Gun Shot Wounds

Author: Brian Weatherford

Topic updated on 02/24/13 11:47pm

Introduction

Epidemiology
- represent second-leading cause of death for youth in United States
Pathoanatomy
- wounding capability of a bullet directly related to its kinetic energy
- damage caused by
  - passage of missile
  - secondary shock wave
  - cavitation
- exponential increase in injury with increasing velocity and efficient energy transfer
- fractures may be caused even without direct impact
Associated conditions
- lead intoxication (plumbism)
  - may be caused by intra-articular missile
  - systemic effects include
    - neurotoxicity
    - anemia
    - emesis
    - abdominal colic

Classification

Low velocity
- muzzle velocity <350 meters per second or < 2,000 feet per second
- most handguns except for magnums
- wounds comparable to Gustillo-Anderson Type I or II
Intermediate velocity
- muzzle velocity 350-500 meters per second
- shotgun blasts
  - highly variable depending on distance from target
  - can reflect wounding potential of high velocity firearms from close range (less than 21 feet) or multiple low velocity weapons
  - wound contamination/infection with close range injuries due to shotgun wadding
  - wounding potential depends on 3 factors
    - shot pattern
    - load (size of individual pellet)
    - distance from target
High velocity
- muzzle velocity >600 meters per second or >2,000 feet per second
- military (assault) and hunting rifles
- wounds comparable to Gustillo-Anderson Type III regardless of size
- high risk of infection
  - secondary to wide zone of injury and devitalized tissue

Presentation

Symptoms
- pain, deformity
Physical exam
- perform careful neurovascular exam
- clinical suspicion for compartment syndrome
  - secondary to increased muscle edema from higher velocity wounds
- examine and document all associated wounds
  - massive bone and soft tissue injuries occur even with low velocity weapons

Evaluation

Radiographs
- obtain to identify bone involvement and/or fracture pattern
CT scan
- identify potential intra-articular missile
- detect hollow viscus injury that may communicate with fracture
  - high index of suspicion for pelvis or spine fractures given increased risk of associated bowel injury

Treatment General

Nonoperative
- local wound care, tetanus, and short course of oral antibiotics
  - indications
    - low-velocity injury with no bone involvement or non-operative fractures
  - technique
    - primary closure contraindicated
    - antibiotic use controversial but currently recommended
Operative
- ORIF/external fixation
  - indications
    - unstable/operative fracture pattern in low-velocity gunshot injury
  - technique
    - treatment dictated by fracture characteristics similar to closed fracture without gunshot wound
    - stabilize extremity with associated vascular or nerve injuries
    - stabilize soft tissues in high velocity/high energy gunshot injuries
      - grossly contaminated/devitalized wounds managed with aggressive debridement per open fracture protocol
- arthrotomy
  - indications
    - intra-articular missile
      - may lead to local inflammation, arthritis and lead intoxication (plumbism)

GSW to Femur

Operative
- intramedullary nailing
  - indications
    - diaphyseal femur fracture secondary to low-velocity gunshot wound
    - superficial wound debridement and immediate reamed nailing
    - similar union and infection rates to closed injuries
- external fixation
  - indications
    - high-velocity gunshot wounds or close range shotgun blasts
    - stabilize soft tissues and debride aggressively
    - associated vascular injury
    - temporize extremity until amenable to intramedullary nailing

GSW to Spine

Nonoperative
- broad spectrum IV antibiotics for 7-14 days
  - indications
    - gunshot wounds to the spine with associated perforated viscus
      - bullets which pass through the alimentary canal and cause spinal cord injuries do not require surgical removal of the bullet
Operative
- surgical decompression and bullet fragment removal
  - indications
    - when a neurologic deficit is present that correlates with radiographic findings of neurologic compression
      - a retained bullet fragment within the spinal canal in patients with incomplete motor deficits is a relative indication for surgical excision of the fragment

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Qbank (3 Questions)

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(SBQ06.2) A 21-year-old male presents to the emergency department after sustaining a gun shot wound to his back. Subsequent radiographs reveal a bullet in the L2 vertebral body. Physical exam shows no neurologic deficits. He undergoes emergent laparotomy and is found to have a small bowel laceration. What would be the preferred treatment following his exploratory laparotomy and small bowel repair? Topic

