Gun Shot Wounds

Author: Brian Weatherford

Topic updated on 08/24/13 4:37pm
Introduction
Epidemiology
o represent second-leading cause of death for youth in United States
Pathoanatomy
o wounding capability of a bullet directly related to its kinetic energy
o damage caused by
passage of missile
secondary shock wave
cavitation
o exponential increase in injury with increasing velocity and efficient
energy transfer
o fractures may be caused even without direct impact
Associated conditions
o lead intoxication (plumbism)
may be caused by intra-articular missile
systemic effects include
neurotoxicity
anemia
emesis
abdominal colic
Classification
Low velocity
o muzzle velocity <350 meters per second or < 2,000 feet per second
o most handguns except for magnums
o wounds comparable to Gustillo-Anderson Type I or II
Intermediate velocity
o muzzle velocity 350-500 meters per second
o 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
o muzzle velocity >600 meters per second or >2,000 feet per second
o military (assault) and hunting rifles
o wounds comparable to Gustillo-Anderson Type III regardless of size
o high risk of infection
secondary to wide zone of injury and devitalized tissue
Presentation
Symptoms
o pain, deformity
Physical exam
o perform careful neurovascular exam
o clinical suspicion for compartment syndrome
secondary to increased muscle edema from higher velocity
wounds
o examine and document all associated wounds
massive bone and soft tissue injuries occur even with low velocity
weapons
Evaluation
Radiographs
o obtain to identify bone involvement and/or fracture pattern
CT scan
o identify potential intra-articular missile
o 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
o local wound care, tetanus, and 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
Operative
o 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
o arthrotomy
indications
intra-articular missile
may lead to local inflammation, arthritis and lead
intoxication (plumbism)
GSW to Femur
Operative
o 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
o 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
o 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
o 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