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Gunshot Wounds:

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Keith Connolly

on 11 August 2016

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Transcript of Gunshot Wounds:


Bullet fragments in disc space or thoracolumbar spinal canal (with neurologic deficit)
Tendon injuries
Superficial fragments of palm or sole
Injuries to pelvis, chest or abdomen
Plain radiographs
Identify fractures
Confirm or rule our presence of missile
Identify fragments
Evaluate bullet tract
Obtain one body cavity below and one body cavity above an entrance or exit wound
If no bullet on radiograph and no exit wound, obtain more radiographs of fluoroscopy
Entrance wound + exit wounds + retained bullets must = Even number

Vascular injury
– look for “hard signs”:
Hemorrhage with pulsatile bleeding
Absent pulse
Ischemia (cold, pale extremity)
Audible bruit
Palpable thrill

Duplex ultrasound
Compares favorably with arteriography and surgical exploration for false negatives after physical exam
Arteriography: thoracic outlet, shotgun, missile tract parallel to vessel, multiple same extremity wounds

No test superior to thorough physical examination
ATLS measures

Assessment

Initial local debridement in ED
Cleanse with povidone-iodine and normal saline
Sterile dressing
Antibiotics
Tetanus prophylaxis
Toxoid (0.5cc booster)
Tetanus Immune Globulin
Incomplete tetanus/diptheria series; HIV
Splint unstable fracture
Two broad categories:

Low energy wounds
More likely from handguns
Often can be managed in emergency department
Antibiotic treatment controversial

High energy wounds
Surgical treatment, serial debridement
Treat like open fracture
More likely to involve vascular injury
“Treat the wound, not the weapon”
Lindsey D: The idolatry of velocity, or lies, damn lies, and ballistics. J Trauma 20:1068–1069, 1980. Letter.

"The amount of debridement required should depend more on the damage inflicted than the nature of the missile"
Dziemian AM, Mendelson J, Lindsey D: Comparison of the wounding characteristics of some commonly encountered bullets. J Trauma 1:341–353, 1961.
Treatment
Total 1557 Patients
Male 1386 (89%)

Injury locations
Trunk 39%
Lower extremities 25%
Upper extremities 16%
Head/Neck 17%
The Gunshot wound patient

Data from orlando regional medical center 2003 - 2011
Summary of factors of projectile tissue disruption:
Amount of kinetic energy of projectile at impact
Stability and entrance profile
Caliber, construction, configuration and shape
Distance and path within the body
Characteristics of tissue
Mechanism of tissue disruption
Bullet fragmentation
Ballistics
Energy of the projectile (KE) = ½mv2
Tissue Destruction ≈ KEentry – Keexit
Velocity affects energy four-fold

3 essential components of ballistics:
Internal
Within the gun barrel
Bullet and weapon design
External
After leaving barrel and before hitting target
Velocity, drag, gravity, bullet design
Terminal
Within the target
Target material, path length, bullet design, velocity, mass
Ballistics
Bullet vs. Shell
Both are projectiles
Shell utilizes explosion of ammo upon contact

Round or cartridge
Combination of bullet, propellant, and casing
Terminology
Firearm Statistics

Weapons and Ballistics

Orthopedic Wounds and Treatment

Management of Joint Trauma

Retained Bullet Material
Overview
About 1/2 of all GSWs involve a joint or cause a fracture

US Trauma Center over a ten year period:
Gunshot wounds accounted for 26% or all orthopaedic trauma cases
14% of the total orthopaedic procedures performed
53% of these requiring more than one orthopaedic procedure
On average require more than a week of hospitalization
one-quarter require intensive care unit admission
Impact on the Orthopod
One years worth of GSWs is estimated to cost:
$1.06 Billion dollars in lifetime medical costs
$32.9 Billion dollars in lifetime productivity losses

About $30,000 per hospitalized patient for a GSW
Halikeman et al. showed orthopedic treatment averaged $13,108 per patient at the Carolinas Medical Center

Russo et al 2007-2013, 3617 gunshot wounds:
total amount billed - $141,995,682
total collected - $30,922,953.
actual hospital costs - $73,572,892
net loss of $42,649,938
Cost to Society
Gunshot wound (GSW) is the leading cause of death in black males age 15 – 24

