The question refers to appropriate management of a gunshot wound to the forearm. The first question that must be answered when evaluating gun shot injuries is whether the gunshot is low velocity or high velocity. Low-velocity wounds are less severe, are more common in the civilian population, and are typically attributed to bullets with muzzle velocities below 1,000 to 2,000 feet per second. Tissue damage is usually more substantial with higher-velocity (greater than 2,000 to 3,000 fps) military and hunting weapons. In this question, a muzzle velocity of 1,000 ft/sec is provided. Low velocity injuries with stable, non-operative fractures can be treated with local wound care and oral antibiotics.
The two referenced articles offer guidance for treating low-velocity gunshot injuries with stable, non-operative fracture patterns. The first article by Geissler et al is a retrospective study comparing 25 patients that prospectively received local irrigation and debridement, tetanus prophylaxis and a long acting cephalosporin intramuscularly to a random retrospective sample of 25 patients with similar ballistic-induced fractures and wounds managed by local debridement and 48h of intravenous antibiotics. One infection occurred in each group, requiring further therapy. It was concluded that patients with low-velocity gunshot induced fractures can be managed without the use of short-term intravenous antibiotics with no increased risk of infection.
In the second study, Dickey et al evaluated the efficacy of an outpatient management protocol for patients with a gunshot-induced fracture with a stable, non-operative configuration. 41 patients with a grade I or II open, non-operative fracture secondary to a low-velocity bullet were treated with 1gm of cefazolin administered in the emergency room and a 7-day course of oral cephalexin. No patient developed a deep infection. Thus, local I&D, tetanus, and oral antibiotics for 2-3 days is adequate for low velocity gunshot wounds.
Geissler WB, Teasedall RD, Tomasin JD, Hughes JL. Management of low velocity gunshot-induced fractures. J Orthop Trauma 1990; 4: 39-41.
PMID:2313428 (Link to Abstract)
Dickey RL, Barnes BC, Kearns RJ, Tullos HS. Efficacy of antibiotics in low velocity gunshot fractures. J Orthop Trauma 1989; 3: 6-10.
PMID:2709206 (Link to Abstract)
Bartlett CS, Helfet DL, Hausman MR, Strauss E. Ballistics and gunshot wounds: Effects on musculoskeletal tissues. JAAOS 2000; 8: 21-36.
PMID:10666650 (Link to Abstract)