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Lunga Z, Laubscher M, Graham SM, Held M, Ferreira N, Magampa R, Maqungo S. Optimising the Orthopaedic Trauma Society Open Fracture Classification system: a proposal for modification in the context of high civilian gunshot fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1667-1674. [PMID: 38386124 PMCID: PMC10980626 DOI: 10.1007/s00590-024-03853-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 02/01/2024] [Indexed: 02/23/2024]
Abstract
OBJECTIVES Uniformly classifying long bone open fractures is challenging. The purpose of this study was to propose a modified Orthopaedic Trauma Society (OTS) Open Fracture Classification System, developed in a setting with a high incidence of civilian gunshot fractures. METHODS From our prospectively collected database, we identified all patients with open tibia and femur fractures treated with intramedullary nailing over a 4 year period. All open fractures were retrospectively reclassified from the Gustilo-Anderson Classification system to the OTS Open Fracture Classification System. RESULTS One hundred and thirty-seven cases were identified. Ninety per cent of subjects were males. Their mean age was 34 years. The most common mechanism of injury was low-velocity civilian gunshot wounds (GSW) in 54.7% of cases. Soft tissue management was primary closure in 23.4% and soft tissue reconstruction in 24.1%. In 52.6% of cases (these all being secondary to civilian GSW), soft tissue management was healing via secondary intention. This is not included as a soft tissue management option in the OTS classification system. Fracture reclassification using the OTS Open Fracture Classification System was only possible in 47.5% of cases (Simple in 23.4%, Complex B in 24.1%). CONCLUSION We conclude that the OTS Open Fracture Classification System is not inclusive of all open tibia and femur fractures as it does not cater for gunshot fractures. We propose a modification as follows: alter 'wound debridement' to 'appropriate wound care' and to subcategorise 'Simple' into type A and B: healing via secondary intention and primary closure, respectively.
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Affiliation(s)
- Zamalunga Lunga
- Orthopaedic Research Unit, Division of Orthopaedic Surgery, Groote Schuur Hospital, University of Cape Town, H49 Old Main Building, Observatory, Cape Town, 7925, South Africa.
- Division of Orthopaedic Surgery, Groote Schuur Hospital, Cape Town, South Africa.
| | - Maritz Laubscher
- Orthopaedic Research Unit, Division of Orthopaedic Surgery, Groote Schuur Hospital, University of Cape Town, H49 Old Main Building, Observatory, Cape Town, 7925, South Africa
- Division of Orthopaedic Surgery, Groote Schuur Hospital, Cape Town, South Africa
| | - Simon Matthew Graham
- Orthopaedic Research Unit, Division of Orthopaedic Surgery, Groote Schuur Hospital, University of Cape Town, H49 Old Main Building, Observatory, Cape Town, 7925, South Africa
- Oxford Trauma and Emergency Care. Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Liverpool Orthopaedic and Trauma Service, Liverpool University Teaching Hospital Trust, Liverpool, UK
| | - Michael Held
- Orthopaedic Research Unit, Division of Orthopaedic Surgery, Groote Schuur Hospital, University of Cape Town, H49 Old Main Building, Observatory, Cape Town, 7925, South Africa
- Division of Orthopaedic Surgery, Groote Schuur Hospital, Cape Town, South Africa
| | - Nando Ferreira
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Ramanare Magampa
- Orthopaedic Research Unit, Division of Orthopaedic Surgery, Groote Schuur Hospital, University of Cape Town, H49 Old Main Building, Observatory, Cape Town, 7925, South Africa
- Division of Orthopaedic Surgery, Groote Schuur Hospital, Cape Town, South Africa
| | - Sithombo Maqungo
- Orthopaedic Research Unit, Division of Orthopaedic Surgery, Groote Schuur Hospital, University of Cape Town, H49 Old Main Building, Observatory, Cape Town, 7925, South Africa
- Division of Orthopaedic Surgery, Groote Schuur Hospital, Cape Town, South Africa
- Division of Global Surgery, University of Cape Town, Cape Town, South Africa
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Antoni A, Maqungo S. Current concepts review: Management of civilian transpelvic gunshot fractures. Injury 2023; 54:111086. [PMID: 37827874 DOI: 10.1016/j.injury.2023.111086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 09/30/2023] [Accepted: 10/02/2023] [Indexed: 10/14/2023]
Abstract
