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Management of gunshot wounds of the foot
S-C6
Management
Robert C Durkin,
of gunshot wounds
MDl, R Richard Coughlin,
of the foot
MD2
1 Resident, Department of Orthopaedic Surgery, University of California, San Francisco 2 Assistant Clinical Professor, Department of Orthopaedic Surgery, San Francisco General Hospital
Summary1 Civilian injuries due to firearms are increasing in the United States (1,Z). Criminal violence has sharply increased the incidence of high-velocity wounds in civilian practice (1). Gunshot wounds of the foot represent a special circumstance of the broad spectrum of firearm injuries. A fundamental understanding of the wounding mechanisms involving energy transfer is paramount to effective management. Furthermore, adequate care of the gunshot wound of the foot requires careful consideration of its unique anatomical constraints and of the biomechanical issues regarding weight-bearing and the gait cycle to ensure functional recovery. The purpose of this article is to review an approach to the care of gunshot wounds of the foot based on the literature and the authors’ experience treating these injuries at San Francisco General Hospital. Keywords: management,
gunshot wounds, foot, fracture, surgical internal fixation, orthopaedic surgery
Introduction Civilian injuries due to firearms are increasing in the United States (1,2). Fifty percent of American homes are estimated to contain a firearm. This leads to over 17,000 unintentional injuries annually. Often, these injuries are self-inflicted and caused by low muzzle velocity handguns (2-13). Criminal violence has sharply increased the
1 Abstracts in German, French, Italian, Spanish and Japanese are printed at the end of this supplement.
incidence of high-velocity wounds in civilian practice (1). One can no longer assume a civilian gunshot wound is of the low-velocity nature, therefore more active intervention by the surgeon is warranted. A fundamental understanding of the wounding mechanisms involved in three types of gunshot injuries - low-velocity, highvelocity, and shotgun - is paramount to effective care. More importantly, the energy transferred to a tissue is equal to the difference in kinetic energy of a bullet on entering and exiting a tissue (Fig. 1). Several authors state that the dissipation of energy is directly related to mass and velocity of a bullet and directly related to the density, tensile strength, and amount of tissue involved. Furthermore, the energy transferred is inversely related to the aerodynamics of the bullet path (5,12,14,15). The salient aspects of ballistics have been described in several excellent reviews (14,15). Gunshot wounds to the foot represent a special circumstance of the broad spectrum of firearm injuries. Despite a multitude of articles outlining the care of gunshot wounds to the limbs, (3,4,7-13,16-21) few authors discuss gunshot-induced injury to the foot (5,6,12). In addition, no prospective or randomized studies of treatment protocols have been reported. Functional outcomes have not been addressed, rather, numerous studies describe wound and fracture healing as study endpoints. Clearly, the foot sustaining a gunshot injury requires special consideration for full functional recovery. An understanding of the anatomy, biomechanics, and function of the foot is important to the management of gunshot wounds to the foot. The increased density of neurovascular structures, the large number of discrete
Durkin and Coughlin: Gunshot wounds of the foot articular relationships, and the limited volume of the foot in 8 fascial compartments allow for only limited deformation of tissues prior to severe injury. The proportion of bone to soft-tissue is high in the foot with a thin envelope dorsally. Therefore, it is not suprising that Boucree et al. (5) report fractures in more than 80% of patients (Fig. 2). Any missile entering the foot will strike a variety of structures before exiting, thereby generating a large number of secondary missiles. For this reason, the standard classification of wounds according to muzzle velocity used so often in the leg and thigh is less valid in the foot. Even low-velocity superficial wounds can lead to long-term sequelae -pain, deformity, and altered gait. In the normal gait cycle, the human foot must support body weight, adapt to the ground surface and absorb the energy of footstrike, and efficiently transfer muscle energy for locomotion. This function depends on painless mobile joint mechanics. Alteration of this intricate relationship will significantly affect functional outcome. Adequate care of the gunshot wound to the foot requires careful consideration of its unique anatomical constraints to ensure functional recovery. The purpose of this article is to review an approach to the care of gunshot wounds of the foot based on the literature and the authors’ experience treating these injuries at San Francisco General Hospital.
