Missile wounds of the extremities: a current concepts review

Retained bullet removal in civilian pelvis and extremity gunshot injuries: a systematic review

BACKGROUND

Although gunshot injuries are relatively common, there is little consensus about whether retained bullets or bullet fragments should be removed routinely or only in selected circumstances.

QUESTIONS/PURPOSES

We performed a systematic review of the literature to answer the following questions: (1) Is bullet and/or bullet fragment removal from gunshot injuries to the pelvis or extremities routinely indicated? And, if not, (2) what are the selected indications for removal of bullets and/or bullet fragments?

METHODS

A search of the English-language literature on the topic of gunshot injury and bullet removal was performed using the National Library of Medicine and MEDLINE(®) and supplemented by hand searching of bibliographies of included references. Studies were included if they provided clinical data on one or both of our study questions; included studies were evaluated using the levels of evidence rubric. Most studies on the subject were expert opinion (Level V evidence), and these were excluded; one Level III study and seven Level IV studies were included.

RESULTS

No studies provided a rationale for routine bullet removal in all cases. The studies identified bullet fragment removal as indicated acutely for those located within a joint, the palm, or the sole. Chronic infection, persistent pain at the bullet site, and lead intoxication were reported as late indications for bullet removal.

CONCLUSIONS

The evidence base for making clinical recommendations on the topic of bullet and bullet fragment removal after gunshot injury is weak. Level I and II evidence is needed to determine the indications for bullet removal after gunshot injury.

The role of débridement in low-velocity civilian gunshot injuries resulting in pelvis fractures: a retrospective review of acute infection and inpatient mortality

OBJECTIVES

To determine the use of surgical débridement in the management of low-velocity gunshot injuries (GSIs) resulting in pelvis fractures.

DESIGN

: Retrospective chart review.

SETTING

Level I trauma center in a major metropolitan area.

PATIENTS

Fifty-six patients from 1991 to 2007 treated for pelvis GSIs with resulting pelvis fractures with six acute mortalities and 40 patients with at least 1-year follow-up.

INTERVENTION

Patient data were reviewed for incidence of infection related to pelvis GSIs. Information regarding surgical débridement of pelvis GSI wounds, retained foreign bodies, and/or concomitant gastrointestinal (GI) injury was analyzed for relationships of such events to infection rate.

MAIN OUTCOME MEASUREMENTS

Incidence of infection related to pelvis GSIs at least 1 year after GSI date.

RESULTS

Three patients (6%) developed a deep infection related to their pelvis GSIs. There were no cases of osteomyelitis. The rate of concomitant GI injuries was 36% and the overall infection rate among those with GI injuries was 12% versus 3% for those without a GI injury (P = 0.34). There were infection rates of 7% and 6% among patients who underwent surgical débridement and those who did not, respectively. Of those with GI injuries, 41% underwent primary surgical débridement and none developed infection. In the group of remaining patients with GI injuries who did not undergo débridement of their GSI wounds, two (20%) developed an infection. The mortality rate of low-energy GSIs to the pelvis was six of 53 (11%).

CONCLUSION

There was no increased incidence of infection in the absence of aggressive surgical débridement of pelvis GSI wounds. The study also demonstrated that retained bullets and bullet fragments did not increase the risk of infection, even after penetrating the GI tract organs. Finally, this study suggests there may be an increased risk of infection related to pelvis GSIs compared with reported infection rates related to GSIs of the extremities, likely secondary to a high rate of concomitant GI injuries associated with pelvis GSIs; however, there was no incidence of osteomyelitis.

Surgical repair of ulnar nerve lesions caused by gunshot and shrapnel: results in 407 lesions

Object

Ulnar nerve lesions caused by gunshot wounds have rarely been reported in the current literature. The authors describe the outcome after surgical repair of such injuries, and the factors influencing the results of treatment.

Methods

This retrospective study includes 455 patients with 462 ulnar nerve injuries caused by gunshot wounds who were treated at Gulhane Military Medical Academy over a 40-year period. A total of 407 ulnar lesions were surgically repaired at that institution between 1966 and 2005; 237 patients were injured by shrapnel and 218 patients by gunshot. The authors evaluated the motor, sensory, and electrophysiological recovery in these patients, as well as the patients' judgment of the outcome. The authors also tested the effect of repair level, nerve graft length, time to operation, repair technique used, and the presence of coexisting damages in the nerve repair region. The final outcome in these patients was defined as poor, fair, or good on the basis of the British Medical Research Council scores.

