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Olson A, Khan U, Wagner L, Davidson V, Diedring B, Bandovic I, Knapp PW, Fahs A, Afsari A, Best B. Low energy gunshot injuries: Does removal of retained bullet fragmentation at the time of internal fixation reduce the risk of fracture related infection? Injury 2024; 55:111423. [PMID: 38422763 DOI: 10.1016/j.injury.2024.111423] [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: 09/10/2023] [Revised: 02/03/2024] [Accepted: 02/09/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVE To examine the effects of RBF (Retained Bullet Fragment) removal at the time of long bone fixation on FRI (fracture related infection) rates in low energy GSI (Gunshot Injury) related fractures. DESIGN Retrospective Cohort Study SETTING: Level 1 Academic Trauma Center INTERVENTION: Retrospective review of the impact of RBFs on the risk of FRI when employing internal fixation in low energy GSI (Gunshot Injury) related fractures. In situations where the injury pattern requires surgical fixation, the question arises as to whether or not the RBFs need to be removed to prevent FRI. MAIN OUTCOME MEASURES Whether or not the RBFs removed in our patient population prevented short- and long-term fracture related infection after low-energy gunshot injury (FRI-LGI). RESULTS Of the 2,136 GSI related fractures, 131 patients met inclusion criteria, 81 patients underwent removal (R) of RBFs at the time of internal fixation while 50 patients did not undergo any removal (NR) at time of internal fixation. Among the patients who underwent surgical intervention, (Open Reduction Internal Fixation) ORIF was performed in 55 cases (R: 39; NR: 16), and (Intramedullary Nail) IMN was performed in 76 cases (R: 42; NR: 34). The overall rate of deep FRI-LGI was 6.9 % of the 131-patient cohort. We found that removal of RBFs had a statistically significant impact on the rate of deep FRI-LGI when compared to the NR group (p = 0.031). In the RBF removal group, only two patients (2.4 %) developed deep FRI-LGIs, whereas in the NR group, seven patients (14.0 %) developed deep FRI-LGIs. The incidence of early FRI-LGI was higher in the NR group (median 0.6 months) compared to the R group, which was associated with late FRI-LGIs (median 10.1 months) when they occurred. DISCUSSION In our study population, we found a statistically significantly increased incidence of deep and early FRI-LGI when RBFs are not removed at the time of extra-articular long bone internal fixation. The presence of retained bullet fragments following internal fixation may pose a risk factor for future development of deep FRI-LGI. We believe a surgeon should use their best judgment as to whether a RBF can safely be removed at the time of long bone fixation. Based on our findings, if safely permitted, RBF removal should be considered at the time of GSI long bone fixation resulting from low energy hand gun injuries.
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Affiliation(s)
- Adrian Olson
- Department of Orthopaedic Surgery, Ascension Macomb-Oakland Hospital, 27351 Dequindre Rd, Madison Heights, MI 48071, USA
| | - Usher Khan
- Department of Orthopaedic Surgery, Ascension Providence, 16001W Nine Mile Rd, Southfield, MI 48075, USA
| | - Lianne Wagner
- Department of Orthopaedic Surgery, Ascension Macomb-Oakland Hospital, 27351 Dequindre Rd, Madison Heights, MI 48071, USA
| | - Valerie Davidson
- Department of Orthopaedic Surgery, Ascension Macomb-Oakland Hospital, 27351 Dequindre Rd, Madison Heights, MI 48071, USA
| | - Benjamin Diedring
- Department of Orthopaedic Surgery, Ascension Macomb-Oakland Hospital, 27351 Dequindre Rd, Madison Heights, MI 48071, USA
| | - Ivan Bandovic
- Department of Orthopaedic Surgery, Ascension Macomb-Oakland Hospital, 27351 Dequindre Rd, Madison Heights, MI 48071, USA
| | - Paul W Knapp
- Department of Orthopaedic Surgery, Ascension Macomb-Oakland Hospital, 27351 Dequindre Rd, Madison Heights, MI 48071, USA; Department of Orthopaedic Surgery, Ascension Providence, 16001W Nine Mile Rd, Southfield, MI 48075, USA
| | - Adam Fahs
- Department of Orthopaedic Surgery, Ascension Macomb-Oakland Hospital, 27351 Dequindre Rd, Madison Heights, MI 48071, USA; Department of Orthopaedic Surgery, Ascension St. John, 2201 Moross Rd, Detroit, MI 48236, USA
| | - Alan Afsari
- Department of Orthopaedic Surgery, Ascension Macomb-Oakland Hospital, 27351 Dequindre Rd, Madison Heights, MI 48071, USA; Department of Orthopaedic Surgery, Ascension St. John, 2201 Moross Rd, Detroit, MI 48236, USA
| | - Benjamin Best
- Department of Orthopaedic Surgery, Ascension Macomb-Oakland Hospital, 27351 Dequindre Rd, Madison Heights, MI 48071, USA; Department of Orthopaedic Surgery, Ascension St. John, 2201 Moross Rd, Detroit, MI 48236, USA.
