Gunshot and blast injuries of the extremities: a review of 45 cases

The Epidemiology, Management, and Outcomes of Civilian Gunshot Wounds to the Upper Extremity at an Urban Trauma Center

Background

Gunshot wounds (GSWs) create significant morbidity in the United States. Upper extremity (UE) GSWs are at high risk of combined injuries involving multiple organ systems and may require variable treatment strategies. This study details the epidemiology, management, and outcomes of civilian UE GSWs at an urban level 1 trauma center.

Methods

Using the University of Pennsylvania Trauma Registry, all adult patients with UE GSWs from 2015 to 2020 who were at least 6-months postinjury were studied for demographics, injury pattern, operative details, and postoperative outcomes. Fisher exact and Wilcoxon rank sum tests were used to determine differences in treatment modalities and outcomes.

Results

In 360 patients, the most common victim was young (x̄ = 29.5 y old), African American (89.4%), male (94.2%), and had multiple GSWs (70.3%). Soft tissue-only trauma (47.8%) and fractures (44.7%) predominated. Presence of fracture was independently predictive of neurologic, vascular, and tendinous injuries (P < 0.001). Most soft tissue-only injuries were managed nonoperatively (162/173), whereas fractures frequently required operative intervention (115 of 161, P < 0.001). Despite a prevalence of comminuted (84.6%) and open (43.6%) fractures, hardware complications (7.5%) and wound infection (1.1%) occurred infrequently.

Conclusions

Civilian GSWs to the UE with only soft tissue involvement can often be managed conservatively with antibiotic administration, bedside washout, and local wound care. Even with combined injuries and open fractures, single-stage operative debridement and fracture care with primary or secondary closure often prevail. As civilian ballistic trauma becomes more frequent in the United States, these data help inform patient expectations and guide management.

Surgery as an Effective Therapy for Ulnar Nerve Neuropathic Pain Caused by Gunshot Wounds: A Retrospective Case Series

BACKGROUND

Peripheral nerve injuries remain a major medical problem worldwide and are associated with multiple causes, including gunshot wounds (GSWs), which are the second most common cause of brachial plexus injuries in peacetime and the main, or only, cause reported in wartime studies. The ulnar nerve (UN) is one of the most affected nerves. Peripheral nerve trauma may cause intense neuropathic pain, which is very difficult to control. Particularly UN gunshot injuries may impact individual daily life, as injuries to this nerve result in both sensory and motor deficits within the hand. We evaluated the improvement of neuropathic pain after surgical treatment in a consecutive series of 20 patients with UN injury due to GSWs.

METHODS

This single-center, retrospective, consecutive case series included 20 patients with UN injuries due to GSWs, who presented with excruciating neuropathic pain and underwent surgical treatment between 2005 and 2017.

RESULTS

Of injuries, 13 occurred in the right upper limb (65%); 12 patients had a high UN injury (60%). Regarding associated injuries, 8 patients had bone injuries (40%), and 4 patients had arterial injuries (20%). A neuroma in continuity was detected in 8 cases (40%), and 4 patients (20%) had shrapnel lodged within the UN. All patients had severe neuropathic pain and functional deficit, with a mean visual analog scale score of 8.45 ± 1.4 and a mean reduction of 6.95 points 12 months after surgery; 10 patients (50%) had a British Medical Research Council score ≥M3.

CONCLUSIONS

Surgery is an effective treatment for neuropathic pain from GSWs. Early isolated external neurolysis is associated with better pain management and functional outcomes postoperatively.

The Role of Plastic Surgeons in Addressing Firearm Morbidity and Mortality

Firearm injuries are now the leading cause of pediatric mortality in the United States. With the number of firearm injuries increasing at an alarming rate, the American Medical Association (AMA) declared firearm violence a public health crisis. In response to this emerging public health issue, the American College of Surgeons (ACS) developed the STOP THE BLEED training to educate laypersons on how to mitigate acute hemorrhage following gunshot wounds (GSWs) and other ballistic injuries. Stabilization of patients following GSWs is often handled by a multidisciplinary team of trauma and reconstructive surgeons. Here, we describe the history and ongoing role of reconstructive surgeons in preventing and addressing firearm morbidity and mortality. Hand surgeons are uniquely positioned to counsel patients on firearm safety, e.g., educating patients on proper firearm storage away from minors in the home, in an effort to mitigate accidental firearm injury to the upper extremity. As the evolving climate of firearm violence continues to rise, plastic and reconstructive surgeons will continue to play a critical role in restoring form and function among patients afflicted with GSWs.

