Gunshot Wounds: Principles and Treatment (Rosen)

MedicalC ontinuingEducation Continuing Medical Education

Educational Goals:

After completion of this CME, the reader will:

1) Understand the Gunshot Wounds: differences between low and high velocity Principles and gunshot wounds. 2) Gain information Treatment on treatment of gunshot wounds. 149

Here’s an in-depth look at these 3) Understand the traumatic injuries. Gustilo classification of compound fractures. By Ritchard Rosen, DPM

Welcome to Podiatry Management’s CME Instructional program. Our journal has been approved as a sponsor of Con- tinuing Medical Education by the Council on Podiatric Medical Education. You may enroll: 1) on a per issue basis (at $26.00 per topic) or 2) per year, for the special rate of $210 (you save $50). You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. You can also take this and other exams on the Internet at www.podiatrym.com/cme. If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earned credits. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake the test at no additional cost. A list of states currently honoring CPME approved credits is listed on pg. 156. Other than those entities currently accepting CPME-approved credit, Podiatry Management cannot guarantee that these CME credits will be acceptable by any state licensing agency, hospital, managed care organization or other entity. PM will, however, use its best efforts to ensure the widest acceptance of this program possible. This instructional CME program is designed to supplement, NOT replace, existing CME seminars. The goal of this program is to advance the knowledge of practicing podiatrists. We will endeavor to publish high quality manu- scripts by noted authors and researchers. If you have any questions or comments about this program, you can write or call us at: Podiatry Management, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us at bblock@ podiatrym.com. Following this article, an answer sheet and full set of instructions are provided (pg. 156).—Editor

ivilian injuries due to fire- ammunition as well as the distance a ity is generally seen in civilian popu- arms are increasing in the missile is shot from. lations (Figure 1). United States.1, 2 As podiat- A small entrance wound and a ric surgeons become more Low Versus High Velocity Gunshot large explosive exit wound is indic- involved with trauma, it Wounds ative of a high velocity projectile Cis important to understand the prin- Gunshots are classified as high fired at close range. A small entrance ciples and types of gunshot wounds velocity, low velocity, high energy wound with a small or no exit wound we are faced with every day. Gun- low velocity shotgun and low energy with the missile retained within the shot wound damage varies with the low velocity gunshots. High velocity host’s tissue generally is indicative type of weapon and caliber of the is seen in the military, and low veloc- Continued on page 150

www.podiatrym.com JUNE/JULY 2016 | PODIATRY MANAGEMENT CME Continuing

Medical EducationGunshot Wounds (from page 149) velocity projectiles, and therefore the nerves, skin, and subcutaneous fat. amount of tissue damage encoun- Although each structure is evaluated, of a low velocity bullet speed less tered as well as the amount of con- the close proximity of all these struc- than 2000 ft./sec (Figures 2,3).3 tamination is much less than with tures in the foot requires knowledge In evaluating the military injury of anatomy as well as function of and treating gunshot (Figure 4).5 each of the above. wounds, the extent The shotgun is When confronting a gunshot of the tissue damage another type of in- wound, the following protocol should caused by the bullet is jury encountered be followed: of utmost importance. in private practice. 1) Take an adequate history. It The local effects Tissue damage is is important to ascertain if a “flash of missile injuries dependent are: on the range 1) Laceration and at which the crushing shotgun is 2) Production of fired.8 Fired shockwave and tem- at point porary cavitation Figure 1: High velocity gunshot wound blank range Laceration and (less than 15 crushing are the principle effects of yards), the shotgun pellets are the bullet passing through the tissue extremely lethal, and produce planes and causing damage primarily an extensive wound with sub- to the permanent cavity region of the stantial bone and soft tissue 150 bullet track.3 loss with comminution and Temporary cavitation is more of damage to the neurovascular a concern with high velocity wounds. structures (Figures 5,6).4, 6, 8, 9 Figure 2: Low velocity GSW

Laceration and crushing are principles of Low velocity wounds.

