Review Question - QID 213985

This patient is presenting with open multiple metacarpal fractures in the setting of a severe blast injury from a low-velocity, high-energy gun shot. Of the above, the most accurate statement is that early debridement and irrigation with normal saline is just as effective as irrigation with betadine solution.

The most important factor in the management of severely contaminated open fracture wounds is early thorough debridement. While previous studies have shown that initial debridement should occur within 6 hours of injury, more recent studies have not demonstrated a significant correlation within that urgent time frame, but rather recommend initial debridement as soon as possible within 24 hours, followed by a “second-look” delayed debridement in wounds that have questionable tissue viability. There is limited evidence to support aggressive irrigation or irrigation with an antiseptic solution in the emergency room. Time to antibiotic administration has also been demonstrated to have a significant effect on decreasing infection risk, and as such the immediate administration of antibiotics in the emergency room is recommended.

Ordog et al. investigated infection in minor gunshot wounds. They reported a <2% infection rate related to minor gunshot wounds and increased complications when a prolonged period occurred between the time of injury and the initial treatment. They concluded that while wound debridement and antibiotics are often unnecessary in minor uncomplicated gunshot wounds, they are beneficial in patients who have sustained multiple injuries, gross wound contamination, significant tissue devitalization, large wounds, or treatment delays.

Tian et al. investigated the quantitative bacteriological study of the wound track in the hind legs of dogs. They reported that as the time increased (6, 12, 24 hours), so did the number of aerobic and anaerobic bacteria in devitalized muscle tissue. They emphasized the importance of early debridement and treatment to minimize bacterial contamination.

Turker et al. reviewed the management of hand gunshot wounds. They reported that comprehensive information regarding the management of gunshot wounds and functional recovery of the hand is lacking in the literature. Thus, they recommended early debridement, antibiotic treatment, reconstruction, and rehabilitation to offer patients the best chance for full functional recovery.

Pereira et al. reviewed the outcomes of complex gunshot wounds to the hand and wrist. They reported that during gunshots, the temporary cavitational effect might create a vacuum that can pull foreign materials, including dirt and bacteria into the wound, potentially leading to wound infection. They observed that shotguns cause higher rates of infection when compared to low-velocity guns. They recommended that while minor wounds do not require aggressive debridement, early debridement is recommended in severely wounded hands and that all devitalized tissue except bone fragments be removed.

Figure A demonstrates a severely wounded hand from a high-velocity gunshot. Figure B demonstrates multiple metacarpal fractures.

Incorrect Answers:
Answer 2: Irrigation with high-pressure lavage is more expensive and not superior to low-pressure lavage.
Answer 3: Tetanus prophylaxis should be administered based on immunization history. For this patient, no prophylaxis is needed if his last dose was given within 5 years.
Answer 4: For this patient with a severely wounded hand, a first-generation cephalosporin and aminoglycoside (i.e. gentamicin) would be sufficient for antibiotic coverage. Gentamicin alone would not be sufficient.
Answer 5: The proper technique involves extending the debridement beyond the zone of injury to ensure good eradication of debris and bacteria.