Incidence of bullet wounds in civilian trauma has increased in many parts of the world. For surgeons with limited experience there is a bewildering range of advice on management. A 'high-energy' bullet may sometimes produce a low-energy transfer wound.
Incidence of bullet wounds in civilian trauma has increased in many parts of the world. For surgeons with limited experience there is a bewildering range of advice on management. A 'high-energy' bullet may sometimes produce a low-energy transfer wound.
Incidence of bullet wounds in civilian trauma has increased in many parts of the world. For surgeons with limited experience there is a bewildering range of advice on management. A 'high-energy' bullet may sometimes produce a low-energy transfer wound.
G. W. Bowyer, MA, FRCS Orth, RAMC, Consultant Trauma and Ortho- paedic Surgeon The Royal Hospital Haslar, Gosport, Hampshire PO12 2AA, UK. N. D. Rossiter, FRCS, RAMC, Specialist Registrar in Trauma and Ortho- paedic Surgery Royal Defence Medical College, Gosport, Hampshire PO12 2AB, UK. Correspondence should be sent to Major G. W. Bowyer. 1997 British Editorial Society of Bone and Joint Surgery 0301-620X/97/66977 $2.00 MANAGEMENT OF GUNSHOT WOUNDS OF THE LIMBS G. W. BOWYER, N. D. ROSSITER From the Royal Hospital, Haslar and the Royal Defence Medical College, Gosport, England The incidence of bullet wounds in civilian trauma has increased in many parts of the world, sometimes approach- ing 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 bac- terial 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 BALLISTICS The 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. 6 Energy 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 ux (E/cross-sectional area). These unfamiliar terms are the major determinants of the pathological effects, 3,7 and mean that wound manage- ment cannot be based on the characteristics of the weapon, be it handgun, rie, or shotgun. The key is to treat the wound, not the weapon. 4 Soft-tissue wounds. A projectile produces a permanent cavity containing fragments of necrotic muscle and clot. Other tissues are stretched as they are thrown aside from the path of the bullet, creating a temporary cavity 8-10 with zones of contusion and concussion, some devitalised tissue, and haemorrhage within and between muscle bres. 11 The extent and shape of this temporary cavity are related to the local transfer of energy (dE/dx). There is a transient low pressure as this temporary cavity collapses, which may draw contamination into the wound. 12 High-speed photographs of temporary cavitation in gela- tin targets illustrate certain ballistic interactions. 2,10 High- energy transfer may produce devastating effects (Fig. 1), but a rie bullet may travel some distance into a target before it gives up its maximal energy. 2,7,10,11 For this reason there may be less cavitation in the wound track closest to the entry. Temporary cavitation does not always cause a large zone of tissue damage, and skeletal muscle is relatively tolerant, especially with low-energy transfer. 3 For this reason it may be unwise to try to excise all the tissue which may have been affected by cavitation. 2 Fractures. Projectiles which cause a fracture will transfer energy of the order of a few hundred Joules to the bone. 13 The pattern and comminution of the fracture will depend on the rate of energy deposition (d/dtE) and energy flux. 7 Severe comminution may arise without high local energy transfer, and may be due either to very fast transfer or to concentration in a small area. The way in which the energy is transferred therefore affects the fragmentation: a gunshot fracture of the tibia, caused by a handgun with low- to medium-energy transfer of a few hundred Joules, may be as radiologically comminuted as a tibial bumper fracture, but in the latter the zone of soft-tissue injury will be much more extensive and severe. A highly-comminuted gunshot frac- ture may have a relatively healthy soft-tissue envelope (Fig. 2), with its important implication for healing potential. Bacterial contamination. A bullet is not sterilised by ring and may carry viable bacteria into a wound. 12 In addition, clothing may distribute bacteria along the wound track INSTRUCTIONAL COURSE LECTURE from both the entry and exit wounds. Bacteria may be drawn into the low pressure of the temporary cavity and distributed along the wound track. 