As the missile penetrates the tissue Fired at long range, shot- planes, an extension of injury occurs gun velocity diminishes and and expands the damage and size the pellets disperse as they of the track greater than the size of reach their target. Subsequent- the missile. The temporary track can ly, long range shotgun pellets cause damage at distances remote cause minimal damage, and to the original clinically observed experience has shown that Figure 3: High velocity GSW track.3, 4, 9 these wounds sustained are of Most gunshot wounds encoun- little sequella to the patient (Figure 7). bleed” has occurred. Flash bleed is tered in private practice involve low rapid blood loss at the time of the Management of Gunshot Wounds injury. When encountering gunshot 2) Check vital signs. wounds to the lower extremity, one 3) Inspect for burns to the tissue, must evaluate bones and joints, mus- swelling, and pallor. These must be cle, tendon units, vascular structures, noted. Entrance and exit wounds must be identified. If, however, there is no exit wound, imaging must be utilized to identify the location of the bullet. 4) Physical exam. Examination by system must be performed (vascular, neurologic and musculoskeletal).

Bone By definition, a gunshot fracture is a high energy open fracture. Sev- Figure 4: Low velocity from distance Figure 5: Shotgun, close range Continued on page 151

JUNE/JULY 2016 | PODIATRY MANAGEMENT www.podiatrym.com MedicalC ontinuingEducation CME

Gunshot Wounds (from page 150) Stabilizing the Fracture is of followed by copious irriga- Utmost Importance (Figure 8). tion and early fixation of the eral studies demonstrated that the Stabilization options include fracture (Figure 9, 10). heat generated during firing does not splints or cast or, usually, hard- Berg, et al. in their study iden- make the bullet sterile.15 Most low ware such as external or internal tified that one-fifth of the fractures velocity gunshot fractures resemble fixation. The choice and timing of were treated by debridement only Gustilo and Ander- without hardware son grade I or II open fixation. These were fracture due to the fractures that are comparatively mild inherently stable or to moderate soft tis- do not require sta- sue damage. bilization (e.g., fib- Definitive treat- ula). Only 8% of ment must be follow the fractures were the rules of treating treated with open open fractures. reduction and inter- The Gustilo nal fixation.14 These open fracture clas- numbers agree with sification system the report by Weil is the most com- and co-authors.30 As monly used classi- reported before, in Figure 6: Shotgun, close range pellets remain Figure 7: Long range shotgun fication system for 8 of the 12 fractures pellets open fractures. It treated with prima- was created by Ramon Gustilo and the stabilization method depends ry external fixators, this was the 151 J.T. Anderson, and then further ex- on the fracture site, pattern and definitive treatment for union. This panded by Gustilo, Mendoza, and comminution, the soft tissue injury, high percentage emphasizes the Williams.10, 11, 12 and the patient’s general condition. comminuted nature of the gunshot Primary fixation is especially useful fracture, type, and the tendency to The Gustilo Classification is as in patients with multiple injuries, prefer a biological splint fixation, follows: complex ipsilateral extremity inju- maintaining a fracture-healing envi- I Open fracture, clean wound, ries, severe injuries that require in- ronment. wound <1 cm in length. tensive wound care, open displaced II Open fracture, wound >1 cm intra-articular fractures, or open Skin Soft Tissue but <10 cm in length without ex- fractures complicated by neurovas- Ordog, et al.18 retrospectively tensive soft-tissue damage, flaps, cular damage.16 reviewed 28,150 patients with gun- avulsions. Ganocy and Lindsey17 suggest- shot wounds; 60% of them were III Open fracture with extensive ed a treatment protocol based on treated as outpatients. Four per- soft-tissue laceration (>10 cm), damage, or loss or an open seg- mental fracture. This type also in- cludes open fractures caused by Temporary cavitation is more of a concern farm injuries, fractures requiring with high velocity wounds. vascular repair, or fractures that have been open for eight hours prior to treatment. IIIA Type III fracture with ad- the final projectile location, the frac- cent had minor fractures not re- equate periosteal coverage of the ture pattern, and the level of con- quiring operative stabilization. The fracture bone despite the extensive tamination. In their opinion, stable, patients were treated with local soft-tissue laceration or damage. non-contaminated extra-articu- wound debridement, irrigation, and IIIB Type III fracture with exten- lar gunshot wounds can be treat- an antibiotic ointment. Only 1.8% sive soft-tissue loss and periosteal ed non-operatively with antibiotics had wound infections that respond- stripping and bone damage. This is only, whereas intra-articular pro- ed well to oral antibiotics without usually associated with massive con- jectiles should be removed, and un- requiring hospital admission. In tamination and will often need fur- stable fractures stabilized. For most their study of 163 patients with ci- ther soft-tissue coverage procedure high velocity injuries in the extrem- vilian gunshot wounds, Brunner (i.e., free or rotational flap). ities, external fixation is the treat- and Fallon19 found no differences IIIC Type III fracture associated ment of choice. The standard of care between patients who had debride- with an arterial injury requiring re- for gunshot fractures is meticulous ment and wound care and patients pair, irrespective of degree of soft-tis- operative debridement of all devital- who had local wound care alone. sue injury. ized soft tissue and bone fragments, Continued on page 152 www.podiatrym.com JUNE/JULY 2016 | PODIATRY MANAGEMENT CME Continuing

