Management of Gunshot Wounds of the Limbs

Abstract

The incidence of bullet wounds in civilian trauma has increased in many parts of the world, sometimes approaching epidemic level.1 For surgeons with limited experience there is a bewildering range of apparently contradictory advice on management. 2-4 An attempt to clarify this for gunshot injuries of the limbs, without major vascular injury, must include current concepts of ballistic wounding, the pathology of soft-tissue wounds and fractures, and of bacterial contamination. Advice on clinical practice and treatment options cannot be prescriptive because of the wide range of injury patterns and settings, but an understanding of the general principles can guide clinical management. WOUND BALLISTICSThe interaction of projectiles and biological targets 5 should not be considered merely in terms of the missile velocity or its available energy. The important factor is its tissue interaction: a 'high-energy' bullet may sometimes produce a low-energy transfer wound. 6Energy transfer. The available kinetic energy of a missile depends on its mass (m) and velocity (v) according to the equation E = 1/2 mv 2 , but the tissues involved and other projectile factors will determine the amount of energy which is transferred (⌬ E). The rate of energy transfer (dE/ dt) is also important; this may vary along the wound track (dE/dx) and in terms of energy flux (⌬E/cross-sectional area). These unfamiliar terms are the major determinants of the pathological effects, 3,7 and mean that wound management cannot be based on the characteristics of the weapon, be it handgun, rifle, or shotgun. The key is to "treat the wound, not the weapon". 4

Management of ballistic soft tissue injuries: a review

“…The results of reviewed articles [8,[11][12][13][14][15][16][17] are summarized in chronological order in Table 1. Following initial wound care, the next step in the subsequent management of soft tissue injuries usually involves definitive reconstruction.…”

“…Although it has been common practice to surgically operate on all ballistic wounds, recent literature suggests that some carefully selected wounds could be treated non-operatively by irrigation, dressing and antibiotics [8,[11][12][13][14]. Such ballistic wounds selected for non-operative management are ideally low-energy wounds, usually involving limited soft tissue damage.…”

“…Other small, isolated wounds involving only the skin, subcutaneous tissues and muscle could also be appropriately managed with irrigation, superficial debridement, dressings and antibiotics [14]. Usually direct closure of the wound is not recommended as it is preferable to leave the wound to heal by second intention [8,11,[13][14][15][16].…”

“…Thirdly, the concussion zone or temporary cavity is due to temporary tissue displacement or stretch [10]. The temporary cavitation is thought to be related to the local transfer of energy [11] and the extent of damage to tissues depends both on the nature of the projectile and on the nature of the affected tissues.…”

Gunshot Injuries in Children Treated in the Department of Orthopedics

“…Bu yazarlar dıştan ve içten tespit ile ilgili olarak, her dört hastanın birinde gerekli olduğunu ve ayrıca dıştan hareketsizlik zorunluluğunu rapor etmişlerdir. Yine içten ve dıştan tespit durumunun benzer şekilde yetişkinlerdeki kırık örneklerinden daha az olduğunu göstermişlerdir [5][6][7][14][15][16][17] . Çalışmamızda, 27 (%79.4) olguda kısa namlulu ateşli silah yaralanması görülmüş olup, üç tanesinde dıştan tespit, bir tanesinde de içten tespit yöntemi uygulanmıştır.…”