Extremity Gunshot Injuries Research Articles

The Impact of Area Deprivation Index, Geography, and Mechanism on Incidence of Ballistic Injury to the Upper Extremity.

This study investigates the intersection of ballistic injuries, geography, and Area Deprivation Index (ADI). We hypothesized that both ADI and geography are correlated with incidence of upper extremity ballistic injuries. Further, we characterize and compare 2 distinct upper extremity gunshot injury populations presenting to our institution: those sustaining violent ballistic injuries and those who suffer an accidental, self-inflicted injury. Our purpose is to evaluate the impact of geography and ADI on the pattern of upper extremity gunshot injuries in Illinois and Missouri. This was a retrospective review of adult patients sustaining ballistic injury to the upper extremity at a single urban level I trauma center over 10 years (n = 797). Seven hundred thirty patients had home addresses in Illinois or Missouri; these addresses were geocoded and included for analysis. Mechanism of injury was self-reported. ADI was measured from the 2019 Neighborhood Atlas, in which deprivation increases from 1 to 100. Comparisons between groups were conducted with unpaired t tests, Fisher exact test, or χ2 testing, where appropriate. Addresses constituted 259 unique census tracts, and the average number of upper extremity gunshot wound incidents per tract was 3, with a maximum of 22; 15.4% of census block tracts made up almost half (48.4%) of the total ballistic injuries in the study period; 97.7% of violent injuries occurred in Urban areas, as compared with only 60% of accidental injuries (P < 0.05). ADI and incidence of upper extremity ballistic injury were positively correlated. ADI varied significantly between patients sustaining violent (median, 94; mean, 86.1) versus accidental self-inflicted (median, 79; mean, 70.9) injuries (P < 0.05). Fifty percent of violent injuries in our data set occurred in block groups from the 2 most deprived quintiles. Upper extremity gunshot wounds in general are concentrated in census blocks with high ADI. Violent injuries in particular are more likely to occur in urban areas with high ADI, whereas patients with accidental, self-inflicted injuries are more geographically and socioeconomically diverse. These differing populations require unique approaches to reduce incidence and morbidity.

Current approaches to surgical treatment of extremity gunshot injuries

Current approaches to surgical treatment of extremity gunshot injuries

Conservative Management in Lower Extremity Gunshot Injuries: A Ten-Year Experience

Indications for immediate operative exploration in vascular trauma have been well described in the literature. However, this indication is often blurred in cases where the patient has diminished but present pulses, or only single-vessel runoff in the injured lower extremity. Improvements in quality of computed tomography angiography (CTA) has allowed for an increase in conservative management of vascular trauma. The objective of this study was to examine outcomes at a tertiary level 1 trauma center to validate practices and confirm that conservative, nonoperative management of diminished runoff has safe outcomes, and additionally to identify areas for improvement in management.