12 Despite this, gunshot fractures due to indirect interactions with the projectile may have minimal disruption of the surrounding soft tissue and periosteum with little or no contamination. 14 The bacterial ora of a gunshot wound changes with time. The species causing infection in the rst few days are 1032 G. W. BOWYER, N. D. ROSSITER THE JOURNAL OF BONE AND JOINT SURGERY Fig. 1a Fig. 1b A high-energy transfer wound of the thigh. The extent of soft-tissue disruption is suggested on the radiograph (a). At operation, much devitalised muscle was found and excised (b). Fig. 2a Fig. 2b A gunshot fracture of the distal femur shows extensive comminution (a), but the soft-tissue wound was small with low-energy transfer. Treatment by retrograde femoral nail resulted in bony healing in three months (b), conrming the viability of the soft-tissue envelope. mainly commensals. The risk of orid infection, rather than contamination, is related to the gross physical character- istics of the wound, the presence of fabric material and the viability of the surrounding tissues. 15 WOUND MANAGEMENT Initial management must identify and treat life-threatening injuries by established resuscitation methods. 16 An involved limb must be assessed and investigated for major vascular injury. 17 All ndings must be recorded and should be photographed when possible. In a civilian setting, foren- sic evidence should be preserved. 5 Initial dressing and antibiotics. A sterile dressing cover should be provided as soon as possible and left in place until the wound can be inspected in an operating theatre. Antibiotics play a part in preventing or delaying the onset of infection in military ballistic wounds. 8,15,18,19 In the past, clostridia and beta-haemolytic streptococci have caused the major fatal infective complications of war wounds to limbs; antibiotic prophylaxis therefore has tended to rely on ben- zylpenicillin as the mainstay of rst-line treatment, partic- ularly for soft-tissue injuries. 15,18 Penicillin has been associated with a reduction in the morbidity and mortality of war wounds and there is strong experimental evidence to support its continued use. 15,20-22 A gunshot fracture carries a risk of staphylococcal osteo- myelitis, and most pathogenic staphylococci are now resist- ant to penicillin. For this reason additional cover is needed with ucloxacillin or a cephalosporin. 15 A short course of antibiotics is commonly advised, 15,16 but the need for this in low- to medium-energy transfer wounds from handguns in civilian practice has been debated. 23 Wound surgery. The traditional approach to the surgery of gunshot wounds is based on the treatment of wounds caused by the rie or machine-gun bullets and large shell fragments of the First World War. The Inter-Allied Surgical Conference 24 of 1917 emphasised the importance of exci- sion of the skin margin, generous extension of the wound, exploration of all layers and the excision of damaged muscle. This advice has inuenced the military manage- ment of war wounds for the remainder of this century, but has now been amended. Incision and irrigation. An incision should pass through the skin wound, trimming only its grossly damaged edges, and continue in the axis of the limb, crossing flexor creases obliquely. Damaged subcutaneous fat and shred- ded fascia are removed. The deep fascia is incised for the length of the incision or beyond it, 8,18 to allow exploration and relieve pressure within the wound and associated compartments. Irrigation with copious volumes of saline is used to reduce the number of bacteria, and pulsating high-pressure irrigation may be even more effective. 16,22 The addition of antiseptic agents or antibiotics remains controversial. 25 Any evidence of raised or increasing pres- sure in compartments is treated by complete fasciotomy by an open technique. 16,22,25 Excision. Muscle is assessed for colour, consistency, con- tractility and capacity for bleeding. 9 The criteria for exci- sion or retention have been validated in war surgery 26 and should be applied in civilian trauma. Piecemeal excision of muscle which fails to meet the criteria for viability ensures that the remaining tissue will be capable of resisting infec- tion from any residual bacteria in the wound. 3,9,11,22 Dressing and closure. Dressing the open wound with uffed-out gauze allows drainage with no need for a surgi- cal drain. Primary closure over a drain is associated with an unacceptable complication rate. 22 The principle of staged treatment, using delayed primary suture (DPS) to close wounds with no excessive loss of skin, is widely accepted. 