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Updated: Feb 22 2024

Gun Shot Wounds

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  • Introduction
    • Gun shot wounds are high energy injuries that contribute to extensive soft tissue damage and comminuted bony fractures.
  • Epidemiology
    • Incidence
      • gun shot wounds represent the second-leading cause of death for youth in United States.
  • Etiology
    • 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
      • GSW to hip and acetabulum are most commonly associated with bowel perforation > vascular injury > urogenital injuries
  • Classification
    • Low velocity
      • muzzle velocity <350 meters per second or < 1,200 feet per second
      • most handguns except for magnums
      • wounds comparable to Gustillo-Anderson Type I or II
    • Intermediate velocity
      • muzzle velocity 350-650 meters per second or 1,200-2,000 feet 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
  • Imaging
    • 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
        • indications
          • low velocity GSW with no bone involvement and clean wound edges
      • local wound care, tetanus +/- short course of oral antibiotics
        • indications
          • low-velocity injury with no bone involvement or non-operative fractures
          • low-velocity injury causing traumatic arthrotomy without retained intra-articular missile
        • technique
          • primary closure contraindicated
          • antibiotic use controversial but currently recommended if wound appears contaminated
    • Operative
      • treatment of other non-orthopedic injuries
        • for trans-abdominal trajectories, laparotomy takes precedence over arthrotomy
      • 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
          • low velocity gunshot injuries can be treated with superficial debridement and gram-positive antibiotic coverage with appropriate fracture stabilization based on injury type
          • high velocity/high energy gunshot injuries
            • grossly contaminated/devitalized wounds managed with aggressive debridement per open fracture protocol with broad-spectrum antibiotic coverage 
      • arthrotomy
        • indications
          • intra-articular missile
            • may lead to local inflammation, arthritis and lead intoxication (plumbism)
          • transabdominal GSW
  • GSW to Hand/Foot
    • Nonoperative
      • antibiotics
        • indications
          • gross contamination
          • joint penetration
          • extent of contamination unclear
    • Operative
      • surgical debridement +/- ORIF/external fixation
        • indications
          • articular involvement
          • unstable fractures
          • tendon involvement
          • superficial fragments in the palm or sole
  • GSW to Femur
    • Operative
      • intramedullary nailing
        • indications
          • diaphyseal femur fracture secondary to low-velocity gunshot wound
        • technique
          • superficial wound debridement and immediate reamed nailing
        • outcomes
          • similar union and infection rates to closed injuries
      • external fixation
        • indications
          • high-velocity gunshot wounds or close range shotgun blasts
          • 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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