Results

A good outcome was noted in 15.06% of patients who underwent high-level repair, 29.60% of patients who underwent intermediate-level repair, and 49.68% of patients after low-level repair. On average, patients with successful outcomes had a significantly shorter time to operation than those with unsuccessful outcomes. The critical period for surgery was within 6 months of injury. Although the optimal graft length was found to be 5 cm, this finding was not statistically significant.

Conclusions

The reported outcome of repairs to ulnar nerves damaged by gunshot has varied in the literature, but there is a consensus that the duration of the interval to surgery, the repair level, and the graft length used influence the outcome of surgical repair for ulnar nerve lesions.

A case report of firearm bullet settling into the thoracic spinal canal without causing neurological deficit or vertebral bone destruction

OBJECTIVE

The main objective of this study was to present a case of gunshot injury in which a bullet particle settled into the inferior-thoracic epidural canal, which was neurologically intact, without causing any vertebral bone destruction. There has been no previous report in the literature regarding a foreign body settling into the vertebral canal following gunshot injury without causing any bony destruction.

CASE REPORT

A 40-year-old male patient was hospitalized in emergency service with the complaints of severe pain in his back and both legs secondary to a gunshot wound. The entrance wound of the traversing projectile was located at the level of the tenth costa at the inferior of the right scapula. Neurological examination revealed no motor deficit. His lung X-ray was normal at radiological examination. Direct radiograph determined a bullet nucleus on the medium line at thoracolumbar level T-12. Intracanalicular bullet nucleus was found at posterior epidural at the T-12 level on thoracic CT, myelography and CT myelography. No vertebral bone destruction was seen in the direct radiograph studies and serial CT. T12 total laminectomy was performed and epidural foreign body removed. The patient, whose pains ameliorated during the postoperative process, was discharged without any neurological deficit.

CONCLUSION

We prefer removal of firearm particles settling into the spinal canal in view of possible later complications such as infection and the toxic effect of the metallic particles, unless there appears any risk of neurological detriment to the patient.

Brown-Séquard syndrome caused by a high velocity gunshot injury: a case report

STUDY DESIGN

Case report.

OBJECTIVE

To present an unusual traumatic neurologic pathology caused by gunshot injury.

SETTING

Spine unit of Department of Trauma and Orthopaedic Surgery, University Medical School, Charité - Campus Benjamin Franklin, Berlin, Germany.

METHOD AND RESULT

A 35-year-old male sustained a gunshot injury from a machine gun. The projectile caused a fracture of the left pedicle of Th10. The spinal cord was indirectly damaged by cavitation that caused a Brown-Séquard syndrome (BSS). After a microscopically assisted posterior revision at T9/10 with removal of bullet and bone fragments from the spinal canal and debridement of the bullet cavity via extended fenestrectomy the patient gained his motor function back. The sensory deficit remained unchanged.

CONCLUSION

BSS can be caused by bullet-related injury of the spinal canal with no direct damage of neural structures. The initial treatment is always based on the total injury pattern. Possible spinal cord injuries are only clarified after restitution of vital functions. Decompression of neural structures in shotgun injury is indicated in incomplete paraplegia, injury of intra-abdominal hollow organs or high velocity bullet wounds. Through debridement and decompression of neural structures and chronic damage caused by foreign body granulomas can be prevented. Secondary destabilization of the spine should be avoided.

Difference in Recovery Potential of Peripheral Nerves after Graft Repairs

OBJECTIVE:

To our knowledge, few studies have been published regarding differences in nerve recovery potentials. In this study, sensory and motor recovery potentials were compared between different nerves.

METHODS:

A prospective study of a homogenous group of 393 graft repairs of the median, ulnar, radial, tibial, peroneal, femoral, and musculocutaneous nerves, with the scoring of motor and sensory recoveries. Sensory and motor recovery potentials, defined on the basis of average scores and rates of useful recovery, were compared between the different nerves, and separately for high-, intermediate-, and low-level repairs.

