Epidemiology of gunshot wounds to the hand

Epidemiology of civilian's gunshot wound injuries admitted to intensive care unit: A retrospective, multi-center study

BACKGROUND

Few studies investigated the outcome of patients admitted to intensive care unit (ICU) for gunshot wounds (GSW). The purpose of this study was to determine the 28-day mortality, and to analyze the impact of variables on the mortality of patients admitted to ICU with GSW in four French University Hospitals level-1 regional trauma centers.

METHOD

All medical files of adult patients (above fifteen years old) admitted to four French University Hospitals level-1 regional trauma centers for GSW were retrospectively analyzed from January 1st 2015 to June 30th 2021. The primary aim was to determine 28-day death rate of patients admitted in ICU for GSW. The secondary aim was to describe biological parameters, injuries and management of patients admitted to our ICUs, and to identify the variables associated with the 28-day mortality rate. A multivariate analysis allowed determining independent mortality factors. A Kaplan-Meier analysis compared mortality according to head injury.

RESULTS

Among 17,262 patients screened, 173 (1 %) were admitted for GSW and 162 were analyzed. The 28-day mortality rate was 24.7 %. 77.5 % of deaths occurred within the first 48 h after ICU admission, and 87.5 % of deaths within three days of ICU admission. The 28-day death rate of patients with head injury was significantly higher as compared to patients without head injury (p < 0.001). Out of forty deaths, twenty-three (57.5 %) were due to head injury, and nine (22.5 %) were due to bleeding. The mechanisms were assault (45.1 %), suicide (34.6 %), accident (4.9 %) and unidentified (15.4 %). In a multivariate analysis, variables associated with the 28-day death rate were age, pre-hospital Glasgow coma score, and Injury Severity Score.

CONCLUSION

GSW represented 1 % of ICU admission. The 28-day mortality rate was 24.7 %. 77.5 % of deaths occurred within the first 48 h due to head injuries and bleeding. Head injuries were associated with significantly higher mortality rate.

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.

Evaluation of Self-Inflicted versus Non-Self-Inflicted Gunshot Wounds and Associated Injuries Involving the Hand and Upper Extremity

Orthopedic costs associated with gunshot wounds (GSWs) totaled approximately USD 510 million from 2005 to 2014. Previous studies have identified differences in injuries associated with self-inflicted (SI) GSWs; however, there remains a gap in understanding injury patterns. This study aims to expand upon the current literature and shed light on injury patterns and outcomes associated with SI vs. non-self-inflicted (NSI) GSWs. This is a retrospective cohort study of upper extremity GSWs from January 2012 to December 2022. Data were analyzed using the two-sample t-test, Pearson's chi-squared test, and Fisher's exact test. SI GSWs tended to be high-velocity GSWs and occurred more often in distal locations compared to NSI GSWs (p = 0.0014 and p < 0.0001, respectively). SI GSWs were associated with higher Gustilo-Anderson (GA) and Tscherne classifications (p < 0.0001 and p = 0.0048, respectively) and with a greater frequency of neurovascular damage (p = 0.0048). There was no difference in fracture rate or need for operative intervention between the groups. GA and Tscherne classifications were associated with the need for and type of surgery (p < 0.0001), with a higher classification being associated with more intricate operative intervention; however, GSW velocity was not associated with operative need (p = 0.42). Our findings demonstrate that velocity, wound grading systems, and other factors are associated with the manner in which GSWs to the upper extremity are inflicted and may thus have potential for use in the prediction of injury patterns and planning of trauma management and surgical intervention.

Fibular Allograft Osteoplasty and Silicone Arthroplasty following Gunshot Injury of the Metacarpal

The complexity of a gunshot wound to the hand with segmental bone loss and adjacent joint disruption presents a unique challenge for the reconstructive surgeon. There are several options for posttraumatic reconstruction of hand joint defects, ranging from arthrodesis, implants, and autologous arthroplasty. Despite the abundance of literature regarding guidelines for isolated osteoplasty and arthroplasty, there are only case reports describing management of bone and joint defects, all within the setting of cancer resection. This case report presents a 24-year-old, right-hand dominant man with a gunshot wound to his left hand involving the fifth metacarpal and metacarpal phalangeal joint. The metacarpal was reconstructed with a fibular bone allograft with simultaneous placement of a silicone arthroplasty implant, allowing preservation of motion at the metacarpal phalangeal joint with satisfactory functional outcomes. This illustrates the feasibility of successfully reconstructing segmental bone loss and adjacent joint defects simultaneously in the traumatic setting of firearm injuries.

