, with the missile entering his spinal canal. This
patient subsequently developed fatal meningitis from Blastomyces dermatitis.22 Patzakis and colleagues, in a review of
78 gunshot fractures, compared patients who were and were
not treated with antibiotics. In their study, patients who were
treated with antibiotics had a significant reduction in infection rate (2.3% infection rate) compared to those who were
not (13.9% infection rate).23 Studies such as these resulted
in recommendations for irrigation and debridement of all
gunshot wounds, regardless of missile velocity, as well as a
mandatory course of intravenous antibiotic therapy.
However, recent studies have questioned the necessity of
formal debridement and intravenous antibiotic use in lowvelocity fractures treated with closed reduction and casting.
Howland and Ritchey, in a study of 111 low-velocity gunshot
fractures, concluded that antibiotics were not required in the
routine management of these injuries and that debridement
should be utilized only if signs and symptoms of infection
develop.24 Geissler and coworkers found no significant difference in the rate of infection in minor gunshot wounds between patients who received 1 gm of intramuscular cefonicid
in the emergency room vs. a three-day inpatient regimen of
intravenous Ancef®. As a result, they concluded that patients
with minor gunshot wound injuries could be managed with
outpatient oral antibiotics without an increased infection
risk.25 In a retrospective study of 3390 patients by Ordog and
colleagues, in 1993, 1.8% developed wound infections related
to minor gunshot wounds. The distribution of infection was
equally divided between those patients receiving prophylactic
antibiotics (56%) and those who did not (44%). Therefore, the
investigators found wound debridement and antibiotics to be
often unnecessary in minor uncomplicated gunshot wounds.26
Ferraro and Zinar treated stable, low-velocity tibia gunshot
wounds with superficial wound cleansing and skin edge debridement in the emergency room. These patients were then
discharged to home on oral antibiotics with no subsequent
infections reported.27 Finally, Woloszyn and coworkers treated
low-velocity gunshot fractures in the emergency room with
superficial debridement, cast immobilization, and antibiotics.
No statistically significant advantage of intravenous over oral
antibiotics was found. However, treatment with oral antibiotics
did result in dramatically reduced medical costs compared to
treatment with inpatient intravenous antibiotics.28
Nevertheless, because wound contamination is not always
apparent, most authors still recommend routine antibiotic
prophylaxis. In high-energy gunshot wounds and shotgun
injuries, treatment with cephalosporin, aminoglycoside,
and/or penicillin is recommended. Wounds with significant
contamination should certainly be treated with gram positive and anaerobic agents. The use of antibiotics should not
be misconstrued, however, as a substitute for the extremely
important surgical principle of an extensive surgical debridement of all devitalized tissue in open fractures.
General Management Principles
In treating gunshot injuries, one should always remember
to follow the fundamental principles (i.e., the “ABCs”) of
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Advanced Trauma Life Support protocols. Attention should
be initially directed toward the stabilization and resuscitation of the patient. A thorough history should be obtained
from the patient, if possible. The patient may know the type
of weapon, approximate range, and angle of the shot. This
is important, as entry wounds created by different types of
weapon may have similar appearances.
One should ensure that all of the patient’s skin has been
visualized on the initial assessment in order to identify the
location of all entrance and exit wounds. One also should
preserve evidence by cutting around, not through, bullet
holes in the patient’s clothing. An adequate wound description should be recorded in the medical chart. A recent study
revealed that fewer than 3% of charts had an adequate wound
description.3 Bullets should be marked only on the nose or
base to preserve rifling characteristics. Wadding or loose
shotgun pellets should also be preserved.
Wounds must not be probed with instruments or fingers.
If close examination of the wound itself is necessary, it
should be explored in the operating room. All major arterial,
venous, and neural structures traversing the area can then
be thoroughly evaluated at that time. Tetanus prophylaxis
is indicated in all gunshot wounds.
Vascular Related
A thorough vascular and neurological exam should be
performed. Throughout the body, a close association exists
between major arterial, venous, osseous, and neural structures. This is especially true of the upper extremity, where
a high frequency of combined injuries occurs, including a
50% incidence of associated significant nerve involvement.29
These nerve injuries are a major determinant of long-term
functional morbidity in patients sustaining gunshot wounds
to the extremities, despite successful management of vascular and orthopedic trauma.
Most vascular injuries that result from penetrating trauma
are manifested by well established “hard” physical findings
that will usually allow a rapid and accurate diagnosis. These
findings include: pulse deficit; a cold, lifeless extremity;
cyanosis distal to the wound; a bruit or thrill; a large or expanding hematoma; and pulsatile or uncontrollable bleeding.
Pulsatile bleeding is considered to be the most reliable sign
of major vessel injury.30,31
If the physical examination reveals such clear evidence
of a significant arterial injury, preoperative angiography
is usually not needed because it may cause further delay
in treatment (i.e., immediate exploration). Outside of the
operating room, hemorrhage should be controlled by direct
pressure applied to the site.32 Tourniquets should not be
used, as they will occlude the rich collateral network that
maintains perfusion distal to the injury site. Perfusion of the
distal extremity via extensive collateral arteries is probably
one reason why the incidence of limb loss in upper extremity
vascular trauma is quite low. Clamps should not be placed
on bleeding points. The same close anatomic relationships
that contribute to the high incidence of combined vascular
and nerve injuries are also implicated in the high probability
of nerve injury when an attempt is made to place clamps on
bleeding vessels. Exploration of the wound, as mentioned
prior, should be reserved for the operating room. The absence
of these “hard” signs does not reliably exclude arterial injury.