Review Topic

1. Intravenous antibiotic coverage for Gram negative bacteria for 7 days
2. Surgical decompression and bullet fragment removal
3. Observation
4. Broad-spectrum oral antibiotic coverage for 7 days
5. Broad-spectrum intravenous antibiotic coverage for 7 days

PREFERRED RESPONSE ▶

DISCUSSION: The clinical presentation is consistent with a GSW with bowel perforation and a retained bullet in the vertebral body. Because the patient is neurologically intact broad-spectrum intravenous antibiotic coverage for 7 days is the most appropriate treatment.

Gunshot wounds to the spine present relatively little risk of infection in most cases. When there has been an injury to the small bowel, the risk of infection can be minimized with a 7-day course of broad-spectrum antibiotics. Indications for surgery include when a neurological deficit is present that correlates with imaging findings of neurological compression by the missile, or when the missile is in contact with the CSF posing a risk for metal toxicity.

Roffi et al performed a Level 4 study of 42 patients that sustained a gunshot wound that perforated the stomach or bowel and then entered the spinal column. They found that an extended regimen of broad spectrum antibiotics combined with bedrest appeared to significantly reduce the risk of spinal or paraspinal infection, whereas early bullet removal did not significantly prevent the occurrence of infection.

Velmahoos et al performed a Level 4 study including 24 patients that sustained a gunshot wound to the spine with associated colonic injury. They found that the incidence of sepsis was 8.4% (compared to 5% in non-bowel injuries) and concluded that retainment of the bullet did not increase the rate of sepsis.

Incorrect Answers:
Answer 1: The patient needs coverage for both Gram+ and Gram- organisms.
Answer 2: There are no indications for surgery at this point.
Answer 3: Antibiotics are indicated to decrease the risk of infection.
Answer 4: Intravenous antibiotic has been found to be more effective than oral antiobiotics.

REFERENCES:

1. Roffi RP, Waters RL, Adkins RH: Gunshot wounds to the spine associated with a perforated viscus. Spine 1989;14:808-811. PMID:2781395 (Link to Abstract)

2. Velmahoos GC, Demetriades D: Gunshot wounds of the spine: Should retained bullets be removed to prevent infection? Ann R Coll Surg Engl 1976;94:85-87. PMID:8154819 (Link to Abstract)

Question Authors:

Michael Hughes MD, Ben Taylor MD, John Badylak MD,

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(OBQ06.91) What is the most appropriate treatment for a 17-year-old boy who sustained a gunshot wound to his forearm from a handgun with a muzzle-velocity of 1000 feet/second if he is neurovascularly intact and radiographs reveal no fracture? Topic

Review Topic

1. Irrigation and local wound care in the emergency department followed by 3 days of oral antibiotics
2. Emergent irrigation and debridement in the operating room with vacuum-assisted wound closure
3. Emergent irrigation and debridement in the operating room with 7 days of intravenous antibiotics
4. Wound closure in the emergency department with follow-up wound check in 1 week
5. Exploration and removal of all bullet fragments in the emergency department and 10 day course of oral antibiotics

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. 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)

2. 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)

3. 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)

Question Authors:

Jan Szatkowski MD, Derek Moore, John Badylak MD,

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(OBQ05.233) A 24-year-old man who sustained a gunshot wound to the abdomen ten hours earlier was brought to the emergency department. On physical examination he was found to have 4 of 5 weakness in his bilateral lower extremities. Radiographs are shown in Figure A. Computed tomography of the lumbar spine showed retained missile in the vertebral body and paraspinal soft tissues, but not within the spinal canal. His FAST was positive and he underwent an emergent exploratory laparotomy where an injury to the cecum was identified and treated. Management should now include which of the following? Topic

Review Topic

FIGURES: A

1. Bullet fragment removal from a transabdominal approach
2. Bullet fragment removal from a retroperitoneal approach
3. Broad-spectrum oral antibiotics for 3-5 days
4. Broad-spectrum intravenous antibiotics for 7-14 days
5. IV methylprednisolone at 5.4mg/kg/h for 48 hours

PREFERRED RESPONSE ▶

DISCUSSION: The patient in the scenario has a GSW to the lumbar spine with neurologic deficits but without a retained missile in the spinal canal. In patients with visceral injury, the treatment is broad-spectrum antibiotic coverage for 7 days.

