Low-velocity Gunshot Wounds Research Articles

The J-wave: A new electrocardiographic sign of an occult cardiac injury

BackgroundThe aim of this study was to determine the sensitivity and specificity of a J wave on the electrocardiogram (ECG) to detect an occult cardiac injury in patients following penetrating chest trauma. MethodA prospective study conducted on patients admitted to the Groote Schuur Hospital Trauma Centre following penetrating chest trauma during the period of 1st October 2001 and 28th February 2009, who did not have an indication for emergency surgery and that underwent an ECG and later a subxiphoid pericardial window (SPW) for a potential cardiac injury. All the patients were easily resuscitatable with less than 2l of crystalloid. A standard 12-lead ECG was performed shortly after admission. A J wave was defined as the small positive reflection on the R-ST junction. ResultsThere were 174 patients where an ECG was performed and the patient underwent SPW for a possible cardiac injury. The mean age of the patients was 28 years (range 11–65). The mechanism of injury was stab wounds in 167 patients and 7 low velocity gunshot wounds. A J-wave was present on the ECG in 65 (37%) of the 174 patients with a possible cardiac injury. The sensitivity of a J wave to detect a hemopericardium was 44%, specificity was 85%, and positive predictive value of 91% (p<0.001). ConclusionThe presence of a ‘J’ wave on ECG signifies a significant risk of an occult cardiac injury after penetrating thoracic trauma.

F4.4 Is reamed intramedullary nailing a safe approach for treatment of femoral fractures associated with gun shot injuries in civilian practice?

Introduction: There is no standard treatment of these fractures since there are no clear guidelines relating these injuries to open fracture classification The aim of this study was to determine the outcome of femoral fractures due to gunshot injuries treated with primary intramedullary nailing with 5 days of injury. Materials and Methods: Between 1995–2010, twentynine femoral fractures caused by low-velocity gunshot injuries were treated with reamed intramedullary nailing within five (1–5) days. The average age was 40 (16–62) years. Associated neurovascular damage was ruled out by clinical examination. The femoral shaft fractures were classified according to the AO system, and comminution was graded according to the classification of Winquest and Hansen. There were 27 male and 2 female patients; 2 fractures were grade IIIC. All fractures were taken emergently to the operating room for irrigation, debridement and intramedullary nailing. Results: Patients were followed for an average of 26 (18–123) months, and the average time to union was 20 (18–26) weeks. There were no infections. Five patients with delayed union required dynamization. Three patients had an average shortening of 2 cm. Nineteen fractures had excellent outcomes and nine had good outcomes. One fracture was graded as poor outcome. Conclusion:Our experience suggests that immediate intramedullary nailing of gunshot femoral fractures has produced results similar to those observed in treating closed femoral fractures. So it can be concluded that patients with gunshot fractures of the femoral shaft can be treated with intramedullary nailing after 6–8 hours post injury, without the added fear of sepsis. The benefits of this treatment is reduction in the duration of hospital stay, and decreased costs in the management of these patients. So it can be recommended as the treatment of choice in fractures of the femoral shaft caused by gunshots.

A rare case of retained, asymptomatic bullet in para spinal space due to homicidal injury by country made weapon

Abstract Gun shot wounds are commonly fatal and among them thoracoabdominal and spinal injuries are significantly hazardous. Usually firearm injuries produce a characteristic pattern with peculiar features, rarely we encounter some very unusual and unique presentation, which requires a lot of skill and competence to handle and may create surgical or medico-legal diagnostic problems. Here we present a case of a 58 years old person, who presented with low-velocity gunshot injury in his chest at the right 3rd intercostals space and the bullet after traveling a long course inside the body, finally lodged anterior to the spine at the level L2–L3 near the great vessels. But surprisingly it did not produce any significant injury and the patient was asymptomatic. He was managed conservatively, and is having no problem on regular follow ups till date.

Concept of Gunshot Wound Spine

Gunshot wound (GSW) to the spine which was earlier common in the military population is now being increasingly noted in civilians due to easy availability of firearms of low velocity either licensed or illegal combined with an increased rate of violence in the society. Contributing to 13% to 17% of all spinal injuries, the management of complex injury to the spine produced by a GSW remains controversial. Surgery for spinal cord injuries resulting from low velocity GSWs is reserved for patients with progressive neurologic deterioration, persistent cerebrospinal fluid fistulae, and sometimes for incomplete spinal cord injuries. Surgery may also be indicated to relieve active neural compression from a bullet, bone, intervertebral disk, or a hematoma within the spinal canal. Spinal instability rarely results from a civilian GSW. Cauda equina injuries from low velocity GSWs have a better overall outcome after surgery. In general, the decision to perform surgery should be made on consideration of multiple patient factors that can vary over a period of time. Although there have been plenty of individual case reports regarding GSW to the spine, a thorough review of unique mechanical and biological factors that affect the final outcome has been lacking. We review the key concepts of pathogenesis and management of GSW to the spine and propose an algorithm to guide decision making in such cases.