Findings suggestive of vascular injury or “soft” signs include
a history of hemorrhage; unexplained hypotension; a small,
stable hematoma; nerve injury; and proximity of the wound
to major vascular structures.
Even after complete arterial disruption, a weak but
palpable pulse might still be present. Apparently, normal
pulses have been found to be present in 20% of cases with
angiographically demonstrable lesions.33 The rich collateral
arterial supply is responsible for pulses being palpable distal
to the site of significant arterial injury in 25% to 49% of
cases.34
With anything less than an easily palpable pulse, the
patient should be resuscitated and reevaluated.35,36 Pulse
oximetry can be a helpful tool to monitor vascular status.
Diminished, noninvasive arterial pressure indices can also be
used reliably to identify limbs at risk of arterial trauma with
a sensitivity, specificity, and accuracy of 90% or greater.37
Advantages of angiography include its accuracy, sensitivity, specificity, low rate of false negative and/or false
positives, its high predictive value, and relatively low rate
of complications. Disadvantages of angiography include
high cost, a possible significant delay in definitive treatment,
interventional risks and complications, and the ability to
detect occult findings that may resolve spontaneously.
Angiography may be more useful for cases in which
the limb is viable but where a high degree of suspicion of
arterial injury exists. If the patient is stable, preoperative
angiography can be performed to exclude the presence of
an injury. Angiography may also be helpful if a coverage
procedure is planned, especially if local tissue, such as a
pectoralis flap, is to be used, to ensure that the blood supply
through the primary vascular pedicle is intact.38 All patients
with multiple wounds in the same extremity should have
angiography, if stable. The extensive dissection required, the
need to identify all sites of injury, and distal outflow provide
the rationale for this approach. However, even in such cases,
early exploration without an angiogram is preferable to a
protracted delay. An angiogram can always be performed
in the operating room. However, in the absence of physical
findings of disturbed circulation, the yield is 10% for occult
vascular injury. Dennis and colleagues noted that only 0.8%
of patients required surgery for injuries that would have
been missed by not performing angiography. These missed
injuries were usually minor and tended to heal.39
Duplex ultrasonography, as an alternative, can be as
sensitive (95%), specific (99%), and accurate (98%) as angiography.37 Furthermore, it carries no interventional risks,
is more cost-effective, and can be performed promptly and
portably in the emergency room. Doppler arterial pressure
measurements have been found to be useful in all but the
most proximal of injuries to the extremities.40
If it is determined that there is a vascular injury requiring
repair, rapid external fixation of the affected limb should be
performed. Fracture stability should be obtained first in order
to protect the vascular repair; however, when significant
ischemia is present, establishing distal perfusion becomes
a priority. In this situation, consideration should be given to
placing a temporary intraluminal shunt in order to restore
distal flow.41 The fracture can then be stabilized, followed by
definitive vascular repair. Otherwise, attempts at achieving
fracture fixation after arterial repair may disrupt the vascular
reconstruction with the repetitive motion of reduction and
correction of alignment. Delays of more than six hours in
revascularization should be accompanied by fasciotomy to
prevent compartment syndrome.32
Vascular injuries caused by gunshot wounds are almost
always appropriately managed by segmental resection, even
when the vessel is not completely transected.32 The zone of
injury attributable to bullet wounds often extends beyond
the area that is visibly damaged. A primary end-to-end
anastomosis may be performed if the proximal and distal
ends can be brought together without tension. Otherwise,
repair should be carried out using an interposition graft.
After completion of the arterial repair, the distal extremity
should be carefully examined to determine the adequacy
of revascularization. An intraoperative arteriogram may be
valuable in demonstrating the patency of the repair and in
identifying anastomotic defects requiring revision.
Due to their close anatomic proximity, combined venous
and arterial injuries occur frequently. This is especially true
in cases involving the upper extremity. Injury to concomitant
veins should be treated with primary repair.32 Ligation has
been found to result in a marked reduction in associated
arterial inflow, which can jeopardize the patency of any
associated arterial repairs.
Nerve Related
Nerve injuries also occur commonly in association with
upper extremity arterial injuries. The concussion zone of
blast injury may cause neurapraxic or contusion injuries that
will recover spontaneously. On the other hand, a progressive
neurologic deficit may signal the presence of an expanding
hematoma or pseudoaneurysm compressing the neurologic
structures. Prompt decompression of the hematoma or resection of the aneurysm can often reverse this deficit.38
Electrodiagnostic studies obtained immediately after
injury are usually not helpful, as they cannot distinguish
between a neurapraxic lesion and more serious injury. Follow-up studies at six weeks and three months can show
signs of early recovery, but, again, their utility is limited.38
Early signs of functional recovery on physical examination are reliable, and the order in which recovery occurs is
significant. In neurapraxia, recovery does not progress in
an anatomic, proximal-to-distal fashion but, rather, is ran-
145
dom. Distal muscle groups may recover first because of the
internal anatomy and topography of the fascicular bundles.