Epidemiological characteristics and comparative outcome of blast versus gunshot injuries of the extremities in Somalia

BACKGROUND

War conflicts and terror-related injuries constitute a significant public health problem in Somalia. We aim to characterize and compare the injury characteristics of gunshot and blast injuries of the extremities.

METHODS

The data of 333 patients with gunshot and blast injuries of the extremities over three years were retrospectively reviewed. The demographics, injury characteristics, and outcomes were analyzed.

RESULTS

Most of the patients had injuries due to gunshot casualties compared with blast victims (n = 222, 66.7% vs. n = 111, 33.3%). Patients with gunshot wounds (GSW) had a more significant proportion of males than those with blast wounds (BW) (95.5% vs. 85.6%, P < 0.001). There were more open extremity fractures in GSW casualties (96.4% vs. 81.1%). The BW victims had significantly higher associated injuries (52.3% vs. 18.5%, P < 0.001). The BW group had a higher injury severity score (ISS ≥ 16 in 55%, P < 0.001). The need for an intensive care unit (ICU) admission was significantly higher in the BW patients (18% vs. 6.3%, P < 0.001); as well as the length of hospital stay (LOS) was higher in the BW group compared with the GW patients (> 2-week hospital stay in 31% vs. 19%, P < 0.04). About a 2.7% mortality rate was observed in BW (P < 0.014).

CONCLUSION

Gunshot and explosion injuries comprise the majority of war and terror-related trauma of the extremities. These injury mechanisms differ in the body regions involved, the severity of the injury, duration of hospital stay, need for ICU admission, and mortality. Assessment and management of such devastating casualties require a complex and multidisciplinary approach.

Treatment of upper extremity palsies, gunshot wounds and scaphoid nonunion: my preferred approaches

The article reviews key considerations and our preferred methods in treating upper extremity palsies, gunshot wounds and scaphoid nonunion. For these three difficult conditions, I highlight the importance of a team approach when treating upper extremity neuromuscular disease, flexibility and creativity when treating gunshot wounds, and my personal protocol for dealing with scaphoid fracture nonunions.Level of evidence: V.

Upper extremity firearm injuries: epidemiology and factors predicting hospital admission

INTRODUCTION

Civilian gun violence is a public health crisis in the USA that will be an economic burden reported to be as high as $17.7 billion with over half coming from US taxpayers dollars through Medicaid-related costs. The purpose of this study is to review the epidemiology of upper extremity firearm injuries in the USA and the associated injury burden.

METHODS

The Inter-university Consortium for Political and Social Research's Firearm Injury Surveillance Study database, collected from the National Electronic Injury Surveillance System, was queried from 1993 to 2015. The following variables were reviewed: patient demographics, date of injury, diagnosis, injury location, firearm type (if provided), incident classification, and a descriptive narrative of the incident. We performed chi-square testing and complex descriptive statistics, and binomial logistic regression model to predict factors associated with hospital admission.

RESULTS

From 1993 to 2015, an estimated 314,369 (95% CI: 291,528-337,750; 16,883 unweighted) nonfatal firearm upper extremity injuries with an average incidence rate of 4.76 per 100,000 persons (SD: 0.9; 03.77-7.49) occurred. The demographics most afflicted with nonfatal gunshot wound injuries were black adolescent and young adult males (ages 15-24 years). Young adults aged 25-34 were the second largest estimate of injuries by age group. Hands were the most commonly injured upper extremity, (55,014; 95% CI: 75,973-89,667) followed by the shoulder, forearm, and upper arm. Patients who underwent amputation (OR: 28.65; 95% CI: 24.85-33.03) or with fractures (OR: 26.20; 95% CI: 23.27-29.50) experienced an increased likelihood for hospitalization. Patients with a shoulder injury were 5.5× more likely to be hospitalized than those with a finger injury (OR:5.57; 95% CI:5.35-5.80). The incidence of upper extremity firearm injuries has remained steady over the last decade ranging between 4 and 5 injuries per 100,000 persons. Patients with proximal injuries or injuries involving the bone were more likely to require hospital admission. This study should bring new information to the forefront for policy makers regarding gun violence.