Medical EducationGunshot Wounds (from page 151) trauma in cases of an arteriovenous are obstruction, extravasation of con- fistula. The presence of “hard signs” trast agent, early venous filling, ir- Neither group received antibiot- of arterial injury such as absent regularity of the vessel wall, a filling ics, and both were treated as out- pulses, unequivocal signs of isch- defect, and a false aneurysm. There patients. The wounds were neither emia, profuse hemorrhage, and pul- is, however, a low yet measurable closed primarily nor did they have sating or expanding hematoma war- complication rate, with complications a delayed primary closure but were left to drain and close secondarily.

Vascular Injuries Fired at point blank range(less than 15 yards), Vascular structures are fre- the shotgun pellets are extremely lethal. quently injured because of their proximity to bone.20 A delay in the diagnosis or treatment can result in a chronic debilitating handicap rants urgent surgical intervention.23 such as allergic reaction, renal fail- due to ischemia and limb loss. Furthermore, Berg and colleagues ure, formation of a local hematoma, Prompt restoration of blood flow identified that arterial pressure index or a false aneurysm at the site of is mandatory in traumatic periph- is a sensitive tool for identifying a catheterization. eral arterial injuries.21 Damage to vascular injury. According to their Historically, angiography was the vessels can result also in death due protocol, an arterial pressure index imaging modality of choice, but re- to exsanguination. The damage ratio of 0.9 or less warrants fur- cent studies show that non-invasive may result directly from the bullet, ther investigation. For patients with studies such as duplex Doppler ul- from secondary missiles such as equivocal findings of vascular inju- trasonography are as sensitive as ar- 152

Figure 8: Low velocity Figure 9: Initial stabilization with external fixator Figure 10: Bone graft for reconstruction and length of 1st metatarsal bone fragment, from cavitation, or ry such as diminished pulses, angi- shockwave effects. The injury to ography yields the greatest benefit, teriography in most cases. In a study the vessel can be occlusive (due particularly in avoiding unnecessary by Knudson et al.,25 86 extremity in- to transection or thrombosis of the surgery.14 juries were assessed using color-flow vessel) or non-occlusive (an intimal Angiography reduces unnec- duplex imaging. No missed arterial flap tear or a pseudoaneurysm). essary explorations for proximity injuries were found. Many centers Due to advances in diagnosis wounds and can provide therapeu- now successfully manage proximity wounds by repeated physical examination over a 24 hour period and reserve angiography only for those Flash bleed is rapid blood loss at the time patients with abnormal physical find- of the injury. ings or an arterial pressure index less than 0.9.26 Norman and co-workers27 studied gunshot fractures to long bones and treatment of vascular injuries, tic intervention such as stenting and concluded that routine use of rates of amputation decreased dra- or embolization. In a study using arteriography is not indicated unless matically, with limb salvage rates routine arteriography, the negative there are abnormal findings on vas- exceeding 86%.22 In a Berg, et al. surgical exploration rate in patients cular examination. Many investiga- study, none of their patients re- with “soft signs” of arterial injury tors still recommend that a gunshot quired amputation—primary or de- or with proximity wounds fell from wound in the immediate vicinity of layed.14 Injuries can present acutely 84% to 2%.24 major vessels should be studied an- or up to several months after the Significant angiographic findings Continued on page 153