Thus, early signs of distal recovery indicate a neurapraxia
and mitigate against surgery. In contrast, axontometic lesions
always recover in an orderly, anatomic proximal-to-distal
direction. Nerve exploration should be strongly considered if
no return of clinically or electromyographically documented
nerve function is seen in three months.
The decision to operate for a neurologic deficit is,
perhaps, the most difficult decision to be made regarding gunshot wounds. There is no consensus regarding the
optimal timing for exploration and repair. Advocates of
delayed repair note that, in these cases, the extent of damage
is frequently beyond the site of transection or laceration.
Difficulty in determining the extent of injury thus leads to
inadequate resection of damaged nerve tissue. Associated
widespread contusion by a high-energy projectile may also
lead to epineurial softening and subsequent suture failure.
Furthermore, spontaneous recovery frequently occurs in
contused nerve tissue. Omer noted a 70% recovery rate for
upper extremity injuries.42 Brien and colleagues noted that
60% of sciatic and peroneal nerves regained some degree
of function.43
Advocates of acute repair note that dissection through
dense scar tissue is extremely difficult. Furthermore, grafting
distances may be shorter before nerve retraction occurs. A
relative indication is the presence of an associated vascular
or osseous injury requiring surgical treatment.
Primary repair is usually indicated only in cases of sharp,
clean transection. Otherwise, the severed ends should be
marked with clips for identification at a later time when
repair is attempted.44 Nerve ends should also be sutured to
the underlying muscle fascia in order to prevent retraction.
Partially transected nerves and severe contusions without
interruption are best left undisturbed and reevaluated at a
later date.
Upper or lower extremity bone fractures may be suspected
by considering the bullet’s path, an obvious deformity of
the extremity, or by pain on palpation or movement. Plain
orthogonal radiographs reliably identify fractures of the
extremities. Preoperative identification of fractures, particularly those that are unstable, takes on added importance
when vascular repair is planned.
It is imperative that close inspection of radiographs be
performed for any metal fragments near a joint space. Bullets
that are left in contact with joint fluid may result in joint sepsis, rapid chondrolysis, and joint destruction. Radiographs
in patients with lead arthropathy may reveal a lead-speckled
lining of the articular cartilage.45 Lead intoxication, or plumbism, is a rare consequence of retained intra-articular bullets.
In bone and soft tissue, rapid encapsulation of most foreign
bodies composed of lead occurs by fibrosis. This process
removes them from exposure to the circulating body fluids.
When lead is exposed to synovial fluid, however, this fibrosis
does not take place due to the fluid’s solvent-like effect on
146
lead.46 This can result in a constant dialysis of synovial lead
into the blood. If any question of joint involvement exists,
a computed tomography (CT) scan should be performed.
Arthrotomy is often necessary for adequate debridement
of the joint, but in uncomplicated cases, arthroscopy may
provide both valuable diagnostic information and definitive
treatment.
Summation of Management Principles
Most low-velocity gunshot injuries may be safely treated
nonoperatively on an outpatient basis, as these wounds
usually involve only the skin, subcutaneous and/or muscle
tissue, and minor cortical bone fragments. Local wound
care consists of superficial irrigation and careful cleansing
followed by a dressing. As discussed above, controversy
persists over the routine use of prophylactic antibiotics in
these injuries. While they may not be essential for wounds
that are not grossly contaminated, at least 24 hours of intravenous antibiotics should be administered postoperatively to
patients with fractures that required stabilization.
High-velocity and shotgun wounds require immediate
and aggressive irrigation and debridement. The margins
of the entrance and exit wounds should be excised and the
missile tract thoroughly irrigated. A wide debridement of
devitalized tissue must be performed and foreign bodies
removed. The patient should then be returned to the operating room every 48 to 72 hours for serial debridements. All
contaminated subcutaneous fat and devitalized muscle must
be removed. Bone without soft tissue attachment should be
excised. Elimination of dead space is vital. Primary closure
of bullet wounds must be avoided because of the possibility
of contamination. Secondary wound closure can usually be
performed within 5 to 7 days after injury. When wounds
A
B
cannot be closed without tension, skin grafting or a muscle
coverage procedure may be necessary.47
Clinical criteria should be used in determining the need
for fasciotomy. Fasciotomy is required less often for upper
extremity vascular trauma than for that of the lower extremity.44 This difference may be because of the more extensive
collateral arterial and venous supply and the smaller muscle
mass in the upper extremity. Upper extremity fasciotomy
is required most frequently in association with complete
transection of both the radial and ulnar arteries.34
Primary amputation of an injured extremity is rarely
required, but the decision is a difficult one to make. When
faced with a severely injured limb, the decision to amputate
must be based on the overall clinical assessment that reasonable functional recovery is extremely unlikely. This situation
usually presents itself when combined injury to nerves,
bones, soft tissues, and vascular structures is extensive (Fig.
10). Close range shotgun blasts may result in this type of
damage.