Kumar et al reviewed 33 patients with GSW to the spine and associated visceral injuries. They concluded that 7 days of antibiotic treatment targeted at colonic flora is the treatment of choice.

Roffi et al reviewed 51 low-velocity GSW that perforated the viscus prior to the spine. They concluded that broad spectrum antibiotics combined with bedrest significantly reduced the risk of spinal or paraspinal infections. Furthermore, bullet removal had no effect on infection rates.

Velmahos et al followed 153 GSW to the spine for 28 months. While rates of sepsis were higher in the lumbar spine than cervical and thoracic spine, they concluded that retained bullets do not increase the likelihood of septic complications.

Incorrect Answers:
Answer 1 & 2: Indications for surgery with a GSW to the lumbar spine include 1) spinal instability 2) a neurologic deficit is present that correlates with radiographic findings of neurologic compression by the missile. 3) Lead missile is in contact with the cerebrospinal fluid (CSF). This patient does not have any of these criteria.
Answer 5: GSWs are a contraindication for spinal dose steroids.

REFERENCES:

1. Kumar et al.: Low-velocity gunshot injuries of the spine with abdominal viscus trauma. JOT 1998;12:514-517 PMID:9781777 (Link to Abstract)

2. Roffi RP, Waters RL, Adkins RH: Gunshot wounds to the spine associated with a perforated viscus. Spine 1989;14:808-811. PMID:2781395 (Link to Abstract)

3. Velmahoos GC, Demetriades D: Gunshot wounds of the spine: Should retained bullets be removed to prevent infection? Ann R Coll Surg Engl 1976;94:85-87. PMID:8154819 (Link to Abstract)

Question Authors:

Terrill Julien MD, Derek Moore, Ben Taylor MD,

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Cases

	Gunshot on the right hip (C1120) Trauma - - Gun Shot Wounds HPI - Patient was shot on the right hip 1 year ago. Was hospitalized but never operate... What would be your treatment of choice at presentation before surgery?	1/2/2012 44 responses
	Gunshot on the left hip (C1121) Trauma - - Gun Shot Wounds HPI - Patient was shot on left buttock. Presented walking w/o neurovascular deficits What approach would you use for the bullet removal?	1/2/2012 23 responses
	Gunshot on left humerus (C1125) Trauma - - Gun Shot Wounds HPI - Patient was shot at left arm. Treated in another hospital where received antibio... How would you treat this patient?	1/5/2012 135 responses
	painful stiff knee (C1176) Trauma - - Gun Shot Wounds HPI - close range (1foot) shotgun injury. bad soft tissues. managed in spanning exfix.... what options does he have	3/14/2012 50 responses

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ABOS II: Gun Shot Wounds

General - Oral Boards Review

7/29/2011

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Evidence & References Show References

Level of Evidence 4 (Case Series)

Roffi RP, Waters RL, Adkins RH: Gunshot wounds to the spine associated with a perforated viscus. Spine 1989;14:808-811. PMID:2781395 (Link to Abstract)
Velmahoos GC, Demetriades D: Gunshot wounds of the spine: Should retained bullets be removed to prevent infection? Ann R Coll Surg Engl 1976;94:85-87. PMID:8154819 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

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)
Kumar et al.: Low-velocity gunshot injuries of the spine with abdominal viscus trauma. JOT 1998;12:514-517 PMID:9781777 (Link to Abstract)
Roffi RP, Waters RL, Adkins RH: Gunshot wounds to the spine associated with a perforated viscus. Spine 1989;14:808-811. PMID:2781395 (Link to Abstract)
Velmahoos GC, Demetriades D: Gunshot wounds of the spine: Should retained bullets be removed to prevent infection? Ann R Coll Surg Engl 1976;94:85-87. PMID:8154819 (Link to Abstract)

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Gun Shot Wounds

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