Firearm Injuries to the Wrist and Hand in Children and Adults: An Epidemiologic Study

BACKGROUND

Gunshot wounds (GSWs) to the wrist and hand are a major health and economic burden in the United States. There are few studies examining the circumstances and epidemiological factors surrounding these injuries. This study assesses the epidemiological factors, as well as the shooting circumstances, injury details, and surgical management of wrist and hand GSWs in children and adults.

METHODS

Medical records and radiographs were reviewed for all patients with ballistic injury to the wrist or hand treated at an urban academic level 1 trauma center from 2016 to 2019. Fisher exact and Pearson χ2 tests were used to assess differences between groups.

RESULTS

Two hundred forty-nine victims (29 children, 220 adults) with complete documentation were identified. Among 180 victims with known shooting circumstances, 132 (70%) were shot by another person and 110 (65%) were injured by intentional gunfire. Eighty-seven victims (35%) suffered a concurrent GSW to another body region. Metacarpal fracture was the most commonly diagnosed bony injury (37%), followed by proximal phalanx fracture (25%). One hundred twenty-nine victims (52%) underwent surgery following their injuries. Nerve discontinuity was diagnosed in 27 victims (11%), while 20 victims (8%) had vascular disruption. There was no significant difference between children and adult victims' type of fracture, concurrent injuries, rates of surgery, or in the most common fracture fixation method.

CONCLUSIONS

Most wrist and hand GSW victims were injured due to intentional, non-self-inflicted gunfire. Most patients present with hand fractures, and fortunately, nerve and vascular disruptions are uncommon.

Mechanism matters: A 10-year experience of ballistic injuries of the upper extremity

INTRODUCTION

Upper Extremity gunshot wounds represent a significant strain on community and hospital resources, and reports of their epidemiology are varied. We hypothesized that demographic and socioeconomic variables would be associated with variable injury patterns and management, and that two distinct populations would be affected by upper extremity ballistic injury based on violent versus accidental, self-inflicted mechanism.

MATERIALS & METHODS

Retrospective review of all adult patients sustaining ballistic injury to the upper extremity at a single urban Level I trauma center over 10 years (n = 797). Demographic, injury pattern, treatment, and outcomes data were collected. Comparisons between groups were conducted with unpaired t-tests and chi-square testing where appropriate.

RESULTS

Most patients were male (89.1%) and mean age was 30.1 years (18-83). Violence accounted for 89.1% of injuries. Black individuals were disproportionately affected at 87% of patients. Shoulder injuries were most common (34%), and wrist least common (7%). Demographics and injury pattern varied significantly between patients sustaining violent injury and those with self-inflicted mechanisms. Patients sustaining violent injury were most often young, Black men more likely to be injured proximally, whereas patients with self-inflicted injuries were more likely to be older, Caucasian men with more comorbidities injured distally. Cumulatively, 35.3% of patients required operative intervention. Distal injuries were more likely operative. The most commonly injured structure across all levels was bone (53%), and 54.3% of fractures required operation. Median follow-up was 24.5 months. Complication rate was 13.6%.

CONCLUSIONS

Gunshot wounds of the upper extremity create complex patterns of injury which vary based on level of injury and mechanism. Violent and self-inflicted injuries occur in dissimilar populations and result in distinctive injury patterns.

Point Blank: A Retrospective Review of Self-inflicted Gunshot Wounds to the Hand

BACKGROUND

A paucity of literature exists specifically examining self-inflicted (SI) gunshot wounds (GSWs) to the hand and wrist, which impart greater energy and have a higher risk of adverse events than non-self-inflicted (NSI) GSWs.