Endovascular Repair of a Left Common Carotid Pseudoaneurysm Associated With a Jugular–Carotid Fistula After Gunshot Wound to the Neck

The management of traumatic injury of the common carotid artery has traditionally required a conventional surgical intervention, which is associated with a high mortality rate. Endovascular procedures might offer a less invasive alternative to treat these injuries, with a lower rate of mortality and morbidity. We report the case of a 30-year-old man who presented after penetrating injury due to a low-velocity gunshot wound to the neck. Angiography demonstrated a high-flow arteriovenous fistula and large false aneurysm of the common carotid artery. A self-expanding covered stent was placed across the injured portion of the artery, resulting in thrombosis of the aneurysm and preservation of the parent artery, without any significant complication. Covered stent placement is an alternative approach to treating carotid artery pseudoaneurysms associated with a jugular-carotid fistula.

External Fixation in a Low-Velocity Gunshot Wound to the Mandible

Low-velocity gunshot wounds to the mandible are complex injuries that can be aesthetically and functionally devastating. Despite advances in plating systems and surgical techniques, repair of such injuries remains a challenging endeavor. Traditionally, external fixation has resulted in longer treatment times and the need for revision surgery. Rigid fixation has many proponents because of shorter postoperative treatment times and fewer complications. We report a case of a low-velocity gunshot injury to the mandible with comminution and a full-thickness soft tissue wound treated definitively with maxillomandibular fixation and an external fixation device.

Diagnostics and treatment of low-velocity gunshot wounds in the hip joint region

In Western Europe, gunshot wounds are relatively rare. Nevertheless, the incidence of firearms-related injuries has been increasing in this region over the past two decades. The majority are low-velocity gunshot wounds, in which the severity of injuries is mainly determined by the structures that are damaged in the bullets’ pathway [1]. To our knowledge, there is a very limited number of recent publications on gunshot wounds located solely around the proximal femur [2]. Most publications are either from several decades ago or describe hip region gunshot wounds with concomitant abdominal injuries or bullets’ pathways actually through the hip joint surface [3–10]. Additionally, we found no publications with an overview of diagnostics and treatment of gunshot wounds in the hip region. Nevertheless, these gunshot wounds do require thorough diagnostics and adequate treatment in order to prevent articular and systemic pathologies. We present a case of a low-velocity gunshot wound in the groin with a very particular bullets’ pathway. Advices for diagnostics and treatment of gunshot wounds around the hip are depicted in a concise review of literature. Case

Gunshot Femoral Fractures with Vascular Injury: A Retrospective Analysis

To retrospectively investigate the experience at one urban level one trauma center with gunshot femoral fractures with vascular injury and to examine the implication of surgical sequence with regards to short-term complications and ischaemia time. We performed a retrospective study of 24 patients treated at an urban level one trauma center over a 10-year period with low velocity gunshot wounds resulting in femur fractures and major vascular injury. Data were stratified according to sequence of surgical intervention. The mean age was 31.3 years. Mean time to revascularization was highest in patients undergoing definitive orthopaedic fixation first (660 min) and lowest in patient undergoing shunting first (210 min). Most complications in patients undergoing vascular repair first, included two disrupted repairs requiring immediate revision after subsequent orthopaedic fixation. Other complications included compartment syndrome and one amputation. Surgical sequence did not appear to impact the outcome with regard to limb loss, compartment syndrome, or mortality. Orthopaedic repair following vascular repair, however, is a risk for disruption of the vascular repair. We suggest that close and early direct communication between the orthopaedic and vascular surgeons take place in order to facilitate a satisfactory outcome.

Outpatient Management Of Low Velocity Gunshot Wound Experience In United Nations Level-Ii Hospital

Introduction: Gunshot wounds are commonly encountered in war as well as in civilian situation. Experience of treating low velocity gunshot wounds (GSW) as outpatients in a war situation is depicted in this study. Aim: The aim of this study was to evaluate the experience of treating low velocity gunshot wounds by simple wound irrigation and marginal excision in war situation. Method: This was a retrospective observational study carried out in a Level-II Hospital of United Nations in Ivory Coast over a period of 7 months. All patients of low velocity GSW were treated with simple wound irrigation with normal saline and povidone iodine solution with excision of wound margin of doubtful viability under local anesthesia, rather than wound debridement. Result: All wounds healed with 6% superficial wound infection that was controlled with oral antibiotics. Conclusion: Outpatient management of low velocity GSW with wound irrigation and marginal excision is an effective method of treatment that can save time, money and hospital-stay. DOI: http://dx.doi.org/10.3329/jafmc.v7i2.10388 JAFMC 2011; 7(2): 12-14

Management challenges in a short-range low-velocity gunshot injury

The use of firearms is becoming more prevalent in the society and hence the number of homicidal and suicidal cases. The severity of gunshot wounds varies depending on the weapons caliber and the distance of firing. Close-range, high-velocity gunshot wounds in the head and neck region can result in devastating esthetic and functional impairment. The complexity in facial skeletal anatomy cause multiple medical and surgical challenges to an operating surgeon, demanding elaborate soft and hard tissue reconstructions. Here we present the successful management of a patient shot by a low-velocity short-range pistol with basic life support measures, wound management, reconstruction, and rehabilitation.

