First surgical treatment of gunshot wounds in bones and soft tissues

First Surgical Treatment of Gunshot Wounds in Bones and Soft Tissues MSF Surgical Days, December 2015/ Paris

Dr. Bernhard Ciritsis University Hospital of Zurich, Switzerland

Summary

1. Principles and Characteristics of Gunshot Wounds (GSWs) 2. Scoring system of GSWs 3. First surgical treatment of GSWs and clinical cases 4. Conclusions

1.: Principles and Characteristics of Gunshot Wounds (GSWs)

High kinetic energy on a small body I

 Kinetic energy of a bullet is 300 to 2000 Joule  Tissue disruption is due to compression, cutting and shear: crush, laceration and stretch  Transfer of kinetic energy does not affect all tissues to the same extent and in the same way

High kinetic energy on a small body II 2000 Joule is the energy of one military rifle bullet.

This energy is equivalent to a body (50kg) falling from a height of 4m.

Full-metal jacket (FMJ), semimetal jacket (SMJ), pistol or rifle gun?

Kinetic energy depends mainly on the velocity, the mass and the caliber.

Three projectile types: unjacketed (lead), full metal jacket, and hollow point.

Every GSW has to be considered dirty and a source of wound infection Case 1 30 year old male with GSW in his right ankle joint. First surgical treatment in a rural hospital with insufficient external fixator and debridement.

On admission severe wound infection and beginning of septic shock. Amputation.

(Nigeria, 2011)

Wound infection Case 2 65 year old female with GSW in her left breast several days before reaching the ER with a beginning infection. Small entry and bigger exit point. After several radical debridements and open wound treatment secondary closure.

No further complications.

(DRC, 2014)

Principle of heterogenity: no GSW is equal.

Even from the same gun.

Be aware of uncommon and sudden complications even if the situation seems under control.

Special case I: Ricochet

Ricochet means that the bullet hits first another target. Then fragments of the bullet or the whole bullet change trajectory. Kinetic energy and wound caracteristics are same as for blast lesions.

Case 3 25 years old male with typical ricochet/blast wound. Brain was not damaged.

(DRC, 2014)

Special case II: Falling bullets

Between 1985 and 1992, a group of physicians at the Martin Luther King / Drew medical centre in Los Angeles studied victims of gunshot wounds and identified 118 cases thought to have been hit by falling bullets.

Case 4 25 year old male hit by falling bullet caused pneumothorax on the left side. FAST showed no abdominal lesion. Typically falling bullets remain intact. Full recovery after debridement of the entry wound, thorax drain and prophylactic antibiotic treatment. (Nigeria, 2011)

GSWs are not common in most of the civil hospitals in Europe Injury. 1997 Jun-Jul;28(5-6):385-7.

Inner city gunshot wounds.

Porteous MJ1, Edwards SA, Groom AF. Abstract A retrospective survey was undertaken to establish the pattern and incidence of gunshot wounds seen at a South London hospital . Forty-two gunshot wounds were seen in 1993 and 1994 ……

Stress factor of medical staff in front of the unusual and unknown: get trained!

2.: Scoring system of GSWs

Scoring of GSWs and classification system  Up to now there is no international scoring and classification system for GSWs that has been established  The only scoring system used in practice since years is the one of the International Committee of the Red Cross (ICRC) (>20,000 cases) Scheme of ICRC Wound Score E (entry)

Centimetres

X (exit)

Centimetres

C (cavity)

C 0, C1

F (fracture)

F0, F1, F2

V (vital structure)

V 0, VN, VT, VA, VH

M (metallic bodies)

M 0, M 1, M 2

Entry and Exit point

Think about and be aware of the anatomy!

Bullet Cavity

6cm

The external appereance of a bullet wound can be deceptive.

Tiny entrance and exit holes can be associated with extensive internal damage.

Rifle Semi Jacket Bullet in soap block.

Shot given from 50m distance. Entry: left side.

Exit: right side

Trajectory and Vital Structures Consider in which position and circumstances the patient was shot to understand better which traject the bullet could have taken.

People seek shelter amid gunfire at an army base in Yemen's southern port city of Aden in 2015

Take the bullet out?

Case 5 X-ray and clinical aspect of a 32 year old male hit by a pump gun/ smallshot cardridge with mandibular and maxillar fractures (Nigeria, 2011)

Do not seek for every piece of metal visible in the X-ray. Exception: Articulations

3.: First surgical treatment of GSWs and clinical cases

First surgical treatment after GSWs  ATLS  X-ray, FAST, body CT  ABCD stabilisation  Thorax drain, thoracotomy or sternotomy  Explorative laparotomy  External fixation  Debridement and lavage, open wound treatment with secondary closure  Prophylactic large antibiotic therapy Reconstructive surgery, nerve suture and ORIF on a second stage.

Thorax

Case 6 33 old male with GSW in the left thorax. B and C unstable.

In a first stage the left pneumothorax was treated by thorax drain. Body CT showed a pericard tamponade.

After sternotomy the tamponade was evacuated and perforation on the apex sutured.

Abdomen

Case 6 (continue) Explorative laparatomy showed perforation of the diaphragm, the liver (II and III) and of the stomac.

Severe tissue distruction of the pancreas between corpus and cauda and retroperitoneal hematoma.

After diaphragma and stomac suture, abdominal irrigation and retroperitoneal drainage, the patient was treated with open abdomen. (Switzerland, 2014)

Pelvis

Case 7 65 year old male with GSW through the left iliac wing, passing the left ISJ with nerve attempt on S1 and S2. No attempt of the rectum, big vessels or the urinary bladder. Exit on the right thigh with severe suband pertrochanteric Gustillo 3B fracture. After explorative laparatomy, debridement, sequestrectomy and open wound management, Girdlestone procedure on the right hip.

(DRC, 2014)

Articulation: always take the bullet out. As soon as possible.

Case 8 32 year old male patient hit by a ricochet in the right hip.

After several days he reached the hospital from a rural area.

X-ray showed an intact bullet with femoral neck fracture.

Postero-lateral approach. Necrotic bone and the bullet were removed and Girdlestone procedure was performed. Postoperative physiotherapy was started after open wound treatment and secondary closure. (DRC, 2014)

Bone I Case 9 38 year old male with Gustillo 3C fracture by GSW of the right humerus with radial nerve section. First stage debridement and sequestrectomy, shortening, external fixation and open wound treatment.

In a second stage autograft from the iliac crest, ORIF, nerve suture and mesh graft.

(Nigeria, 2011)

Bone II

Case 10 28 year old male with left Gustillio 3B pilon fracture. pDMS intact, anterior entry and posterior exit wound. Debridement, sequestrectomy open wound treatment with prophylactic antibiotic therapy. Several surgical irrigations before secondary closure with mesh graft and conservative treatment by plaster immobilization.

(DRC, 2014)

Soft Tissue

Case 10 42 year old male with GSW in the right thigh. pDMS intact.

Small proximal entry and bigger distal exit wound.

Debridement, lavage and open wound treatment with prophylactic antibiotic therapy, secondary closure five days later. No further complications. (DRC, 2014)

4.: Conclusion 

Consider GSW as a specific pathology with its own characteristics, principles and a high risk of infection: get trained.



Use ATLS, Damage Control Surgery and open wound treatment as first tools: ORIF and reconstructive techniques come second.



Be aware of uncommon and multiple type of injuries: always stay humble and alerted until definitive recovery of your patient.

Thank you!