Duke Orthopaedics
Wheeless' Textbook of Orthopaedics

Gun Shot Wounds 

- Discussion:
       - firearms tutorial
       - missile characteristics
       - NRA website
       - Weapons Effects and Parachute Injuries
       - Shooting Soldiers: Civil War Medical Images, Memory, and Identity in America
- General Management: 
    - most important issue is to get the correct diagnosis (no viceral injury, no compartment syndrome, no arterial injury)
    - tetanus prophylaxis and antibiotics as necessary; 
           - for low velocity fractures, expect infection rate of 2%;
           - some studies support antibiotics for simple GSW and some do not;
           - references:
                  - Antibiotic therapy in gunshot wound injuries
                  - Comparison of intravenous and oral antibiotic therapy in the treatment of fractures caused by low-velocity gunshots. A prospective, randomized study of infection rates.
                  - PRS comparing single-agent antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in open fracture wounds.
                  - Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Management of uncomplicated soft tissue gunshot wounds.
                  - A Civilian perspective on ballistic trauma and gunshot injuries
                  - Management Of Gunshot Wounds To The Limbs: A Review
                  - Soft Tissue Infection after Missile Injuries to the Extremities—A Non-Randomized, Prospective Study in Gaza City

    - wound management is greatly influenced by the velocity of the bullet; 
    - arterial injuries
           - references:
                  - The management of vascular injuries of the extremity associated with civilian firearms.
                  - Arteriography for proximity of injury in penetrating extremity trauma. 
                  - Combat related vascular injuries: Dutch experiences from a role 2 MTF in Afghanistan.
    - compartment syndrome:
    - nerve injury:
           - in low velocity GSW, 70% of nerve injuries are neuropraxic in nature and will recover within 9 months (vs
                  80% nerve recovery in fractures after 4 months);
           - references:
                  - Injuries to Nerves of the Upper Extremity.
           - case example: 
                  - 28 year old male who has sustained a GSW to the thigh several years ago and was left with disabling
                         paresthesias (normal motor exam); 
                         - he was managed with surgical exploration of the sciatic nerve, removal of external adhesions and limited
                                   neurolysis of the epineurium;  

    - low velocity injuries:
           - if no fracture is present, wound debridement and wash out can be carried out in ER;
           - management of GSW associated fracture: 
                  - non op treatment may be indicated for non displaced cortical violations of femur and metaphyeal drill holes (use above
                         knee casts and crutches) as well as for humeral shaft fractures; 
                         - can also be treated with oral antibiotics (ie there is no strict indication for prolonged hospitalization w/ IV Atb); 
                  - indications for operative fracture fixation are the same as for any other fracture;
           - references:
                  - A prospective, randomized clinical trial of wound debridement versus conservative wound care in soft-tissue injury from civilian gunshot wounds.
                  - Management of low velocity gunshot-induced fractures. 
                  - Infection in minor gunshot wounds. 
                  - Immediate interlocking nailing of fractures of the femur caused by low- to mid-velocity gunshots
                  - Comparison of intravenous and oral antibiotic therapy in the treatment of fractures caused by low-velocity gunshots. A prospective, randomized study of infection rates
                  - Antibiotic therapy in gunshot wound injuries.
                  - Antibiotics in the Treatment of Low-velocity Gunshot-induced Fractures: A Systematic Literature Review

    - shot gun wounds:
           - note that the shot gun wadding may lie underneath the fascia on the "far side" of the wound;
           - references:
                  - The management of large soft-tissue defects following close-range shotgun injury.
    - high velocity injuries:
           - high velocity GSW need to be treated like open fractures;
           - generally requires formal operative debridement and fixation;
           - references:
                  - Open wound drainage versus wound excision in treating the modern assault rifle wound.
                  - Internal deformation of the AK-74; a possible cause for its erratic path in tissue.
                  - Muscle devitalization in high-energy missile wounds, and its dependence on energy transfer
                  - The U.S. M-16 rifle versus the Russian AK-74 rifle.  

