High-velocity Gunshot Wounds Research Articles

Yüksek Enerjili Balistik Yaralanmalar Sonucu Oluşan Mandibula Kemik Kayıplarının Rekonstrüksiyonunda Serbest Vasküler Fibula Flebi Operasyon Zamanlamasının Tespiti

Free tissue transfers are commonly used popular approach with respect to the development of microsurgery. In the present study, we aimed to evaluate the relationship between the operation timing and the succes of the free fibula flap operations for 11 cases, which were applied for mandible reconstruction after the high velocity gundshot wound of face in Cukurova university, Department of Plastic, Reconstructive and Aesthetic surgery between 1986-2004. The ages of the patients were between 17-42 (Mean age 25.8). Ten of them were male (%90.9) and one of them female (%9.1). Defect of the mandible bone were measured between 4 to13 cm. Nine of them were also required to the reconstruction of soft tissues. Nine patients were operated for free flap transfer during the first year and 2 of the patients were operated after the 1 year as a late reconstruction. Free flap failures were noted independently defect size and localizations for three patients, which were operated at l.month, 12.month and after 1 year as a late reconstruction. Free flap failure were noted especially at groups of 10-30 ages and 40-50 ages. Two of them were reoperated but the succes of flap was achieved at the group of 20-30 ages. Flap ischemia time was found to be directly proportional to the flap failure rate. Flap success rate (%100) were achieved at the operations betvveen the 2 and 7 months (mean 4.4 months) with less than 1 mm decrease of bicortical cortical thickness of flap. In conclusion, free flap reconstructipn of mandible defect after the high velocity gunshot wound can be achieved with better results at 4.4 months and between the 30-40 years of ages.

Penetrating and Orthopaedic Trauma from Blast versus Gunshots Caused by Terrorism: Israel's National Experience

Evaluation of the demographics, features, and outcomes of musculoskeletal injury patterns caused by terrorism in the civil setting and comparing injuries from explosions with gunshot injuries. Retrospective cohort analysis of a prospective database. National trauma registry consisting of all the six Level I and four Level II trauma centers. A total of 1245 casualties with terror-related musculoskeletal trauma. Five hundred fifty-one had high-velocity gunshot wound and 694 blast wounded (BW) caused by explosion. Demographic and injury data analyzed for age, gender, New Injury Severity Score, and associated injuries. Outcome of were analyzed according to length of hospital stay, intensive care unit stay, surgical procedures, and mortality. Severe injuries (New Injury Severity Score 16 or greater) were more common in the BW group (P < 0.01). In the BW group, a significantly higher proportion of casualties had associated injuries (73% versus 43%), intensive care unit care, longer length of stay, and mortality. Orthopaedic injuries were similar among the two groups with more open extremity fractures in the gunshot wound group and less significant injuries in the BW group. With casualties matched to the same New Injury Severity Score groups, the ones with the musculoskeletal injuries had longer hospitalization than those without. Musculoskeletal injury caused by blast is associated with multiple penetrating injuries, differing from more "conventional" penetrating trauma such as caused by gunshot injuries. Although the treatment of specific injuries caused by both mechanisms is essentially similar, the systemic effect of the blast must be taken into consideration in anticipation of an increased overall injury severity.

Avoiding cavity surgery in penetrating torso trauma: the role of the computed tomography scan

Surgical decision-making in torso trauma is complex. This paper looks at the role of the computed tomography (CT) scan in this decision-making process. Patients with significant torso trauma (high velocity gunshot wound [HVGSW], blast, stab) admitted to a military role 2 (enhanced) hospital facility during a 7-week period of Operation HERRICK 9 (Afghanistan, October to November 2008) are reported. The management of those patients undergoing a CT scan as part of the decision-making process at the time of admission is discussed. Twenty eight patients with significant torso trauma were admitted to the facility during the study period; HVGSW (n = 15), blast (n = 9), stab (n = 4). Thirteen patients underwent a CT scan as part of the surgical decision-making process; HVGSW (n = 5), blast (n = 8). Imaging confirmed torso integrity in 12 patients, one of whom subsequently had a laparotomy for vascular control for on-table haemorrhage during lower limb surgery. One patient had a confirmed thoraco-abdominal injury, which was treated conservatively with tube thoracostomy and 'active observation'. A CT scan formed part of the surgical decision-making process in about half of the patients admitted with significant torso trauma, and helped prevent unnecessary laparotomy in this forward military environment. Those patients with a blast injury were more likely to undergo CT scanning than those where the mechanism of injury was a HVGSW.