Gunshot Wounds to the Shoulder
Ordog and coworkers found a 9% incidence of shoulder
injury in gunshot wounds to the upper extremity.48 Vascular
injuries were detected in 15% of those wounds and 15%
had fractures that required hospitalization for definitive
treatment. Major vascular injury was four times more likely
when a patient had a fracture that required definitive treatment.48 Recent large series have noted a 25% association of
nerve damage with high-velocity injuries to the axillary and
subclavian arteries.38
A trauma series of the shoulder, as well as plain films
of the chest, cervical spine, and arm should be obtained
in all cases. An anteroposterior (AP) view of the shoulder
Figure 10 A, This left leg exit wound
exhibits the massive tissue destruction
characteristic of M-16 gunshot wounds
in which bone is hit by the M-16 round.
B, Amputation was the only treatment
possible for this injured extremity.
(From: Swan KG, Swan RC: Gunshot
Wounds: Pathophysiology and Management. Chicago: Year Book Medical
Publishers, 1989. With permission.)
in both internal and external rotation can provide further
information. The chest radiograph can be used to diagnose
hemothorax and pneumothorax.
Fractures of the humerus, scapula, or clavicle caused by
low-velocity or low-energy projectiles usually do not require
surgical intervention. The majority of low-energy humeralhead fractures are not displaced or are minimally displaced,
with an intact rotator cuff mechanism. These injuries also
do not require surgery.
High-energy injuries that have effectively destroyed the
humeral head and articular surface are treated with hemiarthroplasty. Displaced fractures of the greater and lesser
tuberosity, as well as displaced glenoid fractures with intra-articular involvement also require surgical stabilization.
Fractures of the neck and spine of the scapula demonstrate
a high rate of associated disability, especially weakness
with abduction, pain, and a decreased range of motion.49
Scapular neck fractures with more than 40° of angulation and
fractures with 1 cm or more of displacement are, therefore,
147
indications for surgical treatment. Scapular spine fractures
at the base of the acromion and those with more than 5 mm
of displacement are at risk for nonunion and are, therefore,
also surgical considerations. Certainly metallic fragments or
a bullet in the shoulder joint requires surgical removal (Figs.
11 and 12). Marked comminution, segmental (“floating”)
fractures, and early neurovascular repairs are other indications for open reduction and fixation. Anatomic reduction
may not be possible because of comminution and bone loss.
Open reduction and internal fixation with supplementary
iliac bone graft is recommended in fractures that involve the
diaphyseal and metaphyseal junction and surgical neck. Cloverleaf or dynamic compression plates can be used if good
soft-tissue coverage is present, but care should be taken to
avoid subacromial impingement.38 Intramedullary fixation
using locked nails with or without reaming can also be used
if the wounds are minimally contaminated. Stabilization of
fractures due to shotgun wounds often requires the use of
skin grafting or flaps. Shoulder soft-tissue defects may be
Figure 11 Anteroposterior and axillary radiographs of a gunshot wound to the left shoulder joint with associated intra-articular bullet
fragments.
Figure 12 Coronal and axial CT scan
cuts of a gunshot wound to the left
shoulder joint. Note associated intraarticular bullet.
148
resurfaced with random pattern flaps from the trunk. The
deltoid, pectoralis, and latissimus dorsi are the local flaps
of choice.
Although complete plexus lesions are rare, injuries caused
by a shotgun blast or high-caliber bullets can be extensive.
The incidence of nerves transected by shotgun blasts may be
50%.15 Thus, earlier and more aggressive treatment of highenergy, shotgun, and high suspicion injuries is advocated.
Although late reconstruction is always possible, the scarring
of nerve and soft tissue complicates the procedure. This difficulty often leads to multiple surgical stages for neurolysis
and subsequent reconstruction with a substantial loss of time
and muscle mass that can compromise the ultimate result.
Expectations of outcome from surgical reconstruction
of severe brachial plexus injuries must be tempered and
reasonable. In lesions requiring repair or sural nerve grafting, full function will not be restored.38 Late reconstructive
efforts may include shoulder arthrodesis in the absence of
glenohumeral control or muscle transfer to restore deltoid,
biceps, or triceps function. In cases of complete failure with
the end result of a flail, anesthetic limb, amputation may
need to be performed.
Gunshot Wounds to the Humeral Shaft
There are no large series of humeral fractures secondary to
gunshots in the literature.50 The general consensus among
orthopaedic surgeons treating low-velocity, gunshot-induced
humeral shaft fractures is local wound debridement and copious irrigation in the emergency room, tetanus prophylaxis,
and nonoperative treatment with either a hanging arm cast
or a functional brace.50
Indications for the operative stabilization of humeral
shaft fractures caused by gunshot wounds are essentially
identical to those for humeral shaft fractures caused by other
means. The primary indication remains a failure to obtain or
maintain a satisfactory closed reduction. Bullets often cause
comminuted fractures for which adequate reductions are difficult to achieve and maintain using nonoperative measures.
Other indications for operative intervention of humeral shaft
fractures include patients with multiple trauma, segmental
fractures, bilateral humeral fractures, fractures with associated articular injury, and fractures with ipsilateral forearm
fractures, i.e., the “floating elbow”.
Union rates averaging 91% to 100% have been achieved
using compression plate fixation to internally stabilize
humeral shaft fractures in patients with multiple injuries.50
Infection rates of 1.9% to 2.3% after internal fixation of
fractures with grade I open wounds make the risk of infection
nearly comparable with that of closed fractures.51 Stabilization of the fracture using a compression plate may also be
considered in a grade II open humeral shaft fracture with a
primary nerve palsy. This approach allows for exploration
of the nerve combined with rigid fixation of the fracture.
