Upper Extremity Gunshot Wounds



Upper Extremity Gunshot Wounds


Alex C. Lesiak

John R. Fowler



INTRODUCTION



  • Mechanism of injury



    • Penetration of the upper extremity by a bullet or other missile projected by a firearm


  • Pathoanatomy



    • Small entrance wound and larger exit wound


    • Tissue damage occurs due to the passage of the bullet/missile through the tissue, a secondary shock wave, and the cavitation created by the missile.


    • The injury can cause blood vessel, bone, muscle, and other soft-tissue damage.


    • Extent of injury is determined by the type of firearm, projectile velocity, and projectile mass.


  • Epidemiology



    • 33 599 deaths from firearms in 2014 (63.5% from suicide and 32.6% from homicide)


    • 11 101 firearm-related homicides in 2011


    • 70% to 80% of firearm homicides and 90% of nonfatal firearm victimizations were committed with a handgun from 1993 to 2011.


EVALUATION



  • History



    • Type of firearm when known


    • Timing of injury


    • Injuries to other extremities or organ systems


    • Associated symptoms



      • Pain


      • Numbness and/or tingling



  • Physical examination



    • Inspection—identify entrance and exit wounds


    • Assess for wound contamination (clothing, or other debris that may have entered the wound)


    • Detailed neurovascular examination



      • If concern for vascular injury: perform an Allen test and consider use of a doppler machine to evaluate vasculature


    • Evaluate bony stability to assess for fracture/dislo cation


  • Diagnostic data



    • Radiographs of the involved area as well as the joint above and below zone of injury


    • CT scan or saline injection challenge can assist in determining intra-articular involvement if suspected


    • Vascular injury suspected



      • Doppler ultrasonography


      • Arteriography—CTA versus intraoperative angiogram depending on situation and injury


    • EMG/nerve conduction velocity cannot distinguish between neuropraxia and transection in the early postinjury period


  • Classification



    • Low velocity (<2 000 ft/s)


    • High velocity (>2 000 ft/s)


    • Shotgun (Type 0 to Type III)



      • 0: ≥20 yards away and causes very minimal damage


      • I: ≥7 yards and often does not produce major soft-tissue injury due to pellet scatter


      • II: <3 to 7 yards


      • III: <3 yards



        • Types II and III associated with high rates of associated injury



          • ▲ 32% to 48% comminuted fractures


          • ▲ 43% to 59% major soft-tissue disruption


          • ▲ 23% to 45% vascular injury


          • ▲ 21% to 58% peripheral nerve damage


ACUTE MANAGEMENT



  • Initial trauma evaluation: check airway, breathing, and ciculation (ABCs)


  • Thorough history and physical examination


  • Tetanus prophylaxis (Table 58.1)



  • May consider initial dose of antibiotics (1 g cefazolin)


  • Initial debridement



    • Cleanse wounds with povidone/normal saline and debride in emergency department (E.D).


    • Apply sterile dressing


    • Splint/cast








TABLE 58.1 Tetanus Prophylaxis Recommendations for Gunshot Wound Patients























Number of Previous Tetanus Vaccinations


Give Td


Give TIG


Uncertain


Yes


Yes


Less than 3


Yes


Yes


3 or more


No


No


Adults and children 7 years of age or older: Td preferred to tetanus toxoid alone.


Children less than 7 years of age: diphtheria, tetanus, pertussis (DTP; DT, if pertussis vaccine is contraindicated) is preferred to tetanus toxoid alone.


If only three doses of fluid toxoid have been received: give a fourth dose of toxoid, preferably an adsorbed toxoid.


If greater than 5 years since last dose: give a booster.


Abbreviations: Td, adult-type tetanus and diphtheria toxoid; TIG, tetanus immune globulin.


Adapted from Centers for Disease Control and Prevention. Diptheria, tetanus, and pertussis: recommendations for vaccine use and other preventive measures: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR Morb Mortal Wkly Rep. 1991;40(RR-10):1-28.

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May 7, 2019 | Posted by in ORTHOPEDIC | Comments Off on Upper Extremity Gunshot Wounds
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