METHODS

We retrospectively reviewed records of patients who presented to our plastic surgery service after sustaining acute GSWs involving the hand and wrist between 2016 and 2018.

RESULTS

We identified 60 patients who sustained GSWs involving the hand and wrist; 17 (28%) were SI, and 43 (72%) were NSI. Within the SI group, 100% of patients were Caucasian, with an average age of 54 years. Within the NSI cohort, 77% of patients were Black, 19% were Caucasian, and 4% identified as other. While not statistically significant, we noted a substantial increase in patients requiring operative intervention in the SI cohort (65% SI vs 37% NSI, P = .08). There was a statistically significant increase in patients requiring more than 1 operation in SI patients (24% SI vs 5% NSI, P = .04). Patients who sustained SI injuries were also more likely to present with acute carpal tunnel syndrome requiring urgent surgical release and to develop wound infections (12% vs 0%, P = .08).

CONCLUSIONS

Self-inflicted GSWs involving the hand and wrist are associated with greater morbidity than their low-energy NSI counterparts. Individuals presenting with SI GSWs are more likely to be older, to require multiple operations, to develop infections, and to present with acute carpal tunnel syndrome requiring urgent surgical decompression.

Gunshot Injuries of the Hand: Incidence, Treatment Characteristics, and Factors Associated With Healthcare Utilization

BACKGROUND

The objectives of this study are to: (1) describe the demographics, injury patterns, and treatment characteristics of patients who sustained a gunshot injury (GSI) of the hand; and (2) examine the utilization of healthcare resources in patients with a GSI of the hand.

METHODS

We retrospectively identified 148 adult patients who were treated for a GSI of the hand between January 2000 to December 2017 using multiple International Classification of Diseases Ninth and Tenth Edition (ICD-9 and ICD-10) codes. We used bivariate and multivariable analysis to identify which factors are associated with unplanned reoperation, length of hospitalization, and number of operations.

RESULTS

Multivariable logistic regression showed that fracture severity was associated with unplanned reoperation. Multivariable linear regression showed that fracture severity is associated with a higher number of hand operations after a GSI of the hand, and that a retained bullet (fragment) and patients having gunshot injuries in other regions than the hand had a longer length of hospitalization. Seventy (47%) patients had sensory or motor symptoms in the hand after their GSI, of which 22 (15%) patients had a transection of the nerve.

CONCLUSIONS

Sensory and motor nerve deficits are common after a GSI of the hand. However, only 31% of patients with symptoms had a transection of the nerve. A retained bullet (fragment), having more severe hand fractures, and GSI in other regions than the hand are associated with a higher number of operation and a longer period of hospitalization.

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.

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.

Epidemiology and characteristics of firearm injuries in a French level I trauma centre, 2009-2019

BACKGROUND

Firearm injuries (FI) are an increasing problem in Europe but there have been few European epidemiological studies on civilian FI, particularly in France. This study investigated the epidemiology of FI at a French level I trauma centre.

METHODS

A retrospective cohort study was conducted of all patients admitted to our centre with an FI between January 2009 and December 2019. We investigated the epidemiological trends of FI during the study period, and characterised the FI.

RESULTS

A total of 162 patients were victims of FI. Prevalence was 0.11% and the mean annual incidence was 10.4 per 100 000 habs. A significant increase has been observed over the last 10 years, from 5 cases in 2009 (3.1%) to 30 in 2019 (18.5%). Of the 162 victims, 85 (52.5%) died as a direct result of the FI: 72 suicides (88.9%) and 9 victims of urban violence (11.1%) (armed public environment disorder). 95.3% of the patients died before reaching at the hospital. There were 95 cases (58.7%) of suicide and 33 cases (20.4%) of urban violence. The head was shot in 87 cases (48.9%), the thorax in 32 cases (18.5%) and the lower limbs in 24 cases (13.5%). A total of 106 surgeries were performed on 54 patients (33.3%).

CONCLUSIONS

We identified 162 cases of FI with a mean annual incidence of 10.4 per 100 000 habs. A significant increase in FI was observed over the last 10 years. 52.2% of patients died, and the main context was suicide or attempted suicide.

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.