1 / 32

Humeral Shaft Fractures Secondary to GSW

Humeral Shaft Fractures Secondary to GSW. Jeff Easom, D.O. Garden City Hospital. GSW to Extremities. Cost of 14 billion conservatively Fractures of humerus occur infrequently when compared to LE

Download Presentation

Humeral Shaft Fractures Secondary to GSW

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.


Presentation Transcript

  1. Humeral Shaft Fractures Secondary to GSW Jeff Easom, D.O. Garden City Hospital

  2. GSW to Extremities • Cost of 14 billion conservatively • Fractures of humerus occur infrequently when compared to LE • Considerable controversy exists regarding management - surgical v. minimal intervention

  3. Ballistics • Destructive force directly proportional to KE (KE = 1/2 mv^2) • Velocity has greater contribution than mass except in shotgun injuries. Differ by the wt of the shot and presence of wadding which can become embedded in a wound from shotgun blasts at close range. • 12 gauge .00 @ close range~ten .22 cartridges

  4. Ballistics • Low velocity GSW - < 1000ft/sec • High velocity GSW - >2000ft/sec

  5. Pattern of Injury • Laceration and crushing - Primary mechanism of tissue damage • Shock waves - High velocity - damage imparted to distant and surrounding structures • Temporary cavitation - With velocity ~ 1000. Increases risk of bacteria, debris, and clothing being sucked into the wound.

  6. Gunshot Wound • Unique type of open frx. • Bullet is not rendered sterile as it is fired • GSW are contaminated • Low velocity - Typically resemble Type I and II open fractures (mild to moderate soft-tissue damage) • High velocity - Typically resemble Type III (extensive soft tissue damage and NV insult

  7. Initial Management • ATLS protocol • Total body survey for isolation of entry and exit wounds • Thorough NV exam • X-Rays - AP/Lateral of joint above and below • Doppler/Angiography if indicated

  8. Treatment • Cleansing/copious lavage • Early debridement of superficial necrotic tissue with cultures • Tetanus prophylaxis • Immobilization of fracture management • Primary v. delayed closure • ABX - IV v. oral

  9. Surgical exploration with bullet removal indicated only if there is a possiblility of damage to surrounding structures or retained bullet fragments within the joint space

  10. Role of Doppler v. Angiography • Ordog et al (JOT ;Vol 36, No. 3, 1994) • 2 part study over 14 years (1978 to 1992) • Part one - Retrospective - 7 years • Part two - 7 years

  11. Part one • Retrospective - no formal policy at institution for evaluation of GSW or indications for angiography • Pts with s/s of vascular injury and unstable- Sx with intraoperative angiogram if indicated • Pts with stable clinical status and signs of vascular injury - angiogram prior to surgery

  12. Part one cont. • Injuries without s/s of vascular injury not investigated

  13. Part one cont. • Results - 515 of 9035 pts underwent mandatory exploration. Arteriograms performed on 1415 ext. and 1288 studies (91%) were positive for arterial /major venous injury

  14. Part two • Protocol derived and study covered 7 years 1985-1992 • Group 1 - Clinically unstable with s/s vascular injury and tx of rapid stabilization and surgical exploration with or without intra-op angiogram

  15. Group 2 - Clinically stable with s/s of vascular injury. Treatment of assoc problems, angiography to determine injury, and selected surgery dependent on findings • Group 3 - Clinically stable with proximate (within 1 inch radius of known anatomic path of major vessel) and no s/s of vascular injury.

  16. Treatment of associated injuries > DDU of proximate vessel > angiography for positive or equivocal DDU findings and surgery if indicated • Group 4 - Clinically stable with no injury to proximate vascular structures and no s/s of vascular injury. Treatment of assoc injuries only and tx as o/p

  17. Part two results • 379 of 7281 extremity GSW underwent mandatory exploration. Arteriograms performed on 719 ext. with 661 (92%) showing positive arterial or major venous injury • Group 3 - 4194 pts with asymptomatic proximate injuries, with 462(11%) having vascular injuries identified by DDU.Surgery confirmed vascular injury.

  18. Group 4 - No unsuspected vascular injuries in group 4

  19. Authors recommend arteriography for injuries in high-risk areas when fracture is near vessels or proximate vessel injuries (groups 2 and 3) • Clinical evaluation alone is sufficient for pts meeting criteria for group 4 • Role continues to be debatable.

  20. ABX Usage • Controversy exists over use of oral v IV abx • Woloszyn et al - 132 pts with GSW frx. - overall infection rate of 1.5% - 0/80 infections with IV and 2/52 (3.8%) with oral (CORR, No. 26, January, 1988) • Knapp - prospective - 190 pts (222 fractures). Group 1 - 101 pts tx with IV ceph and gent x 3 days. Group 2 -89 pts tx with Cipro x 3 days (JBJS:78-A,No.8,8/96

  21. Two infections resulted in Group 1 and 2 in Group 2. Infection rate of 2% for both. • Conclusion of this study was that IV and oral ABX dosing were equally effective. • Overall, the role of ABX is not clear and remains controversial. Duration ranges from none to 1 week and dosages vary depending on individual authors.

  22. Humeral Shaft Fractures • Infrequent when caused by GSW • Treatment based on Open classification and criteria for surgery or closed reduction is dependent on fracture • Acceptable angulation for closed management is 20 degrees of anterior angulation and 30 degrees of varus angulation and 1 inch of bayonet apposition

  23. Indications for Operative Treatment • Multiple trauma, inadequate closed reduction or inability to maintain acceptable alignment, nonunion, pathologic fracture, assoc vascular injury, progressive radial nerve palsy, floating elbow, and open fractures. • Surgical means include ORIF with plate and screws, external fixation, and IM rodding.

  24. Surgical Management • Initial I&D in OR for Grade III and ER for Grades I and II. • Repeat I&D in 48 hours for Grade III and surgical stabilization if indicated. • Grade III open fractures need addition of AG in addition to cephalosporin.

  25. Initial PE • NVI Left upper extremity • 1cm exit wound postero-lateral aspect LUE • AROM intact @wrist • Active wrist extension

  26. ER Management • Coaptation splint application • Irrigation • Tetanus • ABX - IV Ancef

  27. Pre-op

  28. Pre-op

  29. Post-op Coaptation

  30. Post-op IM Nailing

  31. Two week f/u

  32. Two week f/u

More Related