Humerus fractures associated with poor overlying skin
conditions, as is often the case with gunshot wounds, may be
more amenable to intramedullary fixation inserted at a site
distant from the fracture. Interlocking humeral nails allow for
intramedullary fixation of segmental or severely comminuted
fractures, as are often seen secondary to gunshot wounds.
Overall results of both flexible and rigid intramedullary nailing of humeral fractures are encouraging. Union rates are
in the 92% to 100% range, with an average time to healing
of between 6 and 13 weeks.50
The main indication for external fixation in the treatment
of fractures created by gunshot wounds is for those fractures
associated with large, soft-tissue wounds, including those
requiring neurovascular repair. The fixator causes limited
damage to the blood supply of the fracture, and does not interfere with neurovascular anastomosis or with postoperative
wound care. Because of the lack of large uniform series of
patients treated in this manner, the results of external fixation of humeral fractures associated with gunshot wounds
are difficult to interpret.50 Pin tract infections occur in about
10% of patients treated with external fixators. However,
these infections respond readily to systemic antibiotics
and, if necessary, pin removal. Rates of deep infection vary
dramatically and are probably more closely related to the
degree of underlying soft tissue injury. Functional results
of external fixation, though, appear to be as good as those
from intramedullary or plate fixation. In one study, 93.6%
of patients treated with external fixation regained functional
use of their upper extremities.52 However, incidence of nonunion for externally fixed upper extremity fractures varies
from 5 to 62%.50 Early autogenous iliac crest bone grafting
may be indicated to reduce the rate of nonunion in patients
with extensive soft-tissue injury, bone loss, or no evidence
of radiographic union at 3 months.
Gunshot Wounds to the Elbow
Gunshots wounds to the elbow are not very common. Victims of firearm trauma are more likely to sustain trauma to
other parts of an upper extremity. At Martin Luther King,
Jr. Hospital, only 29 patients were treated for this condition
over a ten-year period.53
Patients with fractures of the distal humerus, whether
intra- or extra-articular, require an angiogram to assess the
integrity of the brachial artery, even in the presence of a
palpable pulse distal to the injury.53 Patients with isolated
fractures of the medial or lateral epicondyle, or of the
proximal radius, ulna or both, do not require angiography,
unless the clinical examination suggests a vascular injury.
Injury to the principal nerves about the elbow joint should
be suspected with all gunshot wounds to this area.
Two orthogonal view plain radiographs of the elbow are
usually sufficient to allow determination of the amount of
comminution of the bony fragments. Intra-articular fractures
of the distal humerus are best managed with dual plate fixation. However, in fractures with significant comminution,
one may consider external fixation as an alternative option.
Should external fixation become necessary, it should be re-
moved as soon as feasible to allow active motion. Fractures
of the radius and ulna are managed using standard AO/ASIF
principles. If the radial head is significantly comminuted,
it will be less likely to support internal fixation and can be
excised. However, prosthetic replacement is ill advised in the
acute setting. If significantly comminuted, consider excision
of the olecranon with repair of the triceps mechanism. After
open reduction and internal fixation, early range of motion
exercises are recommended. Patients with neurologic injuries
should be maintained in the appropriate splints.
Gunshot Wounds to the Forearm
Approximately 4% to 20% of civilian gunshot wounds consist of injuries to the forearm.54 Most civilian injuries fall into
the low-velocity category. Isolated ulnar fractures with less
than 10° of angulation or less than 50% displacement can be
treated with casting or bracing. In displaced isolated ulnar
or radial fractures, compression plate fixation is preferred.
Isolated, nondisplaced radial fractures can be treated with
cast immobilization. Displaced fractures of both bones are
also generally treated with compression plates and early
motion. For fracture patterns not amenable to plate fixation,
external fixators or intramedullary nails can be used. Bone
graft is recommended when significant comminution or
bone loss has occurred.
The treatment of high velocity and shotgun injuries
resulting in types II and III open fractures is controversial
between immediate internal vs. external fixation. Duncan
and coworkers noted a significantly higher complication rate
in types IIIB and IIIC injuries treated with immediate internal fixation.55 Their results supported the use of immediate
internal fixation in types I, II, and IIIA injuries, but questioned its use in types IIIB and IIIC injuries. In their series,
Chapman and Mahoney found an infection rate of 41% with
the use of internal fixation in type III wounds.56 However,
Moed and colleagues encountered only one infection with
internal fixation in 11 type III forearm fractures.57 Jones also
used immediate internal fixation in 18 patients with type III
fractures, and reported a subsequent deep infection rate of
only 5%.58 He also noted that internal fixation caused less
interference with soft tissue reconstructive procedures and
that it allowed easier movement of muscle-tendon units
compared to external fixation.