[Treatment of victims with mine-explosive injuries]

OBJECTIVE

To study the incidence and structure of combat gunshot surgical trauma received during the 2^nd Karabakh War and to analyze the results of treatment of these victims.

MATERIAL AND METHODS

We analyzed surgical treatment of 60 victims with combat gunshot surgical trauma received during the 2^nd Karabakh war. In 25 (41.7%) victims, injury occurred as a result of mine-explosive trauma. These victims were divided into 3 groups depending on mechanism of mine-explosive injury. The 1^st group included 7 (28%) patients who received mine-explosive injury due to indirect (propelling) effect of blast wave. The 2^nd group included 14 (56%) victims in whom mine-explosive injury was caused by non-contact (distant) impact of mine fragments. The 3^rd group consisted of 4 (16%) patients whose mine-explosive injuries were caused by direct impact of explosion factors on various anatomical areas. Patients were also ranked into 3 groups depending on the nature and severity of mine-explosive injury: wounded with isolated injuries (n=16, 64%), wounded with concomitant injuries (n=2.8%), wounded with combined and multiple injuries (n=7, 28%).

RESULTS

Most patients underwent organ-sparing procedures. Resections were performed only in 4 cases (splenectomy - 3, nephrectomy - 1). Postoperative complications developed in 23 (38.3%) wounded (suppuration of postoperative wounds - 13, post-traumatic pleuritis - 5, clotted hemothorax - 2, subphrenic abscess - 1, phlegmon of perineum and perianal region - 2). Mortality rate was 1.7%.

CONCLUSION

Timely sorting and evacuation of victims, early qualified surgical care and correct postoperative management with monitoring of vital functions can improve the results of treatment of victims with mine-explosive trauma. Autologous skin grafting for extensive defects and closure of colostomy with restoration of colon continuity were essential in rehabilitation of these patients.

Pediatric upper extremity firearm injuries: an analysis of demographic factors and recurring mechanisms of injury

BACKGROUND

Little is known regarding risk factors specific to pediatric upper extremity firearm injuries. The purpose of this study is to evaluate pediatric patients treated for these injuries to identify at-risk populations and recurring mechanisms of injury.

METHODS

A 20-year retrospective review was conducted. Patients 17 years of age and younger, with upper extremity injuries related to a firearm, were included. Analysis involved Fisher's exact and Chi-square tests.

RESULTS

One hundred and eighty patients were included. The mean age was 12.04 ± 4.3 years. Most included patients were male (85%). Interestingly, females were more frequently victims of assault (P = 0.03), and males were more frequently injured due to accidental discharge (P < 0.001). The most affected race/ethnicity was White-not Hispanic or Latino (48%). The hand was the most frequent location injured (31%) and was more likely to be accidental than proximal injuries (P = 0.003). Air rifles were the most common firearm type used (56%). Pistols were implicated in 47 (26%) cases, rifles in 17 (9%), and shotguns in 10 (6%). Ninety-nine (55%) patients had procedures in the operating room. The most frequent procedure was foreign body removal (55%).

CONCLUSIONS

Risk factors such as male sex, White-not Hispanic or Latino race/ethnicity, and adolescent age were attributed to increased risk for injury. Male sex was associated with increased risk of injury by accidental discharge and female sex with intentional assault. Air rifles were the most common firearm type overall, although female sex was associated with increased risk for injury by powder weapon.

Epidemiology of Upper Extremity Firearm Injuries among Major Trauma Hospitals in the United States

BACKGROUND

As many as 34 percent of nonfatal firearm injuries involve the upper extremity. Although not lethal, these injuries cause substantial morbidity. The authors conducted an epidemiologic study characterizing upper extremity firearm-related injuries presenting to U.S. trauma centers over a 10-year period.