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Marlor D, Crandall M, Elman M, Stewart S, Cruz-Centeno N, Kim D, Ginger-Wiley M, Juang D. Misplaced Evidence, Missed Opportunities: Protocols for Handling Ballistic Evidence in Pediatric Patients. J Trauma Nurs 2024; 31:40-48. [PMID: 38193491 DOI: 10.1097/jtn.0000000000000761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
BACKGROUND Gun-related injury is now the number one cause of death in pediatric trauma patients. Many hospitals lack dedicated forensic nurses or updated protocols for handling ballistic evidence. Evidence not collected, handled improperly, or misplaced may deny a victim the basic human right to justice. OBJECTIVE This article aims to describe an initiative to highlight the importance of proper management of ballistic evidence and to educate medical providers on best practices for the documentation, handling, removal, and transfer of ballistic evidence. METHODS After discovering 24 "orphaned" bullets and bullet fragments in our hospital that had not been turned over to law enforcement, we sought to turn in evidence to the proper authorities and implement protocols to prevent this error in the future. New protocols were written by forensic staff, and education on new protocols was provided via in-person training, grand rounds, emails, and other collaborative initiatives. RESULTS Evidence was matched to police reports using the patient name and date of birth on evidence labels. The median (interquartile range [IQR]) time of lost ballistic evidence was 1,397 (903, 1604) days, with the oldest bullet removed in 2015. All bullets were successfully returned to law enforcement with a median (IQR) time from bullet discovery to collection of 78 (78, 174) days. CONCLUSIONS Ballistic evidence handling protocols are essential for all hospitals. Dedicated, trained forensic staff should be employed to ensure proper evidence handling.
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Affiliation(s)
- Derek Marlor
- Children's Mercy Hospital, Kansas City, Missouri (Drs Marlor, Elman, Stewart, Cruz-Centeno, and Juang and Mss Crandall and Ginger-Wiley); and Kansas City University School of Medicine, Kansas City, Missouri (Mr Kim)
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Smith RN, Nedergaard RM, Meyer CH, DeSousa N, Ghosh M, Blount Q, Apte A, Resnick S, Hennink MM. Psychological Impacts of Retained Bullets From the Perspective of Survivors. Am Surg 2023; 89:3732-3738. [PMID: 37148273 PMCID: PMC10725717 DOI: 10.1177/00031348231171121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
INTRODUCTION Despite a high prevalence of retained bullet fragments (RBFs) after firearm related injury (FRI) there is limited data on the full spectrum of their consequences, particularly the psychological impacts on those injured. Further, the experiences of FRI survivors with RBFs are missing from existing literature. The objective of this study was to explore the psychological impacts of RBFs on individuals who have experienced recent FRI. METHODS Adult (18-65 years) survivors of FRI with radiographically confirmed RBFs were purposively selected from an urban Level 1 trauma center in Atlanta, Georgia, to participate in an in-depth interview. Interviews were conducted between March 2019 and February 2020. Thematic analysis was used to identify a range of psychological effects from RBFs. RESULTS Interviews from 24 FRI survivors were analyzed: the majority of participants were Black males (N = 22, 92%) with a mean age of 32 years whose FRI occurred ∼8.6 months prior to data collection. The psychological effects of RBFs were grouped into four categories: physical health (eg, pain, limited mobility), emotional well-being (eg, anger, fear), social isolation, and occupational welfare (eg, disability leading to inability to work). A range of coping mechanisms were also identified. CONCLUSION Survivors of FRI with RBFs experience a range of psychological impacts that are far-reaching and affect daily activities, mobility, pain and emotional wellbeing. Study results indicate a need for enhanced resources to support those with RBFs. Further, changes to clinical protocols are warranted on removal of RBFs and communication about the effects of leaving RBFs in situ.