SPECIFIC ASPECTS IN TREATMENT OF SUPPURATIVE-INFLAMMATORY COMPLICATIONS IN GUNSHOT WOUNDS OF EXTREMITIES

Summary. The aim of the study was to present an argument for treatment algorithm of patients with extremity gunshot injuries complicated by suppurative inflammation.&#x0D; Materials and research methods. Examination and treatment of 163 patients with gunshot wounds of the extremities were performed. All the wounded were divided into 3 study groups. The patients of group 1 underwent conventional treatment of gunshot wounds. In group 2, negative pressure wound therapy was used. Wounded patients of group 3 received vacuum-assisted therapy supplemented by the proposed scheme of counter-drainage and flow-through flushing irrigation of wounds with antiseptic solutions of 0.02 % decamethoxine and 3 % hydrogen peroxide. Bacteriological study of wound exudate was carried out, and sensitivity of microorganisms to antibiotics was determined.&#x0D; Results and its discussion. Wound microbiology analysis in victims of blast and mine-blast injuries demonstrated predominance of gram-negative bacteria in wound microbiocenosis — Acinetobacter spp. (53 % of cases) and Pseudomonas spp. (15 % of cases). Gram-positive cocci were isolated in 22.2 % of cases. Sensitivity study of nonfermentative gram-negative rods demonstrated them to have high level of resistance to most antibacterial agents. All strains of Acinetobacter and Pseudomonas spp. were sensitive to polymyxin B and colistin but resistant to inhibitor-protected and -unprotected amino penicillin.&#x0D; Beneficial effect of vacuum therapy in patients of groups 2 and 3 was evidenced by significantly reduced time of wound healing and hospital stay. The use of suggested mixture of antiseptics resulted in decrease of inflammation in 94.45 % and 88.89 % of patients in groups 3 and 2, respectively. Besides, in group 3, duration of hydration phase in wound healing process decreased to 5.7 days. The period of complete wound healing was shorter by 2.5 days, and hospital stay decreased from 14.97 to 10.8 days.&#x0D; Conclusions. Thus, predominance of gram-negative microorganisms in gunshot wounds as well as their high resistance to antibiotics should be considered when undertaking empirical antibiotic therapy in wounded patients. The proposed treatment algorithm involving negative pressure wound therapy supplemented with counter-drainage and flow-through flushing irrigation with a mixture of suggested antiseptics proved to be highly efficient in patients with extremity gunshot injuries complicated by suppurative inflammation.

Gunshot-Related Upper Extremity Nerve Injuries at a Level 1 Trauma Center

Gunshot wounds can result in a spectrum of injuries to nerves, with little data to guide definitive treatment. We performed a retrospective evaluation of gunshot-related upper extremity injuries in an urban trauma center to analyze epidemiology, associated injuries, and short-term outcomes. We hypothesized that gunshot-related injuries would involve soft tissue cavitation, inducing axonotmesis and neuropraxia rather than neurotmesis injuries. All patients over the age of 16 with upper extremity gunshot trauma from May 2018 to May 2019 were identified through the University of Chicago orthopaedic and general surgery trauma databases. Initial nerve injuries were identified by physical examination. Patient demographic data, soft tissue and skeletal injury, treatment modality, and return of function were collected. Ballistic injuries in 1302 patients were treated over 12 months. We identified 126 upper extremity gunshot injuries in 117 patients. Thirty-eight upper extremities (38 patients) had a documented nerve deficit (38/126, 30%) with a follow-up rate of 94% (34/36) at a mean of 351 days after injury (median, 202 days; range, 13-929 days). One patient had a subacute transradial amputation, and 1 patient was deceased at final follow-up. The presence of vascular injury and fracture increased the rate of neurologic injury after gunshot injuries. At the most recent follow-up, 68% (23/34) of patients with upper extremity injury had improvement in nerve function as measured by objective clinical assessment, with 24% (8/34) experiencing full recovery at an average of 368 days (median, 261 days; range, 41-929 days). Nerve injury after ballistic trauma to the upper extremity is common. Vascular injury and fractures were associated with a higher risk of nerve injury. Short-term improvement in nerve function was seen in over half the cohort, suggesting a predominance of neuropraxic effects. Prognostic IV.

Costs of Care for Low-Energy Extremity Gunshot Injuries are Reduced With Standardized Treatment.

(1) To determine the overall treatment costs associated with isolated low-energy gunshot wounds (GSWs) to the extremity and (2) to estimate cost savings associated with a single-dose IV antibiotic strategy administered in the emergency room for patients with simple GSWs. Retrospective review. Level I trauma center. Patients (N = 380) with extremity-only GSW injuries from 2010 to 2015 were retrospectively reviewed. Treatment was recorded including type and duration of antibiotics, admission, and surgical intervention. Costs were calculated including facility services in the operating room and hospital. There were 460 GSWs in 380 patients with a mean age of 30 years old. There were 309 admissions, 273 operations performed, and 1010 days of antibiotics prescribed. The total inpatient facility cost to treat all patients was $1,701,154. Among 179 patients who could be treated by the single-dose antibiotic care pathway for simple GSWs, 132 patients (73%) received additional treatment with 108 hospital admissions, 26 debridement surgeries, and 322 days of additional oral and/or IV antibiotics. The single-dose antibiotic care pathway would have saved an average of $1436 per patient with simple GSWs in actual facility expenses. The overall cost associated with isolated low-energy GSWs to the extremity is high. Limiting antibiotics to a single IV dose in the emergency room can reduce treatment expenses substantially for patients with simple GSWs. Economic Level IV. See instructions for authors for a complete description of levels of evidence.