Gunshot Injuries to the Thoracolumbar Spine

Gunshot wounds to the spine are a common cause of spinal cord injury. The thoracolumbar area is the second most commonly injured region of the spine by gunshot wounds and is the focus of this article. In this article, the authors discuss the fundamentals of ballistics and tissue injury, involved in both low- and high-velocity gunshot wounds to the thoracolumbar spine. A discussion of the diagnostic and therapeutic tools involved in the management of these injuries is undertaken. Furthermore, the approach to the patient with a thoracolumbar gunshot wound is presented. Management must start with maintenance of airway, breathing, and circulation, and proceed with physical examination, laboratory, diagnostic imaging, and medical and surgical interventions. Tetanus prophylaxis and antibiotic administration for 7-14 days are imperative. Surgical debridement and surgical stabilization are rarely necessary in low-velocity, low-energy civilian gunshot wounds. Indications for surgery include wartime gunshot wounds, progression of neurologic deficit, persistent cerebrospinal fluid fistula, cauda equina syndrome with mass effect from bullet or bone fragments, and intracanalicular bullets between T12 and L4.

Heterotopic Ossification Secondary to High-Velocity Gunshot and Fragment Wounds About the Hip: A Report of Three Cases

Heterotopic Ossification Secondary to High-Velocity Gunshot and Fragment Wounds About the Hip: A Report of Three Cases

Short-Term Outcomes of Severe Open Wartime Tibial Fractures Treated with Ring External Fixation

The treatment of complex open tibial fractures sustained in combat remains controversial. This study investigated the short-term outcomes of type-III tibial shaft fractures treated at our institution with ring external fixation. A retrospective review identified sixty-seven type-III tibial shaft fractures in sixty-five consecutive patients treated between April 2004 and January 2007. Of these, forty-five tibiae in forty-three patients received fracture fixation with ring external fixation. The cases of thirty-six patients, who received treatment for thirty-eight tibial shaft fractures to completion with a standardized protocol, were reviewed. A blast mechanism accounted for thirty-five injuries, and three injuries were from high-velocity gunshot wounds. There were twenty-one type-IIIA, thirteen type-IIIB, and four type-IIIC fractures. Rotational or free soft-tissue flap coverage was performed on fifteen patients. Eighteen patients received planned delayed bone-grafting, and nine had only bone morphogenetic protein placed at the fracture site at the time of final wound closure. All fractures healed with <5 degrees of malalignment. One patient underwent elective delayed amputation. The average time to union with frame removal was 221 days (range, 102 to 339 days). Treatment of severe open wartime tibial fractures with a protocol-driven approach to wound management and placement of ring external fixation can result in a low rate of complications and a relatively high rate of fracture union. Most complications can be successfully managed without frame removal.

Traumatic pseudoaneurysms of the head and neck: Early endovascular intervention

Trauma to the head and neck with military munitions often presents with complex multisystem injury patterns. Vascular evaluation typically focuses on the carotid and vertebral arteries; however, trauma to branches of the external carotid artery may also result in devastating complications. Pseudoaneurysms are the most frequent finding on delayed evaluation and can result in life-threatening episodes of rebleeding. Patients evacuated from the Afghanistan and Iraq conflicts with penetrating injury to the face and neck were evaluated by the vascular surgery service to determine the potential for unsuspected vascular injury. Patients with significant penetrating injury underwent computed tomography angiography (CTA) as the initial evaluation and subsequent arteriography in cases where injuries were suspected or metallic fragments produced artifacts obscuring the vasculature. Data on all vascular evaluations were entered prospectively into a database and retrospectively reviewed. Between February 2003 and March 2007, 124 patients were evaluated for significant penetrating trauma to the head and neck. Thirteen pseudoaneurysms of the head and neck were found in 11 patients: two in the internal carotid artery, one of the vertebral artery, and 10 involving branches of the external carotid. Seven pseudoaneurysms were symptomatic, of which two presented with episodes of massive bleeding and airway compromise. Seven pseudoaneurysms were treated with coil embolization, 1 with Gelfoam (Upjohn, Kalamazoo, Mich) embolization, 2 with stent grafts, 2 with open repair, and 1 with observation alone. None of the patients undergoing embolization had complications; however, a stent graft of the internal carotid artery occluded early, without stroke. All of the pseudoaneurysms had resolved on follow-up CTA or angiogram. Pseudoaneurysms are a common finding in patients with high-velocity gunshot wounds or blast injuries to the head and neck. Most involve branches of the external carotid artery and can be treated by embolization. CTA should be performed on all patients with high-velocity gunshot wounds or in cases of blast trauma with fragmentation injuries of the head and neck.