RESULTS:

Sensory recovery potential was similar for all nerves tested (P > 0.05), but motor recovery potential differed significantly. After high-level repairs, motor recovery potential was significantly better for the radial and tibial nerves (useful recovery in 66.7 and 54.5% of patients, respectively), than for the ulnar and peroneal nerves (useful recovery in 15.4 and 13.8% of patients, respectively; P < 0.05). After intermediate-level repairs, motor recovery potential was better for the musculocutaneous, radial, and femoral nerves (useful recovery in 100, 98.3, and 87.5% of repairs, respectively), than for the tibial, median and ulnar nerves (useful recovery in 63.9, 52, and 43.6% of repairs, respectively; P < 0.05). In addition, motor recovery potential was significantly the worst with peroneal nerve repairs (useful recovery in 15.2% of patients; P < 0.05). After low-level repairs, motor recovery potential was similar for all nerves (useful recovery in the range of 88.9–100% of patients and in 56.3% of peroneal nerve repairs).

CONCLUSION:

Sensory recovery potential is similar for the median, ulnar, and tibial nerves. The expression of motor recovery potential depends on the repair level. With low- and high-level repairs, it does not stand out in an obvious way, but it is fully expressed with intermediate-level repairs, classifying nerves into three categories with excellent, moderate, and poor recovery potential.

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.

Antibiotic therapy in gunshot wound injuries

Protocols for antibiotic prophylaxis in the treatment of fractures caused by gunshots have not been delineated clearly in the literature to date. The current review of the literature reveals that antibiotic therapy for treatment of these fractures is predicated on the muzzle velocity of the weapon used to inflict the fracture. General consensus has been reached regarding the requirement of at least 24 hours of intravenous antibiotic treatment in fractures caused by high-velocity weapons in conjunction with the appropriate wound and fracture care. Similarly, in fractures caused by shotguns, thorough wound debridement and 24- to 48-hour administration of intravenous antibiotics is necessary. However, in fractures caused by low-velocity weapons, there is not a preponderance of the evidence showing that there is a distinct advantage to using antibiotic prophylaxis in these injuries. Special clinical consideration must be given regarding the use of antibiotics in fractures caused by gunshots that are intraarticular and those about the hand, foot, and ankle.

Recent advances in the treatment of gunshot fractures of the humeral shaft

The increase in violent crime has lead to an increase in gunshot-induced fractures in the United States. Injuries to the upper extremity are common. The treatment of gunshot injuries depends on the extent of soft tissue disruption and the type and location of fracture. Most of these injuries are a result of low-energy gunshot wounds that may be treated conservatively under the appropriate conditions. Low-energy fractures that require operative stabilization may be done with predictable results for achieving union with intramedullary fixation or compression plating. Complex open fractures from gunshot wounds associated with neurovascular injuries present a therapeutic challenge to the orthopaedic surgeon. The fractures associated with these injuries often are comminuted and unstable. Bone loss is common. Soft tissue disruption plays a more important role in high-energy gunshot-induced fractures. In these cases, external fixation is the treatment of choice for stabilization. Recent advances in the use of external fixation have led to quick fracture stabilization, stability for vascular repair, and access to the wound for debridement and subsequent soft tissue surgery.

Spinal cord injuries from gunshot wounds to the spine

Although vehicular trauma traditionally has accounted for the majority of spinal cord injuries, gunshot wounds are the second most common cause. Furthermore, the proportion of spinal cord injuries caused by gunshot wounds are increasing although the proportion of injuries caused by high-speed vehicular trauma is decreasing. Gunshot wounds to the spine commonly are thought to be stable injuries. There is, however, a potential for instability if the bullet passes transversely through the spinal canal and fractures pedicles and facets. Injuries to the thoracic region of the spine are the most common, followed by the thoracolumbar area and the cervical spine. Completeness of injury is related to the anatomic region. Patients with incomplete injuries and patients with injuries in the thoracolumbar region have the greatest improvement in motor function. Approximately (1/4) of individuals are able to ambulate 1 year after injury. Surgical decompression of bullets from the spinal canal has been shown to improve neurologic recovery below the T12 level. Improvement of neurologic recovery after bullet removal has not been shown in other regions of the spine. Rare instances of late neurologic decline because of retained bullet fragments have been documented.