Level I Activation for Extremity Gunshot Injuries: Findings at an Urban Trauma Center

Level I Activation for Extremity Gunshot Injuries: Findings at an Urban Trauma Center

Le traitement des lésions balistiques du membre supérieur : l’expérience de Cape Town

BackgroundUpper extremity gunshot fractures are generally treated conservatively or surgically using open reduction and internal fixation (ORIF), intra-medullary nails (IM) or external fixators. However, there is no gold standard for the management of these complex, multi-fragmentary upper extremity fractures. The aim of this study was to describe and identify the injury patterns, management, complications and associated risk factors for upper extremity gunshot fractures. Patient and methodsData of patients with upper extremity gunshot injuries that presented to a Level I Trauma Unit in Cape Town, South Africa was collected prospectively over a ten-month period from June 2014 to April 2015. Clinical notes and radiographs were reviewed retrospectively. ResultsFifty-one of 90 patients (56.7 %) with ballistic injuries had fractures, 30 % had neurovascular injuries and 75 % had additional injuries to other anatomical structures including head, neck, spine, chest, abdomen, pelvis and urogenital tract. Most fractures were diaphyseal, multifragmentary and extra-articular. Fractures were treated conservatively in more than half of the cases. Median fracture length was 5.5centimetres. A longer fracture zone was statistically associated with surgical treatment. When surgically treated, open reduction and internal fixation was most often performed. Median hospital stay was six days. Infection and injury severity prolonged hospital stay. DiscussionIn contrast to studies from the USA and Europe, most fractures in this study were managed conservatively. High quality prospective controlled trials are required to evaluate radiographic and clinical outcomes of treatment methods for upper extremity gunshot injuries. Level of evidenceIV, case series.

Treating fractures in upper limb gunshot injuries: The Cape Town experience

BackgroundUpper extremity gunshot fractures are generally treated conservatively or surgically using open reduction and internal fixation (ORIF), intramedullary nails (IM) or external fixators. However, there is no gold standard for the management of these complex, multi-fragmentary upper extremity fractures. The aim was to describe and identify the injury patterns, management, complications and associated risk factors for upper extremity gunshot fractures. Patient and methodsData of patients with upper extremity gunshot injuries that presented to a Level I Trauma Unit in Cape Town, South Africa was collected prospectively over a ten-month period from June 2014 to April 2015. Clinical notes and radiographs were reviewed retrospectively. ResultsFifty-one of 90 patients (56.7%) with ballistic injuries had fractures, 30% had neurovascular injuries and 75% had additional injuries to other anatomical structures including head, neck, spine, chest, abdomen, pelvis and urogenital tract. Most fractures were diaphyseal, multi-fragmentary and extra-articular. Fractures were treated conservatively in more than half of the cases. Median fracture length was 5.5 centimetres. A longer fracture zone was statistically associated with surgical treatment. When surgically treated, open reduction and internal fixation was most often performed. Median hospital stay was six days. Infection and injury severity prolonged hospital stay. DiscussionIn contrast to studies from the USA and Europe, most fractures in this study were managed conservatively. High quality prospective controlled trials are required to evaluate radiographic and clinical outcomes of treatment methods for upper extremity gunshot injuries. Level of evidenceIV, case series.