JUNE/JULY 2016 | PODIATRY MANAGEMENT www.podiatrym.com MedicalC ontinuingEducation CME

Gunshot Wounds (from page 152) and axonotmesis. Several studies ad- syndrome must be identified dressed this issue. Omer29 reported in a timely fashion, and emer- giographically or explored surgical- spontaneous recovery in 69% of pa- gency fasciotomy is indicated. ly. Wound exploration involves low tients with nerve injuries due to gun- Tetanus prophylaxis is always morbidity (3%) and is often a routine shot wounds between three and nine indicated: however, antibiotics pro- part of wound management. Angiog- months after the injury. phylaxis is not essential for wounds raphy can be used intra-operatively In light of the above literature, that are not grossly contaminated. with a fluoroscope. In our institution, the podiatric surgeon should be fa- Antibiotic coverage is, however, indi- we do not use angiography routinely, miliar with anatomy and function cated for compound fractures. even in proximity wounds, but rely on serial physical examination of the limb at risk. Gunshot wounds are generally Limbs can tolerate warm ischemia time of up to six hours. More not closed by primary intention as they may be than six hours of ischemia will al- most always result in muscle necro- considered contaminated. sis and possibly permanent damage. In patients with combined vascular and nerve injuries, prophylactic prior to entering the surgical field. Summary fasciotomy should be performed at This brief summary should be kept in • Civilian gunshot wounds are the time of arterial repair unless mind as you treat gunshot wounds: generally low velocity, resulting in a method for continuous pressure Surgical debridement and surgical laceration and crushing damage to measurement is available. Since cleansing is always indicated in gun- the bullet track. Low velocity, small most vascular gunshot injuries in- shot wounds.3 entrance and small exit wounds can 153 volve damage to a segment of the Cleansing a wound involves copi- lead to simple fractures or to commi- artery, a temporary shunt, followed ous irrigation at the entrance wound nution. Treatment should consist of by prompt skeletal stabilization and with removal of surface debris. Prob- debridement and stabilization, and then a definite arterial repair should ing the wound blindly should never the bullet may or may not be excised. be performed.14 be performed and extending the inci- • In military practice, high veloc- sion for visibility is not indicated.13 ity wounds cause temporary cavita- Nerves Gunshot wounds are generally tion and severe loss of soft tissue. Nerves pass in close proximity not closed by primary intention as • Close range shot gun blasts to bones and vascular structures and they may be considered contami- also cause massive damage and are fraught with a large degree of con- tamination. • Surgical debridement is imper- Surgical debridement and surgical cleansing is ative due to cavitation and retained always indicated in gunshot wounds. foreign bodies. • The judgment of the initial treating podiatric surgeon is of utmost importance. Adhering to the are commonly injured when vascular nated. Foreign bodies should be re- principles of treatment previously injury is present. In fact, a physi- moved as long as excessive dissec- identified will benefit the prognosis cal examination demonstrating acute tion is not required. Bullets are also of the patient. nerve injury raises suspicion of vas- not recommended to be excised if • Aggressive yet prudent judg- cular injury and usually warrants fur- extensive exploration is necessary. ment and treatment are the best ways ther investigation to rule out arteri- Stabilizing large fragments of