Low-velocity Gunshot Wounds Research Articles

Low velocity gunshot wounds in the maxillofacial area: Preliminary evaluation of 24 cases

Low velocity gunshot wounds in the maxillofacial area: Preliminary evaluation of 24 cases

Low velocity gunshot injuries to the temporal bone.

To review the presentation, symptoms and management associated with low velocity gunshot injuries to the temporal bone. A retrospective analysis of 26 patients treated for low velocity gunshot injuries to the temporal bone. Initial presentation included otorrhoea (69 per cent), facial nerve injury (27 per cent), hearing loss (65 per cent), intracranial injuries (50 per cent), and cranial neuropathies (58 per cent). Nine patients (35 per cent) underwent angiography, which showed vascular injury in five of them. Four patients died. Low velocity gunshot injuries can be devastating and may result in functional sequelae. Low velocity missiles crush and lacerate surrounding structures, while high velocity missiles cause extensive wound cavity formation. Early aggressive management for intracranial, vascular and facial nerve injury can improve outcome.

Low-velocity gunshot injuries of the spine with abdominal viscus trauma.

To evaluate the risk of infection of the spine and associated complications after colonic or rectal injury associated with gunshot injury of the spine. Retrospective review. Presley Memorial Trauma Center, Regional Medical Center, Memphis, Tennessee, a statewide Level 1 trauma center. Thirty-three patients with gunshot wounds to the spine and associated viscus injury were treated between 1989 and 1994; in thirteen, the bullet passed through the colon or rectum before damaging the spine. Six patients received a single antibiotic (Cefotetan) and seven were given multiple antibiotics. Total duration of antibiotic treatment ranged from two to forty-three days. None of the thirteen patients developed osteomyelitis or disc space infection. Most intraabdominal complications were secondary to dehiscence of colonic repair. Because the magnitude of bacterial colonization of the vertebrae after colonic injury may not be high, a nonoperative approach to treatment of abdominal viscus injuries is appropriate in patients with gunshot wounds to the spine. Broad-spectrum antibiotic coverage for at least seven days appears to be effective in preventing spinal infection, but colonic injuries are associated with an increased incidence of intraabdominal abscess and peritonitis.

Gunshot wounds to the spine

In the USA, low velocity gunshot injuries (GSI) account for 13% of all urban spinal injuries, and they have become the second leading cause of all spinal cord injuries. The initial clinical evaluation should assess vascular, visceral, and/or neurological injury. Early imaging studies are required with computerized tomography in addition to plain radiographs to assess accurately the location and extent of the bone injury. The role of steroids is unclear, and if given, should be administered to GSI patients with complete or partial neurological deficit who present within eight hours of injury. The indications for prophylactic antibiotics have not been well established and although recommended, these are deemed essential only in patients with associated visceral perforation. Early surgical exploration is most appropriate to address associated vascular or visceral injury, while spinal decompression does not appear to influence neurological recovery. The majority of GSI spine fractures are stable; instability is usually due to ill-advised decompression of cervical spine GSI. Retained bullet fragments are rarely problematic; lead toxicity can occur due to missile contact with the synovial fluid, disc space, or contact with a pseudocyst.

Low-velocity gunshot wounds of the proximal phalanx: Treatment by early stable fixation

Twenty-eight proximal phalangeal fractures secondary to low-velocity gunshot wounds in 27 patients treated by stable fixation were retrospectively reviewed. Definitive fixation was performed within 1 week of injury. Fractures were stabilized with either a plate, intramedullary spacer, or a combination of both. When necessary, supplemental fixation was achieved with cerclage wires or interfragmentary screws. Twenty fractures with bone loss or comminution were primarily supplemented with iliac crest bone graft. After surgery, the fingers were splinted in 90 degrees of metacarpophalangeal (MP) flexion. An aggressive supervised therapy program was initiated within 24 hours of surgery. The average length of follow-up care was 9 months (range, 3-29 months). Primary union was achieved in all fractures. The average range of motion was 83 degrees for the MP joint and 66 degrees for the proximal interphalangeal joint. The average total active motion (TAM) for the involved digits was 200 degrees (range, 65 degrees-250 degrees). Fractures without intra-articular extension had a significantly better average TAM (213 degrees) than did those with intra-articular extension (169 degrees; p = .05). Primary bone grafting did not adversely effect the final TAM. There were no infections. Early stable fracture fixation of these injuries achieved union, alignment, and early rehabilitation with no appreciable increase in morbidity.