Prospective analysis of extremity gunshot injuries treated in a Nigerian regional trauma center

Background: Extremity gunshot injuries are a common cause of morbidity and mortality in our environment. They pose a management challenge because of the complex soft tissue and bony injuries. Objectives: The objectives of this study was to determine the pattern and treatment outcomes of these injuries in our setting. Materials and Methods: This was a prospective study of extremity gunshot injuries treated at National Orthopaedic Hospital, Enugu, Nigeria over a 12-month period. Results: Fifty-five patients were studied, with a mean age of 36.9 ± 13.39 years and a male-to-female ratio of 8.2:1. The two top causes of gunshot injuries were armed robbery (41; 74.5%) and assaults/communal clash (6; 10.9%), and the most common type of gun was the rifle (21; 38.2%). Gunshot fracture was the commonest type of injury among the patients (39, 70.9%). Only 34.5.1% of our patients presented to hospital within the first 6h. Secondary wound closure was the commonest method of wound cover. Majority of the gunshot fractures were treated non-operatively. The duration of hospitalization ranged from 2 days to 13 weeks with a mean duration of 4.9 weeks. Late presentation, presence of fracture, and wound infection were associated with prolonged hospital stay. Outcome of treatment was good in 80% of patients and the mortality rate was 1.8%. Conclusion: The young adult males are more involved in extremity gunshot injuries. The fracture rate of these injuries is high with associated increased morbidity. Effective control measures aimed at reducing the incidence of gunshot injuries will reduce the negative socioeconomic impact of these injuries.

Epidemiology and injury severity of 294 extremity gunshot wounds in ten months: a report from the Cape Town trauma registry

Aims: To describe the epidemiology and injury severity of patients with extremity gunshot injuries in an area with a high rate of interpersonal violence. Patients and methods: This is a prospective cohort study of patients who presented with an extremity gunshot injury and were recorded as part of a trauma registry at a large tertiary care hospital in Cape Town, South Africa, between June 2015 and April 2016. Patient demographics, injury severity scores, injury patterns and referral pathways were evaluated. Results: Of 1 123 gunshot trauma admissions in ten months, 290 (25.8%) patients (91.5% males, n=269) with a median age of 26 years (IQR 13.0) presented with extremity injuries. Median injury severity score (ISS) was 4.0 (IQR 8.0). Only one-fifth of patients had an ISS of 15 or more (n=50, 17%). Upper extremity injuries were associated with a higher risk of fractures (RR 2.15, p=0.05), higher number of nerve injuries (p=0.01), and a two times higher mean ISS (p=0.01). Admissions between 7pm and 7am with limited staffing at the emergency department were twice as high as the day admissions (n=169, 57.5% versus n=79, 26.9%). Conclusion: There is a high trauma load on the emergency department and orthopaedic service due to extremity gunshot injuries. Although upper extremity gunshot wounds constituted a red flag for higher injury severity, the overall injury severity was low. Inadequate timing and selection of emergency referrals of patients with low ISS are avoidable aggravators of this burden and should be targeted to increase efficiencies in the care of these patients. Level of evidence: Level 4

Infection Rates and Treatment of Low-Velocity Extremity Gunshot Injuries.

To determine the rates of infection in low-energy gunshot wounds (GSWs) to the extremity. Retrospective review. Level I trauma center. Patients (N = 140) with at least 90-day follow-up for extremity-only low-energy GSW injuries from 2010-2014 were retrospectively reviewed. Treatment was recorded, including type and duration of antibiotics and details of nonoperative and operative managements. The rates of superficial and deep infections. The overall infection rate was 15.7% (22 patients), and the deep infection rate was 3.6% (5 patients). Age, sex, and injury location were similar between the groups that did and did not receive antibiotic prophylaxis. Injury Severity Scores were higher in the group that did receive antibiotics. Regarding soft tissue-only injuries, antibiotic prophylaxis trended toward a lower rate of overall infection versus no antibiotic prophylaxis (6.1% vs. 25.9%, respectively, P = 0.07). Multiple doses of antibiotics did not reduce the rate of infection when compared with a single dose (14.6% vs. 12.5%, respectively, P = 1.00). No deep infections occurred in patients with nonoperatively treated fractures, regardless of antibiotic administration. All operatively treated fractures received antibiotic prophylaxis and demonstrated superficial and deep infection rates of 15.1% and 5.7%, respectively. Infections after low-energy extremity GSWs are infrequent. For soft tissue injuries without fracture, a single dose of intravenous antibiotics in the emergency department was associated with a lower rate of infection compared with no antibiotics. Operatively treated low-energy GSW fractures should receive standard perioperative antibiotics. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Computed tomography angiography of lower extremities in the emergency room for evaluation of patients with gunshot wounds.