Current treatment of gunshot wounds to the hip and pelvis

Gunshot wounds to the pelvis can result in injuries to various organ systems. These injuries require the care of a multispecialty trauma team at a trauma center. Orthopaedic care includes wound treatment, fracture stabilization, and infection prophylaxis. Wound care is determined by the personality of the injury, and not solely based on the velocity of the missile. Antibiotic treatment usually is indicated for patients with gunshot wounds to the pelvis, but is controversial in patients with low-energy wounds. Fractures are treated based on their stability. Regional consideration of pelvic gunshot wounds includes injuries with associated abdominal viscus injury, intraarticular bullets, and retained bullets in the spinal canal.

Extremity handgun injuries in children and adolescents

The majority of gunshot wounds in the urban pediatric population are inflicted by handguns. This study reviewed the trauma center management of 66 handgun injuries to the upper and lower extremities among 51 children who were aged < or =16 years. As expected, gunshot wounds were more frequent in adolescent males and were usually intentional. About half of the children had police records prior to the gunshot wounds. Fifty-two percent of the extremity handgun injuries resulted in fractures, most commonly to the tibia or forearm. Seventy-nine orthopedic procedures were recorded with an average hospital stay of 4.3 days. Permanent morbidity was undoubtedly underestimated due to poor long-term follow-up.

Results of suture of the radial, median, and ulnar nerves after missile injury below the axilla

OBJECTIVE

To evaluate the functional outcome and return to work after suture of upper extremity nerves after low-velocity missile injury.

METHODS

Forty-one patients had suture of the radial, median, and/or ulnar nerves between the wrist and axilla, 3 to 17 weeks after low-velocity missile injury. Postoperative functional outcome was good if no supplemental techniques (permanent splints, tendon or muscle transfer, fusion) were required, fair if supplemental techniques were required to restore a functional hand, and poor if the hand was severely deformed. The follow-up period was 14 to 38 months.

RESULTS

Supplemental techniques followed the suture of 11% of radial, 45% of median, 72% of ulnar, and 100% of combined median and ulnar nerve injury. After suture +/- supplemental techniques, patients returned to work in 100% of radial, 55% of median, 57% of ulnar, and 0% of combined median and ulnar nerve injuries.

CONCLUSION

Nerve suture between the wrist and axilla and supplemental techniques achieve functional recovery in the majority of patients after missile injury with good expectations for return to work, except in combined median and ulnar nerve injuries.

Results of suture of the sciatic nerve after missile injury

OBJECTIVE

To evaluate functional recovery after suture of the sciatic nerve after missile injury.

METHODS

We reviewed the outcome of 23 adults and four children who had the sciatic nerve sutured above the knee 3 to 14 weeks after missile injury and who were followed for 14 to 36 months.

RESULTS

In adults, useful motor recovery was significantly better after suture of tibial (83%) than peroneal (39%) nerves, after suture of nerves at the thigh (71%) than at the buttock (31%) level, and after end-to-end anastomosis (74%) than grafting (39%). Useful sensory function was recovered in 78% of tibial nerves. Fifty-seven percent of adults walked wearing special shoes or pads. Significantly better recovery occurred in children, who all walked with normal footwear.

CONCLUSION

We advocate exploration of the sciatic nerve at any level within 3 months if no spontaneous recovery occurs after a missile injury. We do not advocate exploration of the sciatic nerve at the buttock level if only peroneal function is lost except in children.

Low-velocity gunshot fractures of the radius and ulna: case report and review of the literature

This report describes a case of right radial-ulnar fracture with bone loss, and left olecranon fracture with radial nerve palsy resulting from a small caliber, low-velocity gunshot. Initial wound debridement and extraskeletal fixation were done to fix the radial-ulnar fracture. Wound debridement, bullet removal, and tension band wiring were performed on the left forearm. Definitive operations with rigid plate fixation and full segmental iliac bone grafting of the right radial-ulnar fracture were done 2 months later. Left radial nerve palsy resolved 9 months after the index injury. The fractures were fully united and both forearm functions were in normal range 3 years postoperatively. Implications of this case and a review of the literature are presented.

Treatment of open fractures of the foot and ankle: a preliminary report

A retrospective study was performed on 33 patients who sustained isolated open-fracture injuries to the foot and ankle. A wide variety of open-fracture injuries of the foot and ankle are documented. Of the 33 cases, only 2 became clinically infected, translating into an infection rate of 6.06%. A literature review of open-fracture injuries is presented along with the preliminary results of the retrospective study.