18,22 Wounds may be reinspected in an operating theatre at 48 hours, but closure should be planned for four to ve days after injury. Suturing is appropriate only if all tissues appear healthy and the edges of the skin and deeper tissues can be approximated without undue tension. Alternatives to DPS. A few areas of skin have sufcient vascularity to allow immediate primary closure; the face, neck, scalp and genitalia may be sutured, but only after careful wound excision. A larger skin decit may be difcult to close without tension. Split-skin grafting at four to ve days may be used over healthy granulation tissue but, as in all trauma surgery, a large defect should be managed with the early help of a plastic surgeon. 25 The use of an antibiotic bead pouch 27 is a temporising measure to prevent wound desiccation 16 and maintain antibiotic levels 28 until second-look surgery and planned cover. Splintage. Even when there is no fracture, the injured limb needs support and stabilisation by a plaster cast or back- slab, to protect the soft tissues. 29 Non-operative management. In recent decades a much less aggressive surgical approach with non-operative man- agement for simple gunshot wounds has been reported from a number of North American hospitals. 30,31 Soft tissues. Civilian experience has led to a concept of the minor gunshot wound which is a low-energy transfer injury of the soft tissues (Fig. 3). At some centres these soft-tissue wounds have been treated on an outpatient basis after wound irrigation. In one series of over 3000 patients the overall infection rate was under 2%. 30 About 40% of these had antibiotic cover, but infection (mostly Staphyl- ococcus aureus) was not signicantly reduced by this. Risk factors for infection in such wounds include undue delay between wounding and treatment, the lack of basic wound cleansing before attendance, a wound size of between 1 and 2 cm, and failure to comply with instructions on wound care. Fractures. Carefully selected gunshot fractures may also be treated by early wound irrigation, dressing, antibiotics and splintage. 32 Many low- to medium-energy transfer wounds involving fractures which do not need operative xation are 1033 MANAGEMENT OF GUNSHOT WOUNDS TO THE LIMBS VOL. 79-B, NO. 6, NOVEMBER 1997 treated in this way at the Shock Trauma Centre in Balti- more; 33 infection rates are low, but follow-up is generally poor (unpublished data). In certain centres with great experience this non-surgical approach may be a safe and efcient use of resources, but it must be emphasised that proper assessment of soft-tissue injuries may actually require surgical exploration. The indi- rect evidence inferred from the position, size and extent of the entry and exit wounds, and the radiological appearance may not be enough at centres without considerable experi- ence. If there is any doubt about the amount of non-viable tissue in the missile track, the safe management is by operative exploration. Military setting. In this situation the main problems arise from high-energy transfer wounds, rather than the smaller wounds seen in civilian practice. Small-fragment (shrap- nel) wounds, however, are now common in modern war- fare and are similar to civilian low-energy transfer wounds. This has led to the recognition that carefully selected soft- tissue wounds may be treated without operation. 34-39 A major concern in military surgery is how to distinguish those wounds which can be managed by non-operative treatment, with prompt antibiotic cover, from those which require operation. Treatment of fractures. There is still much debate over the treatment of fractures caused by gunshot. A wide range of methods ranging from the non-operative such as low-tech splintage through external xation to internal xation or intramedullary nailing, has been advised. The basic princi- ples should be borne in mind. 40 Does the wound need exploration? Does the fracture need reduction? Will the reduction be stable without xation? What are the facilities and expertise available for immediate after-care and for follow-up? Traditionally, the internal xation of gunshot fractures has been condemned, 41 but several major trauma centres have shown that intramedullary nailing of such fractures of the femur gives a favourable outcome 42 as does internal xation of other gunshot fractures. 