To assess the role of CT angiography in the evaluation of patients with lower extremity gunshot wounds in the emergency room. Eighty patients (73 male, 7 female, mean age 26 years) underwent CT angiography for the evaluation of lower extremity gunshot injuries. Imaging was conducted on the basis of standardized protocols utilizing 16-slice and 64-slice multidetector systems and images were qualitatively graded and assessed for various forms of arterial injury. CT angiography findings indicative of arterial injury were observed in 24 patients (30%) and a total of 43 arterial injuries were noted; the most common form was focal narrowing/spasm (n = 16, 37.2%); the most common artery involved was the superficial femoral artery (n = 12, 50%). In qualitative assessment of images based on a 4-point grading system, both readers considered CT angiography diagnostically excellent (grade 4) in most cases. Surgical findings were consistent with CT angiography and follow-up of patients' medical records showed no arterial injuries in patients with normal findings on initial imaging. Our findings demonstrate that CT angiography is an effective imaging modality for evaluation of lower extremity gunshot wounds and could help limit more invasive procedures such as catheter angiography to a select group of patients. • CT angiography efficiently evaluates lower extremity gunshot wounds. • CT angiography provides image quality sufficiently reliable for assessment of gunshot injuries. • CT angiography could help limit invasive procedures to select patients.

Retained Bullet Removal in Civilian Pelvis and Extremity Gunshot Injuries: A Systematic Review

Although gunshot injuries are relatively common, there is little consensus about whether retained bullets or bullet fragments should be removed routinely or only in selected circumstances. We performed a systematic review of the literature to answer the following questions: (1) Is bullet and/or bullet fragment removal from gunshot injuries to the pelvis or extremities routinely indicated? And, if not, (2) what are the selected indications for removal of bullets and/or bullet fragments? A search of the English-language literature on the topic of gunshot injury and bullet removal was performed using the National Library of Medicine and MEDLINE(®) and supplemented by hand searching of bibliographies of included references. Studies were included if they provided clinical data on one or both of our study questions; included studies were evaluated using the levels of evidence rubric. Most studies on the subject were expert opinion (Level V evidence), and these were excluded; one Level III study and seven Level IV studies were included. No studies provided a rationale for routine bullet removal in all cases. The studies identified bullet fragment removal as indicated acutely for those located within a joint, the palm, or the sole. Chronic infection, persistent pain at the bullet site, and lead intoxication were reported as late indications for bullet removal. The evidence base for making clinical recommendations on the topic of bullet and bullet fragment removal after gunshot injury is weak. Level I and II evidence is needed to determine the indications for bullet removal after gunshot injury.

Inner city gunshot injuries: south London experience

Background: The Metropolitan Police figures in 2009 suggest a 23% decrease in the incidence of injuries related to offensive weapons in London compared to 2002. We conducted a retrospective analysis of extremity gunshot injuries over a 1-year period. Our aim is to report on our (1) incidence, (2) experience in treating these injuries and (3) complications. Methods: Over a 1-year period (2008–2009), 27 extremity gunshot injuries in 23 patients were identified and case notes reviewed retrospectively. The following were identified and analysed: fracture patterns (AO classification), treatment (operative/ non-operative), complications and patient compliance. Results: Our results show a 15% increase the rate of extremity gunshot injuries compared to data from 2002. Two-third of our injuries were managed non-operatively. Complications were as follows: four wound infections, one delayed union, one compartment syndrome, one vascular injury and three nerve injuries. Outpatient compliance was below average. Conclusion: Our data suggests that extremity gunshot injuries are on an increase in the south London highlighting the need for trauma surgeons’ knowledge of the management of these injuries. This group of patients have poor compliance and one should take this into account when treating these injuries in outpatient setting.