Humeral fracture secondary to civilian gunshot injury

Violence is the leading cause of death in the USA. The cost of violence due to gunshot wound is about $425 billion. While the closed fracture of the humerus is common, humeral shaft fractures caused by gunshot wound occur infrequently. There is much controversy regarding their management, i.e. should these injuries be treated surgically or can they be safely treated with minimal intervention. The aim of this study is to review our experience in the management of fourteen patients with a humeral fracture due to gunshot wounds. Of fourteen, seven patients were treated with local debridement, oral antibiotics and fracture brace. The remaining seven patients underwent surgical stabilization of the fracture. The time to union was similar in both groups (6 weeks in non-operative to 9 weeks in open treatment). In conclusion, fracture of the humeral shaft secondary to low velocity gunshot wound in the civilian setting can safely be treated as a closed fracture with local wound care and oral antibiotics.

Management of civilian gunshot injuries of the femur A review of the literature

Gunshot fractures of the femur are becoming more commonplace in modern civilization. The initial assessment must accurately document the vascular and neurological status of the limb as well as the characteristics of the fracture. Low velocity gunshot wounds require a brief course of broad spectrum intravenous prophylactic antibiotics and limited surgical debridement of the wound. Definitive stabilization should consist of locked, reamed, intramedullary nailing for low velocity injuries, and non-reamed nailing for high velocity injuries. External or plate fixations are best reserved for the more severe Grade IIIC injuries. Successful limb salvage is most dependent on the associated vascular injury, while neurological injury is a major determinant of long-term disability.

The management of civilian intra-articular gunshot wounds: Treatment considerations and proposal of a classification system

The incidence of intra-articular low-velocity gunshot wounds is increasing as the number of civilians injured by handguns grows. The severity of these injuries can vary and the general principles of managing them, particularly in regards to the role of irrigation, debridement and prophylactic antibiotics, are evolving. The authors suggest that injuries can be classified according to the ultimate location of the projectile, the level of contamination, and the type of fracture present. Injuries in which the projectile has no contact with the synovial fluid, with a low level of contamination, and a stable fracture pattern may be treated non-operatively, with antibiotics only. Wounds in which the bullet remains in contact with synovial fluid have a higher level of contamination or have a fracture requiring internal fixation and intravenous antibiotics in combination with more aggressive surgical treatment.

Low-velocity civilian gunshot wounds of the spine.

This article describes a retrospective study on patients admitted to a level I trauma center between 1989 and 1993 with low-velocity gunshot wounds to the spine. Medical records and imaging studies were reviewed to determine patient demographics, neurologic deficit, prophylactic antibiotic administration, and rate of infection, spine stability, and principle associated injuries. A total of 37 patients with low-velocity gunshot wounds to the spine were identified and comprised 34% of all spinal injury patients. Neurologic outcome of the low-velocity gunshot wound to the spine depended on the level of the injury and the presenting neurologic deficit, as improvement of one or two Frankel grades occurred in only seven patients. Prophylactic antibiotics were given to 20 patients, and one infection occurred and was associated with colon perforation. In the absence of hollow viscus perforation, antibiotic prophylaxis did not appear beneficial. Spinal instability was noted in three patients with cervical injury and one patient with lumbar injury, and neurologic deficit was variable despite the presence of instability. The major associated injury was vascular occlusion or disruption in 8 of 12 (66%) cervical low-velocity gunshot wounds to the spine.

Low-velocity gunshot wounds to the paranasal sinuses

There are more than 200 million private firearms in the United States today. Firearm-associated deaths are the second leading cause of mortality for men 1 to 38 years of age. There are many studies in the literature concerning the management of high-velocity gunshot injuries to the head and neck. However, there are no studies in the English language literature concerning the management of isolated low-velocity gunshot wounds to the paranasal sinuses. We retrospectively reviewed 35 patients treated for low-velocity gunshot wounds of the paranasal sinuses between 1985 and 1994 at Kings County Hospital Center. The injuries sustained by these patients were less severe than previously reported for high-velocity missile or shotgun injuries. The management of these injuries is outlined with emphasis on (1) indications for angiographic studies, (2) airway management, and (3) indications for operative removal of bullet fragments. (Otolaryngol Head Neck Surg 1997;116:372-8.)