Delayed rupture of traumatic aneurysm after civilian craniocerebral gunshot injury in children

There are few published large series on civilian craniocerebral gunshot injuries in children. Traumatic intracranial aneurysms (TICAs) are rare and highly unstable lesions. They represent less than 1% of all aneurysms and can either rupture within minutes after formation or remain quiescent for several weeks or years, manifesting with delayed hemorrhage and neurologic deterioration. We report the case of a 10-year-old girl who was referred for coma after high-velocity craniocerebral gunshot wound and neurological deterioration 7 days after the initial injury. A massive right posterior occipital hematoma caused by the rupture of an unsuspected right posterior cerebral artery TICA was discovered. TICA was treated by coil embolization, with a good neurological recovery at 6-month follow-up. We discuss the pathogenesis and the management of TICA in a child after civilian craniocerebral gunshot injuries. TICAs should be suspected in patients with civilian craniocerebral gunshot injuries, presenting with secondary neurological deterioration, to carry out emergent CT scan and angiographic exploration before contemplating definitive endovascular treatment. Endovascular management may be a prompt safe-to-use technique and a valuable option, especially when surgery is highly risky.

Antibiotic Prophylaxis: Current Recommendations

Antibiotic prophylaxis consists of a brief course of antibiotics initiated preoperatively in order to decrease the risk of postoperative wound infection in the patient with a clean wound. The antibiotic should be started within 60 minutes before skin incision and continued for not more than 24 hours. Antibiotic therapy is indicated for the contaminated or dirty wound. In open fractures, antibiotics should be started as soon as possible after injury and continued for 3 days (type I and II fractures) or 5 days (type III). This treatment should be combined with local therapy consisting of antibiotic-impregnated polymethylmethacrylate beads. Although the utility of antibiotics in low-velocity gunshot wounds is controversial, high-velocity gunshot wounds should be treated with 48 to 72 hours of antibiotic therapy.

Delayed evaluation of combat-related penetrating neck trauma

The approach to penetrating trauma of the head and neck has undergone significant evolution and offers unique challenges during wartime. Military munitions produce complex injury patterns that challenge conventional diagnosis and management. Mass casualties may not allow for routine exploration of all stable cervical blast injuries. The objective of this study was to review the delayed evaluation of combat-related penetrating neck trauma in patients after evacuation to the United States. From February 2003 through April 2005, a series of patients with military-associated penetrating cervical trauma were evacuated to a single institution, prospectively entered into a database, and retrospectively reviewed. Suspected vascular injury from penetrating neck trauma occurred in 63 patients. Injuries were to zone II in 33%, zone III in 33%, and zone I in 11%. The remaining injuries involved multiple zones, including the lower face or posterior neck. Explosive devices wounded 50 patients (79%), 13 (21%) had high-velocity gunshot wounds, and 19 (30%) had associated intracranial or cervical spine injury. Of the 39 patients (62%) who underwent emergent neck exploration in Iraq or Afghanistan, 21 had 24 injuries requiring ligation (18), vein interposition or primary repair (4), polytetrafluoroethylene (PTFE) graft interposition (1), or patch angioplasty (1). Injuries occurred to the carotid, vertebral, or innominate arteries, or the jugular vein. After evacuation to the United States, all patients underwent radiologic evaluation of the head and neck vasculature. Computed tomography angiography was performed in 45 patients (71%), including six zone II injuries without prior exploration. Forty (63%) underwent diagnostic arteriography that detected pseudoaneurysms (5) or occlusions (8) of the carotid and vertebral arteries. No occult venous injuries were noted. Delayed evaluation resulted in the detection of 12 additional occult injuries and one graft thrombosis in 11 patients. Management included observation (5), vein or PTFE graft repair (3), coil embolization (2), or ligation (1). Penetrating multiple fragment injury to the head and neck is common during wartime. Computed tomography angiography is useful in the delayed evaluation of stable patients, but retained fragments produce suboptimal imaging in the zone of injury. Arteriography remains the imaging study of choice to evaluate for cervical vascular trauma, and its use should be liberalized for combat injuries. Stable injuries may not require immediate neck exploration; however, the high prevalence of occult injuries discovered in this review underscores the need for a complete re-evaluation upon return to the United States.