Advantages of external over internal fixation include
faster times of application and less collateral blood supply
damage. External fixation has provided satisfactory results
in the treatment of severe forearm injuries, such as is seen
in close range shotgun injuries. Smith and Cooney have
proposed a compromise solution. These investigators found
good to excellent results with initial external fixation of open
forearm fractures, followed by delayed plate fixation and
bone grafting as needed.59
It is critical to thoroughly assess the vascular status of the
limb. In the presence of an injured vessel, Orcutt and coworkers found pulse deficits in 86% of radial injuries and 83%
149
of ulnar injuries.35 However, the presence of a pulse does
not rule out an isolated radial or ulnar artery injury. This is
most often due to retrograde flow through the arches of the
hand. In addition to palpating the radial and ulnar arteries,
and performing an Allen’s test, a vessel with a suspected
injury should be palpated while the uninjured vessel is occluded. Loss of the pulse with occlusion of the uninjured
vessel documents retrograde flow.
The need for repair of a single vessel injury in the presence of a well perfused hand is debated. However, the repair
of a vessel in a two-vessel forearm injury or a one-vessel
forearm injury with signs of distal ischemia is well accepted.
Data from World War II showed amputation rates of 39%
when both radial and ulnar arteries were ligated and 5%
when just the radial artery was ligated.54 Repair of vessels
has resulted in patency rates of 47% to 86%.54
The surgeon should have a high index of suspicion for the
possibility of compartment syndrome in any gunshot wound
to the forearm. Lenihan and colleagues recommended 24
hours of close observation for all gunshot wounds to the forearm.60 Rates of approximately 10% in low velocity injuries
have been found. Moed and Fakhouri found a compartment
syndrome incidence of 36% in patients with low velocity
proximal one-third fractures, and a high incidence was also
found with highly comminuted and displaced fractures.61
Even in the absence of fracture, Moed and Fakhouri found
an incidence of 6%.54 If a compartment syndrome is suspected, intracompartmental pressure measurements should
be taken. A single or double incision fasciotomy should then
be performed as clinically indicated.
Gunshot Wounds to the Hand
The majority of gunshot wounds to the hand are the result
of low-velocity handguns. However, the spectrum of these
injuries is wide, and includes high velocity assault weapons,
shotguns, BB guns, and pellet guns. Appropriate radiographs
of the extremity should be obtained in the standard planes.
CT scans may be indicated, especially in gunshot wounds to
the carpal bones, to assess the extent of bony and articular
involvement.
Indications for nonoperative management include absence of joint involvement, fracture displacement, and/or
bone loss. Treatment in such cases usually consists of
cast immobilization, a short course of oral or intravenous
antibiotics, and close follow-up. In cases where joints are
involved and obvious disruption of the extensor tendons,
flexor tendons, or both is found, the patient should undergo
prompt formal irrigation and debridement, stabilization of
fractures, and repair of injured tendons or neurovascular
structures. The specific means of immobilization and stabilization depend on the fracture pattern and the existence of
bone loss. Kirschner wires, mini-plates and screw fixation,
cerclage wires, mini external fixator devices (Fig. 13), or
primary stabilization with subsequent fusion have all been
used with good results.62 Of key importance is early post-
150
B
A
C
Figure 13 A, Anteroposterior and B, lateral radiographs of a gunshot wound to the hand, s/p mini-external fixation. Note comminuted
middle metacarpal and bullet fragments. C, Note dorsal entrance wound.
operative occupational and physical therapy.
Gunshot Wounds to the Hip
A gunshot wound to the hip is associated with substantial
morbidity and mortality.63 This injury is often accompanied
by concomitant injuries to the abdomen. Both the abdomen
and hip require immediate evaluation and surgical treatment
to reduce the incidence of sepsis, functional disability, and
death.
An AP radiograph of the pelvis and a cross-table lateral
should be obtained in all patients who have sustained a
gunshot wound near the hip. Judet 45° oblique views of the
pelvis are useful when an acetabular injury is suspected.
Joint contamination can occur when a bullet enters the
hip capsule. Bacteria can gain access to the hip by contiguous spread from the bullet through the fracture caused by
the bullet. Any patient with a bullet wound between the
umbilicus and the proximal one third of the thigh is at risk of
hip joint penetration.63 Fractures of the acetabulum, femoral
head, or intracapsular portion of the femoral neck are the
best radiographic evidence of joint violation.
When plain radiographs are inconclusive, a fluoroscopically assisted arthrogram can be used to detect hip joint
violation or an intracapsular bullet (Fig. 14). A hemarthrosis
indicates joint violation. The aspirate should be sent for cell
count, culture, and gram stain. The arthrogram may show
a missile in contact with or surrounded by contrast. A hole
in the capsule results in extravasation of contrast. A trail of
contrast may demonstrate communication between the joint
and bowel or bladder.64,65
CT of the hip should be obtained prior to an arthrotomy
to remove a bullet in the acetabulum. By identifying associated intra-articular fractures as well as localizing the bullet,
the CT scan can assist in planning the surgical approach.
A hip aspiration and arthrogram should be performed on
every high-energy gunshot wound to the hip. Every gunshot
wound to the hip that has an associated transabdominal injury
requires an immediate arthrotomy.63 All patients who sustain
large bowel injuries should have a colostomy, and small
bowel injuries should be repaired. Bullets in communication with synovial fluid and intra-articular bone fragments
should also be removed by an arthrotomy. Indications for
internal fixation include unstable intra-articular fractures
and unstable femoral neck fractures. Emergent reduction
and stabilization of displaced femoral neck fractures is recommended when bone stock is adequate to achieve stable
fixation. If the blood supply to the femoral head remains
intact and the fracture unites, a good result can be antici-
151
Figure 14 A, Arthrographic view of the hip shows a bullet that appears to be surrounded by contrast material. B, These views were
obtained by rotating the hip through a full range of motion. The bullet is clearly extra-articular, and thus the hip joint was never violated. (From: Long WT, Brien EW, Boucre JB Jr, et al. Management of civilian gunshot injuries to the hip. Orthop Clin North Am.