INTRODUCTION Civilian gunshot fractures of the pelvic ring represent a unique challenge for orthopaedic surgeons due to a high incidence of complicating associated injuries. Internationally accepted guidelines for these injuries are not available. The aim of this review is to summarize the available literature and to provide concise management recommendations. METHODS Literature search was performed using PubMed. The review focuses on civilian gunshot fractures of the pelvic ring and includes the acetabulum and hip joint only where it was deemed necessary for the understanding of the management of these patients. RESULTS The management of civilian transpelvic gunshot fractures is complicated by potentially life-threatening associated injuries, the risk of contamination with bowel content and retained bullets in joints. The infection risk is higher compared to extremity gunshot fractures. There is no clear evidence for the use of antibiotics available. The studies focusing on civilian pelvic ring gunshot fractures reported no case of orthopaedic fracture fixation in their series. Routine wash-out and debridement of fractures is not warranted based on the literature but conflicting recommendations for surgical interventions exist. CONCLUSION There is limited evidence available for civilian transpelvic gunshot fractures. The high frequency of associated injuries requires a thorough clinical examination and multidisciplinary management. We recommend routine antibiotic prophylaxis for all transpelvic gunshots. For fractures with a high risk of infection, a minimum of 24 h broad-spectrum antibiotics is recommended. The indication for orthopaedic fixation of civilian transpelvic gunshot fractures is based on the assessment of the stability of the fracture and is rarely necessary. Although conflicting recommendations exist, routine wash-out and debridement is not recommended based on the literature. Bullets buried in bone without contact to synovial fluid do not warrant removal, unless they have traversed large bowel and are accessible without undue morbidity. Furthermore, bullets should be routinely removed if they are retained in the hip joint, if mechanical irritation of soft tissues by projectiles is expected or if the bullet traversed large bowel before entering the hip joint.
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Affiliation(s)
- Anna Antoni
- University of Cape Town, Division of Orthopaedic Surgery, Private Bag X3, Rondebosch, 7701, Cape Town, South Africa; Medical University of Vienna, Department of Orthopaedics and Trauma-Surgery, Spitalgasse 23, 1090 Vienna, Austria
| | - Sithombo Maqungo
- University of Cape Town, Division of Orthopaedic Surgery, Private Bag X3, Rondebosch, 7701, Cape Town, South Africa; University of Cape Town, Division of Global Surgery, Private Bag X3, Rondebosch, 7701, Cape Town, South Africa.
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Wolf JM, Mathieu L, Tintle S, Wilson K, Luria S, Vandentorren S, Boussaud M, Strelzow J. A global perspective on gun violence injuries. Injury 2023:S0020-1383(23)00392-3. [PMID: 37183087 DOI: 10.1016/j.injury.2023.04.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 04/26/2023] [Accepted: 04/27/2023] [Indexed: 05/16/2023]
Abstract
INTRODUCTION AND DEFINITIONS Civilian gunshot violence is a growing public health issue on a global scale. Treatment of patients with gunshot injuries is based on algorithms derived from military studies, but the distinct differences in weaponry, energy of injury, timing and type of care, and environment translate to a gap in knowledge. With a focus on non-accidental gunshot trauma and excluding suicide etiologies, we propose to build a collaborative research group to address important questions focused on best practices for gunshot injury patients. PRE-HOSPITAL CARE There are important differences in the care of gunshot victims across the globe; some countries provide advanced interventions in the field and others deliver basic support until transport to a higher level of care in hospital. Some simple interventions include the use of extremity tourniquets and intravenous fluid support; others to consider are tranexamic acid, whole blood, and hemostatic agents. ACUTE TREATMENT Control of exsanguinating hemorrhage is a key priority for gunshot injuries. Military doctrine has evolved to prioritize exsanguination over airway or breathing as the critical first step. The X-ABC protocol focuses on exsanguinating hemorrhage, then standard evaluation of Airway, Breathing and Circulation (ABCs) to enhance survival in trauma patients. The timing of bony stabilization, in terms of damage-control vs definitive care, needs further study in this population, as does use of antibiotics for bony extremity injuries. Finally, recognition of the mental health effects of gun trauma, including post-traumatic stress disorder (PTSD), anxiety disorders, substance abuse and depression is important in advocating for prevention such as implementation of social support and specific interventions. DEFINITIVE CARE The need for abdominal closure after exploratory laparotomy, definitive fracture treatment, and other treatment all contribute to length of stay for gunshot injured patients. Optimizing stabilization allows earlier mobilization and decreases nosocomial complications. Nerve injuries are often a source of long-term disability and their evaluation and treatment require further investigation. RESOURCES AND ETHICS There are growing numbers of mass-casualty gunshot events, which require consideration of how to organize and use resources for treatment, including staff, operating room access, blood products, and order of treatment. Drills and planning for incident command hierarchy and communication are key to optimizing resource utilization. The ethics of choosing treatment priorities and resources are important considerations as well.
