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