Low-velocity gunshot wounds to the paranasal sinuses.

There are more than 200 million private firearms in the United States today. Firearm-associated deaths are the second leading cause of mortality for men 1 to 38 years of age. There are many studies in the literature concerning the management of high-velocity gunshot injuries to the head and neck. However, there are no studies in the English language literature concerning the management of isolated low-velocity gunshot wounds to the paranasal sinuses. We retrospectively reviewed 35 patients treated for low-velocity gunshot wounds of the paranasal sinuses between 1985 and 1994 at Kings County Hospital Center. The injuries sustained by these patients were less severe than previously reported for high-velocity missile or shotgun injuries. The management of these injuries is outlined with emphasis on (1) indications for angiographic studies, (2) airway management, and (3) indications for operative removal of bullet fragments.

Low-velocity gunshot injuries to the temporal bone

Low-velocity gunshot injuries to the temporal bone

Isolated thoracic duct injury after penetrating chest trauma

Isolated thoracic duct injuries as a result of penetrating chest trauma without any major vascular or tracheoesophageal injury seldom are seen. A retrospective 13-year review identified 8 patients with this injury. Seven had supraclavicular or suprascapular knife stabs, and the eighth had a low-velocity gunshot injury entering the mid-lateral right chest wall. All 7 stab victims presented with left-sided chylothoraces, and the site of injury of the thoracic duct was within Poirier's triangle, the borders of which are the arch of aorta, the left subclavian artery, and the vertebral column as seen from a lateral approach. Five patients initially were treated conservatively for 13.4 +/- 4.4 days without success. Surgical intervention thus was necessary and was successful in all 8 patients. The thoracic duct injury was controlled successfully through a left posterolateral thoracotomy in 6 patients. A supraclavicular repair was attempted in 1 patient but failed to control the leak and required reexploration via the supraclavicular approach. The right chylothorax from the gunshot injury was explored via a right posterolateral thoracotomy; the leak into the pleura was identified and obliterated. As conservative management was uniformly unsuccessful, we advocate early operative management through a thoracotomy on the side of the chylothorax for this relatively rare injury.

Low velocity gun shot wounds of the brachial plexus

28 patients with low velocity gunshot wounds of the brachial plexus were treated at Groote Schuur Hospital from 1980 to 1991. Delayed exploration of the brachial plexus (up to 7 months after injury) was performed in nine (30%) of the patients. The other 19 patients did not have exploration of the plexus; most of these patients showed signs of recovery within 2 to 4 weeks of injury. Injury to the subclavian or axillary artery occurred in nine (30%) of the cases. The average length of follow-up of the patients was 19 months (range 2-90 months). Of the 19 patients treated non-operatively, 15 (79%) had an excellent or good result and four (21%) a fair result. The indications for surgery were the absence of improvement within 3 months of injury or persistent pain. Surgery was indicated for significant pain in five of the nine patients; postoperatively two had complete relief of pain, two improvement in the pain and one no improvement. Of the nine surgically treated patients, three (33%) had a good result, two (22%) a fair result and four (45%) a poor result. The potential for recovery was not dependent on the severity of the injury at presentation or the presence of vascular injury but on the appearance of signs of recovery within 4 weeks of injury.

Low-Velocity Gunshot Wounds to the Spine with an Associated Transperitoneal Injury

Twenty-nine patients who incurred a transperitoneal low-velocity gunshot wound to their spine were evaluated for the occurrence of spinal infectious complications. All patients underwent an exploratory laparotomy to determine the extent of viscera involvement. No attempt was made to debride the involved spinal area, and the bullet was not removed unless it was easily accessible. Of the 21 patients with a parenchymal and/or noncolonic viscous injury, 17 (77%) were treated with intravenous (i.v.) antibiotics for a minimum of 5 days the remainder received treatment for a maximum of 48 h. All 8 patients with colonic injuries received a minimum of > or = 5 days of antibiotic treatment. Follow-up averaged 44.9 months (range 3-144 months). Only 1 (4.7%) patient with either a noncolonic or parenchymal perforation developed an infectious complication (subdiaphragmatic abscess); two patients (25%) with colonic perforations developed a psoas abscess. No patient developed a spinal infection. This study suggests that patients who sustain a transperitoneal low-velocity gunshot wound to their spine do not need to undergo spinal debridement and may be treated with parenteral antibiotics. Any course of broad-spectrum antibiotics for 5 days appears to minimize infectious complications. Bullet removal and missile tract debridement of the spine is not routinely necessary.