METHODS

The authors used the National Trauma Databank from 2007 to 2017 to identify isolated upper extremity firearm-related injuries. Descriptive statistics were performed to characterize patient demographic data, firearm type, extremity injury patterns, treatments received, hospital length of stay, and regional variation.

RESULTS

The authors identified 48,254 upper extremity firearm-related injuries. The patients were largely male patients (85 percent), and over half were between the ages of 20 and 39 years. Handguns (34 percent) were the most frequently used firearm. Shoulder and upper arm were the most frequently injured areas (54 percent); however, 18 percent of patients injured two or more areas. Patients were most often treated at university hospitals (59 percent) with Level I or II trauma designation. Seventy percent were admitted and/or taken directly to the operating room. The mean hospital length of stay was 3 days. Payer mix among these patients was variable: Medicaid, 20 percent; private insurance, 20 percent; and self-pay, 29 percent.

CONCLUSIONS

Upper-extremity firearm injuries are resource intensive, with three-quarters of patients requiring operative intervention and/or hospitalization. Level I and II trauma centers were the site of care for the majority of patients. Targeted gun policy reform and prevention measures directed toward at-risk groups have the potential to limit the unnecessary morbidity and costs associated with these injuries.

Surgical Treatment of Upper Extremity Gunshot Injures: An Updated Review

INTRODUCTION

Firearm morbidity and mortality have been increasing in recent years, and with this, the demand for medical personnel firearm injury treatment knowledge. Extremities contribute to a majority of firearm injuries, with these injuries being particularly complex because of neurovascular proximity within a confined space. Knowledge of firearm mechanism of injury and treatment management options is important for any trauma hand surgeon. Many factors play vital roles in the treatment of complex upper extremity (UE) gunshot wounds (GSWs). The aim of our review and case illustrations is to provide hand surgeons with an up-to-date guide for initial emergent management, soft tissue, bony, and nerve repair and reconstruction.

PATIENT AND METHODS

A literature review was conducted in the current management of UE GSW injuries, and 2 specific patient case examples were included. High-energy versus low-energy GSWs were documented and compared, as well as containment injures. Management including soft tissue, bony, and nerve injuries was explored along with patient outcome. Based on these findings, guidelines for GSW management were purposed.

CONCLUSION

Gunshot wounds of the UE encompass a group of highly heterogeneous injuries. High-energy wounds are more extensive, and concomitant injuries to bone, vessel, nerve, muscle, and soft tissue are common. Early treatment with adequate debridement, skeletal fixation, and soft tissue coverage is indicated for complex injuries, and antibiotic treatment in the pre-, peri-, and postoperative period is indicated for operative injuries. Soft tissue coverage options include the entire reconstructive ladder, with pattern of injury and considerations of wound characteristics dictating reconstructive choice. There are arguments to using either external or internal bony fixation techniques for bone fracture management, with choice tailored to the patient. For management of nerve injuries, we advocate earlier nerve repair and a shorter duration of observation before secondary reconstruction in selective cases. If transected nerve endings cannot be brought together, nerve autografts of shorter length are recommended to bridge nerve ending gaps. A significant number of patients with GSW fail to make necessary follow-up appointments, which adds to challenges in treatment.

Epidemiology of orthopaedic fractures due to firearms

The majority of firearm injuries involve the extremities and have concomitant orthopaedic injuries. National data on the epidemiology of wounds caused by firearms may better inform physicians and identify areas of public health intervention. We conducted an analysis of a national database to describe the epidemiology of orthopaedic firearm injuries in the United States. The Nationwide Inpatient Sample 2001-2013 database was queried for adult patients with fractures excluding those of the skull using injury billing codes. Characterization of injury was determined using External Cause of Injury billing codes. Sociodemographic and geographic variables were reported. Chi square and multinomial logistic regression analyses were performed to identify predictors of type of firearm implicated in injury. 334,212 firearm injuries were reported in the database and about half had concomitant orthopaedic fractures. Most patients were between the ages 19 and 29, were African American, and were male. The most frequent circumstance of injury was assault/homicide, the most common firearm used was a handgun, and the most common fracture site was the femur. Patients without insurance and patients of lower income were most commonly afflicted. Knowing this distribution of the burden of this class of injury provides the opportunity to identify and intervene on behalf of at-risk populations, potentially reducing injuries by promoting firearm safety to these groups and advocating sensible practices to reduce inequitable outcomes caused by these injuries.