43 Many military medi- cal services now recommend early external xation for the stabilisation of fractures. It is recognised that this is not denitive treatment, but allows good management during evacuation through later echelons of care. 29 The use of external xation as denitive treatment has been associated with high rates of complication, 44,45 and it has been shown that femoral and humeral fractures can be well managed even more simply by splintage or bracing in third-world conditions. 46 In the choice of management it is important to remember that, like any other compound fracture, a gunshot fracture requires careful assessment, especially of the soft-tissue injury, and the use of xation methods which are appro- priate to the fracture pattern, the associated envelope and the expertise which is available. CHOICE OF TREATMENT Surgeons faced with a gunshot wound need to make care- fully reasoned clinical decisions based on an understanding of the mechanisms involved. Figure 4 shows a proposed decision-making sequence which takes account of some of the variables. Neither bullet velocity nor available energy can provide a guide to tissue damage in gunshot fractures; the surgeon should not treat the weapon. The state of the soft-tissue envelope and the fracture pattern are the key factors, and are determined by energy transfer. The aim is the preserva- tion of healthy soft tissue with minimal non-viable tissue 1034 G. W. BOWYER, N. D. ROSSITER THE JOURNAL OF BONE AND JOINT SURGERY Fig. 3a Fig. 3b Fig. 3c A low-energy transfer injury from a handgun bullet. The entry (a) and exit (b) wounds are small. There is little radiological comminution (c) and this type of gunshot fracture is commonly managed non-operatively. and contamination. This will allow fracture healing with any of a variety of different methods of stabilisation appro- priate to the fracture pattern. Especially for massive wounds, a viable soft-tissue environment must be estab- lished before addressing the bony problem. Treatment must be based on careful assessment of the wound and available expertise and facilities. There is no dogmatic treatment of choice for gunshot fractures. 1035 MANAGEMENT OF GUNSHOT WOUNDS TO THE LIMBS VOL. 79-B, NO. 6, NOVEMBER 1997 Fig. 4 Algorithm for the management of gunshot fractures. This emphasises the stepwise approach and the importance of soft-tissue management. REFERENCES 1. Schwab CW. Violence: Americas uncivil war: Presidential Address, sixth scientic assembly of the Eastern Association for the Surgery of Trauma. J Trauma 1993;35:657-65. 2. Fackler ML. Wound ballistics: a review of common misconceptions. JAMA 1988;259:2730-6. 3. Cooper GJ, Ryan JM. Interaction of penetrating missiles with tissues: some common misapprehensions and implications for wound manage- ment. Br J Surg 1990;77:606-10. 4. Lindsey D. Editorial. The idolatry of velocity, or lies, damn lies, and ballistics. J Trauma 1980;20:1068-9. 5. Swan KG, Swan RC. Principles of ballistics applicable to the treatment of gunshot wounds. Surgical Clinics of North America 1991; 71:221-39. 6. Molde A, Gray R. High-velocity gunshot wound through bone with low energy transfer. Injury 1995;26:131. 7. Sellier KG, Kneubuehl BP. Wound ballistics and the scientic background. Amsterdam: Elsevier, 1994: 8. Ryan JM, Cooper GJ, Maynard RL. Wound ballistics: contempo- rary and future research. J R Army Med Corps 1988;134:119. 9. Ryan JM, Cooper GJ, Haywood IR, Milner SM. Field surgery on a future conventional battleeld: strategy and wound management. Ann R Coll Surg Engl 1991;73:13-20. 10. Thoresby FP. Cavitation: the wounding process of the high velocity missile, a review. J R Army Med Corps 1966;112:89-99. 11. Bellamy RF, Zajtchuk R. The physics and biophysics of wound ballistics. In: Bellamy RF, Zajtchuk R, eds. Textbook of military medicine: conventional warfare: ballistic, blast and burn injuries. Part 1. Vol. 3. Washington: Ofce of the Surgeon General, Depart- ment of the Army, 1991:107-62. 12. Thoresby FP, Darlow HM. The mechanism of primary infection of bullet wounds. Br J Surg 1967;54:359-61. 13. Rossiter ND. Ballistic femoral fractures. J Bone Joint Surg [Br] 1996; 78-B:Suppl II and III:134. 14. Rossiter ND. Contamination of high energy transfer ballistic femoral fractures. J Bone Joint Surg [Br] 1996;78-B:Suppl II and III:165. 15. Mellor SG, Easmon CSF, Sanford JP. Wound contamination and antibiotics. In: Ryan JM, Rich NM, Dale RF, Morgans BT, Cooper GJ, eds. Ballistic trauma. London: Edward Arnold, 1997;61-71. 16. Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg [Am] 1990;72-A:299-304. 17. Barros DSa AAB. Complex vascular and orthopaedic limb injuries. J Bone Joint Surg [Br] 1992;74-B:176-8. 18. Kirby NG, Blackburn G. Field surgery pocket book. London: HMSO, 1981: 19. Mellor SG, Cooper GJ, Bowyer GW. Efcacy of delayed administra- tion of benzylpenicillin in the control of infection in penetrating soft tissue injuries in war. J Trauma 1996;40:128-34. 20. Thoresby FP, Matheson JM. Gas gangrene of the high velocity missile wound. II: an experimental study of penicillin prophylaxis. J R Army Corpos 1967;113:36-9. 21. Owen-Smith MS, Matheson JM. Successful prophylaxis of gas gangrene of the high-velocity missile wound in sheep. Br J Surg 1968;55:36-9. 22. Bowyer GW, Ryan JM, Kaufmann CR, Ochsner MG. General principles of wound management. In: Ryan JM, Rich NM, Dale RF, Morgans BT, Cooper CJ, eds. Ballistic trauma. London: Edward Arnold, 1997: 23. Dickey RL, Barnes BC, Kearns RJ, Tullos HS. Efcacy of anti- biotics in low-velocity gunshot fractures. J Orthop Trauma 1989; 3:6-10. 24. Surgery. Volume XI. In: The Medical Department of the United States Army in the World War. Washington DC: Government Printing Ofce, 1927: 25. Sanders R, Swiontkowski M, Nunley J, Spiegel P. The management of fractures with soft-tissue disruptions. J Bone Joint Surg [Am] 1993; 75-A:778-89. 26. Scully RE, Artz CP, Sako Y. An evaluation of the surgeons criteria for determining the viability of muscle during debridement. Arch Surg 1956;73:1031-5. 27. Henry SL, Ostermann PA, Seligson D. The antibiotic bead pouch technique: the management of severe compound fractures. Clinical Orthopaedics & Related Research 1993:54-62. 28. Bowyer GW. Antibiotic impregnated beds in open fractures: a report on the technique and possible applications in military surgery. J R Army Med Corps 1993;139:100-4. 29. Coull JT. War Injuries. In: Coombs R, Green S, Sarmiento A, eds. External xation and functional bracing. London: Orthotext 1979: 239-43. 30. Ordog GJ, Sheppard GF, Wasserberger JS, Balasubramanium S, Shoemaker WC. Infection in minor gunshot wounds. J Trauma 1993; 34:358-65. 31. McAndrew MP, Johnson KD. Penetrating orthopedic injuries. Surg Clin North Am 1991;71:297-303. 32. Hansraj KK, Weaver LD, Todd AO, et al. Efcacy of ceftriaxone versus cefazolin in the prophylactic management of extra-articular cortical violation of bone due to low-velocity gunshot wounds. Orthop Clin North Am 1995;26:9-17. 33. Bowyer GW, Brown M, Marsicano J, Burgess AR. Civilian gunshot wounds to the limbs: patterns of injury. Injury 1995;26:135. 34. Coupland RM. War wounds of limbs: surgical management. Oxford, Butterworth Heineman, 1993. 35. Rowley DI. War wounds with fractures: a guide to surgical manage- ment. Geneva: International Committee of the Red Cross, 1996. 36. Gray R. War wounds: basic surgical management. International Committee of the Red Cross, 1994. 37. Hoffer MM, Johnson B. Shrapnel wounds in children. J Bone Joint Surg [Am] 1992;74-A:766-9. 38. Bowyer GW. Management of small fragment wounds in modern warfare: a return to Hunterian principles. Ann R Coll Surg Engl 1997; 79:175-82. 39. Bowyer GW. Management of small fragment wounds: experience from the Afghan border. J Trauma 1996;40:170-2. 40. Apley AG, Solomon L. Principles of fractures. In: Apleys system of orthopaedics and fractures. 6th edition. London: Butterworth Scien- tic 1982;333-68. 41. Farquharson-Roberts MA, Somerville DW, Rossiter ND. Limb injury. In: Ryan JM, Rich NM, Dale RF, Morgans BT, Cooper GJ, eds. Ballistic trauma. London: Edward Arnold, 1997:123-32. 42. Brien WW, Kuschner SH, Brien EW, Wiss DA. The management of gunshot wounds to the femur. Orthopedic Clinics of North America 1995;26:133-8. 43. Brien EW, Long WT, Serocki JH. Management of gunshot wounds to the tibia. Orthopedic Clinics of North America 1995;26:165-80. 44. Has B, Jovanovic S, Wertheimer B, Mikolasevic I, Grdic P. Externalf xation as a primary and denitive treatment of open limb fractures. Injury 1995;26:245-8. 45. Reis ND, Zinman C, Besser MI, Shifrin LZ, Rosen H. A philosophy of limb salvage in war: use of the xateur extreme. Mil Med 1991; 156:505-20. 46. Rowley DI. The management of war wounds involving bone. J Bone Joint Surg [Br] 1996;78-B:706-9. 1036 G. W. BOWYER, N. D. ROSSITER THE JOURNAL OF BONE AND JOINT SURGERY