to approach a gunshot wound. al injury. Concomitant arterial and bone, whether with external fixation nerve injury will most likely result in if there are large tissue defects, or by Case 1: Low Velocity Gunshot a non-functional limb. K-wire fixation, is indicated. (Figures Wound In a study by Visser, et al.28, only 11-18) A 46-year old male presented to 7% of patients with concomitant In stable gunshot wounds where the emergency department with a low nerve and arterial injury had a nor- there is no damage to the vascular velocity gunshot wound. A small en- mal functioning limb, despite suc- status, irrigate, splint, and observe trance wound was noted on the dorsal cessful vascular repair, as opposed to for signs of infection. The patient aspect of the foot. X-rays revealed a 39% of patients with arterial injury may be discharged from the emer- comminuted fracture of the 2nd meta- alone. Nerve injury presents clinical- gency department. In unstable or tarsal. The wound was debrided and ly with hypoesthesia parasthesias, vascular compromised patients, ex- the fragments of bone were irrigated or paralysis. Spontaneous recovery ploration is indicated immediately. with copious amounts of saline. An is usually expected in neuropraxia In gunshot wounds, compartment Continued on page 154 www.podiatrym.com JUNE/JULY 2016 | PODIATRY MANAGEMENT CME Continuing gunshot wounds and gunshot fracture in pp 242-247, Wiley, New York, 1984. Medical EducationGunshot Wounds (from page 153) civilian practice. Clin. Orthop. 114:296, 8 Demuth, W.E. the mechanism oof external fixation was placed across 1976. shotgun wounds. J Trauma 11:219, 1971. the fracture site to maintain osseous 4 Demuth, W.E. and Smith, J.M. High 9 Anania, W.A., Rosen, R.C., Giuffre, length. After a few weeks, the fracture velocity bullet wounds of muscle and A. M. Gunshot wounds ot the lower ex- site was resected and a bone graft bone: the basis of rational early treatment. tremity: Principales and Treatment. J Foot Surg 26, number 3,228, 1987. was placed within the fracture frag- J. Trauma 6:744, 1966. ments. A K-wire was used to transfix the bone graft and the external fixation remained for 8 additional weeks Spontaneous recovery is usually expected in (Figures 11—Figure 18). PM neuropraxia and axonotmesis. References 1 Ryan, M., Leighton, T., Pianism, N., Klein, S., Bongard, F. Medical and economic consequences of gang related 5 Marcus, N.A., Blair, W.F., Schuk, 10 Thomas P. Rüedi; Richard E. Buck- shootings. American surgeon, 59, 831- J.M., and Omer, G.E. Low velocity gun- ley; Christopher G. Moran (2007). AO 833, 1993. shot wounds to the extremities. J Trauma principles of fracture management, Vol- 2 Sinauer, N., Annest, J., Mercy, J., 20:2016, 1980. ume 1. Thieme. p. Page 96. ISBN 3-13- Unintentional nongatal firearm related 6 Wolf, W., Benson,D.R.,Shoji, H, Ho- 117442-0. injuries. A preventable public health bur- eprich, P, and Gilmore, A., Autosteriliza- 11 Gustilo RB, Anderson JT. Preven- den. JAMA, 275. Pp 1740-1743. 1996. tion in low velocity bullets. J. Trauma tion of infection in the treatment of one 3 Hennessy, M.J., Banks,H.H., 18:63, 1978. thousand and twenty-five open fractures Leach, R.B. and Quigley, T.B. Extremity 7 May, H.L. (ed) Emergency Medicine, of long bones: Retrospective and prospec- 154 tive analyses. J Bone Joint Surg Am. 1976; 58:453–8. 12 Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: A new classification of type III open fractures. J Trau- ma. 1984; 24:742–6.). 13 Brettler, D., Sedlin,E.D., and Men- dler, D.G. Conservative treatment of low velocity gunshot wounds. Clin. Orthop 140:26, 1979. Continued on page 155 Figure 11: Low velocity GSW Figure 12: Low velocity compound fracture