Pattern Of Extremity Gunshot Injuries Seen In Lagos University Teaching Hospital,

The rising incidence of gunshot injuries (GSI) remains one of the leading causes of death, long hospitalization and economic losses worldwide. This study was undertaken due to rising incidence of civilian GSI in Lagos, Nigeria. To determine the epidemiological characteristics of extremity gunshot injuries in Lagos, Nigeria. This three year crossectional study of extremity gunshot injuries was conducted at the Lagos University Teaching Hospital (LUTH), Lagos, Nigeria between 1st January 2000 and 31st December 2002. Two hundred and fifty four patients with extremity gunshot injuries presented with 240 analyzed. Those brought in dead (BID) were excluded from the study. Ninety-five percent of the patients were males. One hundred and twenty six patients (52.5%) were in the 21-40 years age group. The patients were shot mainly (75%) at night and mostly (80%) by armed robbers. Shot guns were used in shooting 47.5% of patients. The study showed that young adult males were more affected by GSI. Most of the shootings occurred at night by armed robbers.

Gunshot injuries to the extremities: experience of a U.K. trauma centre

The Metropolitan Police figures suggest an increase in the incidence of injuries related to gun crime. We conducted a retrospective analysis of extremity gunshot injuries over a five-year period. Our aim is to report on our (1) incidence, (2) complications and (3) experience in treating these injuries. Over a five-year period (1998-2002), 70 extremity gunshot injuries in 61 patients were identified from a trauma register and case notes reviewed retrospectively. The following were identified and analysed: type of injury (low or high-energy transfer), treatment (early/late), complications, patient demographics and compliance. There was a four-fold increase in incidence. Our incidence correlated well with The Metropolitan Police figures (r = 0.93). One-third of our injuries were managed non-operatively and on an outpatient basis. Complications were as follows: eight wound infections, one fracture non-union, one compartment syndrome, one vascular injury and five nerve injuries. Compliance was excellent for high-energy transfer injuries. Extremity gunshot injuries are on an increase in the United Kingdom highlighting the need for trauma surgeons' knowledge of the management of these injuries. Complications can be reduced to a minimum if the basic principles of management are strictly adhered to.

Arterial gunshot injuries of the extremities: a South African experience.

This is a retrospective study of 173 patients with gunshot injuries of the major arteries of the extremities. A selective policy for the use of angiography was followed. The arterial repair was achieved by various means: primary end-to-end anastomosis, vein interposition graft, and polytetrafluoroethylene (Teflon) interposition grafts. Overall, there were nine amputations in the lower limb. Ninety-eight percent of the patients had a palpable pulse on discharge. There were 3 preoperative deaths, 1 intraoperative death, and 5 postoperative deaths (overall perioperative mortality, 3.5%). We conclude that the results of vascular extremity gunshot injuries are satisfactory when standard methods of management are used. Morbidity and mortality can be further reduced by prompt admission to appropriate centers.

Extremity gunshot injuries treated in an urban children's hospital.

In the years 1985 to 1989 75 children and adolescents presented to an urban children's hospital for treatment of 76 incidents of extremity gunshot wounds. Although the population ranged widely, the "typical" patient was a preteen or teenager (n = 70) who was shot in the lower extremity (n = 53) with a low velocity handgun (n = 74). No vascular injuries and only two transient nerve injuries accompanied the wounds. Only 30% of the shots caused fractures. Many (43%) of the patients had other relevant psychosocial or medical problems. Previous treatment for other gunshot wounds or trauma had occurred in 27 patients. Although follow-up was not good, no consequent infections were identified. Outpatient local wound irrigation with minimal debridement sufficed as treatment for entry/exit wounds without contamination or fracture. Intravenous antibiotics are necessary in these wounds only for short-term prophylactic coverage of fractures. Larger soft tissue wounds, intraarticular foreign bodies, and fracture stabilization require operative treatment.