Low-velocity gunshot wounds of the proximal phalanx: treatment by early stable fixation

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.

Current Trends in the Management of Ballistic Fractures of the Hand and Wrist: Experiences of a High-Volume Level I Trauma Center

BACKGROUND

Ballistic fractures of the carpus and hand are routinely treated in large urban centers. These injuries can be challenging due to many factors. Various treatment options exist for these complicated injuries, but there are limited data available. This report analyzes patient demographics, treatments, and outcomes at a large urban trauma center.

METHODS

All ballistic fractures of the hand and wrist of the patients who presented to a single center from 2011 to 2014 were retrospectively reviewed. Patient demographics, injury mechanism, treatment modalities, and outcomes were analyzed.

RESULTS

Seventy-seven patients were identified; 70 were male, and 7 were female. Average age of the patients was 29.6 years. Seventy-five injuries were low velocity, whereas 2 were high velocity. Sixty-seven patients had fractures of a metacarpal or phalanx, whereas 4 had isolated carpal injuries. Six had combined carpal and metacarpal or phalanx fractures. Thirty-six patients had concomitant tendon, nerve, or vascular injuries requiring repair. Sixty-three patients underwent operative intervention, with the most common intervention being percutaneous fixation. Sixteen patients required secondary surgery. Eighteen complications were reported.

CONCLUSIONS

The majority of patients in this report underwent early operative intervention with percutaneous fixation. Antibiotics were administered in almost all cases and can usually be discontinued within 24 hours after surgery. It is important to consider concomitant nerve, vascular, or tendon injuries requiring repair. We recommend early treatment of these injuries with debridement and stabilization. Due to lack of follow-up and patient noncompliance, early definitive treatment with primary bone grafting should be considered.

The Radial Aspect of the Distal Radial Metaphysis/Diaphysis as a Source of Cortical Bone Graft

Cortical bone grafting is commonly required in the finger, hand, and carpus when managing bony trauma. A donor site that can provide a small or large amount of cortical bone graft that is easily accessible and within the same surgical field would be the ideal donor site. In high-energy injuries, a long cortical graft may be needed to reconstruct massive bony defects. In low-energy injuries such as scaphoid nonunions in which a wedge graft is needed, a reliable and easily accessible source of bone grafting would be beneficial. Although the traditional iliac bone grafting can be used, this option requires a separate sterile field to be prepared and may lead to donor site pain and morbidity. We propose an option that places the donor source close to the hand and wrist. The radial aspect of the distal radius metaphysis/diaphysis is superficial, which makes access and closure simpler than other alternatives. Furthermore, the technique only partly violates 1 of the 3 surfaces of the radius so that there is minimal weakening of the integrity of the bone and the likelihood of fracture is low. In this article, we describe the indications, contraindications, surgical technique, and postoperative management of the radial aspect of the distal radius metaphysis/diaphysis as a source of bone grafting.

Immediate Corticocancellous Bone Autografting in Segmental Bone Defects of the Hand

We performed a retrospective analysis of 12 type III open hand fractures in seven patients with segmental bone loss and associated soft tissue injuries to determine the effectiveness of immediate autologous corticocancellous bone grafting. Radical débridement and fracture fixation were performed prior to bone grafting. Results were interpreted according to clinical and radiologic time of bony healing, rate of infection, time to return to regular work duty, grip strength, rate of complications and range of motion. The final union rate was 92%, with a mean time to bony union of 18 weeks. The infection rate was 0%. The mean time to return to regular work duty, including recovery time after secondary surgeries, was 5 months and 21 days. All patients returned to their pre-injury employment. The mean total active motion of the combined metacarpophalangeal proximal interphalangeal and distal interphalangeal joints in bone-grafted digits was 178±53° at final follow-up.

Gunshot-induced fractures of the extremities: a review of antibiotic and debridement practices

The use of antibiotic prophylaxis and debridement is controversial when treating low- and high-velocity gunshot-induced fractures, and established treatment guidelines are currently unavailable. The purpose of this review was to evaluate the literature for the prophylactic antibiotic and debridement policies for (1) low-velocity gunshot fractures of the extremities, joints, and pelvis and (2) high-velocity gunshot fractures of the extremities. Low-velocity gunshot fractures of the extremities were subcategorized into operative and non-operative cases, whereas low-velocity gunshot fractures of the joints and pelvis were evaluated based on the presence or absence of concomitant bowel injury. In the absence of surgical necessity for fracture care such as concomitant absence of gross wound contamination, vascular injury, large soft-tissue defect, or associated compartment syndrome, the literature suggests that superficial debridement for low-velocity ballistic fractures with administration of antibiotics is a satisfactory alternative to extensive operative irrigation and debridement. In operative cases or those involving bowel injuries secondary to pelvic fractures, the literature provides support for and against extensive debridement but does suggest the use of intravenous antibiotics. For high-velocity ballistic injuries, the literature points towards the practice of extensive immediate debridement with prophylactic intravenous antibiotics. Our systematic review demonstrates weak evidence for superficial debridement of low-velocity ballistic fractures, extensive debridement for high-velocity ballistic injuries, and antibiotic use for both types of injury. Intra-articular fractures seem to warrant debridement, while pelvic fractures with bowel injury have conflicting evidence for debridement but stronger evidence for antibiotic use. Given a relatively low number of studies on this subject, we recommend that further high-quality research on the debridement and antibiotic use for gunshot-induced fractures of the extremities should be conducted before definitive recommendations and guidelines are developed.