Figure 15: Debridement of wound and irrigation of fracture site Figure 13: Stabilization with external fixator Figure 14: Stabilization with external fixator

Figure 16: Bone Graft for reconstruction Figure 17: Bone Graft for reconstruction Figure 18: Bone graft with fixation

JUNE/JULY 2016 | PODIATRY MANAGEMENT www.podiatrym.com MedicalC ontinuingEducation CME

Gunshot Wounds (from page 154) 20 Saletta JD, Freeark RJ. Vascular bone fractures of the extremities. injuries associated with fractures. Orthop Am Surg .1995; 61: 146-50. 14 Burg,A., Nachum, G, Salai, M, Clin .North Am 1970; 1: 93-7 28 Visser PA, Hemreck AS, Pierce Haviv,B., Heller,S., Velkes,S. and Dud- 21 Perry MD, Thal ER, Shires GT. GE. Prognosis of nerve injuries incurred kiewicz, I. Treating Civilian Gunshot Management of arterial injuries. Am Surg .during acute trauma to peripheral arter- wounds to the extremities in a level 1 .1971; 173: 403. ies. Am J Surg 1980; 140: 596-9. trauma center: Our experience and recom- 22 Adinolfi MF, Hardin WD, O’Con- 29 Omer GE Jr. Acute management of mendations. IMAJ • VOL 11 • september nell RC, Kerstein MD. Amputations after peripheral nerve injuries. Hand Clin 1986 2009, p 546-551. .vascular trauma in civilians. South Med J .2: 19. 15 Wolf AW, Benson DR, Shoji H. Au- 1983; 76: 1241-3. 30 Weil YA, Petrov K, Liebergall M, tosterilization in low-velocity bullets .J 23 Smith RF, Elliott JP, Hageman JH. Mintz Y, Mosheiff R. Long bone fractures Trauma 1978; 18: 63. Acute penetrating arterial injuries of the .neck .caused by penetrating injuries in terrorist 16 Anderson JT, Gustilo RB. Imme- and limbs. Arch Surg 1974; 109: 198-205. attacks. J Trauma 2007; 62: 909-12. diate internal fixation in open fractures 24 Reid JDS. Assessment of proximity .Orthop Clin North Am 1980; 11: 569-78. of a wound to major vascular structures 17 Ganocy K 2nd, Lindsey RW. The .as an indication for arteriography. Arch Dr. Rosen is chief of management of civilian intraarticular gun- Surg 1988; 123: 942-6. podiatric surgery at shot wounds: treatment considerations 25 Knudson MM, Lewis FR, Atkinson Holy Name Medical and proposal of a classification .system. K, Neuhaus A. The role of duplex .ultra- Center in Teaneck, NJ. Injury 1998; 29 Suppl 1: SA1-6. sound arterial imaging in patients with He is adjunct faculty at 18 Ordog GJ, Wasserberger JS, Balasu- penetrating extremity trauma .Arch Surg UMDNJ-Newark and bramanium S. Civilian gunshot wounds 1993; 128: 1033-7. Associate Clinical facul- .outpatient management. J Trauma 1994; 26 Levy BA, Zlowodzki MP, Graves M, ty at Touro College of 36: 106-111. Cole PA. Screening for extremity arterial Osteopathic Medicine. 19 Brunner RG, Fallon WF. A prospec- .injury with the arterial pressure index. He has been in private tive, randomized clinical trial of wound Am J Emerg Med 2005; 23(5): 689-95. practice at Northeast Podiatry Group for the 155 debridement versus conservative wound 27 Norman J, Gahtan V, Franz M, past 28 years and is active in teaching residents care in soft-tissue injury from .civilian Bramson R. Occult vascular injuries fol- at UMDNJ, Holy Name Medical Center and gunshot wounds. Am Surg 1990; 2: 104-7. lowing gunshot wounds resulting in long Englewood Medical Center.

CME EXAMINATION

See answer sheet on pagE 157.

