Introduction: Despite extensive experience with civilian gunshot fractures or wounds, no consensus exists on a standard protocol to manage these injuries. Many authors recommended immediate debridement, but the optimal timing of internal fixation and the use of antibiotic have not been determined. The purpose of this paper is to present and discuss our experience. Material and methods: In January 2007, a treatment protocol was put in place for the evaluation and management of fractured extremities resulting from civilian gunshot wounds. Sixty-three patients with 64 fractures had been managed by this protocol for gunshot fractures between January 2005 and January 2012. There were 56 male and seven female. Their mean age was 33.1 years (range: 17 - 61 years). Thirteen patients (20.6%) were able to provide a description of the weapon. Only 15 patients had entry and exit wounds. The mean follow-up period was 27 (range, 20 - 58) months. The main factors assessed were the surgical site infection, the fracture union and the functional status. Results: Out of the 63 patients, 14 patients developed a wound infection (five superficial and seven deep infections). Wound infection was significantly associated with associated injuries (p = 0.0388), fractures sites requiring fixation (p = 0.024), the fracture pattern (p = 0.0412), operative modalities (p = 0.0400). There were nine cases (14.1%) of fracture non-union. The mean time to union was 15 weeks (range: 5 - 32 weeks). Five patients developed chronics osteomyelitis. The average SMFA score for all of the patients was 23.8 (range: 0 - 56.3). The mean dysfunctional and bother indexes were 18.3 (range: 0 - 52.7) and 22.6 (range: 0 - 66.1), respectively. The SMFA total score and dysfunction index had a significant correlation based on presence or absence of associated injuries (p < 0.0001). But bother index did not show the same correlation (p = 0.452). The average length of hospital stay was 11.3 days (range: 3 - 64). Conclusion: In civilian’s gunshot induced fractures, internal fixation can be made according to standard protocol, with acceptable result.
References
[1]
Russotti, G.M. and Sim, F.H. (1985) Missile Wounds of the Extremities: A Current Concepts Review. Orthopedics, 8, 1106-1116.
[2]
Max, W. and Rice, D.P. (1993) Shooting in the Dark: Estimating the Cost of Firearm Injuries. Health Affairs (Millwood), 12, 171-185. http://dx.doi.org/10.1377/hlthaff.12.4.171
[3]
Brettler, D., Sedlin, E.D. and Mendes, D.G. (1979) Conservative Treatment of Low Velocity Gunshot Wounds. Clinical Orthopaedics and Related Research, No. 140, 26-31.
[4]
Dickey, R.L., Barnes, B.C., Kearns, R.J. and Tullos, H.S. (1989) Efficacy of Antibiotics in Low-Velocity Gunshot Fractures. Journal of Orthopaedic Trauma, 3, 6-10. http://dx.doi.org/10.1097/00005131-198903010-00002
[5]
Bartlett, C.S., Helfet, D.L., Hausman, M.R. and Strauss, E. (2000) Ballistics and Gunshot Wounds: Effects on Musculoskeletal Tissues. Journal of the American Academy of Orthopaedic Surgeons, 8, 21-36.
[6]
Howland Jr., W.S. and Ritchey, S.J. (1971) Gunshot Fractures in Civilian Practice. An Evaluation of the Results of Limited Surgical Treatment. The Journal of Bone & Joint Surgery, 53, 47-55.
[7]
Woloszyn, J.T., Uitvlugt, G.M. and Castle, M.E. (1988) Management of Civilian Gunshot Fractures of the Extremities. Clinical Orthopaedics and Related Research, No. 226, 247-51.
[8]
Molinari, R.W., Yang, E.C., Strauss, E. and Einhorn, T.A. (1994) Timing of Internal Fixation in Low-Velocity Extremity Gunshot Fractures. Contemporary Orthopaedics, 29, 335-339.
