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Introduction
  • Epidemiology
    • Gun shot wounds represent the 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
    • 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 < 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
      • 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
      • 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   
        • 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) 
        • 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
        • presentation 8 or more hours after injury
        • 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  
        • 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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(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? Review Topic

QID: 202
1

Irrigation and local wound care in the emergency department

79%

(532/674)

2

Emergent irrigation and debridement in the operating room with vacuum-assisted wound closure

3%

(21/674)

3

Emergent irrigation and debridement in the operating room with 7 days of intravenous antibiotics

10%

(66/674)

4

Wound closure in the emergency department with follow-up wound check in 1 week

4%

(29/674)

5

Exploration and removal of all bullet fragments in the emergency department and 10 day course of oral antibiotics

3%

(21/674)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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(OBQ13.6) A ballistics expert examines the effects of bullets on tissues. He defines a "penetrating missile" as one that delivers an entrance wound but no exit wound, and a "perforating missile" as one that possesses both entrance and exit wounds. He also defines bullet "yaw" as the tumble of a bullet or its tendency to turn sideways in flight. A diagram of bullet yaw is seen in Figure A. Which of the following scenarios leads to the greatest transfer of kinetic energy to tissues? Review Topic

QID: 4641
FIGURES:
1

Penetrating missile with mass "2m", velocity "v", yaw of 90 degrees at the point of impact

12%

(278/2230)

2

Perforating missile with mass "m", velocity "2v", yaw of 0 degrees at the point of impact

6%

(123/2230)

3

Penetrating missile with mass "m", velocity "2v", yaw of 90 degrees at the point of impact

58%

(1299/2230)

4

Perforating missile with mass "m", velocity "2v", yaw of 90 degrees at the point of impact

20%

(444/2230)

5

Penetrating missile with mass "2m", velocity "v", yaw of 0 degrees at the point of impact

3%

(65/2230)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ12.193) A 24-year-old male presents after being shot in the lower back. Radiographs and advanced imaging show that the bullet traversed the paraspinal musculature, entered the pelvis below the pelvic brim, and is currently lodged in the ilium. No intra-articular involvement was noted, and the bony injury is stable. No occult blood is noted on the rectal examination. The police report indicates that the bullet was fired from a low-velocity weapon. Which of the following is the most important treatment for this patient assuming he is hemodynamically stable? Review Topic

QID: 4553
1

Immediate exploratory laparotomy and bullet removal

4%

(153/3999)

2

Bullet removal followed by surgical stabilization of the ilium

1%

(35/3999)

3

Immediate surgical debridement of the bullet tract and delayed closure of the soft tissue wound

6%

(232/3999)

4

Empiric antibiotic therapy and observation

86%

(3431/3999)

5

Sigmoidoscopy

3%

(120/3999)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(SBQ06SN.2) A 21-year-old male presents to the emergency department after sustaining a gun shot wound to his abdomen. 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? Review Topic

QID: 1687
1

Intravenous antibiotic coverage for Gram negative bacteria for 7 days

17%

(401/2352)

2

Surgical decompression and bullet fragment removal

4%

(87/2352)

3

Observation

6%

(147/2352)

4

Broad-spectrum oral antibiotic coverage for 7 days

6%

(139/2352)

5

Broad-spectrum intravenous antibiotic coverage for 7 days

67%

(1571/2352)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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? Review Topic

QID: 1119
FIGURES:
1

Bullet fragment removal from a transabdominal approach

2%

(11/674)

2

Bullet fragment removal from a retroperitoneal approach

3%

(22/674)

3

Broad-spectrum oral antibiotics for 3-5 days

11%

(72/674)

4

Broad-spectrum intravenous antibiotics for 7-14 days

76%

(514/674)

5

IV methylprednisolone at 5.4mg/kg/h for 48 hours

8%

(54/674)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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