Kills more teenage males than all natural causes combined

GSW deaths in the United States are 90 times greater than any other industrialized nation
Prevalence of Firearm Trauma
Americans deaths as a result of firearm violence since 1980





Orlando Pulse shooting in June
= 49 killed
Prevalence of Firearm Trauma
Keith P Connolly, MD

University of Pennsylvania Orthoapedic Surgery Grand Rounds

8/11/16

Gunshot Wounds and Orthoapedic Management
Significant source of trauma

Base management on extent of underlying damage

Thorough debridement critical

Judiciously investigate and treat joint involvement
Conclusion
Stabilizing the fracture first should protect the vascular repair

However, when significant ischemia is present, establishing distal perfusion is a priority

Placement of temporary arterial shunt can restore distal flow prior to soft tissue and fracture management

If arterial injury is evident, but with adequate perfusion, it is reasonable to stabilize the fracture first

Fasciotomies if 6+ hour delay in revascularization


High Energy - treat like typical open fractures
First Generation Cephalosporin (Ancef)
Aminoglycoside (Gentamicin)
Penicillin for gross contamination or farm material

Duration = 48-72 hours of IV antibiotics

One to two weeks of broad-spectrum coverage has also been suggested for bowel contamination
Antibiotics
Several observational studies on antibiotic treatment in GSWs
Few RCTs and weak evidence

Low energy wounds have little consensus
Nearly all studies show infection rates in low single digits regardless of antibiotic course
Most articles still recommend routine prophylaxis
3 day course of PO antibiotics likely sufficient
African American male

Age 15 – 35

Long bones or spine involvement
Prior criminal history --> truncal involvement more likely
> 20% with prior GSI

Weekends, around midnight

Positive for alcohol and/or at least 1 drug

Vast majority uninsured
< 4% with private insurance
The Patient
Number of Patients
May arise in unexpected locations
If no exit wound exists, then all of the bullet’s kinetic energy has been dissipated into tissue
Occassionally, a bullet may be found protruding from its exit.

Entrance wound + exit wounds + retained bullets must = Even number
Exit Wounds
Characterized by a narrow 1-2mm “abrasion ring”
Oval or circular, “punched-out” lesions, moist and fleshy
In palm and sole, stellate in appearance
Entrance Wounds
Gun powder tattooing of skin
Occurs in intermediate range gunshot wounds
Bullet Wounds
Near contact wounds:
Muzzle is a short distance away from the skin
Have a wide zone of powder soot deposited in a zone overlying seared blackened skin
However, powder grains emerging from the muzzle blast don’t have a chance to disperse and powder tattoo the skin
Bullet Wounds
4 categories of bullet wounds based on target range:
Contact, near-contact, intermediate, and distant wounds

Contact wounds :
Muzzle of weapon is held against the body surface at the time of discharge
Blackened seared margins
Bullet Wounds
Terminal Ballistics

Damage to tissue result of multiple factors:
Permanent cavity
Projectile crushing
Temporary Cavity
Elastic stretching of tissue at periphery
Secondary projectiles and shock waves
Metal, clothing, bone
Ballistics
External Ballistics - Rifles

Minimizing yaw by rifling
Spiraling lands and grooves in the barrel
Creates spin of bullet about longitudinal axis
Non-spinning bullet is more unstable
Ballistics
Volga D, et. al.. Ballistics: A primer for the surgeon. Injury. 2005. Vol 36. pp 373-379.
Browner: Skeletal Trauma: Basic Science, Management, and Reconstruction, 3rd edition.
Internal Ballistics

Features of handguns, rifles, shotguns and ammunition
Muzzle velocity is most medical literature:
Low: <2000 ft/sec
High: >2000 ft/sec
Ballistics
Many factors involved in tissue damage

Bullet characteristics
Caliber
Shape
Weight distribution
Velocity
Tumbling characteristics
Tissue
Elasticity
Damage to the Body
Violent crime in and around metropolitan areas is disproportionately higher than rates in other communities around the country