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Affiliation(s)
- Jennifer Moriatis Wolf
- Department of Orthopaedic Surgery, Hand Surgery Fellowship, University of Chicago Medicine, 5841 S. Maryland Avenue, Room P211, Chicago, IL 60637, USA.
| | - Laurent Mathieu
- Department of Hand and Upper Extremity Surgery, Edouard Herriot Hospital, 5 place d'Arsonval, Lyon 69003, France; Department of Surgery, French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France
| | - Scott Tintle
- Department of Orthopedic Surgery, Walter Reed National Military Medical Center, MD, USA
| | - Kenneth Wilson
- Division of Trauma Surgery, Department of Surgery, University of Chicago Medicine, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
| | - Shai Luria
- Hand and Microvascular Surgery, Hadassah University Hospital, Kiryat Hadassah, POB 12000, Jerusalem 91120, Israel
| | - Stephanie Vandentorren
- Direction Scientifique et International, Santé Publique France, INSERM UMR 1219, Bordeaux Population Health Research Center, PHARes Team, University of Bordeaux, Bordeaux, France; Centre National de Ressources et de Résilience Lille-Paris (CN2R), Lille, France
| | - Marie Boussaud
- Department of Psychiatry, Percy Military Hospital, 101 Avenue Henri Barbusse, Clamart 92140, France
| | - Jason Strelzow
- Department of Orthopaedic Surgery, Hand Surgery Fellowship, University of Chicago Medicine, 5841 S. Maryland Avenue, Room P211, Chicago, IL 60637, USA
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Epidemiology of ballistic fractures in the United States: A 20-year analysis of the Firearm Injury Surveillance Study. Injury 2022; 53:3663-3672. [PMID: 36130861 DOI: 10.1016/j.injury.2022.09.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/25/2022] [Accepted: 09/11/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Ballistic (i.e., gunshot-induced) fractures present unique treatment challenges and can be associated with high rates of complications and considerable morbidity. Large-scale epidemiologic data on these types of fractures are scarce. There is concern that gun-related violence may be on the rise, potentially increasing the burden of ballistic orthopaedic trauma, but there are few contemporary studies on the topic. The aim of this study, therefore, was to investigate the incidence and demographics of patients with ballistic fractures in the United States (US) over the last 20 years. MATERIALS AND METHODS This descriptive epidemiology study retrospectively analyzed the Firearm Injury Surveillance Study to identify cases of ballistic fractures in the US from 2000 to 2019. Overall and annual numbers of fractures and fracture incidence rates (IRs), patient demographics, incident characteristics, and temporal trends were analyzed. Patients of all ages were included. Ballistic fractures were grouped by anatomic location for comparisons (non-spine axial, spine, upper extremity, lower extremity). RESULTS An estimated N = 240,555 patients (n = 8,322 unweighted cases) sustained ballistic fractures over the 20-year study period for an overall IR of 39.2 per 1,000,000 person-years at-risk (PYR). Overall, lower extremity fractures accounted for the largest percentage of cases (45.9%; IR=18.8 PYR), followed by upper extremity fractures (32.8%; IR=13.4 PYR), non-spine axial fractures (16.1%; IR=6.6 PYR), and spine fractures (5.2%; IR=2.1 PYR). Diaphyseal femur fractures were the most common ballistic fractures overall. Nearly three-fourths (71.2%) of all cases occurred in males in the second through fourth decades. The most common injury intent was assault (71.8%) and a majority of patients (71.2%) required hospital admission. Accounting for population growth yielded a significantly increasing incidence of all ballistic fractures over the study period from 15.7 PYR in 2000 to 96.8 PYR in 2019 (average annual percent change=10.3, p < 0.00001). CONCLUSION These data suggest that the nationwide burden of ballistic fractures in the US has increased significantly in the last two decades. Ballistic fractures are associated with significant morbidity and societal cost, and increasing injury rates highlight the need for future research aimed at better understanding the ideal treatment of these types of fractures and their outcomes.