1) Temporary cavitation is an important 4) Shotgun injuries: effect of: A) Are lethal at less than 15 yards A) Low velocity wounds B) Are lethal at greater than 15 yards B) High velocity wounds C) Cause minimal damage at less than 15 yards C) Shotguns D) Cause maximum damage from greater D) 22 gauge bullet than 15 yards

2) Laceration and crushing are principles 5) With Gunshot wounds, surgical debridement of: and surgical cleansing is: A) Low velocity wounds A) Always indicated B) High velocity wounds B) Never indicated C) Shotgun C) Sometimes indicated D) 22 gauge bullet D) Dependent on injury

3) “Flash Bleed” refers to: 6) Gunshot wounds are considered: A) Bleeding from the wound A) Contaminated B) Rapid blood loss at time of injury B) Clean C) Rapid blood loss after delay C) Dirty D) Bleeding upon wound inspection D) Sterile Continued on page 156 www.podiatrym.com JUNE/JULY 2016 | PODIATRY MANAGEMENT $ CME EXAMINATION PM’s Continuing

Medical Education CME Program 7) Laceration and Crushing Welcome to the innovative Continuing Education A) Cause damage distant to the track of Program brought to you by Podiatry Management the bullet Magazine. Our journal has been approved as a B) Cause major tissue loss sponsor of Continuing Medical Education by the C) Cause damage confined to the Council on Podiatric Medical Education. permanent cavity D) Cause damage at the entrance or Now it’s even easier and more convenient to exit only enroll in PM’s CE program! You can now enroll at any time during the year 8) Prophylactic antibiotics and submit eligible exams at any time during your A) Are never essential to gunshot enrollment period. wounds PM enrollees are entitled to submit ten exams B) Are indicated for compound fractures published during their consecutive, twelve–month C) Should be determined by the surgeon enrollment period. Your enrollment period begins D) B and C with the month payment is received. For example, if your payment is received on November 1, 2014, 156 9) Which of the following is not related to your enrollment is valid through October 31, 2015. low velocity injuries? If you’re not enrolled, you may also submit any A) Bullet speed is less than exam(s) published in PM magazine within the past 2000 ft/sec twelve months. CME articles and examination B) Small entrance wound questions from past issues of Podiatry Manage- C) Bullet speed is greater than ment can be found on the Internet at http:// 2000 ft/sec www.podiatrym.com/cme. Each lesson is ap- D) Small exit wound proved for 1.5 hours continuing education contact hours. Please read the testing, grading and payment 10) Spontaneous recovery of nerves is instructions to decide which method of participa- expected in tion is best for you. A) neuropraxia Please call (631) 563-1604 if you have any ques- B) axonotmesis tions. A personal operator will be happy to assist you. C) neurotmesis Each of the 10 lessons will count as 1.5 credits; D) A and B thus a maximum of 15 CME credits may be earned during any 12-month period. You may select any 10 in a 24-month period.

The Podiatry Management Magazine CME program is approved by the Council on Podiatric Education in all states where credits in instructional media are accepted. This article is approved for 1.5 Continuing Education Contact Hours (or 0.15 CEU’s) for each examination successfully completed.