1995;26(1):123-30. With permission.)
pated. Otherwise, hip arthroplasty or fusion can be planned
on an elective basis. Femoral neck fractures with small
cortical defects at the point of bullet impact can be treated
nonoperatively.
Gunshot Wounds to the Femur
At the time of presentation, conventional anteroposterior
and lateral radiographs of the femur, including the hip
and knee, should be obtained. Patients should be placed in
balanced skeletal traction if a surgical delay is indicated.
Ninety-three percent of femur fractures resulting from lowvelocity gunshot wounds are classified as having Winquist
and Hansen grades III or IV comminution.66 Early femoral
stabilization using an interlocked nail should be used for
all patients. Cephalomedullary nails are used for complex
femur fractures that have fracture extension proximal to the
lesser trochanter.
An indication for external fixation of a femoral shaft
fracture is a large soft tissue wound associated with highvelocity missile and shrapnel injuries.13 However, the complication rate, including implant failure, pin tract infection,
and residual loss of knee motion are significant. As a result,
the treatment for high-velocity gunshot wounds to the femur
is local wound care and intravenous antibiotics followed
by delayed closed intramedullary nailing with aggressive
wound debridement and flap closure.67 However, Nicholas
and McCoy and Bergman and coworkers have both recommended immediate reamed intramedullary nailing regardless
of bullet velocity.68,69 Even though there was extensive bony
comminution and soft tissue disruption in these high veloc-
ity injuries, the immediate insertion of an intramedullary
nail did not appear to disturb fracture or soft tissue healing.
When coupled with wound irrigation and debridement,
and a delayed primary closure, no significant increase in
deep wound infections were noted. Furthermore, Bone and
colleagues showed a significant decrease in the number of
pulmonary complications in their group undergoing early
instead of delayed femoral stabilization.70
Gunshot Wounds to the Knee
Radiographic examination of a gunshot wound around the
knee includes an anteroposterior, lateral and oblique view.
CT can provide valuable information regarding the extent
and complexity of the fracture pattern.
The evaluation of a patient with a gunshot injury to the
knee must pay particular attention to the likelihood of a
vascular injury. After the patient’s neurovascular status has
been evaluated, one may then proceed to defining the skeletal
implications of the bullet and/or its fragments. One must
determine whether the bullet has penetrated the knee joint,
because this directly affects the treatment plan. The trajectory of the bullet may raise the clinician’s index of suspicion.
When an intra-articular fracture is not evident on plain
radiographs or other studies, infiltrating the knee joint with
saline may be useful. Subsequent extravasation would help
to confirm knee joint penetration. Knee joint aspiration may
also be useful. A bloody aspiration, which is consistent with
joint penetration, requires joint irrigation and debridement.
When isolated missile penetration has occurred, joint irrigation and debridement may be accomplished successfully
152
using arthroscopy.19 Retained intracapsular bullet fragments
should be removed at this time. Excellent results have been
reported in the arthroscopic treatment of patients with lowvelocity gunshot wounds involving the knee joint.71
If no fracture or only unicortical knee defects are present,
and the wound was due to a low-velocity force, then nonoperative treatment is indicated. Unstable fracture patterns
should be treated with open reduction and internal fixation.
In cases with massive soft-tissue injury, external fixation
spanning the knee with later conversion to internal fixation
should be performed. The use of postoperative bracing and
early motion for fractures with stable fixation is recommended.19
Gunshot Wounds to the Tibia
Radiographic examination consists of anteroposterior and
lateral views, which should include both the knee and ankle
joints. In proximal and distal gunshot wounds, CT may help
to assess the possibility of intra-articular bone and metal
fragments as well as articular displacement.
The majority of gunshot fractures encountered in a
civilian population are low velocity with minimal soft-tissue damage. These low velocity fractures are frequently
associated with a Type I open wound and a nondisplaced or
locally comminuted fracture. These injuries can be treated
essentially as closed fractures on an outpatient basis. This
usually consists of long leg casting after superficial wound
cleansing and skin edge debridement in the emergency
department.27 A functional brace can be exchanged for the
cast within the first six weeks after injury.
Patients with low-velocity gunshot injuries involving the
diaphysis or metaphysis associated with an unstable tibia
fracture (Winquist-Hansen types III or IV) should be treated
with debridement and osseous stabilization. After soft tissue
debridement, immediate interlocked, intramedullary nailing
is recommended for diaphyseal fractures.72 Velazco and coworkers, Wiss, Henley and Mayo, Whittle and colleagues,
and others have shown excellent results in unreamed nailing
of open tibial fractures.73,74,75,76 However, unreamed nails offer less stability and stiffness than reamed nails. Since the
nonunion rate for unreamed, interlocked nails approaches
that of external fixation, one may want to use a reamed nail
or consider the use of early bone grafting.72
Open tibial pilon and plateau fractures are often complicated by massive soft tissue swelling and late wound
problems. Therefore, for proximal and distal gunshot wounds
to the tibia, some authors recommend a thin-wire, external
fixator. This protocol has been reported to reduce the incidence of skin slough and infections without compromising
the principles of stable fixation and early motion.72 In a
similar fashion, a spanning external fixator may be used to
stabilize this injury primarily. When sufficient healing of the
soft tissue envelope has occurred, conversion to definitive
internal fixation can then be performed.
