Urban Surgeons Share Their Knowledge of Gunshot Wound Treatment

Gunshot wounds are not your everyday ordinary problems. But they do occur with some regularity in the United States. In fact, there are a reported 80,000 nonfatal gunshot wounds every year. The average orthopedic surgeon won’t see a steady flow of these patients, but still must be prepared for any that do show up.

In this instructional course, orthopedic surgeons from the Henry Ford Hospital in Detroit, Michigan review musculoskeletal injuries from gunshot wounds. In particular, joint injuries affecting the shoulder, wrist, hip, and ankle are discussed. A separate section is included with a discussion of long-bone fractures affecting the humerus (upper arm bone), forearm, femur (thigh bone), and tibia (lower leg bone).

All of the patients treated were admitted to the hospital with at least one gunshot-related bone fracture. Frequently, the joint nearest the fracture was affected. For example, fractures of the humerus often involved the scapula (shoulder blade) and/or the clavicle (collar bone). Gunshot wounds to the femur or tibia often involved the knee joint.

Penetration to the joint isn’t always obvious, so surgeons are advised to examine patients carefully. Any sign of air or blood in the joint is a suspicious clue. Likewise, fractures affecting the joint (called intraarticular fractures) raise a red flag pointing to joint penetration.

Once the damaged area has been cleaned up and all debris removed, then it’s possible to look at the joint more carefully before stabilizing the bone fracture. Bullets and bullet fragments must be removed to prevent lead toxicity from developing. Any foreign body left in the joint can interfere with normal joint mechanical movement. Over time, this can lead to arthritis.

Surgery often requires a multiteam approach with orthopedic surgeons, vascular and microvascular specialists, and plastic surgeons on hand. Severe injuries involving muscles, tendons, ligaments, bones, and joint cartilage take the skill of all those individuals to stabilize and repair so much damage.

Small bone and/or bullet fragments will be removed. Large pieces of shattered bone or cartilage are more likely to be reattached or reconstructed. Arthroscopic techniques work well for minor, stable injuries, but an open-incision approach is needed for patients with more extensive damage. Some joints have so much destruction, they can’t be repaired. In such cases, reconstruction with a joint replacement may be needed.

Gunshot wounds of the elbow can be especially difficult to treat. Nerve and blood vessel injuries compromise recovery. The bones are small enough that it may be necessary to use external fixation to stabilize the area. This means there are pins and metal plates holding things together. There’s also a rod or device on the outside of the skin to support and hold the forearm in place until healing can occur.

The extent of damage may be determined by the type of gunshot wound (low- versus high-velocity). Low-velocity gunshot wounds occur when the speed of the bullet is less than 1.5 meters per second. The amount of energy transferred to and through the body at the time of impact determines whether the gunshot wound is a low- or high-velocity injury. Soft tissue defects caused by high-energy gunshot wounds may be severe enough to need skin grafts.

The specific areas affected must be determined using advanced imaging techniques. X-rays help identify the location and severity of bone fractures. But sometimes the view isn’t clear enough and additional imaging is needed. Arthrograms of the joint, CT scans, and MRIs may be needed before a surgical treatment plan can be finalized. Gunshot wounds to the buttock area can compromise the abdomen and bladder. Advanced imaging is needed before transabdominal surgery is performed.

Complications of gunshot wounds are many and varied. Infection, the formation of a fistula (pocket of blood and/or pus), fractures that don’t heal, and loss of blood circulation resulting in osteonecrosis (death of bone) are the main concerns early on. Anyone with a significant positive health history for diabetes, heart disease, peripheral vascular disease, or alcohol abuse is at increased risk for delayed wound healing and impaired recovery.

Nerve injuries take a long time to heal. Recovery is slow as the nerve regenerates. Unstable fractures that don’t heal increase the risk of a second surgery later on. In some cases, amputation becomes the final treatment required. This is especially likely when blood vessels have been damaged and blood loss to the area causes necrosis (death of soft tissues).

The authors offer details about each type of bone fracture and what to expect. Common patterns of soft tissue involvement for each fracture type are discussed. Treatment approaches such as open vs- closed surgery, internal vs. external fixation, and wound care for war wounds are also discussed at length.

Stable fractures are relatively easier to handle than displaced fractures or fractures associated with multiple soft tissue injuries. The need for long range planning based on treatment approach and presence of any complications is also presented for the readers’ consideration. It may be necessary to complete the surgical reconstruction in stages. The need for bone and/or skin grafts complicates the picture. Many times, additional surgeries are needed because of the destructive effects of infection.

Besides surgery, fracture bracing is an important topic. After surgery, the affected area (arm, leg, wrist, ankle) is put in a cast to allow the bones to knit together. After the cast is removed, a brace is prescribed. Some gunshot fractures take months to heal completely. Bracing allows for increased function while still off-loading the area enough to promote healing.

Studies are being done to help determine what kind of approach works best to speed up healing and recovery. Of course, this type of research is difficult because there are so many different variables to consider. Severity of injury, development of complications, and persistent wound drainage are just three of the many factors that can affect results.

There isn’t consensus on how to treat every type of gunshot wound. But some experts recommend following these guidelines for gunshot wounds affecting the long-bones:

  • Use antibiotics and cast immobilization for stable fractures without additional soft tissue injury
  • Internal or external fixation is used for unstable fractures; the choice depends on the extent of soft-tissue disruption
  • Bone with many tiny fractures called comminuted fractures are better managed with internal fixation
  • External fixation is advised until soft tissues are reconstructed, and then switch to internal fixation

    And finally, long-term care is needed to follow patients and prevent (or treat) long-term complications such as joint stiffness, arthritis, lead toxicity, and infection. The efforts of the entire team are needed for the best outcome possible.