Management of gunshot wounds to the hand: a literature review

Hand trauma resulting from firearms is becoming more common in civilian life. In the past, as in wartime, infection was a main source of concern following firearm-related hand injuries, whereas in current civilian life with modern medical care, infection rates are actually low for such injuries. As infection is now of lesser concern, the focus should shift to improve functional outcomes. This review summarizes available literature regarding the management of gunshot wounds to the hand, with particular focus on functional outcomes. In conducting this review, we found that there is not comprehensive information regarding management of gunshot wounds to the hand, and literature discussing functional recovery of the hand is limited. Given the current evidence related to management of gunshot wounds to the hand, we believe that early debridement, antibiotic treatment, reconstruction, and rehabilitation offer patients the best chance for full functional recovery.

Corticocancellous olecranon autograft for metacarpal defect reconstruction: a case report

BACKGROUND

High-energy injuries to the hand frequently lead to bone defects as well as soft tissue loss. Early bone grafting of defects is well established in the literature; however, few options are available for autologous corticocancellous grafts. Most frequently cited studies describe the iliac crest or the distal radius donor sites.

METHODS

In this case report, we describe a new technique of obtaining corticocancellous bone graft from the olecranon.

RESULTS

Complete union of the segmental defect was achieved with this technique.

CONCLUSIONS

The olecranon donor site is outside the zone of injury and therefore safe to access, but within the upper extremity, thus avoiding the need for harvest from a distant site such as the iliac crest or the distal femur. Additional benefits of this site are the greater volume of graft that can be harvested compared to the distal radius as well as a more optimal ratio of cancellous to cortical graft available, compared to the iliac crest where the graft may be excessively cortical in nature.

Functional outcome after surgical treatment of phalangeal fractures in severely injured hands

We assessed functional results after treatment of phalangeal fractures in severely injured hands. Our aim was to quantify digital functional loss with (combinations of) risk factors of unsatisfactory function. Patients who had multiple phalangeal fractures necessitating operation in a 10-year time period were tested, using measurements of total active movement. Seventy-eight patients with 228 phalangeal fractures were available for follow-up. In 88 fingers, the fractures ended in amputation and were excluded from the study. In the resulting 140 fractures, 74 (53%) had a good result (movement >180degrees for fingers 2-5, and >98degrees for the thumb), and 66 (47%) in an unsatisfactory result. Associated soft tissue injury, level of injury, and arthrodesis were risk factors for diminished function. Intra-articular fractures and multiple fractures within the same finger predisposed to arthrodesis. Despite the extensive and severe injuries more than half had good results, which is comparable with reports describing hand injuries with less extensive trauma.

Fractures of the proximal phalanx and metacarpals in the hand: preferred methods of stabilization

Treatment of fractures of the proximal phalanx and metacarpals is based on the presentation of the fracture, degree of displacement, and difficulty in maintaining fracture reduction. A wide array of treatment options exists for the variation in fracture patterns observed. Inherently stable fractures do not require surgical treatment; all other fractures should be considered for additional stabilization. In general, of the many combinations of internal fixation possible, Kirschner wires and screw-and-plate fixation predominate. Early closed reduction typically is successful for unicondylar fractures of the head of the proximal phalanx. Bicondylar proximal phalanx fractures usually are treated with plate fixation. Transverse and short oblique proximal phalanx fractures generally are treated with Kirschner wires, although a stable short oblique transverse shaft fracture can be managed with an intrinsic plus splint. Plate fixation is used in comminuted proximal phalanx as well as comminuted metacarpal fractures, and lag screws in spiral long oblique phalanx shaft fractures and metacarpal head fractures. Kirschner wire fixation is successful in metacarpal neck fractures as well as both short and long transverse oblique shaft fractures.

Nonvascularized autogenous bone graft for extensive phalangeal bone loss: case report

A 47-year-old man, a fine woodworker, sustained extensive phalangeal and soft tissue loss of his dominant left long and index fingers in a table saw injury. We report the long-term clinical and radiographic outcomes of the patient following reconstruction with corticocancellous iliac crest bone grafts. Rarely described in recent literature, we believe that primary nonvascularized autogenous bone grafting for phalangeal reconstruction is a worthwhile alternative to amputation when the soft tissue envelope is satisfactory.