Home Study CME credits now

accepted in PennsylvaniaContinued on page 156

JUNE/JULY 2016 | PODIATRY MANAGEMENT $ MedicalC ontinuingEducation Enrollment/Testing Information and Answer Sheet Note: If you are mailing your answer sheet, you must complete all rolled in the annual exam CME program, and we receive this exam info. on the front and back of this page and mail with your credit card during your current enrollment period. If you are not enrolled, please information to: Podiatry Management, P.O. Box 490, East Islip, send $26.00 per exam, or $210 to cover all 10 exams (thus saving $50 NY 11730. over the cost of 10 individual exam fees). Testing, Grading and Payment Instructions Facsimile Grading (1) Each participant achieving a passing grade of 70% or higher to receive your CME certificate, complete all information and fax on any examination will receive an official computer form stating the 24 hours a day to 1-631-563-1907. Your CME certificate will be dated number of CE credits earned. This form should be safeguarded and and mailed within 48 hours. This service is available for $2.50 per exam may be used as documentation of credits earned. if you are currently enrolled in the annual 10-exam CME program (and (2) Participants receiving a failing grade on any exam will be noti- this exam falls within your enrollment period), and can be charged to fied and permitted to take one re-examination at no extra cost. your Visa, MasterCard, or American Express. (3) All answers should be recorded on the answer form below. if you are not enrolled in the annual 10-exam CME program, the For each question, decide which choice is the best answer, and circle fee is $26 per exam. the letter representing your choice. Phone-In Grading (4) Complete all other information on the front and back of this page. You may also complete your exam by using the toll-free service. (5) Choose one out of the 3 options for testgrading: mail-in, fax, Call 1-800-232-4422 from 10 a.m. to 5 p.m. EST, Monday through or phone. To select the type of service that best suits your needs, Friday. Your CME certificate will be dated the same day you call and please read the following section, “Test Grading Options”. mailed within 48 hours. There is a $2.50 charge for this service if you are Test Grading Options currently enrolled in the annual 10-exam CME program (and this exam 157 Mail-In Grading falls within your enrollment period), and this fee can be charged to your to receive your CME certificate, complete all information and Visa, Mastercard, American Express, or Discover. If you are not current- mail with your credit card information to: ly enrolled, the fee is $26 per exam. When you call, please have ready: 1. Program number (Month and Year) Podiatry Management 2. The answers to the test P.O. Box 490, East Islip, NY 11730 3. Your social security number PLEASE DO NOT SEND WITH SIGNATURE REQUIRED, AS 4. Credit card information THESE WILL NOT BE ACCEPTED. in the event you require additional CME information, please there is no charge for the mail-in service if you have already en- contact PMS, Inc., at 1-631-563-1604.

Enrollment Form & Answer Sheet Please print clearly...Certificate will be issued from information below.

Name ______Soc. Sec. #______Please Print: First MI Last Address______City______State______Zip______Charge to: _____Visa _____ MasterCard _____ American Express Card #______Exp. Date______Note: Credit card is the only method of payment. Checks are no longer accepted. Signature______Soc. Sec.#______Daytime Phone______State License(s)______Is this a new address? Yes______No______

Check one: ______I am currently enrolled. (If faxing or phoning in your answer form please note that $2.50 will be charged to your credit card.) ______I am not enrolled. Enclosed is my credit card information. Please charge my credit card $26.00 for each exam submitted. (plus $2.50 for each exam if submitting by fax or phone). ______I am not enrolled and I wish to enroll for 10 courses at $210.00 (thus saving me $50 over the cost of 10 individual exam fees). I understand there will be an additional fee of $2.50 for any exam I wish to submit via fax or phone. Over, please www.podiatrym.com JUNE/JULY 2016 | PODIATRY MANAGEMENT Enrollment Form & Answer Sheet (continued) Continuing

Medical Education

EXAM #5/16 Gunshot Wounds: Principles and Treatment (Rosen)

Circle: 1. A B c d 6. A B c d 2. A B c d 7. A B c d 3. A B c d 8. A B c d 4. A B c d 9. A B c d 5. A B c d 10. a B c d

Medical Education Lesson Evaluation

158 Strongly Strongly agree Agree neutral Disagree disagree [5] [4] [3] [2] [1]

1) This CME lesson was helpful to my practice ____

2) The educational objectives were accomplished ____

3) I will apply the knowledge I learned from this lesson ____

4) I will makes changes in my practice behavior based on this lesson ____

5) This lesson presented quality information with adequate current references ____ 6) What overall grade would you assign this lesson? ABCD How long did it take you to complete this lesson? ______hour ______minutes

What topics would you like to see in future CME lessons ? Please list : ______

JUNE/JULY 2016 | PODIATRY MANAGEMENT www.podiatrym.com