High Velocity Gunshot Fractures of Humerus: Results of Primary Plate Osteosynthesis

BACKGROUND

High velocity gunshot fractures usually seen in conflict zones, often mandate external fixation due to delayed presentation and associated contamination. In the presented observational study, we managed high velocity gunshot fractures of humerus with adequate debridement and primary plate osteosynthesis under controlled conditions with gratifying results.

MATERIAL AND METHODS

Eighteen consecutive cases of fracture of the humerus secondary to high velocity gunshot wounds with ages ranging from 28 to 45 years reporting within 6 h of the initial injury formed our study group. Immediate debridement, lavage and primary plate osteosynthesis was carried out following hemodynamic stabilisation and intravenous antibiotics. All the cases were followed up at 2, 4, 6 months, 1 year and then annual follow-up including telephonic follow-up for six patients.

RESULTS

Fifteen cases of Gustillo Anderson type III A, two of type III B and one of type III C were managed with primary plate osteosynthesis. Brachial artery injury was addressed immediately, however injured radial nerve ends were tagged. Five cases showed delayed/non-union and were managed with decortication and autologous bone grafting. Two cases of deep infection could be managed with implant retention till union. The implants were removed following fracture consolidation. All the fractures united and no patient was left with sequelae of chronic infection.

CONCLUSION

Timely presentation of high velocity gunshot fractures of humerus teamed up with adequate debridement, soft tissue management and primary plate osteosynthesis can offer satisfactory outcomes. Associated vascular injury needs immediate attention. Nerve injuries can be addressed in a staged procedure. Our results have been satisfactory and add to the scant literature available on the subject, however further studies are warranted.

Management of upper extremity war injuries in the subacute period: A review of 62 cases

OBJECTIVE

In this study, we aimed to describe the relationship between the localization of rarely seen upper extremity war injuries and their complications in the subacute period, and define our preferences for surgery and antibiotic use.

METHODS

Patients with an upper extremity war injury who presented to our institution between 2015 and 2018 were retrospectively evaluated. Data regarding demographics, time between injury and presentation, location of injury, type of damage, complications, treatment methods, infection rates and antibiotic use were recorded. Tissue defects, fracture fixation, neurovascular damage, infection development and treatment approaches were analyzed.

RESULTS

Sixty-two male patients with isolated upper extremity injuries (mean age: 31.66 ± 8.28 years) were included in the study. The average time between trauma and hospitalization was 14 days. The mean hematocrit (Hct) level at presentation was 36.3 ± 6.8%. Patients had been followed up for an average period of 95.6 ± 32.1 days. Twenty-nine patients (46.8%) had nerve injury, eight (12.9%) had arterial injury that required repair, and 23 had infection (37.1%), of which five developed osteomyelitis. Infection was polymicrobial in nine cases and monobacterial in 14. A positive correlation was found between the presence of fracture and nerve injury (p = 0.013). The frequency of nerve injuries due to gunshot wounds was higher in the mid-section and lower part of the arms and in the proximal forearm when compared to other regions (p = 0.011). The infection rates were significantly higher in patients with fractures (p = 0.033). The mean hematocrit (Hct) level at presentation of the patients with infection (32.1 ± 6.3%) was significantly lower than that of those who did not have infection (38.8 ± 5.9%) (p<0.001).

CONCLUSION

Upper extremity war injuries require case-specific solutions. Microbiological samples should be taken prior to empirical antibiotic treatment for infection management and rational antibiotic use principles should be applied according to the culture and antibiogram results. The holistic and ambiguous character of nerve injuries often requires early exploration and combined reconstructive interventions. Arterial injuries can be overlooked by physical examination alone and thus routine angiography should be performed. Completion of the bone and soft tissue reconstructions in the same session using a holistic approach minimizes the possible risks.