Increasing size of bullet caliber and changes in ammunition

Increasing use of higher velocity semiautomatic weapons

Rise in the number of fatalities prior to arrival at Emergency Department
Updates on Urban Trauma
Treated per accepted protocol for each area
Surgical approach and implant may be influenced by wound and coverage options
May be complete or incomplete
Significant loss of bone can occur
Bone grafting
Limb lengthening
Fibula transfer
Fracture Treatment
Larger in size than entrance wounds
More irregular in shape (e.g. stellate, slit-like, crescent)
No abrasion ring
High velocity missiles may create very large exit wounds
Exit Wounds
Angled Near Contact Wounds
Barrel held at an acute angle to the skin
Complete circumference of muzzle not in contact with the skin
Gas and soot emerging from the gap radiate outward, producing an eccentrically arranged pattern of soot
Blackened seared zone on same side as muzzle (i.e. points toward the weapon)
Identifies the site as the wound of entrance, and also identifies the bullet’s direction of travel
Angled Near Contact Wounds
Temporary Cavity

Expansion and contraction of tissue adjacent to the bullet path
Ballistics
Permanent Cavity

Laceration and crushing of tissue
Relatively small
Increase with tumbling/yaw/deformation
Pointed-tip bullets
poor balance because center of gravity is shifted to the rear
as tumbles within the target
Ballistics
Shotgun wounding capacity

At a range of 1-2 yards :
Single, large, ragged entrance wound with massive destruction
At a range of 3-4 yards :
Large, central wound
Surrounded by several single pellet wounds, each of which may be significantly destructive
At a range of 7+ yards :
Pattern of pellet dispersion will be 1-3 feet in diameter
Only a few pellets will hit the target
Moderately destructive
At a range of 20 to 50 yards :
Wounding capacity is negligible
AMMUNITION
Hollow-point Bullet

Enhance bullet profile > 2x perpendicular to its tract
Modern ammunition
Sport/Personal Protection
Desire to
increase stopping power
of bullet
Bullet does not pass through intended target
Opposite of military ammunition intent
Expend all kinetic energy on target

Hollow-point/Soft-point
Designed to expand in the body cavity
Makes a larger cavity in soft tissue
Prevent over penetration
http://www.madehow.com/Volume-2/Ammunition.html
Trigger depressed

Firing pin releases and strikes primer

Primer ignites as the pin compresses it against the anvil

Flame enters the main chamber of the cartridge

Powder propellant is ignited
Mechanics
Shotgun
Un-riffled barrel
Mid Range Velocity
Lower velocity then rifles but can cause significant injury
12 gauge shotgun (1000-1500 feet/sec)
Unique characteristics
Multiple projectiles
Choke
Partial constriction at end of muzzle
Wadding
Fills dead space
Protects powder and shot
Seals the bore during firing to keep gas behind it
Weapons
Rockwood and Green’s Fractures in Adults, 6th edition
Why is this topic worth reviewing?
How common?
How deadly?
How costly?
How does it impact an orthopaedic trauma service
Gunshot Wounds
Secondary projectiles
Bullet impacts objects such as bone, teeth, buckles, buttons
Erratic, unpredictable
More frequently produced with increasing velocity
Can significantly increase resulting damage
Sonic pressure “shock” waves
In theory, peripheral nerve injury, cell membrane rupture
Little evidence of actual damage
Ballistics
Temporary Cavity

Significantly affected by:
Bullet deformation
Hollow point bullet can increase size 4-10x
Velocity
Ballistics
Shotgun Ballistics

Differ from projectiles
Damage related to tremendous kinetic energy generated by increased mass of pellets.
Range is most critical determinant of wounding capacity
Shotgun pellets decelerate rapidly
Poor aerodynamic shape of a spherical pellet
Significant loss of KE with range
Ballistics
Full Metal Jacket
Invented in 1882
Copper jacket provides heat resistance
Bullets made of lead
Low cost
High density
Low melting point
Protects bullet from environment of barrel
Allowed greater muzzle velocities and repetitive firing
Round musket bullet

16th to mid-19th century











Minié ball

Introduced in 1848
Widespread use in Civil War
Point decreased bullet yaw
Improved accuracy
http://www.army.mil/fact_files_site/m-9_pistol/index.html
http://www.rt66.com/%5C%5C~korteng/SmallArms/357ammo.html
Handgun
Low velocity (<2000 ft/sec, often <1000)
Usually low energy
Least Powerful
Concealable
Most commonly used in fatalities
Examples
9 mm pistol
.357 magnum
Weapons
http://www.firearmsresearch.org/content.cfm/spotlight
Level of knowledge highly variable
Weapons
External Ballistics

