Gunshot wounds (GSW) of the hand have become common injuries at

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					Title: Fracture Management of Gunshot Wounds to the Hand

Authors: Mark W. Kiehn, MD, Karol A. Gutowski, MD, Amit Mitra, MD

Gunshot wounds (GSW) of the hand have become common injuries at inner city trauma
centers.1, 2 Principles for the management of these injuries have evolved from experience in
the treatment of military wounds, often caused by high-velocity weapons in contaminated
conditions. Such injuries were treated with extensive debridement and staged wound
management that included delayed fracture fixation and bone grafting.3, 4 In contrast, civilian
GSW are most often caused by low-velocity handguns, which cause a localized pattern of
injury and usually occur under conditions of limited contamination. For cases of civilian upper
extremity GSW, surgeons have advocated a trend toward limited debridement and early
definitive care.1, 2, 4 - 7 The purpose of this paper is to evaluate the results of early definitive
treatment of urban hand GSW fractures and to evaluate patient compliance and its affect on
the management of hand GSW fractures.

Methods: A retrospective review was conducted of medical records of patients treated by the
Department of Plastic and Reconstructive Surgery at Temple University Hospital, for hand
GSW from January 1989 to December 1998. The incidence of hand fractures, means of
fracture fixation, and incidence of infection were determined. Patterns of patient compliance
with post-hospital follow-up were also studied.

Upon presentation to the hospital, patients underwent trauma and hand surgery evaluations.
After clinical examination and x-rays, wounds were cleansed, and fractures were reduced
and splinted. Intravenous antibiotics (cefazolin or vancomycin) and tetanus prophylaxis were
administered. Patients with adequate fracture reduction and stability, without significant soft-
tissue injury, were managed non-operatively. Patients with devascularized tissues requiring
revascularization or amputation, need for soft-tissue coverage, significant fracture
misalignment or instability, bone loss, tendon or ligament injury, or evidence of compartment
syndrome were considered surgical candidates.

Results: Ninety-eight hand GSW fractures were treated in 72 patients (Fig. 1). Seventy-four
percent of patients required surgical intervention and 25% of patients received definitive
fracture care in the emergency department or intensive care unit. One patient refused care.
Fracture fixation techniques included Kirschner wires, internal plates, external fixators, lag
screws, and cerclage wires (Table 1). Some patients required more than one technique for
fracture fixation. Eleven patients (15%) required more than one operation (5 patients –
revision of soft-tissue coverage, 5 patients – revision of fracture fixation, 1 patient – soft-
tissue coverage and revision of fracture fixation). Three patients (4%) underwent primary
amputation of single digits. Three patients (4%) underwent bone grafting at the initial
surgery. Five patients (7%) required an additional operation after discharge from the hospital
(2 patients – arthrodesis, 3 patients – bone grafting). The average time from presentation to
the hospital to surgical intervention was 2 days (range = 0 to 8 days) and the average
hospital stay was 6 days (range = 0 to 32 days). Both times were influenced most by the
presence and treatment of concomitant injuries to other areas of the body.

Two in-hospital and 4 post-hospital infections were diagnosed (Table 2), for an 8% total
incidence. There was not an association between type of fixation device used and incidence
of infection (Fischer’s Exact Test, p=0.630). All cases of infection were limited to superficial
soft-tissues and resolved with antibiotic therapy. No case required surgical intervention or
removal of a fixation device.
Following discharge from the hospital, only 11 patients (15%) returned to clinic until complete
fracture healing was documented. Thirty-three patients (46%) followed-up initially and 28
patients (39%) were lost to follow-up upon discharge from the hospital. Nineteen patients
(26%) were lost to follow-up with a removable fixation device in place.

Conclusion: Firearms create a wide variety of injuries to the hand, depending upon the type
of weapon and the circumstances of wounding. Civilian gunshot wounds are generally
caused by low velocity handguns, which typically cause a localized pattern of injury and
limited tissue destruction. Such injuries can be managed like other open fractures, with many
cases managed non-operatively. In most cases that are managed surgically, debridement
should be limited and internal fixation is not contraindicated. In cases of extensive or
contaminated wounds, such as those caused by shotguns or high-velocity weapons, more
extensive debridement and a staged approach to reconstruction is warranted. In such cases,
definitive fixation and bone grafting should be delayed until the wound is controlled for
contamination and soft-tissue coverage has been achieved.

In this study, infections were infrequent and comparable to rates of other types of open
fractures.8 Though the use of transcutaneous fixation devices and open wound management
are associated with low rates of infection in compliant patient populations, 3, 8 their use may
increase the risk of infection in the generally non-compliant urban trauma population, in which
pin-site and wound care are apt to be neglected. Because the infections involved only
superficial tissues and responded to antibiotic therapy alone, a more aggressive approach to
debridement and soft-tissue coverage would have increased the complexity of management
without significantly improving patient outcomes.

The treating surgeon should anticipate poor compliance from patients treated for GSW of the
hand. The surgeon should attempt to accomplish the treatment goals in a limited number of
surgeries and focus the treatment plan to meet the patient’s goals. The choice of fixation
device should limit the need for device care and removal and have limited susceptibility to
manipulation by the patient. Limiting joint immobilization may improve hand function for
patients who are unlikely to participate in postoperative hand therapy.

      35                                    33                  Distal Phalanx
      30                                                        Distal Interphalangeal Joint

  N                                                             Middle Phalanx
      25                                                        Thumb Interphalangeal Joint
  m   20                                                        Proximal Interphalangeal Joint
                                  17                            Proximal Phalanx
  b   15
                                       12                       Metacapophalangeal Joint
  r   10          9                                             Metacarpal
                              6                      5 4        Carpometacarpal Joint
       5      4       3 3                        2              Carpal Bones
       0                                                        Distal Radius/Ulna
                      Location of Fracture
Figure 1. Distribution of Hand Gunshot Fractures
   Fixation Method             Number of Patients
    Kirschner Wires                       33
     Internal Plates                      16
   External Fixation                      12
  Screws or Cerclage                       4
          Splint                          18

Table 1. Fixation Techniques for Fracture Management

 Method of Fixation           Number of Infections
    Kirschner Wires                  2/33 (6%)
     Internal Plates                 2/16 (13%)
   External Fixation                 2/12 (16%)
  Screws or Cerclage                       0
          Splint                           0

Table 2. Incidence of Superficial Infection Among Fixation Techniques

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