Review Question - QID 5845

This patient has (1) penetrating abdominal trauma (entry bullet wound, no exit wound), (2) signs of peritonism (which alone is indication for laparotomy) and (3) positive tests for hemoperitoneum on FAST. Laparotomy takes precedence over extraction of intra-articular bullet fragments.

Gunshot wounds (GSW) to the hip are difficult injuries to treat. This is because of surrounding vasculature and the joint’s proximity to intrapelvic structures. Surgical treatment focuses on stabilization, assessment of neurovascular function, and fracture fixation. Recovery of the bullet is a secondary priority. Retained bullets may lead to infection, foreign body reaction, mechanical damage of the joint cartilage, proliferative synovitis, and plumbism. The trajectory of the bullet is also important: A bullet that enters directly into the hip joint is unlikely to lead to an infection, but an trans-abdominal trajectory represents a high risk for infection.

Bartkiw et al. reviewed 2808 GSWs and found 1235 associated fractures including 42 fractures of the hip and pelvis. Ten orthopaedic operative procedures were performed in 7 patients. Associated nonorthopaedic injuries included 15 small/large bowel perforations (36%), 7 vessel lacerations (17%), and 2 urogenital injuries (5%) that required surgery. They recommend orthopedic intervention for intra-articular projectiles or bone fragments, and reconstruction of the hip and acetabulum.

Najibi et al. reviewed 39 GSW to acetabulum. They found 32 simple and 7 associated fracture patterns. The most common simple and associated patterns were anterior column and both column, respectively. Bowel injuries were the most common associated injures (42%). Predictors of poor outcome include high-velocity missile, involvement of acetabular dome, abdominal injury, nerve injury, vascular injury, and male gender. Deep infection was associated with primary anastomosis of bowel injury and an associated fracture pattern.

Figure A shows an intra-articular bullet in the right hip.

Incorrect Answers:
Answer 1: Diagnostic peritoneal lavage is not necessary as FAST is already positive.
Answer 2: A CT scan can confirm FAST findings. But with a positive FAST and peritonism in the presence of penetrating trauma, laparotomy is indicated, even without a CT scan
Answer 3: Saline load test of the hip is not indicated
Answer 4: Removal of the bullet is not a priority at this point.