Does Body Armor Protect from Firearm Injuries?

Bullet-proof vests and helmets protect from harm in combat and military engagements. The use of armor against shrapnel has been studied, yet little has been documented as to how they protect from high velocity gunshots. This study aims to describe the medical consequences of high velocity firearm injuries and to differentiate between patients injured while using protective wear and those injured unprotected. National trauma registry data on injury characteristics, treatment and outcomes between October 1, 2000 and December 31, 2003 were retrieved and analyzed. There were 669 terror-related firearm injuries recorded: 236 (37.8%) in soldiers (protected) and 433 (62.2%) in civilians (unprotected). Injury severity was notably higher in civilian patients (31% versus 16% with Injury Severity Score>or=16). Civilians had more ICU care (26% versus 20%, p=0.06), and double the inpatient mortality (8.6% [n=37] versus 3.4% [n=8] patients). Protected body regions such as abdomen, chest, and brain, were injured less frequently. Once a traumatic brain injury was sustained, no statistical differences were found in severity distribution, ICU stay, or inpatient death between protected and unprotected patients. But injury severity in patients with chest injuries was much higher in those who were unprotected (Injury Severity Score>or=25, 41% versus 23%, respectively, p=0.08). This increased severity could be attributed partly to more multiple injuries involving the chest. Abdominal injuries showed a similar pattern. Body armor has a protective effect on victims of high velocity gunshot wounds; lower rates of head, brain, chest, and abdominal injuries are seen. In addition, armor reduces the severity of injuries to the chest and the abdomen.

Thoracic firearm injuries in children: management and analysis of prognostic factors.

Thoracic firearm injuries (TFI) have become increasingly prevalent in children. Our purpose is to assess the injury pattern, Injury Severity Score (ISS), length of hospital stay (LOS), management and outcome of children with TFI with respect to the type of injury and to evaluate the value of ISS for predicting injury severity and the eventual need for thoracotomy, as well as the rate of morbidity and mortality. Between January 1987 and June 2002, 110 children (88 boys and 22 girls) </=16 years of age with firearm injuries to the chest were evaluated. The children were divided in four groups according to cause of injury. An ISS was calculated for each child. Those children who died before admission were excluded from the study. The relationship between ISS and prognostic factors was analyzed in all four groups. The mean age was 11.1+/-3.0 (range 3-16) years. Eighty-eight (80%) were male and 22 (20%) were female. The causes of firearm injuries were high-velocity gunshot wounds (HVGSW) in 52 (47.2%), low-velocity gunshot wounds (LVGSW) in 23 (20.9%), shotgun wounds (SGW) in 18 (16.3%), and explosives wounds (EW) in 17 (15.4%). Lung injury occurred in 72 (65.5%) patients. Tube thoracostomy was sufficient in 76.3% (84 of 110) for thoracic injury. The morbidity rate was 16.3% (18/110) and the mortality rate was 4.5% (5/110). Mean ISS was 16.62+/-8.2 (range 4-48). Fifty-eight patients (52.7%) had an ISS </=16, while 31 (28.2%) had a score between 17 and 25, and 21 (19.1%) had a score greater than 25. The need for thoracotomy, as well as the rate of morbidity and mortality were significantly higher in children for those with an ISS >25. SGW and EW groups had a significantly higher ISS. The mean LOS was 10.84+/-4.7 days (range 4-42). The value of LOS was significantly higher in children with SGW and EW. The majority of TFI in children can be treated successfully by tube thoracostomy if there are no gross pulmonary lacerations and airway injuries. SGW and EW were commonly associated with higher ISS and LOS. The ISS was found to be an independent predictor of the need for thoracotomy, as well as for rates of morbidity and mortality.