- Sites of Involvement:
    - spine: 
           - The management of transpharyngeal gunshot wounds to the cervical spine
    - femur: (see open femur frx)
           - Femur fractures caused by gunshots: treatment by immediate reamed intramedullary nailing.
           - Immediate interlocking nailing of fractures of the femur caused by low- to mid-velocity gunshots.
    - hand:
           - Low-velocity gunshot wounds of the metacarpal: treatment by early stable fixation and bone grafting.
           - Hand and forearm injuries from penetrating projectiles. 
           - Gunshot wounds to the hand: management and economic impact.
           - Fracture management of civilian gunshot wounds to the hand.
           - The management of penetrating trauma to the hand.
    - humerus:
           - Civilian Gunshot Injuries of the Humerus 

    - joint injuries: 
           - ref: The early management of open joint injuries. A prospective study of one hundred and forty patients
           - shoulder (brachial plexus):
                    -  Stewart MP, et al (2001), the authors studied a consecutive series of 58 patients with penetrating missile injuries of
                            brachial plexus to establish indications for exploration and review the results of operation;
                            - 51 patients were operated on for known or suspected vascular injury, severe persistent pain or complete loss of
                                      function in the distribution of one or more elements of the brachial plexus;
                            - repair of the nerve and vascular lesions abolished, or significantly relieved, severe pain in 33 patients (94%);
                            - 36 patients underwent nerve graft of one or more elements of the plexus, good or useful results were obtained in 26 (72%);
                            - poor results were observed after repairs of the medial cord and ulnar nerve, and in patients with injury of  spinal cord;
                            - neurolysis of lesions in continuity produced good or useful results in 21 of 23 patients (91%);
                            - primary intervention is mandatory when there is evidence of a vascular lesion;
                            - intervention is indicated w/ debilitating pain, failure to progress and progression of the lesion while under observation;
                            - with nerve repair better results were seen in the roots C5, C6 and C7 and of the lateral and posterior cords, but
                                    prognosis for complete lesions of plexus associated with damage to cervical spinal cord is particularly poor;
                            - ref: Penetrating missile injuries of the brachial plexus
                    - consider hip aspiration followed by arthrogram to detect joint penetration;
                    - all transabdominal wounds require open debridement to ensure that the joint is free of bowel contaminants; 
                    - ref: The role of débridement in low-velocity gunshot wounds resulting in pelvis fractures: a retrospective review of acute infection and inpatient mortality.
           - knee joint:
                    - Intraarticular findings after gun shot wound through the knee.
                    - Arthroscopic debridement after intraarticular low-velocity gun shot wound.
                    - Low Velocity Gunshot Wounds Involving the Knee Joint: Surgical Management.  
                    - Gun shot wound to the knee.   
                    - Gunshot Wounds to the Knee

- Complications:
    - metal debris:
           - plumbism:
           - mecury exposure:
                  Pulmonary Emboli Caused by Mercury
           - references:
                  The reaction of copper and other projectile metals in body tissues.
                  Lead arthropathy: arthritis caused by retained intra-articular bullets.
    - infection:
           - historically infection has been most often due clostridia and beta hemolytic streptococci, both of which are sensitive to penicillins

Orthopaedic firearm injuries in children and adolescents: An eight-year experience at a major urban trauma center.

The Relationship Between Mechanisms of Wounding and Principles of Treatment of Missile Wounds.

Wound ballistics. A review of common misconceptions

A reconsideration of the wounding mechanism of very high velocity projectiles--importance of projectile shape.

Ballistic injury.

Bullet fragmentation: a major cause of tissue disruption.

Improper use of the term "shrapnel"

Ballistics and gunshot wounds: effects on musculoskeletal tissues.

Management of gunshot wounds of the limbs 

Slide Show: Gun Shot Wounds

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Monday, November 16, 2015 11:32 am

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