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Muss TE, Hu S, Bauder AR, Lin IC. The Epidemiology, Management, and Outcomes of Civilian Gunshot Wounds to the Upper Extremity at an Urban Trauma Center. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5753. [PMID: 38633511 PMCID: PMC11023610 DOI: 10.1097/gox.0000000000005753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/20/2024] [Indexed: 04/19/2024]
Abstract
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.
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Affiliation(s)
- Tessa E. Muss
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Sophia Hu
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Andrew R. Bauder
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Ines C. Lin
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pa
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Pan T, Giuffrida BM, Trivedi AH, Contestabile D, Vyas PS, Cheng BC, Altman DT, Regal SM. Evaluation of Self-Inflicted versus Non-Self-Inflicted Gunshot Wounds and Associated Injuries Involving the Hand and Upper Extremity. Healthcare (Basel) 2024; 12:564. [PMID: 38470675 PMCID: PMC10931217 DOI: 10.3390/healthcare12050564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/19/2024] [Accepted: 02/23/2024] [Indexed: 03/14/2024] Open
Abstract
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.
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Affiliation(s)
- Tommy Pan
- Allegheny Health Network Orthopaedic Institute, Pittsburgh, PA 15212, USA; (T.P.); (B.M.G.); (A.H.T.); (D.C.); (P.S.V.); (D.T.A.); (S.M.R.)
| | - Brianne M. Giuffrida
- Allegheny Health Network Orthopaedic Institute, Pittsburgh, PA 15212, USA; (T.P.); (B.M.G.); (A.H.T.); (D.C.); (P.S.V.); (D.T.A.); (S.M.R.)
- Drexel University College of Medicine, Drexel University, University City Campus, Philadelphia, PA 19104, USA
| | - Amol H. Trivedi
- Allegheny Health Network Orthopaedic Institute, Pittsburgh, PA 15212, USA; (T.P.); (B.M.G.); (A.H.T.); (D.C.); (P.S.V.); (D.T.A.); (S.M.R.)
- Drexel University College of Medicine, Drexel University, University City Campus, Philadelphia, PA 19104, USA
| | - Dom Contestabile
- Allegheny Health Network Orthopaedic Institute, Pittsburgh, PA 15212, USA; (T.P.); (B.M.G.); (A.H.T.); (D.C.); (P.S.V.); (D.T.A.); (S.M.R.)
| | - Praveer S. Vyas
- Allegheny Health Network Orthopaedic Institute, Pittsburgh, PA 15212, USA; (T.P.); (B.M.G.); (A.H.T.); (D.C.); (P.S.V.); (D.T.A.); (S.M.R.)
| | - Boyle C. Cheng
- Allegheny Health Network Orthopaedic Institute, Pittsburgh, PA 15212, USA; (T.P.); (B.M.G.); (A.H.T.); (D.C.); (P.S.V.); (D.T.A.); (S.M.R.)
| | - Daniel T. Altman
- Allegheny Health Network Orthopaedic Institute, Pittsburgh, PA 15212, USA; (T.P.); (B.M.G.); (A.H.T.); (D.C.); (P.S.V.); (D.T.A.); (S.M.R.)
| | - Steven M. Regal
- Allegheny Health Network Orthopaedic Institute, Pittsburgh, PA 15212, USA; (T.P.); (B.M.G.); (A.H.T.); (D.C.); (P.S.V.); (D.T.A.); (S.M.R.)
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Safeek RH, Ching J, Chim H, Satteson E. The Role of Plastic Surgeons in Addressing Firearm Morbidity and Mortality. Cureus 2023; 15:e36414. [PMID: 37090311 PMCID: PMC10115152 DOI: 10.7759/cureus.36414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2023] [Indexed: 03/22/2023] Open
Abstract
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.
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Myers PL, Chung KC. Role of Health Equity Research and Policy for Diverse Populations Requiring Hand Surgery Care. Hand Clin 2023; 39:17-24. [PMID: 36402522 DOI: 10.1016/j.hcl.2022.08.002] [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] [Indexed: 11/17/2022]
Abstract
Health equity requires allocation of resources to eliminate the systematic disparities in health, imposed on marginalized groups, which adversely impact outcomes. A socioecological approach is implemented to elucidate the role of health equity research and policy for underrepresented minority and socioeconomically disadvantaged populations. Through investigation of the individual, community, institution, and public policy, we investigate problems and propose solutions to ensure fair and just treatment of all patients requiring hand surgery.
