- Discussion:
- firearms tutorial
- missile characteristics:
- NRA website
- Weapons Effects and Parachute Injuries
- Shooting Soldiers: Civil War Medical Images, Memory, and Identity in America
- General Management:
- tetanus prophylaxis and antibiotics as necessary;
- wound management is greatly influenced by the velocity of the bullet;
- arterial injuries:
- references:
- The management of vascular injuries of the extremity associated with civilian firearms. 
- Arteriography for proximity of injury in penetrating extremity trauma.
- compartment syndrome:
- nerve injury:
- in low velocity GSW, 70% of nerve injuries are neuropraxic in nature and will recover within 9 months (vs
80% nerve recovery in fractures after 4 months);
- references:
- Injuries to Nerves of the Upper Extremity.
- case example:
- 28 year old male who has sustained a GSW to the thigh several years ago and was left with disabling
paresthesias (normal motor exam);
- he was managed with surgical exploration of the sciatic nerve, removal of external adhesions and limited
neurolysis of the epineurium; 
-
low velocity injuries:
- if no fracture is present, wound debridement and wash out can be carried out in ER;
- management of GSW associated fracture:
- non operative treatment may be indicated for non displaced cortical violations of the femur and metaphyeal drill holes (use above knee casts
and crutches) as well as for humeral shaft fractures;
- these patients can also be treated with oral
antibiotics (ie there is no strict indication for prolonged hospitalization w/ IV Atb);
- the indications for operative fracture fixation are the same as for any other fracture;
- references:
-
A prospective, randomized clinical trial of wound debridement versus conservative wound care in soft-tissue injury from civilian GS wounds.
-
Management of low velocity gunshot-induced fractures.
-
Infection in minor gunshot wounds.
- Immediate interlocking nailing of fractures of the femur caused by low to mid velocity gunshots.
P Nowotarski and RJ Brumback. J. Orthop. Trauma. Vol 8. 1994. p 134-141.
-
Comparison of intravenous and oral antibiotic therapy in the treatment of frx caused by low-velocity gunshots. A prospective, randomized study of infection rates.
-
Antibiotic therapy in gunshot wound injuries.
-
shot gun wounds:
- note that the shot gun wadding may lie underneath the fascia on the "far side" of the wound;
- references:
-
The management of large soft-tissue defects following close-range shotgun injury.
-
high velocity injuries:
- high velocity GSW need to be treated like
open fractures;
- generally requires formal operative debridement and fixation;
- references:
-
Open wound drainage versus wound excision in treating the modern assault rifle wound.
-
Internal deformation of the AK-74; a possible cause for its erratic path in tissue.
- Muscle devitalization in high-energy missile wounds, and its dependence on energy transfer. Fackler ML. Journal of Trauma. 26(3):297, 1986 Mar.
- The U.S. M-16 rifle versus the Russian AK-74 rifle. Fackler ML. American Surgeon. 50(9):515-6, 1984 Sep.
- Sites of Involvement:
-
spine:
-
The management of transpharyngeal gunshot wounds to the cervical spine.
-
femur: (see
open femur frx)
-
Femur fractures caused by gunshots: treatment by immediate reamed intramedullary nailing.
- Immediate interlocking nailing of fractures of the femur caused by low to mid-velocity gunshots. J. Orthop. Trauma. Vol 8. 1994. p 134-141.
-
hand:
-
Low-velocity gunshot wounds of the metacarpal: treatment by early stable fixation and bone grafting.
-
Hand and forearm injuries from penetrating projectiles.
-
Gunshot wounds to the hand: management and economic impact.
-
Fracture management of civilian gunshot wounds to the hand.
-
The management of penetrating trauma to the hand.
-
joint injuries:
- ref:
The early management of open joint injuries. A prospective study of one hundred and forty patients.
- shoulder (
brachial plexus):
- MPM Stewart et al 2001, the authors studied a consecutive series of 58 patients with penetrating missile injuries of the
brachial plexus to establish the indications for exploration and review the results of operation;
- at a mean of 17 weeks after the initial injury, 51 patients were operated on for known or suspected vascular injury, severe persistent pain
or complete loss of function in the distribution of one or more elements of the brachial plexus;
- repair of the nerve and vascular lesions abolished, or significantly relieved, severe pain in 33 patients (94%);
- of the 36 patients who underwent nerve graft of one or more elements of the plexus, good or useful results were obtained in 26 (72%);
- poor results were observed after repairs of the medial cord and ulnar nerve, and in patients with associated injury of the spinal cord;
- neurolysis of lesions in continuity produced good or useful results in 21 of 23 patients (91%);
- primary intervention is mandatory when there is evidence of a vascular lesion;
- secondary intervention is indicated in patients with debilitating pain, failure to progress and progression of the lesion while under observation;
- with nerve repair better results were seen in the roots C5, C6 and C7 and of the lateral and posterior cords, but the
prognosis for complete lesions of the plexus associated with damage to the cervical spinal cord is particularly poor;
- ref: Penetrating missile injuries of the brachial plexus. MPM Stewart et al. J Bone Joint Surg [Br] 2001;83-B:517-24.
- hip joint:
- consider
hip aspiration followed by arthrogram to detect joint penetration;
- all transabdominal wounds require open debridement to ensure that the joint is free of bowel contaminants;
- knee joint:
-
Intra-articular findings after GSW through the knee.
-
Arthroscopic debridement after intra-articular low velocity GSW.
- Low Velocity Gunshot Wounds Involving the Knee Joint: Surgical Management. Ashby, M. JBJS 56-A: 1047-1053, 1974.
- Gun shot wounds to the knee. L Dean, V Dvonch. Orthopedics 1988. 963-965.
- Gun Shot Wounds to the Knee. Orthop Clin North Am. Vol 26. 1995. p 155-163.
- Complications:
- metal debris:
-
plumbism:
- references:
The reaction of copper and other projectile metals in body tissues.
Lead arthropathy: arthritis caused by retained intra-articular bullets.
- infection:
- historically infection has been most often due
clostridia and beta hemolytic
streptococci, both of which are sensitive to
penicillins;
The Relationship Between Mechanisms of Wounding and Principles of Treatment of Missile Wounds.
Wound ballistics. A review of common misconceptions
A reconsideration of the wounding mechanism of very high velocity projectiles--importance of projectile shape.
Ballistic injury.
Bullet fragmentation: a major cause of tissue disruption.
Improper use of the term "shrapnel".Rich NM, Burris DG.
Ballistics and gunshot wounds: effects on musculoskeletal tissues.