Combined ventral and retroperitoneal laparostomy in ballistic trauma to the colon and retroperitoneum

Retroperitoneal spillage and infection in ballistic trauma to the large intestine is a difficult surgical problem. Experience with four consecutive cases of high-velocity gunshot wounds to the abdomen, colonic injury, and retroperitoneal fecal spillage is reviewed. The patients underwent repeat exploration of the abdomen and retroperitoneum through ventral and retroperitoneal laparostomies. All patients survived. The cavities of the posterior laparostomies were in gravitationally favorable positions, facilitating thorough debridement and drainage. Closure of the posterior abdominal wall using prosthetic materials was achieved in all patients. Retroperitoneal laparostomy is a useful adjunct in management of gunshot trauma to the abdomen with retroperitoneal fecal contamination. After eradication of sepsis, defect closure is complex. Tissue-impervious material on the peritoneal side prevents adhesions.

Treatment of Type IIIa Open Fractures with Ilizarov Fixation and Delayed Primary Closure in High-Velocity Gunshot Wounds

A total of 142 patients with 163 Gustilo-Anderson type IIIa limb fractures resulting from high-velocity gunshot wounds were treated with primary delayed closure and Ilizarov fixation in our department between 1988 and 1998. Average follow-up was 72.4 months. The average union period in fractures without bone loss was 16.8 weeks. It took 2 months for each 1 cm of bone defect to heal in fractures with bone loss. All fractures healed with good anatomic alignment and functional outcomes. Complications included pin-track infection in 72 fractures (50.7%), post-traumatic osteomyelitis in 5 tibial fractures without bone loss (3.1%), delayed union in 25 fractures (15.3%), nonunion in 10 (4 with bone loss) fractures (6.1%), and refracture in 4 fractures (2.4%). Our results indicate that type IIIa limb fractures caused by high-velocity gunshot wounds can be treated with Ilizarov fixation and primary delayed closure with a low overall complication rate and a remarkably low infection rate.

Stomas and Trauma

The use of stomas for the surgical treatment of abdominal trauma has generated controversy for the last two decades as surgeons have questioned the propriety of applying military standards of care to civilian injuries. While diversion has been advocated in the treatment of colon injuries to obviate the potential morbidity associated with anastomotic leak, multiple retrospective and prospective trials have consistently demonstrated improved outcomes with primary repair or resection and anastomosis. Initially, primary repair was proposed only in selected patients without shock, high CIS or ATI scores, or extensive fecal contamination. However, these negative variables contribute to an adverse outcome independent of the type of bowel repair. Colon injury itself logically predisposes patients to increased infectious complications but colostomy may actually increase morbidity, particularly if the risk of subsequent surgery to restore bowel continuity is factored in. High-velocity gunshot wounds are still best treated with diversion.

Digital Nerve Repair by Autogenous Vein Graft in High-Velocity Gunshot Wounds

Gunshot wounds to the hands are high-energy injuries that cause widespread tissue damage, including to the nerves. Great difficulty is encountered in later reconstruction with nerve grafting of gaps in these destructive and scarred wounds. We present our experience with three patients with digital nerve repair by autogenous vein graft performed at an early stage in this type of injury. Based on our experience and that of others, this simple and rapid technique suggests a high rate of satisfactory results. It also avoids extensive and destructive late dissection and the morbidity associated with other late reconstructive procedures.

Treatment of tibial bone defects with the Ilizarov circular external fixator in high-velocity gunshot wounds.

