Upper Extremity Gunshot Wounds

Upper Extremity Gunshot Wounds

Alex C. Lesiak

John R. Fowler


  • 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.


  • 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


  • 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




Less than 3



3 or more



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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