Compartment syndrome after low-velocity gunshot wounds to the forearm

Between 1980 and 1988, 127 patients with 131 low-velocity gunshot wounds to the forearm were treated. In 71 extremities there was no bony injury; 60 extremities sustained fractures. The diagnosis of a compartment syndrome was based on tissue pressure measurements and/or clinical examination. A univariate analysis followed by a multivariate stepwise logistic regression was used to evaluate potential risk factors including fracture location, displacement, comminution, and the quantity of radiographically determined metallic foreign bodies in the wound. A compartment syndrome was diagnosed in 13 of the extremities (10%). Fracture location was the only significant risk factor for the development of a compartment syndrome. Low-velocity gunshot injuries to the forearm are at definite risk for the occurrence of a compartment syndrome. A high index of suspicion is necessary to prevent untoward sequelae. Patients with this injury, especially those with a proximal one-third fracture who constitute an extremely high-risk group, should be monitored closely.     

Exploration of low-velocity gunshot wounds of the neck.

Review of 68 consecutive patients seen between 1966 and 1976 with low-velocity gunshot wounds of the neck is reported. Treatment and results are compared. Comparison of preoperative evaluation and operative findings shows that the initial evaluation may miss serious injuries. Associated severe injuries are common. Morbidity following exploration is low. Exploration of all low-velocity gunshot wounds to the neck is recommended.     

Arthroscopic management of intra-articular low-velocity gunshot wounds of the knee

This article reports on the arthroscopic management of intra-articular low-velocity gunshot wounds. Thirteen (12 men and 1 woman) patients comprised the study population treated over a 5-year period. All patients underwent arthroscopy within 24 hours of injury. Four patients had additional limited arthrotomies for internal fixation of associated fractures and removal of an embedded bullet. Allograft reconstruction as a delayed procedure was required in 1 patient with extensive bone deficiency of the medial femoral condyle. Two patients suffered cruciate ligament tears: one avulsion fracture of the femoral attachment of the posterior cruciate ligament and one avulsion tear of the tibial attachment of the anterior cruciate ligament. Meniscal damage was observed in 2 patients, one of which required a primary repair. No infections or operative complications occurred. Arthroscopic evaluation of the affected knees allowed debridement of osteochondral loose bodies, retained foreign materials and bullet fragments, and also aided in surgical decision making.     

Concomitant injuries of the hip joint and abdomen resulting from gunshot wounds.

Septic arthritis is a devastating complication of transabdominal gunshot wounds to the hip. Five patients sustained gunshot wounds to the hip which violated the alimentary tract. Diagnosis was established with plain radiographs in three patients, arthrogram in one patient, and a gastrointestinal series in one patient. Three patients had an exploratory laparotomy with diverting colostomy followed by immediate hip arthrotomy within 24 hours and no joint infections occurred. In the other two patients, hip involvement was identified late after septic arthritis occurred. Early diagnosis, diverting colostomy, and immediate arthrotomy are recommended for gunshot wounds to the hip which involve the alimentary tract.     

Reappraisal of low-velocity gunshot wounds of the aorta and inferior vena cava in civilian practice.

Eighteen low-velocity gunshot wounds of the abdominal aorta and inferior vena cava were analyzed. Injury to the aorta and inferior vena cava occurred in 9.2% of all penetrating abdominal injuries due to gunshot wounds in our series. The mortality rate was 33% for the suprarenal and 25% for the infrarenal inferior vena cava, 50% for the infrarenal aorta, 100% for the suprarenal aorta and for the combined injuries. Control of active bleeding is more closely related to survival than any other single factor.     

The role of arthroscopy in the management of low-velocity gunshot wounds of the knee joint

Eight patients with low-velocity civilian gunshot wounds of the knee were examined and evaluated by arthroscopy. Three of these patients were also treated by surgical arthroscopy and underwent limited arthrotomy for bullet removal. In two patients small arthrotomy incisions were made following arthroscopic exploration for removal of bullets. Two patients underwent diagnostic arthroscopy. One underwent internal fixation for a chondral fracture of the femoral condyle. The majority of patients sustained intra-articular damage and retained foreign materials (denim flecks and metallic shards) and osteochondral fragments. There were no postoperative infections after a minimum follow-up period of one year. Arthroscopy is highly effective in the diagnosis and surgical management of low-velocity gunshot wounds of the knee both alone and in combination with limited arthrotomy depending on the severity of the condylar damage. The length of the hospital stay is reduced (length of stay exceeded 3-4 days only as a result of intravenous antibiotic coverage). Physical therapy requirements are minimal. Active mobility and a full range of motion are regained more rapidly with arthroscopy than with surgical exposure of multiple exploratory incisions or conventional standard arthrotomy.     