Retinal Detachment Due to Facial Gunshot Wound: The Utility of Ultrasonography in a Medically Austere Environment

BackgroundRetinal detachment is one complication of ocular trauma. Retinal detachments resulting from gunshot wounds are typically associated with significant facial trauma, orbital trauma, or globe penetration. Ultrasonography has been shown to be of diagnostic utility in the evaluation of retinal detachments. ObjectivesIn this case, an atypical mechanism for retinal detachment is described. The aim is to describe the successful use of ultrasound as an aid for accurate diagnosis and disposition of a retinal detachment in practice environments with limited medical resources. Case ReportWe present a case of a low-velocity gunshot wound resulting in retinal detachment from pressure wave forces. A 21-year-old patient sustained a facial gunshot wound injury from a ricocheting AK-47 round, resulting in a closed globe retinal detachment. Portable ultrasonography was utilized as an accurate diagnostic modality in the management and disposition of this patient, allowing prompt confirmation of the diagnosis in a medically austere environment. ConclusionUltrasonography can be a valuable diagnostic tool in the evaluation of ocular trauma in medically austere environments.

Intra- and Periarticular Heterotopic Ossification in the Knee After a Low-Velocity Gunshot Wound Treated With Retrograde Intramedullary Nailing of the Femur

This is a case of a 32-year-old man who developed intra- and periarticular heterotopic ossification (HO) after sustaining a low-velocity gunshot wound to the femur treated with intramedullary nailing of the fracture using a retrograde technique. The association between HO after a high-velocity gunshot wounds is well established. In addition, there have been two case reports of intra-articular HO after retrograde intramedullary femoral nailing. However, HO in and around the knee after a low-velocity gunshot wound has not been reported and may be more common than initially thought.

The Role of Débridement in Low-Velocity Civilian Gunshot Injuries Resulting in Pelvis Fractures: A Retrospective Review of Acute Infection and Inpatient Mortality

To determine the use of surgical débridement in the management of low-velocity gunshot injuries (GSIs) resulting in pelvis fractures. : Retrospective chart review. Level I trauma center in a major metropolitan area. Fifty-six patients from 1991 to 2007 treated for pelvis GSIs with resulting pelvis fractures with six acute mortalities and 40 patients with at least 1-year follow-up. Patient data were reviewed for incidence of infection related to pelvis GSIs. Information regarding surgical débridement of pelvis GSI wounds, retained foreign bodies, and/or concomitant gastrointestinal (GI) injury was analyzed for relationships of such events to infection rate. Incidence of infection related to pelvis GSIs at least 1 year after GSI date. Three patients (6%) developed a deep infection related to their pelvis GSIs. There were no cases of osteomyelitis. The rate of concomitant GI injuries was 36% and the overall infection rate among those with GI injuries was 12% versus 3% for those without a GI injury (P = 0.34). There were infection rates of 7% and 6% among patients who underwent surgical débridement and those who did not, respectively. Of those with GI injuries, 41% underwent primary surgical débridement and none developed infection. In the group of remaining patients with GI injuries who did not undergo débridement of their GSI wounds, two (20%) developed an infection. The mortality rate of low-energy GSIs to the pelvis was six of 53 (11%). There was no increased incidence of infection in the absence of aggressive surgical débridement of pelvis GSI wounds. The study also demonstrated that retained bullets and bullet fragments did not increase the risk of infection, even after penetrating the GI tract organs. Finally, this study suggests there may be an increased risk of infection related to pelvis GSIs compared with reported infection rates related to GSIs of the extremities, likely secondary to a high rate of concomitant GI injuries associated with pelvis GSIs; however, there was no incidence of osteomyelitis.

Management of low velocity gunshot wounds to the anterior urethra: the role of primary repair versus urinary diversion alone

Management of low velocity gunshot wounds to the anterior urethra: the role of primary repair versus urinary diversion alone

Arrow Shaft Injury of the Wrist and Hand: Case Report, Management, and Surgical Technique

A case of accidental, self-inflicted injury to the hand from a hollow carbon shaft arrow which broke in its midshaft while attempting to shoot the arrow from a compound bow is presented. Basic knowledge of low velocity gunshot wounds and arrow injuries was applied in the treatment of this injury along with a unique management technique. The outcome, including hand function was good without any functional loss.