Gravity
Wind
Drag
Product of air resistance and bullet design
Results in deviations about the longitudinal axis of flight
Cause deceleration
Ballistics
homestudy.ihea.com/aboutfirearms/
Gauge

The inside diameter or bore of the shotgun barrel and corresponding cartridge (shell)
= Number of lead balls the size of the bore to weigh 1 pound

Shot number
The diameter of each of the lead pellets in a shotgun shell
As the shot # increases, the number of pellets increases but the size become smaller
Shotgun
www2.huntercourse.com
http://www.fas.org/man/dod-101/sys/land/m-16-dvic534.jpg
Rifle
Riffled barrel
High velocity (>2000 ft/sec)
Longer barrel = more time for acceleration by expanding gases
Usually high energy
Most powerful
May be fully automatic
Not concealable
Examples
.22 long rifle
30/06
M-16
AK-47
AR-15
Weapons
Center for Disease Control and Prevention, National Center for Injury Prevention and Control. 1990 - 2010, United States Firearm Deaths and Rates per 100,000. http://www.cdc.gov/injury/wisqars/fatal_injury_reports.html
Fischer, H: American War and Military Operations Casualties: Lists and Statistics. pp. Congressional Research Service Report for Congress. Edited, Congressional Research Service Report for Congress, Navy Department Library, 2005.

Vyrostek SB, Annest JL, Ryan GW. Surveillance for fatal and nonfatal injuries--United States, 2001. MMWR Surveill Summ. Sep 3 2004;53(7):1-57.
The Violence Prevention Task Force of the Eastern Association for the Surgery of Trauma: Violence in America: A Public health crisis: The role of firearms. J Trauma 28:163-168, 1995.

Corso PS, Mercy JA, Simon TR, Finkelstein EA, Miller TR. Medical costs and productivity losses due to interpersonal and self-directed violence in the United States. Am J Prev Med 2007; 32: 474-82.
The Violence Prevention Task Force of the Eastern Association for the Surgery of Trauma: Violence in America: A Public health crisis: The role of firearms. J Trauma 28:163-168, 1995.
Bartlett, R. Clinical Update: Gunshot Wound Ballistics. Clin Orthop 2003; 408: 28-57.

Brown, TD; Michas, P; Williams, RE; Dawson, G; Whitecloud, TS; and Barrack, RL: The impact of gunshot wounds on an orthopaedic surgical service in an urban trauma center. J Orthop Trauma. 1997;11:149-53.


FBI: Crime in the United States. Edited, 2010.
Simpson, BM, and Grant, RE: A synopsis of urban firearm ballistics: Washington, DC model. Clin Orthop Relat Res. 2003:12-6.
Adibe OO, Caruso RP, Swan KG. Gunshot wounds: bullet caliber is increasing, 1998-2003. Am Surg 2004; 70: 322-5.
BALLISTICS
Bartlett, R. Clinical Update: Gunshot Wound Ballistics. Clin Orthop 2003; 408: 28-57.






Volga D, et. al.. Ballistics: A primer for the surgeon. Injury. 2005. Vol 36. pp 373-379.
Volga D, et. al.. Ballistics: A primer for the surgeon. Injury. 2005. Vol 36. pp 373-379.
Bartlett, R. Clinical Update: Gunshot Wound Ballistics. Clin Orthop 2003; 408: 28-57.
Bartlett, R. Clinical Update: Gunshot Wound Ballistics. Clin Orthop 2003; 408: 28-57.
Harvey EN, Korr IM, Oster G, McMillin JH: Secondary damage in wounding due to the pressure changes accompany the passage of high-velocity missiles. Surgery 21:218–239, 1946.
Swan KG. Swan RC. Gunshot Wounds: Pathophysiology and Management. PSG Publishing Company, MA: 1980.
Bartlett, R. Clinical Update: Gunshot Wound Ballistics. Clin Orthop 2003; 408: 28-57.
Number of Gunshot wound and mortality
patients by age
patients by race
Wolf AW, Benson DR, Shoji H, Hoeprich P, Gilmore A. Autosterilization in low-velocity bullets. J Trauma. Jan 1978;18(1):63.