Fractures with major vascular injuries from gunshot wounds: implications of surgical sequence

BACKGROUND: The sequence of surgical repair for penetrating extremity injuries requiring both vascular repair and fracture fixation is controversial. The optimal determination of repair order and its consequences is the purpose of this study. METHODS: A retrospective review was performed of 27 patients over a 10-year period requiring acute revascularization and fracture fixation for isolated gunshot wound injuries. Injuries to the brachial artery and the femoral and popliteal vessels with accompanying fractures requiring operative stabilization were considered. The Mangled Extremity Severity Score, surgical sequence, limb viability, fasciotomy, incidence of iatrogenic vascular repair disruption, and length of hospitalization were analyzed. RESULTS: There were 17 lower and 10 upper extremity injuries, with a mean Mangled Extremity Severity Score of 4.1. Fracture fixation preceded vascular repair in five cases, whereas revascularization preceded bone fixation in 22 cases. A temporary vascular shunt was used in 13 and definitive vascular repair with used in 9 patients. There were no cases of vascular repair, shunt disruption, or amputation after fracture fixation. Four of five (80%) patients with orthopedic fixation before revascularization required fasciotomies, whereas 8 of 22 (36%) patients with revascularization before fixation required fasciotomies, and this difference approached significance (p = 0.10). Patients with fasciotomies had a significantly longer mean length of hospitalization, 18.3 +/- 8.6 days compared with 10.8 +/- 8.1 days (p = 0.03).CONCLUSION For patients with combined injuries, priority should be given to revascularization before orthopedic fixation because of shorter hospitalization and a trend toward lower fasciotomy rates. Revascularization before fracture fixation did not result in iatrogenic disruption of the vascular repair.     

Extra-articular low-velocity gunshot fractures of the radius and ulna.

Low-velocity gunshot fractures of the forearm are complex injuries and previously published studies have not emphasized the problems particular to these forearm lesions. Of the twenty-nine patients in this series, thirteen had peripheral nerve injuries, three had impending Voklmann's ischemia, and ten had delayed union or malunion of fractures after treatment by closed methods. Only thirteen had none of these problems. Eight patients had long-term disability resulting either from permanent nerve damage with loss of sensation or weakness of grip, or from significant loss of motion following delayed union or malunion. Although external fixation was adequate for undisplaced fractures, delayed (seven to fourteen days) primary internal fixation after the initial phase of wound healing had proved benign gave superior results in displaced fractures.     

Penetrating thoraco-abdominal gunshot wounds procedure.

Gunshot injuries of the trunk in the peace time are rare, but always represent great therapeutic and organisational problems. It concern especially thoraco-abdominal injury. Aim of this report is to present our treatment experiences with 19 wounded patients. Different procedure was applied. In 16 cases wounded laparotomy was done, in 4 cases following pleura cavity drainage. After that in 4 wounded thoracotomy was performed. In the 3 rest wounded thoraco-phrenolaparotomy was done. All of them had lung injury and a few of them have had great vessel and heart lesions. In the abdomen we found 1-4 organs injury. 7 (37%) wounded died, among these 6 after abdominal complications. Injuries mentioned above are severe, complicated and required individual and differentiated procedure. Above all severity of abdominal organs injury determined prognosis. Not enough experienced thoracic surgeon can cooperate with abdominal specialist surgeon during treatment procedure such a patients.     

Efficacy of antibiotics in low-velocity gunshot fractures

We have investigated the efficacy of intravenous antibiotic therapy as a prophylactic measure to prevent infection following low-velocity gunshot fractures. Ninety-six consecutive patients were randomized prospectively to either an antibiotic group (Group I) or a nonantibiotic group (Group II) and were followed in a special gunshot wound clinic. Only patients with fractures that could be treated by closed techniques and did not require internal fixation were included. Sixty-seven patients (73 fractures) were followed radiographically. At follow-up, 36 fractures in Group 1 and 37 fractures in Group II comprised the study group. A total of two infections, one in each group, was documented. No significant infection prophylaxis was demonstrated by the use of intravenous antibiotics in these injuries.     

Low-velocity gunshot wounds to the maxillofacial complex.

A review of the past literature of gunshot wounds indicates that the clinical material deals mainly with high-velocity missile injuries from military experience. A series of 66 cases of low-velocity gunshot wounds to the maxillofacial complex at San Francisco General Hospital between 1971 and 1978 indicates a clinical difference between injuries caused by low-velocity as compared to previously reported high-velocity missiles. Damage to vital structures resulting from missile injury to the maxillofacial complex are classified in three anatomic areas: 1) supra-orbital (28 cases of which 20 involved neurological damage); 2) mid-face (24 cases of which 8 involved the orbits and/or globe); 3) lower face (14 cases, of which 3 involved laceration of the carotid and 2 involved airway obstruction necessitating tracheostomy). The management of gunshot wounds to the maxillofacial area is outlined, emphasizing: 1) Debridement and prompt closure of intraoral wounds with antibiotic coverage: 2) Early stabilization of mandible fractures: 3) Indications for tracheostomy; 4) Arteriographic studies. In our series there were only four infections, which were treated easily with incision and drainage and appropriate antibiotic selection.     

Management of transperitoneal gunshot wounds of the spine.