[9]
Bergman, M., Tornetta, P., Kerina, M., Sandhu, H., Simon, G., Deysine, G. and Alcindor, F. (1993) Femur Fractures Caused by Gunshots: Treatment by Immediate Reamed Intramedullary Nailing. The Journal of Trauma, 34, 783-785. http://dx.doi.org/10.1097/00005373-199306000-00005
[10]
Hollmann, M.W. and Horowitz, M. (1990) Femoral Fractures Secondary to Low Velocity Missiles: Treatment with Delayed Intramedullary Fixation. Journal of Orthopaedic Trauma, 4, 64-69. http://dx.doi.org/10.1097/00005131-199003000-00011
[11]
Wiss, D.A., Brien, W.W. and Becker Jr., V. (1991) Interlocking Nailing for the Treatment of Femoral Fractures Due to Gunshot Wounds. Journal of Bone and Joint Surgery, 73, 598-606.
[12]
Hansraj, K.K., Weaver, L.D., Todd, A.O., Taylor, S.M., Griffin, M.D., Dukhram, K.M., Judd, T.P. and Hansraj, M.S. (1995) Efficacy of Ceftriaxone versus Cefazolin in the Prophylactic Management of Extra-Articular Cortical Violation of Bone Due to Low-Velocity Gunshot Wounds. Orthopedic Clinics of North America, 26, 9-17.
[13]
Abalo, A., Tomta, K., Walla, A., Ayouba, G. and Dossim, A. (2010) Incidence and Risk Factors for Pin Tract Infection in Extrenal Fixation for Fractures. Nigerian Journal of Orthopaedics and Trauma, 9, 17-20. http://dx.doi.org/10.4314/njotra.v9i1.54724
[14]
Swiontkowski, M.F, Engelberg, R., Martin, D.P. and Angel, J. (1999) Short Musculoskeletal Function Assessment Questionnaire: Reliability, Validity and Responsiveness. Journal of Bone and Joint Surgery, 81, 1245-1260
[15]
Geissler, W.B., Teasedall, R.D., Tomasin, J.D. and Hughes, J.L. (1990) Management of Low Velocity Gunshot-Induced Fractures. Journal of Orthopaedic Trauma, 4, 39-41. http://dx.doi.org/10.1097/00005131-199003000-00007
[16]
Brien, W.W., Kuschner, S.H., Brien, E.W. and Wiss, D.A. (1995) The Management of Gunshot Wounds to the Femur. Orthopedic Clinics of North America, 26, 133-138.
[17]
Fackler, M.L. (1988) Wound Ballistics. A Review of Common Misconceptions. JAMA, 259, 2730-2736. http://dx.doi.org/10.1001/jama.1988.03720180056033
[18]
Finck, P.A. (1965) Ballistic and Forensic Pathologic Aspects of Missile Wounds. Conversion between Anglo-American and Metric-System Units. Military Medicine, 130, 545-569.
[19]
Anania, W.C., Rosen, R.C. and Giuffre, A.M. (1987) Gunshot Wounds to the Lower Extremity: Principles and Treatment. The Journal of Foot Surgery, 26, 228-232.
[20]
Billings, J.B., Zimmerman, M.C., Aurori, B., Parsons, J.R. and Swan, K.G. (1991) Gunshot Wounds to the Extremities. Experience of a Level I Trauma Center. Orthopedic Reviews, 20, 519-524.
[21]
Papasoulis, E., Patzakis, M.J. and Zalavras, C.G. (2013) Antibiotics in the Treatment of Low-Velocity Gunshot-In- duced Fractures: A Systematic Literature Review. Clinical Orthopaedics and Related Research, 471, 3937-3944. http://dx.doi.org/10.1007/s11999-013-2884-z
[22]
Ordog, G.J., Wasserberger, J., Balasubramanium, S. and Shoemaker, W. (1994) Civilian Gunshot Wounds--Outpatient Management. The Journal of Trauma, 36, 106-111. http://dx.doi.org/10.1097/00005373-199401000-00017
[23]
Abghari, M., Monroy, A., Schubl, S., Davidovitch, R. and Egol, K. (2015) Outcomes Following Low-Energy Civilian Gunshot Wound Trauma to the Lower Extremities: Results of a Standard Protocol at an Urban Trauma Center. Iowa Orthopaedic Journal, 35, 65-69.
[24]
Burg, A., Nachum, G., Salai, M., Haviv, B., Heller, S., Velkes, S. and Dudkiewicz, I. (2009) Treating Civilian Gunshot Wounds to the Extremities in a Level 1 Trauma Center: Our Experience and Recommendations. Israel Medical Association Journal, 11, 546-551.