Arthroscopically Assisted Minimally Invasive Intraarticular Bullet Extraction: Technique, Indications, and Results

We describe a new arthroscopically assisted, minimally invasive approach to intraarticular bullet extraction limited in its surgical dissection to the bullet tract itself. This procedure accomplishes intraarticular irrigation and removal of the retained missile without the need for a formal open approach. Additionally, we report on a novel extension of this technique to include bullet removal from the sacroiliac joint. During a 5-year period (April 2001 to April 2006), 11 patients with retained intraarticular missiles as a result of low-velocity gunshot wounds were treated at our institution with attempted arthroscopically assisted minimally invasive bullet extraction. All patients were male with a mean age of 22.3 years (range, 17-45). Anatomic location of the retained bullets included the knee (6), hip (4), and sacroiliac joint (1). We report a 90.9% success rate of arthroscopically assisted intraarticular bullet extraction from the hip, knee, and sacroiliac joint. One case involving the knee required conversion to an open approach to avoid iatrogenic osseous damage to the posterior aspect of the femoral condyle. Surgical extraction of retained intraarticular missiles from low-velocity handguns should be performed to minimize the risk of mechanical arthritis, synovitis, and lead toxicity. Arthroscopically assisted bullet extraction using the bullet tract with a minimally invasive approach should be considered when it can be safely accomplished without iatrogenic damage associated.

Migration of a Bullet in the Lumbar Intervertebral Disc Space Causing Back Pain -Case Report-

A 41-year-old man presented with low-velocity gunshot injury in the right abdomen. Neuroimaging showed the bullet located in the L2-3 intervertebral disc space, but neurological examination found no abnormalities. Exploratory laparotomy was performed because of retroperitoneal hematoma. Two months after the gunshot injury, the patient presented with severe low back pain. Serial neuroimaging showed that the bullet had migrated in the intervertebral disc space. The bullet was removed via right L2 hemilaminectomy. The patient had no complaints after the operation. Early recognition and surgical intervention for bullets embedded in the intervertebral disc space may present with neurological and related complications.

Handgun injuries with metacarpal and proximal phalangeal fractures: early definitive treatment

Most gunshot injuries to the hand involve a combination of tissue types. The goal of this study is to report the results of early definitive treatment in extra-articular metacarpal and proximal phalangeal fractures due to low velocity gunshot wounds and to analyse their outcomes. A retrospective analysis of 51 metacarpal and 41 proximal phalangeal fractures of 76 patients due to low velocity gunshot wounds treated between January 2001 and December 2004 was carried out. We applied acute fixation in the first 24 hours. The patients were evaluated with total active motion scores, radiographic control, complication rate and the need for revision surgery. The infection frequency was 10.5% and the need for a revision surgery was 7%. The plate fixation group had significantly higher total active motion scores than the external fixation group. The K wire group had the highest revision rate. The bone grafting group was associated with good total active motion scores and low complication rates. The majority of the low velocity gunshot injuries are surgically clean wounds which allow not only early fracture fixation, but also early bone grafting and soft tissue reconstruction. Plate and screw fixation is associated with significantly better functional outcomes than the minimal fixation group.

Increased Blood Lead Levels in an Adolescent Girl from a Retained Bullet

The current literature suggests that the majority of patients with a low-velocity gunshot wound can be treated nonoperatively with local wound care and antibiotic prophylaxis. Surgical removal of the bullet is not typically recommended for nonarticular fragments1,2, as the long-term consequences of a retained bullet are thought to be insignificant. However, increased lead levels in any patient and particularly in a fetus or growing child can result in permanent disability3-6. We describe the case of an adolescent girl who sustained a gunshot wound to the foot resulting in an elevated blood lead concentration to a dangerous and teratogenic level. Both the patient and her mother were informed that data concerning the case would be submitted for publication. A fourteen-year-old girl sustained a gunshot wound to the back of the ankle when walking up the stairs in front of her house as she was returning from school. The bullet entered the posterolateral aspect of the heel. Radiographs revealed fractures of the talus and lateral malleolus, as well as a bullet embedded in the talar neck and multiple shards of metal along the bullet track (Fig. 1). The results of neurovascular examination were normal. In the emergency room, antibiotics and tetanus prophylaxis were administered. She was taken to the operating room emergently for irrigation and debridement of local soft tissue as well as the ankle and subtalar joints. The bullet had passed between the fibula and tibia, removing bone from each, and from the posterior aspect of the talar body into the talar neck, where it had created a comminuted fracture. Because of softtissue swelling and concerns for the vascular supply to the talus, no attempt was made initially to access the talus or bullet from an anterior approach, and the bullet could not …

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.