Hoekstra SM, Bender JS, Levison MA.The management of large soft-tissue defects following close-range shotgun injury.J Trauma. 1990 Dec;30(12):1489-93

DeMuth WE, Smith JM: High-velocity bullet wounds of muscle and bone: The basis of rational early treatment. J Trauma 6:744–755, 1966.
Absence of hard signs warrants a period of observation

Immediate exploration for arterial injury

Angiography in operative suite if location in doubt
No
Yes
Wound contaminant
Wadding, casing debris, surface material

Joint involvement
Proximity of injury
Fracture pattern
Radiographs
Joint aspiration
Saline with methylene blue injection
Fluoroscopically assisted arthrogram
CT
Surgical indications for fracture management as per accepted protocols
operative treatment:
assessment
No

Definitive wound and fracture care
Remove visible foreign material and debridement
Irrigation of wound track
Excision of skin margin
Do not remove bullet
Leave wound open
Splint or cast fracture as required

Antibiotic treatment

Discharge home if indicated
Nonoperative /
Outpatient Treatment
Low energy transfer
high energy transfer
Yes
Serial Debridement
Search for foreign material
Excise skin margins, enlarge wound, irrigate tract
Pass saline soaked gauze through tract
Debride necrotic tissue and devitalized bone
4 Cs: color, consistency, capacity to bleed, contractility - indicate viability of muscle
Small, bony fragments cut off from viable soft tissue attachment and blood supply become necrotic
Allows for bacteria to use bone protein and increase bacterial survival
Consider fasciotomy
Do not excessively dissect to remove bullet far from operating area

Stabilize or definitive treatment for fracture

Closure by secondary intention - Consider delayed primary closure in no less than 5 days

Antibiotics
operative Treatment
Contamination
Bullets are not autosterilized on discharge

Wadding associated with high degree of wound contamination

Negative pressure from temporary cavity also draws in contaminants

Non-viable muscle ideal medium for bacterial growth, particularly clostridia
Cellulitis to diffuse myonecrosis
Concomittant vascular injury
“Over the past few years, authorities have arrested more than 200 gang members in an unexpected place: the tree-lined suburbs along the Hudson River in New York”

“Authorities say they brought shootings and stabbings with them”

NPR, March 14, 2012
Surgical intervention typically only required for unstable fracture
Standard fracture care
Arthroplasty or arthrodesis not recommended in acute setting
Illiac wing most common pelvic fracture
Acetabular fractures rarely produce instability requiring stabilization
Femoral neck fractures of small cortical defect may be treated with protected weight bearing without fixation
Long et al -
recommend the following indications for arthrotomy:
High energy projectile and hip penetration
Transabdominal injury
Possible bowel contamination
Visible retained bullet or fragments at articular site
Intraarticular fractures requiring internal fixation

Low energy wound with hip penetration not meeting the above criterea:
Zura et al - suggest 3 days of IV cefazolin and gentamycin sufficient to prevent infection and septic arthritis
Bartikow - recommend I&D for all joints violated even without retained fragments to decrease risk of infection
Also provide opportunity to repair intraarticular injury
A/P of pelvis and cross-table lateral of hip
Judet 45 degree oblique views of pelvis
CT required in stable patient
determine bullet track

Evidence for joint violation:
Fracture of femoral head, femoral neck or acetabulum
Air in joint
Intraarticular hematoma

When plain x-rays are inconclusive, a fluoroscopically assisted arthrogram can be used to confirm hip joint violation
Large intraarticular retained bullet fragments
Local inflammation
Arthritis
Plumbism
Systemic lead intoxication
Neurotoxicity, anemeia, emsis, abdominal pain, etc
Pelvis/Hip Involvement

Hemodynamic instability and vascular injury must be rapidly addressed

Any bullet wounds between umbilicus and proximal third of femur must be considered as possibly penetrating the hip

Intraarticular contrast injection useful in determining violation of joint
Arthrogram shows contrast extravasation along permanent cavity path
Perform for known joint capsule penetration to show track
Gunshot wounds to the hip
Gunshot wounds to the KNEE
Severe soft tissue damage and contamination with unstable fractue
Spanning external fixation
Repeat I&D with delayed primary closure
Acute reconstruction of knee ligaments not recommended
Perform after fracture healing and rehab
Meniscal tears and large osteochondral fragments may be fixed acutely

