Gunshot Wounds

Ovid: Handbook of Fractures

Authors: Koval, Kenneth J.; Zuckerman, Joseph D.
Title: Handbook of Fractures, 3rd Edition
> Table of Contents > I – General Considerations > 4 – Gunshot Wounds

Gunshot Wounds
  • Low-velocity (<2,000 ft/sec): This includes all handguns.
  • High-velocity (>2,000 ft/sec): This includes all military rifles and most hunting rifles.
  • Shotgun wounding potential is dependent on:
    • Chote (shot pattern)
    • Load (size of the individual pellet)
    • Distance from the target
  • The kinetic energy (KE) of any moving object is directly proportional to its mass (m) and the square of its velocity (v2), and is defined by the equation: KE = 1/2 (mv2).
  • The energy delivered by a missile to a target is dependent on:
    • The energy of the missile on impact (striking energy).
    • The energy of the missile on exiting the tissue (exit energy).
    • The behavior of the missile while traversing the target: tumbling, deformation, fragmentation.
  • The wounding potential of a bullet
    depends on the missile parameters, including caliber, mass, velocity,
    range, composition, and design, as well as those of the target tissue.
  • The degree of injury created by the
    missile is generally dependent on the specific gravity of the traversed
    tissue: higher specific gravity = greater tissue damage.
  • A missile projectile achieves a high
    kinetic energy because of its relatively high velocity. The impact area
    is relatively small, resulting in a small area of entry with a
    momentary vacuum created by the soft tissue shock wave. This can draw
    adjacent material, such as clothing and skin, into the wound.
  • The direct passage of the missile through
    the target tissue becomes the permanent cavity. The permanent cavity is
    small, and its tissues are subjected to crush (Fig. 4.1).
  • The temporary cavity (cone of cavitation)
    is the result of a stretch-type injury from the dissipation of imparted
    kinetic energy (i.e., shock wave). It is large, and its size
    distinguishes high-energy from low-energy wounds.
  • Gases are compressible, whereas liquids
    are not; therefore, penetrating missile injuries to the chest may
    produce destructive patterns only along the direct path of impact as a
    result of air-filled structures, whereas similar injuries to
    fluid-filled structures (e.g., liver, muscle) produce considerable
    displacement of the incompressible liquid with shock-wave dissipation,
    resulting in significant momentary cavities. This may lead to regions
    of destruction apparently distant to the immediate path of the missile
    with resultant soft tissue compromise.


4.1. The two areas of tissue injury: the permanent cavity and the
temporary cavity. The permanent cavity is caused by localized areas of
cell necrosis proportional to the size of the projectile as it travels
through. Temporary cavitization causes a transient lateral displacement
of tissue. The shock wave, although measurable, has not been found to
cause injury in tissue.

(From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.)
  • Following initial trauma survey and management (see Chapter 2),
    specific evaluation of the gunshot injury will vary based on the
    location of injury and patient presentation. Careful neurovascular
    examination must be undertaken to rule out the possibility of
    disruption to vascular or neural elements.
  • Attention must also be paid to possible
    injuries sustained after the missile impact, such as those that may
    occur following a fall from a height.
  • Standard AP and lateral radiographs of the injured sites should be obtained.
  • Specific attention must be paid to
    retained missile fragments, degree of fracture comminution, and the
    presence of other foreign bodies (e.g., gravel).
  • Missile fragments can often be found distant to the site of missile entry or exit.


Low-Velocity Wounds
  • Victims can usually be treated as outpatients.
  • Steps in treatment include:
    • Administration of antibiotics (first-generation cephalosporin), tetanus toxoid, and antitoxin.
    • Irrigation and debridement of the entrance and exit skin edges.
    • Indications for operative debridement:
      • Retention in the subarachnoid space
      • Articular involvement (intraarticular bone or missile fragments)
      • Vascular disruption
      • Gross contamination
      • Missile superficial on the palm or sole
      • Massive hematoma
      • Severe tissue damage
      • Compartment syndrome
      • Gastrointestinal contamination
    • Fracture treatment: Generally treat this injury as a closed fracture.
High-Velocity and Shotgun Wounds
  • These should be treated as high-energy injuries with significant soft tissue damage.
  • Steps in treatment include:
    • Administration of antibiotics (first-generation cephalosporin), tetanus toxoid, and antitoxin.
    • Extensive and often multiple operative debridements.
    • Fracture stabilization.
    • Delayed wound closure with possible skin grafts or flaps for extensive soft tissue loss.
Important: Gunshot wounds
that pass through the abdomen and exit through the soft tissues with
bowel contamination deserve special attention. These require
debridement of the intraabdominal and extraabdominal missile paths,
along with administration of broad spectrum antibiotics covering
gram-negative and anaerobic pathogens.
  • Retained missile fragments: These are
    generally tolerated well by the patient and do not warrant a specific
    indication for surgery or a hunt for fragments at the time of surgery
    unless they are causing symptoms (pain, loss of function), are
    superficial in location especially on the palms or soles, are involved
    in an infected wound, or are intraarticular in location. Occasionally,
    the patient will develop a draining sinus through which fragments will
    be expressed.
  • Infection: Studies have demonstrated that
    gunshot injuries are not necessarily “sterile injuries” as was once
    thought. This is secondary to skin flora, clothing, and other foreign
    bodies that are drawn into the wound at the time of injury. In


    that pass through the mouth or abdomen are seeded with pathogens that
    are then dispersed along the missile path. Meticulous debridement and
    copious irrigation will minimize the possibility of wound infection,
    abscess formation, and osteomyelitis.

  • Neurovascular disruption: The incidence
    of damage to neurovascular structures is much higher in high-velocity
    injuries (military weapons, hunting rifles), owing to the energy
    dissipation through tissues created by the shock wave. Temporary
    cavitation may produce traction or avulsion injuries to structures
    remote from the immediate path of the missile. These may result in
    injuries ranging from neuropraxia and thrombosis to frank disruption of
    neural and vascular structures.
  • Lead poisoning: Synovial or cerebrospinal
    fluid is caustic to lead components of bullet missiles, resulting in
    lead breakdown products that may produce severe synovitis and low-grade
    lead poisoning. Intraarticular or subarachnoid retention of missiles or
    missile fragments is thus an indication for exploration and removal.

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