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Background Pistol caliber gunshot wounds (PC GSW) are the most common mode of firearm injury treated in the civilian emergency setting, but there is a paucity of data guiding best practice treatment. The goal of this study was to examine the effect of bedside positive pressure irrigation (PPI) on removal of gross debris from PC GSW. Methods Fourteen bovine shanks were prepared with metal impregnated fabric placed in front of the impending impact zones to mimic radio-opaque clothing-like material. They were then shot with a 9 mm bullet from a distance of 3 meters. Specimens were imaged three separate times with standardized computer tomography: immediately after impact, after 250 ml irrigation, and after a total of 750 ml of irrigation. Scanned images were examined for change in radio-opaque contamination at both the entry site and within the wound cavity. Results No samples demonstrated a decrease of debris contamination within the cavity of the wound after 250 ml of irrigation and only one did after 750 ml. Six (42.86%) samples demonstrated a shift of debris without decrease in cavity contamination after 250 ml of irrigation and ten after 750 ml total irrigation. Five samples demonstrated decrease in debris at the entry site of the gunshot projectile wound after 250 ml of irrigation and two showed further superficial decrease with additional irrigations up to 750 ml. No statistically significant differences were found between 250 ml and 750 ml PPI treatments in both superficial and cavity contamination categories. Conclusion Positive pressure irrigation with up to 750 ml of 0.9% normal saline at a rate of 20 ml/sec has limited effect on the removal of gross debris within the cavity of pistol caliber gunshot wounds. The data within this study bring into question the benefits of attempted removal of pistol caliber gunshot wound contaminants utilizing bedside positive pressure irrigation.

Squamous cell carcinoma is the most common tumor of the hand. This malignancy requires unique treatment considerations; the surgeon and patient must balance retention of maximal functional capacity of the hand and minimization of the risk of recurrence and metastasis. Digital-sparing and digital-sacrificing therapies should be considered. Chance for cure, recurrence and metastasis risk, cosmetic concerns, and functional concerns should be addressed on a case-by-case basis. We report a case of a fifty-three-year-old man with cutaneous squamous cell carcinoma of his non-dominant hand. Ulceration and rapid growth of a long-standing lesion of the dorsal hand prompted evaluation and treatment. Over the course of a year, three separate surgeries including digital amputations and metacarpal resections were required to manage this recurrent and invasive malignancy. Seven years post-operatively, our patient retained a full, painless range of motion arc of the left thumb and ability to grip utilizing a functional brace. Treatment of squamous cell carcinoma of the hand is not always straightforward. High rates of local recurrence require negative margins and diligent postoperative surveillance. Digital sparing therapy should be considered to minimize functional impairment and maximize cosmesis. However, aggressive treatment and amputation must be considered for advanced disease and if pursued, should focus on maximization of functional capacity as one of the treatment goals.

CONTEXT CONTEXT Sidearm pistols are more frequently involved in violent crimes due to their relatively small size and ability to be concealed. The extent to which the thermal energy released from such medium velocity pistol projectiles contributes to peripheral nerve injury requires further testing. The purpose of this paper is to describe a method to quantify how much thermal energy is released during impact of medium velocity pistol projectiles and report how thermal energy contributes to peripheral nerve injury. METHODS METHODS Eleven seven-centimeter segments of radial, median, and ulnar nerves were dissected from a thawed fresh frozen cadaver. The nerve segments were placed in a 10% ballistics gel block, one centimeter from the end of the block nearest the shooter. A series of 115-grain 9 mm. NATO-classified ammunitions were fired through the nerve and ballistics gel construct with a pistol. The impacts were recorded with a high-speed infrared camera and nerve samples were sent for histologic analysis by two board-certified pathologists. RESULTS RESULTS The average velocity of the projectiles were 391m/s, 95% CI [387-395 m/s], with an average kinetic energy of 572.0 J, 95% CI [560.0-583.0J]. The average observable temperature of the ballistics gel/nerve prior to impact was 28.8°C±0.6ºC, 95% CI [26.4-30.3°C]. Average observable temperature of the surrounding ballistics gel/nerve during projectile impact was 55.1°C±2.4ºC, 95% CI [51.3-62.1°C], yielding an average observable increase of 26.4°C±3.2ºC, 95% CI [20.2-35.4°C]. An adjusted temperature increase was also surprisingly high 63.4°C ± 3.2, 95% CI [57.2-72.4ºC]. Histology reports of the impacted nerve tissue failed to show any sign of thermal or even crush injury. CONCLUSIONS CONCLUSIONS Medium velocity handgun projectiles release a significant amount of heat energy when impacting a substance similar to human tissue. The authors' temperature data points were greater than those previously reported to cause thermal injury to peripheral nerves. The authors' findings suggest that nerve injury after collision with pistol projectiles may be secondary to thermal injury in addition to the classic model of concussion and penetration given our documented levels of heat generated during impact.