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Grading System for Gunshot Injuries to the Femoral Diaphysis in Civilians

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Grading System for Gunshot Injuries to the Femoral Diaphysis in Civilians CORR-03/03-119711-Long 1/20/03 3:21 PM Page 92 CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Number 408, pp. 92–100 © 2003 Lippincott Williams & Wilkins, Inc. Grading System for Gunshot Injuries to the Femoral Diaphysis in Civilians William T. Long, MD; Wayne Chang, MD; and Earl W. Brien, MD One hundred patients had surgical treatment for lization are determined by examination of the a gunshot injury to the femur at the authors’ hos- wound and radiographs, and not by determining pital. Each injury was classified (Grade 1–3) muzzle velocity. based on clinical and radiographic signs of deep soft tissue necrosis. All patients were followed up for a minimum of 6 months (average, 18 months; An orthopaedic surgeon practicing in the range, 6 months–72 months). Grade 1 injuries United States rarely will encounter a patient are defined by small entry and exit wounds (< 2 with a femur fracture caused by a gunshot. cm) and the absence of high-energy characteris- 1 Less than ⁄2 of cases reported each year present tics on plain radiographs. Grade 2 gunshot in- juries have small wounds (< 5 cm) and radio- to urban trauma centers, whereas the remain- graphic evidence of a high-energy injury. Grade der present to community hospitals with little 3 gunshot injuries are diagnosed by physical ex- or no experience treating these injuries. Guide- amination whenever necrotic muscle is present at lines used today for the treatment of gunshot the fracture site. Radiographs show extensive su- injuries in civilians are based on the velocity 1 2 3,8,29 perficial and deep soft tissue disruption and seg- of the projectile (KE ϭ ⁄2 mv ). Weapons mental bone destruction. Seventy-nine patients are classified according to muzzle velocity as with Grade 1 fractures had intramedullary nail- low-velocity (Ͻ 600 m/s, most handguns) and ing without wound exploration; all fractures high-velocity (Ͼ 600 m/s, most military ri- united without infection. Seven patients with fles). In the military ballistics laboratory, the Grade 2 injuries had wound exploration; a zone of soft tissue destruction expands as necrotic cavity was discovered in five patients 10–13 and three (43%) patients had deep infection de- muzzle velocity increases. Low-velocity velop. Fourteen patients with Grade 3 injuries gunshot wounds are classified as Gustilo Type had one or more debridements followed by skele- I injuries and high-velocity gunshot wounds tal stabilization, and seven patients (50%) had are classified as Gustilo Type III injuries.15,16 deep infection develop. Important decisions re- The recommended treatment includes imme- garding wound debridement and fracture stabi- diate nailing of Type I injuries.14 Debride- ment, broad-spectrum antibiotics, and delayed From the Dr. Martin Luther King/Charles Drew Medical nailing are recommended for Type III in- Center; Los Angeles, CA. juries.23 Leffers and Chandler19 described in- Reprint requests to William T. Long, MD, Dr. Martin termediate-energy gunshot injuries to the Luther King/Charles Drew Medical Center, 12021 S. Wilm- ington #3024, Los Angeles, CA 90059. Phone: 310–668- tibia (680–1627 N-m). These injuries were 4534; Fax: 310–223-0733; E-mail: [email protected]. characterized by highly comminuted fractures DOI: 10.1097/01.blo.0000052644.74302.3a and they had complication rates similar to 92 CORR-03/03-119711-Long 1/20/03 3:21 PM Page 93 Number 408 March, 2003 Gunshot Injuries to the Femoral Diaphysis 93 high-velocity gunshot injuries. Knowledge of multiple factors is necessary for an adequate understanding of wound production. Factors such as bullet caliber, mass, yaw, shape, im- pact velocity, and target tissue density all mod- ify the severity of the wound formed.6,18,23,26 A civilian physician who treats these emergen- cies has little information regarding these bul- let characteristics and no reliable method to determine muzzle velocity. A classification system is described that provides guidelines for emergency surgical treatment of patients who sustain a gunshot injury to the femoral diaphysis. MATERIALS AND METHODS One hundred patients had surgical treatment for a gunshot injury to the femoral diaphysis at the au- thors’ hospital between January 1993 and December 1996. The study group included every patient with a gunshot injury to the femoral diaphysis who was treated surgically. The femur is divided into three zones to emphasize the risk of joint violation (Fig 1). Fig 1. Zone I (hip at risk) includes fractures of the Zone I (hip at risk) includes fractures of the femur femur proximal to the lesser trochanter. Zone II (the femoral diaphysis) is defined as a fracture proximal to the distal end of the lesser trochanter. distal to the distal end of the lesser trochanter and Zone II (the femoral diaphysis) is