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Affiliation(s)
- R. N. Smith
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Health System, Atlanta, GA, USA
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - R. M. Nedergaard
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
- National Health Service, South East London, England, UK
| | - C. H. Meyer
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Health System, Atlanta, GA, USA
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - N. DeSousa
- Emory University School of Medicine, Atlanta, GA, USA
| | - M. Ghosh
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Q. Blount
- Emory University School of Medicine, Atlanta, GA, USA
| | - A. Apte
- Emory University School of Medicine, Atlanta, GA, USA
| | | | - M. M. Hennink
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Hayes J, Punch L, Mueller K. Care of Bullet-related Injuries: A Cross-sectional Study of Instructions and Prescriptions Provided on Discharge from the Emergency Department. West J Emerg Med 2023; 24:363-367. [PMID: 36976600 PMCID: PMC10047738 DOI: 10.5811/westjem.2022.11.57574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 11/17/2022] [Indexed: 03/22/2023] Open
Abstract
Introduction: There are more than 80,000 emergency department (ED) visits for non-fatal bullet- related injuries (BRI) per year in the United States. Approximately half of these patients are discharged home from the ED. Our objective in this study was to characterize the discharge instructions, prescriptions, and follow-up plans provided to patients discharged from the ED after BRI.
Methods: This was a single-center, cross-sectional study of the first 100 consecutive patients who presented to an urban, academic, Level I trauma center ED with an acute BRI beginning on January 1, 2020. We queried the electronic health record for patient demographics, insurance status, cause of injury, hospital arrival and discharge timestamps, discharge prescriptions, and documented instructions regarding wound care, pain management, and follow-up plans. We analyzed data using descriptive statistics and chi-square tests.
Results: During the study period, 100 patients presented to the ED with an acute firearm injury. Patients were predominantly young (median age 29, interquartile range 23-38 years), male (86%), Black (85%), non-Hispanic (98%), and uninsured (70%). We found that 12% of patients did not receive any type of written wound care instruction, while 37% received discharge paperwork that included instructions to take both an NSAID and acetaminophen. Fifty-one percent of patients received an opioid prescription, with a range from 3-42 tablets (median 10 tablets). The proportion of patients receiving an opioid prescription was significantly higher among White patients (77%) than among Black patients (47%).
Conclusion: There is variability in prescriptions and instructions provided to survivors of bullet injuries upon ED discharge at our institution. Our data indicates that standardized discharge protocols could improve quality of care and equity in the treatment of patients who have survived a BRI. Current variable quality in discharge planning is an entry point for structural racism and disparity.
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Affiliation(s)
- Jane Hayes
- Washington University School of Medicine, St. Louis, Missouri
| | | | - Kristen Mueller
- Washington University School of Medicine, Department of Emergency Medicine, St. Louis, Missouri
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Baum GR, Baum JT, Hayward D, MacKay BJ. Gunshot Wounds: Ballistics, Pathology, and Treatment Recommendations, with a Focus on Retained Bullets. Orthop Res Rev 2022; 14:293-317. [PMID: 36090309 PMCID: PMC9462949 DOI: 10.2147/orr.s378278] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 08/16/2022] [Indexed: 02/05/2023] Open
Abstract
As the epidemic of gunshot injuries and firearm fatalities continues to proliferate in the United States, knowledge regarding gunshot wound (GSW) injury and management is increasingly relevant to health-care providers. Unfortunately, existing guidelines are largely outdated, written in a time that high-velocity weapons and deforming bullets were chiefly restricted to military use. Advances in firearm technology and increased accessibility of military grade firearms to civilians has exacerbated the nature of domestic GSW injury and complicated clinical decision-making, as these weapons are associated with increased tissue damage and often result in retained bullets. Currently, there is a lack of literature addressing recent advances in the field of projectile-related trauma, specifically injuries with retained bullets. This review aims to aggregate the available yet dispersed findings regarding ballistics, GSW etiology, and treatment, particularly for cases involving retained projectiles.
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Affiliation(s)
- Gracie R Baum
- Department of Orthopedic Hand Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Jaxon T Baum
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Dan Hayward
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Brendan J MacKay
- Department of Orthopedic Hand Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA,Correspondence: Brendan J MacKay, Department of Orthopedic Hand Surgery, Texas Tech University Health Sciences Center, 808 Joliet Ave Suite 310, Lubbock, TX, 79415, USA, Tel +1 806 743 4600, Email
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Hayes JM, Hann I, Punch LJ. The Bullet Related Injury Clinic-Healing the Deep Wounds of Gun Violence. JAMA Surg 2021; 157:167-168. [PMID: 34935864 DOI: 10.1001/jamasurg.2021.4889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jane M Hayes
- The T, St Louis, Missouri.,Washington University School of Medicine in St Louis, St Louis, Missouri
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