Joint reconstruction may be performed once soft tissue healed

Articular fractures
Anatomic reduction of articular surface
Bone loss often present - grafting
gingival lead lines
muscle and joint aches
GI manifestations
abdominal colic
anorexia
weight loss
altered bowel habits
peripheral neuropathy
fatigue
headaches
memory loss
seizure
coma
hypertension
anemia
Lead Toxicity
Circulates systemically to liver, brain, bone marrow, kidneys
Diffuses in to bone in 1-2 months
Incorporated into hydroxyapatite lattice
Inert and nontoxic
Bone remodeling believed to re-introduce lead into bloodstream
Children, pregnancy, advancing age, bed rest, medication
Lead Intoxication
Plumbism known to be linked to retained bullets since 1867

Intra-articular bullet (or within spinal canal) at highest risk
High acidity synovial fluid dissolves bullet
Failure to form protective fibrous capsule
Friction of joint increases fragmentation
Increased surface area and exposure
Arthritic inflammation increases vascularity
Retained Lead
Open surgical debridement is gold standard for intraarticular bullet track

In cases of missile penetration only, joint irrigation and debridement may be performed arthroscopically
Tornetta and Hui - 42% incidence of meniscal injury and 15% incidence of chondral damage
Must pay particular attention to likelihood of vascular injury
Clinically unstable patients:
consider exploration or intraoperative angiography
Clinically stable patients :
noninvasive arterial pressure indices, duplex Doppler ultrasonography, CTA, angiography
In all cases of vascular injury or significant ischemia:
fasciotomy should be performed
Gunshot Wounds to the shoulder
Determine whether bullet has penetrated knee joint
Trajectory of bullet
Saline challenge or joint aspiration may be useful
Imaging
A/P, lateral, oblique views
CT can provide valuable information
knee involvement
Significant tissue damage
Major vascular injury
Progressive neurological deficit
Obvious contamination
Joint or GI involvement
Presenting 8 or more hours after injury

Most common joint involved - 9% of all injuries
Must consider thoracic involvement
Principles of previously discussed for the knee also apply to other joints
Tornetta P 3rd, Hui RC.Intraarticular findings after gunshot wounds through the
knee.J Orthop Trauma. 1997 Aug;11(6):422-4.

Dougherty, P.J., et al. Joint and long-bone gunshot injuries. Instr Course Lect, 59:465.
US soldiers killed in combat in all wars in the history of this country = 1,011,429
Daily firearm deaths in the United States
>
<

Caliber (rifles and handguns)
Diameter of bore
hundredths of an inch, reported as decimal
millimeters
c
Dicpinigaitis, P. Gunshot Wounds to the Extremeties. Hospital for Joint Disease. Lecture. 2002
Dicpinigaitis, P. Gunshot Wounds to the Extremeties. Hospital for Joint Disease. Lecture. 2002
Dicpinigaitis, P. Gunshot Wounds to the Extremeties. Hospital for Joint Disease. Lecture. 2002
Dicpinigaitis, P. Gunshot Wounds to the Extremeties. Hospital for Joint Disease. Lecture. 2002
Dicpinigaitis, P. Gunshot Wounds to the Extremeties. Hospital for Joint Disease. Lecture. 2002
Dicpinigaitis, P. Gunshot Wounds to the Extremeties. Hospital for Joint Disease. Lecture. 2002
Dicpinigaitis, P. Gunshot Wounds to the Extremeties. Hospital for Joint Disease. Lecture. 2002
Dicpinigaitis, P. Gunshot Wounds to the Extremeties. Hospital for Joint Disease. Lecture. 2002
Dicpinigaitis, P. Gunshot Wounds to the Extremeties. Hospital for Joint Disease. Lecture. 2002
Dicpinigaitis, P. Gunshot Wounds to the Extremeties. Hospital for Joint Disease. Lecture. 2002
Treatment - Hip Joint Violation
Imaging
Arthrogram
Treatment - Hip and Pelvis Fractures
spinal involvement

Bullet removal from spinal canal only indicated in patients with deteriorating neurologic function

Prophylactic removal of bullet from spinal canal is not indicated for prevention of late infection, neurologic decline or lead toxicity
effect of retained bullet fragments on time to union
Prognostic information regarding time to union
May influence surgeon’s decision on timing of secondary surgery
Provide expectations for patient