One of the applications for circular external fixators is the treatment of large-bone defects which may be difficult to manage with conventional methods. Successful results have been reported with the use of circular external fixators, particularly in the treatment of infected tibial pseudoarthroses and those with bone loss. In this study, a total of 43 cases with tibial bone defects (18 infected) as a result of high-velocity gun-shot injuries were treated with circular external fixators between January 1, 1988 and December 31, 1995. The mean follow-up period was 50 months (range: 28-98 months) after the removal of the Ilizarov device. Satisfactory union was obtained in 40 cases without any major complication or additional surgical intervention, in spite of the large and in some cases infected defects. We conclude that this is a safe method for the treatment of infected or noninfected tibial bone defects.

Penetrating chest injuries: unusually high incidence of high-velocity gunshot wounds in civilian practice.

Penetrating chest injuries are a challenge to the thoracic or trauma surgeon. Penetrating thoracic trauma, especially that due to high-velocity gunshot wounds, is increasing at an alarming rate in our region. We report our experience with penetrating chest injuries mainly due to high-velocity gunshot wounds. During a period of 6 years we retrospectively reviewed the hospital records of 755 patients admitted to the Department of Thoracic and Cardiovascular Surgery, Dicle University School of Medicine, with the diagnosis of penetrating thoracic trauma. The mean age was 27.48 years, and 89-8% were male. The causes of penetrating injury were stab wounds in 45.3% and gunshot wounds in 54.7%. About 30% of the wounds were due to high-velocity gunshots; and among the gunshot wounds 56.2% were due to high-velocity shots. The most common thoracic injury was hemothorax (n = 190) followed by hemopneumothorax (n = 184). Isolated thoracic injuries were found in 53% of the patients. Nonoperative management was sufficient in 92% of the patients. Thoracotomy was performed in 8.1%. The mean duration of hospitalization was 11.2 days. The mean injury severity score (ISS) was 20.17 +/- 13.87. The morbidity was 23.3% and the mortality 5.6%. Fifty percent of all deaths were due to adult respiratory distress syndrome. Altogether 17% of patients with an ISS > 25 died, whereas only 0.9% of those with a score < 16 died. The mortality due to firearms was 8.95%. We concluded that in civilian practice chest tube thoracostomy remains by far the most common method of treating penetrating injury to the chest. The easy availability of high-velocity guns will continue to increase the number of civilians injured by these weapons.

High-Velocity Gunshot Wounds to the Head and Neck: A Review of Wound Ballistics

Patients who sustain gunshot injuries to the head and neck face heavy tissue damage and eventually life-threatening conditions. A very significant factor that determines the degree of injury is the course and extent of the missile track. The missile track is well correlated with bullet structure, size, and velocity, which have distinct features in civilian and military firearm injuries. The missile entrance or exist wound may be out of sight in some injuries, and often it is difficult to predict the severity of the injury in the chaotic circumstances of the battlefield. We studied the wound ballistics in five soldiers who suffered penetrating cranial and cervical firearm injuries.

Surveyed opinion of American trauma surgeons in management of colon injuries.

Primary repair or resection and anastomosis of colon wounds have been advocated in many recent studies, but the proportion of trauma surgeons accepting these recommendations is unknown. To determine the current preferences of American trauma surgeons for colon injury management. Four hundred forty-nine members of the American Association for the Surgery of Trauma were surveyed regarding their preferred management of eight types of colon wounds among three options: diverting colostomy (DC), primary repair (PR), or resection and anastomosis (RA). The influence of selected patient factors and surgeons' characteristics on the choice of management was also surveyed. Seventy-three percent of surgeons completed the survey. Ninety-eight percent chose PR for at least one type of injury. Thirty percent never selected DC. High-velocity gunshot wound was the only injury for which the majority (54%) would perform DC. More than 55% of the surgeons favored RA when the isolated colon injury was a contusion with possible devascularization, laceration greater than 50% of the diameter, or transection. Surgeons who managed five or fewer colon wounds per year chose DC more frequently (p < 0.001) and PR less frequently (p < 0.001) than surgeons who managed six or more colon wounds per year. The prevailing opinion of trauma surgeons favors primary repair or resection of colon injuries, including anastomosis of unprepared bowel. Surgeons who manage fewer colon wounds prefer colostomy more frequently.