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Affiliation(s)
- Paige L Myers
- Department of Surgery, Section of Plastic Surgery, University of Michigan, 2130 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
| | - Kevin C Chung
- Department of Surgery, Section of Plastic Surgery, University of Michigan, 2130 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
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Kershner EK, Tobarran N, Chambers A, Wills BK, Cumpston KL. Retained bullets and lead toxicity: a systematic review. Clin Toxicol (Phila) 2022; 60:1176-1186. [PMID: 36074021 DOI: 10.1080/15563650.2022.2116336] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Lead toxicity secondary to retained bullet(s) (RB) after a penetrating gunshot wound is a rare but likely underdiagnosed condition, given the substantial number of firearm injuries in the United States. There is currently no consensus on the indications for surveillance, chelation, or surgical intervention. OBJECTIVE The purpose of our review is to summarize the literature on systemic lead toxicity secondary to RBs to help guide clinicians in the management of these patients. METHODOLOGY The primary literature search was conducted in Medline (PubMed), EMBASE, Cochrane, and CENTRAL using the following MESH terms: "chelation" and "lead poisoning" or "lead toxicity" or "lead" and "bullet" or "missile" or "gunshot", or "bullet". RESULTS The search identified 1,082 articles. After exclusions, a total of 142 articles were included in our final review, the majority of which were case reports. Several factors appear to increase the risk of developing lead toxicity including the location of the RB, the presence of a fracture or recent trauma, number of fragments, hypermetabolic states, and bullet retention duration. Particularly, RBs located within a body fluid compartment like an intra-articular space appear to be at a substantially higher risk of developing lead toxicity. Even though patients with lead toxicity from RBs will have similar symptoms to patients with lead toxicity from other sources, the diagnosis of lead poisoning may occur months or years after a gunshot wound. Symptomatic patients with high blood lead levels (BLLs) tended to improve with a combination of chelation and surgical removal of RBs. CONCLUSIONS We suggest surveillance with serial BLLs should be performed. Patients with intra-articular RBs appear to be at increased risk of lead toxicity and if possible, early surgical removal of the RBs is warranted, especially given that signs of toxicity are vague, and patients may not have access to follow-up. Long-term chelation should not be used as a surgical alternative and management should be multidisciplinary.
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Affiliation(s)
- Emily K Kershner
- Department of Emergency Medicine, Division of Clinical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA.,Virginia Poison Center, Richmond, VA, USA
| | - Natasha Tobarran
- Department of Emergency Medicine, Division of Clinical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA.,Virginia Poison Center, Richmond, VA, USA
| | - Andrew Chambers
- Department of Emergency Medicine, Division of Clinical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA.,Virginia Poison Center, Richmond, VA, USA
| | - Brandon K Wills
- Department of Emergency Medicine, Division of Clinical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA.,Virginia Poison Center, Richmond, VA, USA
| | - Kirk L Cumpston
- Department of Emergency Medicine, Division of Clinical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA.,Virginia Poison Center, Richmond, VA, USA
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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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Kani KK, Porrino JA, Chew FS. Low-velocity, civilian firearm extremity injuries-review and update for radiologists. Skeletal Radiol 2022; 51:1153-1171. [PMID: 34718857 DOI: 10.1007/s00256-021-03935-0] [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: 07/28/2021] [Revised: 09/03/2021] [Accepted: 09/05/2021] [Indexed: 02/02/2023]
Abstract
Firearm injuries are a preventable epidemic in the USA. Extremities are commonly affected in gunshot injuries. Such injuries may be complex with concomitant osseous, soft tissue, and neurovascular components. The maximum wounding potential of a projectile is determined by its kinetic energy and the proportion of the kinetic energy that is transmitted to the target. Accurate assessment of ballistic injuries is dependent on utilizing the principles of wound ballistics, accurate bullet count, and ballistic trajectory analysis. The goals of this article are to review wound ballistics and the imaging evaluation of extremity civilian firearm injuries in the adult population, with emphasis on ballistic trajectory analysis, specific ballistic fracture patterns, and diffuse, secondary soft tissue ballistic injuries.
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Affiliation(s)
- Kimia Khalatbari Kani
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Jack A Porrino
- Yale Radiology and Biomedical Imaging, 330 Cedar Street, New Haven, CT, 06520-8042, USA
| | - Felix S Chew
- Department of Radiology, University of Washington, 4245 Roosevelt Way NE, Box 354755, Seattle, WA, 98105, USA
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