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Early outcomes of surgically managed civilian gunshot femur fractures at a level one trauma unit in Cape Town, South Africa: a retrospective review. Eur J Trauma Emerg Surg 2022; 49:859-865. [PMID: 36253481 DOI: 10.1007/s00068-022-02138-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 10/10/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE To assess the outcome of surgically fixated femur shaft and distal femur fractures following low-velocity civilian gunshot injuries over a 4-year period. METHODS A retrospective review was conducted on all patients who sustained femur shaft and distal femur fractures from civilian low-velocity gunshot injuries that required definitive surgical fixation between January 2014 and December 2017. Patient demographics, comorbidities, injury characteristics, duration between injury and surgical fixation and presence of complications were captured. RESULTS A total of 122 patients (mean age, 29.1 ± 9.5 years) were included. Supracondylar femur fractures (AO 33) accounted for 49% of total injuries, followed by femoral shaft (AO 32) and intra-articular distal femur fractures (AO 33 B & C) with 40% and 11%, respectively. Intramedullary nail fixation was the choice of treatment for femur shaft fractures (49.98%) and supracondylar fractures (63%). Intra-articular injuries were predominantly treated with distal femoral locking plates (85%). Arterial and nerve injuries were the most commonly encountered associated injuries occurring in five patients (4.1%) each. Fracture-related infection was diagnosed in two patients (1.6%). No cases of non-union and compartment syndrome were recorded. CONCLUSION Femur shaft and supracondylar fractures fixated with intramedullary nails are associated with low complication rates and perfect union rates. Our study suggests that intra-articular distal femur fractures fixated with locking plates and cannulated screws have a high complication rate and poorer surgical outcomes. Non-union and compartment syndrome are rare complications of gunshot femur fractures fixated with either intramedullary nails or locking plates.
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Abstract
Recovery from injury involves painful movement and activity, painful stretches and muscle strengthening, and adjustment to permanent impairment. Recovery is facilitated by embracing the concept that painful movement can be healthy, which is easier when one has more hope, less worry, and greater social supports and security. Evolution of one's identity to match the new physical status is a hallmark of a healthy outcome and is largely determined by mental and social health factors. When infection, loss of alignment or fixation, and nerve issues or compartment syndrome are unlikely, greater discomfort and incapability that usual for a given pathology or stage of recovery signal opportunities for improved mental and social health. Surgeons may be the clinicians most qualified to make this discernment. A surgeon who has gained a patient's trust can start to noticed despair, worry, and unhelpful thinking such as fear of painful movement. Reorienting people to greater hope and security and a healthier interpretation of the pains associated with the body's recovery can be initiated by the surgeon and facilitated by social workers, psychologist, and physical, occupational and hand therapists trained in treatments that combine mental and physical therapies.