defined as a frac- proximal to the distal metaphyseal diaphyseal ture distal to the distal end of the lesser trochanter and junction. Zone III (knee at risk) includes fractures proximal to the distal metaphyseal diaphyseal junc- below the distal metaphyseal diaphyseal junction. tion. Zone III (knee at risk) includes fractures below Every patient in the current study had a Zone II the distal metaphyseal diaphyseal junction. Every gunshot fracture. patient in this study had a Zone II gunshot fracture. Patients ranged in age from 18 to 58 years (mean, 36 years). There were 94 men and six women. Followup tients with shotgun injuries and injuries in Zones I was from 6 to 72 months (mean, 18 months). and III were excluded from the study. Physical ex- Seventy-three patients who sustained a gunshot amination includes the basic principles of advanced wound from January 1993 to December 1995 were trauma life support. A complete evaluation of gun- studied retrospectively. Twenty-seven patients in- shot victims includes turning the patient to exam- jured from January 1996 to December 1996 were ine the gluteal folds and crease and the popliteal studied prospectively, and data collection began space. Each wound is identified as an entry or exit when these patients presented to the orthopaedic wound. The size, location, and appearance of each service. All patients had followup until the fracture wound are recorded using a diagram. united. The medical history and clinical informa- Standard radiographs include an anteroposterior tion were obtained by reviewing medical records (AP) view of the pelvis and AP and lateral views of and radiographs. Missing or incomplete data were the femur and knee. A systematic evaluation of the obtained by telephone interview or by examination soft tissues, the bone, and the bullet will provide in the orthopaedic clinic at the authors’ institution. valuable signs to identify the fracture as low- In addition to routine information, evaluation of energy or high-energy. The superficial soft tissue gunshot injuries included a description of the shadows are examined for defects in the skin and weapon as a handgun, rifle, or assault weapon. Pa- subcutaneous tissue. The deep tissues are examined CORR-03/03-119711-Long 1/20/03 3:21 PM Page 94 Clinical Orthopaedics 94 Long et al and Related Research for disruption of muscle and infiltration with air, bullet, and bone debris. The bone is evaluated by counting the number of small (Ͻ 3 cm) and large fracture fragments. A fracture with greater than 10 large fragments and greater than 10 small frag- ments is described as severely comminuted. Seg- mental bone destruction describes a 7-cm area of bone that cannot be reconstructed by all of the frag- ments present on the radiograph. A retained bullet is evaluated by estimating the caliber and recording the size, number, and distribution of metal frag- ments. Bullet fragments combined with bone parti- cles and air provides objective evidence regarding the area of tissue violated by the gunshot wound. The radiographs of a low-energy gunshot show an intact soft tissue shadow. Small air infiltrates may be present along the bullet tract but they are not dispersed widely throughout the tissues. Com- mon low-energy fracture patterns include oblique fractures with several large fragments and several small cortical fragments around the point of bullet impact. Segmental bone destruction is not charac- teristic of low-energy gunshot injuries of the femur. The low-energy bullet appears as a solid projectile, or it may be broken into several small fragments Fig 2. Radiographs of a low-energy gunshot along a narrow tract (Fig 2). show an intact soft tissue shadow. Scant air infil- The radiographic signs that are most important tration is present along the bullet tract. The dia- physis is comminuted and there are several large in identifying a Grade 3 gunshot injury are found in and small fragments. The projectile consists of a the soft tissue. A large defect in the shadow that solid bullet plus a few small fragments along a outlines skin and subcutaneous tissue represents an narrow wound channel. entry or exit wound. The muscle shadow is swollen and irregular. A mixture of bone fragments, bullet fragments, and air penetrate a wide area within the thigh. Severe comminution and segmental bone de- A Grade 3 gunshot can be defined by the size struction are fracture patterns that characterize a and appearance of the entry or exit wound or by ra- Grade 3 gunshot injury (Fig 3). diographs alone. A patient with a large (Ͼ 5 cm) Each gunshot is classified as Grade 1, 2, or 3, devitalized entry or exit wound is classified as hav- based on examination of the wound and the ra- ing a Grade 3 injury. A patient with a smaller diographic findings (Table 1). Grade 1 is a low- wound (2–5 cm) also is classified as having a Grade energy injury with small (Ͻ 2 cm) entrance and exit 3 injury whenever devitalized muscle is identified wounds.
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