Further study is needed
Recommendations/ Clinical Significance
The quantity of retained bullet material near the fracture site appears to affect the rate of fracture union.
Fractures with bullet fragmentation exceeding 20% of the cortical width demonstrated a significantly higher rate of delayed union or nonunion compared to those fractures with less retained bullet material at the fracture site.
Recommendations/ Clinical Significance
Retrospective study
Multiple different fracture types (UE, LE)
Lead cortical ratio is an estimation based on AP and lateral radiographs
Limitations
Local cytotoxic effect of lead from bullet fragments on fracture healing? May be result of:
Reduced osteoprogenitor cell formation
Unknown biologic impact of the metal debris

Further research required to understand mechanism
Conclusions
Results
75 patients internal fixation

32 patients (34 fx’s) minimum 4 month f/u

Mean follow up 4.5 months

Seventeen of 34 fractures (50%) united within 4 months. Remaining seventeen:
16/34 (47%) delayed union
1/34 (3%) nonunion requiring revision surgery
Results
Two-variable Pearson correlation test used to compare variables
Outcome comparison was fracture union at four months or delayed/non-union

Lead-Cortical Ratio was analyzed by grouping fractures into two categories based on being above or below a specified value
Group A
Lead-cortical ratio < 20%
Group B
Lead-cortical ratio >/= 20%
Statistics
Radiographic evidence of healing was determined by bridging callus on 3 of 4 cortices on AP and lateral views

Delayed union was defined as lack of radiographic union by 4 months from surgery, and nonunion as failure to heal by one year or implant failure requiring reoperation.
Study Design
Despite findings of a positive correlation between retained bullet material and delayed union, at this time we do not recommend additional dissection for bullet removal at the fracture site
Recommendations/ Clinical Significance
Impact on osteoblast and osteoclast activity
Dose dependent relationship has been observed
Lead Toxicity
Animal studies showing bone lead levels affecting healing
Lead Toxicity
Group A ( < 20%)
16/17 fractures (94%) united by 4 months
Group B ( >/= 20%)
1/17 (6%) united by 4 months
(p = 0.001).

Nearly equal number of comminuted and non-comminuted fractures in the comparison groups. Fracture comminution had no effect on time to fracture union (p = 0.372).
Results
B
A
A = Sum of fragmented pieces laid end to end
B = Diameter of bone at fracture site
Lead-Cortical Ratio = A/B
Lead-Cortical Ratio
Retained bullet load near the fracture site (within 5 mm) was calculated based on percentage of material retained compared to the cortical diameter of the involved bone (Lead-Cortical Ratio)
Study Design
Inclusion Criteria
Patient age >18 years
Operative fracture fixation
Minimum follow up of 4 months or fracture union
Study Design
Retrospective review
Level 1 Trauma Center
2008-2011
Study Design
Anecdotal observation that more bullet fragments delayed or nonunion
Therefore, reviewed all GSW involving fractures operatively treated at our institution with attention to time to bony union
Background
357 Days
The rate of fracture union in this study correlated with the quantity of bullet material at the fracture site

There appeared to be a threshold at 20% of the lead-cortical ratio, above which a significant delay in fracture union time was observed
Conclusions
Dougherty, PJ; Vaidya, R; Silverton, CD; Bartlett, CS, 3rd; and Najibi, S: Joint and long-bone gunshot injuries. Instr Course Lect.59:465-79.
Long, WT; Brien, EW; Boucree, JB, Jr.; Filler, B; Stark, HH; and Dorr, LD: Management of civilian gunshot injuries to the hip. Orthop Clin North Am. 1995;26:123-31.
Zura, RD, and Bosse, MJ: Current treatment of gunshot wounds to the hip and pelvis. Clin Orthop Relat Res. 2003:110-4.
Zura, RD, and Bosse, MJ: Current treatment of gunshot wounds to the hip and pelvis. Clin Orthop Relat Res. 2003:110-4.
Bartlett, CS; Helfet, DL; Hausman, MR; and Strauss, E: Ballistics and gunshot wounds: effects on musculoskeletal tissues. J Am Acad Orthop Surg. 2000;8:21-36.
Treatment
Treatment
Dougherty, PJ; Vaidya, R; Silverton, CD; Bartlett, CS, 3rd; and Najibi, S: Joint and long-bone gunshot injuries. Instr Course Lect.59:465-79.
Thank you
Dicpinigaitis, P. Gunshot Wounds to the Extremeties. Hospital for Joint Disease. Lecture. 2002
= 92 per day

Bowel contamination significant concern

Most common associated injury

= 1,118,157
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