To evaluate the results of a conservative approach to gunshot wounds of the spine with a transperitoneal trajectory, we analyzed our 4-year experience with 21 patients. The management protocol consisted of standard treatment of the intra-abdominal injuries, vigorous irrigation of the missile track, and a 48-hour course of antibiotic therapy. The lumbar spine was involved in 14 patients (67%) and the thoracic spine was injured in seven (33%). Eleven patients (52%) were paraplegic on admission and ten patients (48%) had a fixed partial neurologic deficit. One patient with an ISS of 75 died intraoperatively from exsanguination (mortality, 5%). Early morbidity correlated with ISS greater than 40 and spinal AIS greater than 3. Late nonneurologic morbidity was independent of ISS and spinal AIS. One patient required reoperation for a retroperitoneal abscess secondary to a leak from a repaired ureter. Another patient had a retroperitoneal collection on a CT scan which resolved spontaneously. There were no spinal or paraspinal infectious complications in the presence (five cases) or absence of a colonic injury. No change in neurologic status was observed in any patient during a mean follow-up period of 3 months. This preliminary experience suggests that a conservative approach consisting of irrigation of the missile track and short-term antibiotic therapy without laminectomy or removal of fragments from the spinal canal yields optimal results without increasing infectious complications of the spine.     

Spinal cord injuries from gunshot wounds to the spine

Although vehicular trauma traditionally has accounted for the majority of spinal cord injuries, gunshot wounds are the second most common cause. Furthermore, the proportion of spinal cord injuries caused by gunshot wounds are increasing although the proportion of injuries caused by high-speed vehicular trauma is decreasing. Gunshot wounds to the spine commonly are thought to be stable injuries. There is, however, a potential for instability if the bullet passes transversely through the spinal canal and fractures pedicles and facets. Injuries to the thoracic region of the spine are the most common, followed by the thoracolumbar area and the cervical spine. Completeness of injury is related to the anatomic region. Patients with incomplete injuries and patients with injuries in the thoracolumbar region have the greatest improvement in motor function. Approximately (1/4) of individuals are able to ambulate 1 year after injury. Surgical decompression of bullets from the spinal canal has been shown to improve neurologic recovery below the T12 level. Improvement of neurologic recovery after bullet removal has not been shown in other regions of the spine. Rare instances of late neurologic decline because of retained bullet fragments have been documented.     

The management of gunshot wounds to the face.

Treatment principles for penetrating neck trauma are well described yet few exist for facial injuries. To help delineate these issues, we viewed our recent experience with gunshot wounds to the face. Since 1986 we have treated 100 patients with such injuries. Their mean age was 28.9 years (range, 12-77 years). There were 89 male patients and 11 female patients. Ninety-six patients were considered stable on initial examination. Yet 35 patients required urgent airway control in the ED; only two needed a surgical airway. Emergency angiography was performed in 37 patients; 19 vascular injuries were identified. Eleven required therapy for vascular injuries, five by neck exploration and six by embolization. In 15 patients the trajectory suggested an intracranial injury, i.e., across the base of the skull. Although 14 of 16 patients were awake and alert at examination, head CT scans demonstrated serious intracranial pathologic processes in 9 patients. Sixty-seven patients sustained bony injury, 19 patients a significant nonvascular soft-tissue injury, and 38 patients a significant neurologic injury (26 peripheral, one spinal and 20 cerebral injuries). Ultimately, 44% of all patients required some surgical treatment and 25% had a complication from their injury. Six patients died, three of CNS injury, one of exsanguination, and two of sepsis. The bony, soft tissue, nervous, and vascular anatomy make the management of gunshot wounds to the face challenging. Although initially stable, many patients require early airway control and urgent work-up for vascular and intracranial injuries. Early subspecialty input is helpful in delineating the often complex injury pattern and planning an optimal management strategy.     

Management of gunshot wounds: the Johannesburg experience.

The Johannesburg hospitals see large numbers of gunshot wounds and there is, therefore, considerable experience in their management. Historically, management has been dictated by experimental theories of wounding mechanisms. More modern work has indicated that some of these theories have been somewhat misleading, and some traditional means of management have changed. The basic military surgical lessons of the excision of dead tissue, delayed primary suture remain valid, it is the understanding of tissue damage and the more logical response which has changed. It is the wound as encountered which is managed, irrespective or the theoretical velocity of the bullet. The Johannesburg practice is outlined with regard to regions of the body, with discussion of, among others, the conservative management of gunshot wounds of the abdomen, primary repair of the colon, non operative management of certain limb wounds. The practice is summarised, based on considerable experience and the logistic implications of large numbers and may be useful to surgeons less experienced in gunshot wound management.     

Civilian gunshot wounds of the brain

The authors report on 42 fatal gunshot wounds to the brain in civilians. The firearms used were those commonly available to civilians, ranging from a .22 revolver to a .45 semiautomatic pistol. Missle tracks were measured and the volume computed. The relatively low-velocity missles produced by these weapons to not create the devastation that characterizes wounds from high-velocity military firearms. Instead, there is much variation in the size of the missle tracks, and they cannot be directly related to caliber. Pressure marks and contusions, impaction of bone chips, internal richochet, and cerebral edema occurred frequently. The missle passed through the brain completely in very case but was retained by the skull or soft tissues in a large percentage of cases. The mechanism of death may be acute pressure on the brain stem from the passage of the missle through the brain.