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Cornelissen AJ, Ferreira N, Burger MC, Jordaan JD. Proximal femur anatomy-implant geometry discrepancies. SICOT J 2022; 8:5. [PMID: 35244535 PMCID: PMC8895924 DOI: 10.1051/sicotj/2022004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/04/2022] [Indexed: 11/14/2022] Open
Abstract
Objectives: Due to ongoing concern about femur anatomy-implant mismatches, this cross-sectional study aimed to create a geometric femur profile and used it to identify and quantify possible mismatches between femur anatomy and cephalomedullary nail dimensions. The work further aimed to assess whether patient demographics affect anatomy-implant coherence. Methods: One hundred skeletally mature complete femur computer tomography (CT) scans were collected and exported to software enabling landmark placement and measures with multiplanar reconstruction techniques. Results: Clinically relevant anatomy-implant discrepancies included the femur neck and shaft axis offset 6.1 ± 1.7 mm (95% CI [5.7–6.4]), femur radius of curvature 1.2 ± 0.3 m (95% CI [1.1–1.2]), femur anteversion 18.8 ± 9.2 (95% CI [16.9–20.6]). The implants reviewed in this study did not compensate for the femur neck and shaft axis offset and had a larger radius of curvature than the studied population. Clinically significant demographic geometry differences were not identified. Conclusion: There were discrepancies between femur anatomy and cephalomedullary nail implant design; however, no clinically significant femur feature inconsistency was identified among the demographic subgroups. Due to the identified anatomy-implant discrepancies, including the femur neck and shaft axis offset, we suggest that these measurements be considered for future implant design and surgical technique.
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Affiliation(s)
- Andries Johannes Cornelissen
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
| | - Nando Ferreira
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
| | - Marilize Cornelle Burger
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
| | - Jacobus Daniel Jordaan
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
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Laubscher M, Ferreira N, Birkholtz FF, Graham SM, Maqungo S, Held M. Civilian gunshot injuries in orthopaedics: a narrative review of ballistics, current concepts, and the South African experience. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:923-930. [PMID: 33760996 DOI: 10.1007/s00590-021-02934-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/08/2021] [Indexed: 11/30/2022]
Abstract
The incidence of civilian gunshot injuries is on the rise worldwide.Unfortunately, there is a lack of high-level evidence guiding management. The treatment of orthopaedic injuries from gunshots is complex and requires consideration of multiple aspects, including energy transfer to the tissue, severity of the wound, possible contamination, presence of fractures and associated injuries. With this narrative review we aim to discuss some of the relevant ballistics, current concepts, and controversies in the general management of civilian gunshot-related orthopaedic injuries based on the available evidence and personal experience. Important points which will be highlighted are the initial management in the emergency room, the assessment and management of soft tissue injuries, associated injuries, use of antibiotics, indication and techniques for fracture fixation, and gunshot injuries to joints.
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Affiliation(s)
- Maritz Laubscher
- Orthopaedic Research Unit, Division of Orthopaedic Surgery, H49 OMB, Groote Schuur Hospital, University of Cape Town, Cape Town, 7925, South Africa.
| | - Nando Ferreira
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, 7505, South Africa
| | - Franz Friedrich Birkholtz
- Walk-A-Mile Centre and Department of Orthopaedics, University of Pretoria, Pretoria, 0002, South Africa
| | - Simon Matthew Graham
- Orthopaedic Research Unit, Division of Orthopaedic Surgery, H49 OMB, Groote Schuur Hospital, University of Cape Town, Cape Town, 7925, South Africa.,Institute of Population Health Sciences, University of Liverpool, Liverpool, UK.,Department of Orthopaedic and Trauma Surgery, Liverpool University Teaching Hospital Trust, Liverpool, UK
| | - Sithombo Maqungo
- Orthopaedic Research Unit, Division of Orthopaedic Surgery, H49 OMB, Groote Schuur Hospital, University of Cape Town, Cape Town, 7925, South Africa
| | - Michael Held
- Orthopaedic Research Unit, Division of Orthopaedic Surgery, H49 OMB, Groote Schuur Hospital, University of Cape Town, Cape Town, 7925, South Africa
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