Handgun injuries with metacarpal and proximal phalangeal fractures: early definitive treatment

Most gunshot injuries to the hand involve a combination of tissue types. The goal of this study is to report the results of early definitive treatment in extra-articular metacarpal and proximal phalangeal fractures due to low velocity gunshot wounds and to analyse their outcomes. A retrospective analysis of 51 metacarpal and 41 proximal phalangeal fractures of 76 patients due to low velocity gunshot wounds treated between January 2001 and December 2004 was carried out. We applied acute fixation in the first 24 hours. The patients were evaluated with total active motion scores, radiographic control, complication rate and the need for revision surgery. The infection frequency was 10.5% and the need for a revision surgery was 7%. The plate fixation group had significantly higher total active motion scores than the external fixation group. The K wire group had the highest revision rate. The bone grafting group was associated with good total active motion scores and low complication rates. The majority of the low velocity gunshot injuries are surgically clean wounds which allow not only early fracture fixation, but also early bone grafting and soft tissue reconstruction. Plate and screw fixation is associated with significantly better functional outcomes than the minimal fixation group.

Primary internal fixation and bone grafting for open fractures of the hand

Primary bone grafting and internal fixation is a reliable option for the treatment of segmental hand defects resulting from high-energy crush or avulsion injuries. Immediate reconstruction can be performed safely if radical debridement and adequate soft tissue coverage of bone can be achieved. When these two criteria cannot be met, staged reconstruction should be performed. The low infection rate (0%), the high union rate (92%), and the return to full, unrestricted, previous employment for all patients in the authors' series supports the use of primary bone grafting in an acute setting. This single-stage approach to fracture management also permits earlier and more aggressive hand therapy that, in turn, can lower the high functional morbidity so often associated with these injuries.

Treatment of Complex Below-the-Elbow Gunshot Wounds

Firearm injuries, many of which involve the hand, wrist, or forearm, pose a serious public health concern in the United States in both medical and economic terms. Despite the preponderance of low-velocity weapons, complex below-the-elbow gunshot injuries are commonly seen. A successful approach to these patients requires efficient treatment and early initiation of rehabilitation. Unfortunately, this goal is often not met because of multiple factors including wound infections, the need to coordinate multiple surgical specialties, long hospital stays, and delayed definitive reconstruction. At our institution, the plastic surgery hand service is able to treat all aspects of below-the-elbow trauma. A protocol of early aggressive debridement and skeletal stabilization, with definitive reconstruction within 1 week of injury, is used. We retrospectively reviewed all complex below-the-elbow gunshot injuries treated by the senior author between 1996 and 2003. Eighteen such patients were identified. All limbs were salvaged and all patients regained functional use of the extremity. There was no incidence of wound infection. The average length of inpatient stay was 8.9 days (median, 7 days). The use of this protocol by a single surgical specialty allows efficient reconstruction, short hospital stays, and early initiation of rehabilitation.

Rehabilitation for proximal phalangeal fractures

Proximal phalangeal fracture stability is crucial for the initiation of early and effective exercises designed to recover digital and especially proximal interphalangeal joint motion. Active digital flexion and extension exercises are implemented by synergistic wrist motion. Joint blocking exercises and active tendon gliding exercises in protective blocking splints are instrumental elements of early treatment. Dynamic splinting and serial finger casting are used in recalcitrant, severe, and late presenting cases. Surgical release is a last resort in regaining proximal interphalangeal joint motion. This measure is reserved for a failure of treatment when residual proximal interphalangeal joint contracture is persistent and severe enough to cause serious impairment of digital motion and hand function.

Gunshots to the hand and upper extremity

Gunshot injuries to the hand and upper extremity have been studied during military conflicts and in urban settings. Treatment concepts include identification of injured structures, aggressive surgical wound care, and reconstruction of important functional structures. There are various types of missile injuries. For simplicity, low-energy injuries imply limited damage, and require only conservative approaches. High-energy injuries are complicated by significant tissue destruction, rehabilitation dilemmas, and uncertain outcomes. The surgeon must recognize the anatomic complexity of the hand and proceed with caution. Most gunshot injuries to the hand involve a combination of tissue types. Bone injury is dramatic and is seen radiographically. However, injury to the soft tissue including skin, tendon, blood vessel, and nerve also must be appreciated. Individually, the tissues have varied function and properties of healing. Therefore, the challenge is to prioritize the injury, select an aggressive surgical approach, and integrate a suitable rehabilitation plan.

Fracture fixation in the mutilated hand

Early anatomic (or near anatomic; lingers do not impinge or overlap during flexion or extension) stable fracture fixation provides the foundation for successful wound management and for the repair, reconstruction, and healing of all damaged tissues in a mutilating hand injury. It also plays an instrumental role in pain control and affords an optimal opportunity for timely and favorable rehabilitation of and recovery from mutilating injuries of the hand. Kirschner or other wiring systems or mini external fixators may be used for simple fractures, in children, when rapid fracture fixation is necessary, and for provisional fracture fixation. Mini plates should be considered for fractures with comminution or loss and in instances of multiple fractures. Fingers with segmental injury of three or more tissues should be considered for early amputation to avoid prolonged and impaired recovery of the hand. Every effort should be made to preserve the thumb and its function by repair or reconstruction.