Management of gunshot injuries to the penis and anterior urethra.

To verify the appropriate methods of diagnosis and treatment of gunshot injuries to the penis and anterior urethra. Retrospective study. Fourteen patients presented over 5 years with gunshot wounds to the male genitalia with injuries involving the penis and or the anterior urethra. All patients underwent a full physical examination and retrograde urethrogram to fully stage suspected injuries. Of the nine patients sustaining penile wounds, four were superficial, requiring only debridement, and five involved the corpus cavernosum, necessitating formal repair. Physical findings of an expanding hematoma, a palpable corporeal defect, and excessive bleeding via the wounds were indicative of cavernosal injury and warranted a penile exploration. All patients were potent in follow-up, although two patients with extensive injuries did complain of curvatures. Retrograde urethrograms noted anterior urethral injuries in eight patients, three of whom also had sustained cavernosal injuries. Five were repaired primarily, and three were treated by urinary diversion via a suprapubic tube. Three patients developed urethral strictures: one in the primary repair group and two in the diversion group. The preferred method of handling low-velocity gunshot wounds to the penis and anterior urethral includes debridement of superficial wounds, repair of cavernosal defects, and primary repair of urethral injuries wherein tissue loss is not extensive to result in high-potency rates and lower rates of urethral stricture disease.

Efficacy of Ceftriaxone Versus Cefazolin in the Prophylactic Management of Extra-Articular Cortical Violation of Bone Due to Low-Velocity Gunshot Wounds

One hundred patients sustained gunshot wounds involving bone but not joint with a low-velocity bullet. Soft-tissue involvement was less than 1 cm at its greatest diameter. All patients were free from artery or nerve damage. No formal fixation of fracture was required. The results of the study suggest that patients need not be hospitalized longer than 2 days after an extra-articular, low-velocity gunshot wound that violates the cortex. In addition, through the use of long half-life antibiotics, such as ceftriaxone, the length of hospitalization may further be reduced to a day, while the potential for morbidity from infection is not increased.

Gunshot Wounds to the Hand: The Martin Luther King, Jr, General Hospital Experience

This article is a retrospective review of patients who presented to Martin Luther King, Jr./Drew Medical Center with gunshot wounds and had either isolated or associated injuries to the hand. The following is an account of those injuries noting the location, soft-tissue or bony involvement, and interventional methods that were implemented in the treatment of these patients who resided primarily in South Central Los Angeles. Prompt evaluation and initiation of treatment is essential in the management of both high- and low-velocity gunshot wounds so as to decrease the potential morbidity that often follows. Society must also look at the prevalence of these injuries and address the underlying issues that often are the root of the acts of violence.

Gunshot Wounds to the Foot

One hundred and one patients who sustained gunshot wounds to their feet were retrospectively reviewed. All patients were treated at King/Drew Medical Center between 1982 and 1994. From the authors' experience, they believe that patients with low-velocity gunshot wounds to the foot should be hospitalized and treated with at least a 3-day course of intravenous antibiotics of a first generation cephalosporin. Low-energy shotgun injuries should be treated the same as low-velocity injuries. Patients with high-velocity and high-energy shotgun wounds should be hospitalized and receive broad-spectrum intravenous antibiotics with multiple irrigation and debridements.

Arthroscopic debridement after intraarticular low-velocity gunshot wounds

An unexpected degree of joint contamination was detected during arthroscopic debridement of three intraarticular, low-velocity gunshot wounds to the knee. When bullet wounds traverse a joint, it is recommended that clothing be inspected for fabric defects and that arthroscopy be considered for the surgical debridement.