High-velocity gunshot wounds to the tibia require repeat
debridement, early wound coverage, and subsequent bone
grafting. These high-energy injuries may be complicated
by neurovascular deficit, compartment syndrome, infection,
and nonunion. Indications for the use of external fixation for
high energy gunshot wounds to the tibia include: (1) injuries
with significant soft tissue deficit (grade IIIB); (2) significant
bone loss; (3) vascular injury; (4) severe contamination;
(5) injuries that are at risk for amputation and that require
multiple dedridements (grade IIIA and IIIB); and (6) comminuted fractures too proximal or distal for intramedullary
nailing.27 However, external fixation pin infections can result
in joint sepsis when pins penetrate the joint capsule or there
is fracture extension within the joint. Complications such
as these can therefore exceed the benefits that unreamed,
interlocked nails provide for lower-grade (I to IIIA) open
fractures. Secondary intramedullary nailing, after initial or
failed external fixation for open tibial fractures, has been
reported to have satisfactory results; but caution must be
taken with this method because of the risk of spreading
infection from pin tracks.77,78
Despite the principles of fracture stabilization, intravenous antibiotics, extensive soft-tissue irrigation and debridement, and delayed wound closure, some patients with highenergy, grade IIIB and IIIC injuries will do best with early
below-the-knee amputations.79,80 When considering primary
amputation vs. limb salvage, the following questions must
be asked:
• Is the vascular injury reparable? Failure of arterial
repair was the main cause of limb loss in one series
of patients.81
• Can the skeletal injury be reconstructed?
• Is the soft tissue viable or can durable soft tissue
coverage be achieved? Increasing severity of soft
tissue injury is associated with a greater probability
of limb loss.82,83
• Is innervation present, or possible? Although an
extremity with motor power might function as an
autoprosthesis, in the absence of protective sensation such an extremity can become a severe liability,
prone to unrecognized injury and chronic infection.
If all four of these questions cannot be answered affirmatively, then primary amputation should be strongly
considered.117 The duration between injury and repair is less
important than the severity of ischemia. While several formulas have been developed to determine if primary amputation
is appropriate, they are not infallible.82,83 When the course of
action is unclear, it is reasonable to attempt salvage. If it then
becomes evident that the extremity is nonviable or it remains
insensate, an amputation should then be performed.
Gunshot Wounds to the Foot
Nonoperative treatment consisting of local wound cleansing
with antiseptics and copious lavage irrigation, with superficial debridement of necrotic tissues at the entrance and exit
sites, can be performed in low velocity gunshot wounds.84 In
general, high-velocity and shotgun induced fractures of the
foot should be stabilized at the earliest possible opportunity,
either by closed or open reduction, using a minimum of
internal fixation.121 Internal fixation is indicated in cases of
intra-articular fractures, in those near vascular repairs, and
in low-velocity gunshot wounds.85
More commonly, temporary external fixation is advocated, especially in cases involving significant soft tissue
or osseous loss.46 Determination of the full extent of tissue
necrosis may not be possible at the time of initial debridement. As a result, it is prudent to do limited debridement
of all obvious necrotic tissue acutely. When the tissue has
been adequately and serially debrided, definitive internal
fracture fixation with or without soft-tissue free flaps can
be performed.
It is a positive trend that the number of gun dealers, or
federal firearms licenses (FFLs), in the United States was
reduced from 245,628 to 54,902 between 1994 and 2005, a
reduction of almost 80%. Only five states (Alaska, Idaho,
Montana, Oregon, and Wyoming) are now credited with
having more intrastate licensed gun dealers than gas stations.
These dramatic reductions in FFLs are due to, in part, to
various types of licensing and legislative reforms, such as
the Brady Law (1994) and better implementation of laws
requiring FFL holders to be held only by legitimate business
owners.86
4.
Battlefield Conditions
14.
While this discussion centers on the care of gun wounds
from the perspective of civilian events; contemporary combat
theatre is germane in terms of management principles under
field conditions. On the modern battle field, extremity vascular injuries dominate and conditions are, by comparison to
civilian settings, uncontrolled and unclean. During Operation
Iraqi Freedom, extremity vascular wounds comprised 50%
to 75% of treated injuries, keeping in mind that these are all
virtually high-kinetic energy injuries from high explosives
and munitions with shrapnel as well as high-velocity firearms. Adding to the volume of extremity wound presentations in contemporary combat is that there is now a better
survival rate for truncal injury casualties who also typically
have extremity injuries.87 In both civilian and military settings, application of principles of good wound management
and continuity of care by the transporting personnel and the
trauma surgeon is vital to limb salvage and recovery.
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Gunshot Wounds to the Extremities

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