Initial
treatment
The patient with a gunshot wound to the foot should inspected carefully and the soft tissue defect should characterized and documented in the medical record photograph or drawing to assist in subsequent care.
be be by An
Fig. 2: The proportion of bone to soft tissue is high in the foot leading to a high incidence of osseous injury with gunshot wounds. initial assessment of the extent of devitalization of tissue can also be made at this time. However, the full extent of tissue damage may take up to 72 hours to evolve (11,22). The limb must be palpated for crepitance indicative of fracture, for masses suggestive of foreign bodies, and for overall stability of the osseous and soft
Fig. la,b: The energy transferred to the tissues of the foot is equal to the difference in kinetic energy of the bullet on entering and exiting. Secondary projectiles due to bullet fragmentation and tissue interaction lead to further injury. Injury 1997, Vol. 28, Suppl. 3
S-C8 tissue envelope. An assessment of vascularity is also made by direct palpation of peripheral pulses, nail-bed capillary refill times, and doppler ultrasound of peripheral vessels. Multiplanar reontgenograms are important to obtain while the patient is stabilized but prior to the application of dressings or casts that would impair the quality of the radiograph. Compartment syndrome can be difficult to diagnose after trauma to the foot since the patient frequently has severe pain and the compartments are difficult to evaluate by manual palpation (23,24). Pain out of proportion to the insult is an early sign of increased compartment pressure. Injuries to the forefoot make passive flexion tests less useful. Direct measurement of compartmental pressures in the foot using a slit catheter may help to confirm the diagnosis (25). Normal compartment pressures are in the range of 4-5 mmHg. Elevation of the compartment pressure so that the difference between diastolic blood pressure and compartment pressure is less than 30 mmHg is suggestive of compartment syndrome and warrants a decompressive fasciotomy
(23,25-27). The initial treatment in the emergency room should include lavage of the soft tissue wounds and tract. Superficial debridement of grossly contaminated tissue with foreign material such as wadding or clothing is indicated. Routine coring of the skin wound and missile tract is not necessary; but should be reserved for those wounds demonstrating significant tissue devitalization (9-11). A sterile dressing should be applied with a temporary splint.
Antibiotics The use of antibiotics for gunshot wounds of the feet remains controversial. In earlier literature concerning gunshot fractures of the limbs, culture and routine antibiotic prophylaxis were not recommended (8-10,18). Ordog et al. reviewed the outpatient management of civilian gunshot wounds at a major county hospital in Los Angeles, California, over a 4 year period (28). Approximately 28,000 patients with superficial soft tissue gunshot wounds were seen during the study period with 16,000 (60%) treated as outpatients. Fractures were excluded from the study group. Interestingly, while less than 5% of the patients received antibiotics, only 1.8% developed wound infections. Approximately three percent of injuries involved the foot. Geissler et al. demonstrated that a single intramuscular injection of a long-acting third-generation cephalosporin (Cefonicid 1 gm) prevented infection as well as a 48 hour regimen of intravenous antibiotics in two groups of patients sustaining low-velocity gunshot fractures (7). Hull suggested that antibiotics were necessary for 24 - 48 hours only if internal fixation was used (11). In contrast, other authors recommend 2-3 days of
intravenous first-generation cephalosporin for gunshot wounds to the foot (5,12,29,30). Patzakis et al. demonstrated a clear benefit of intravenous administration of a first-generation cephalosporin over no antibiotics in gunshot wounds to the limbs. In a separate study, this author observed half the infection rate in open fractures treated with antibiotics within 3 hours of injury in comparison to injuries where antibiotics were delayed for over 3 hours (31,32).
Operative
debridement
A thorough assessment of the soft tissue contamination and vascularity is imperative. Classically, surgical debridement was recommended for high-energy wounds to the limbs only (4,8,10). Morgan reviewed 40 low energy, lower limb gunshot wounds managed with 5 days of antibiotics without debridement. Despite 17 patients with fevers >102 “F, none became infected or required re-admission, antibiotics, or surgical procedures (18). Caution, however, must be exercised in the foot where the ratio of bone to soft tissue is high. Even low velocity missiles can cause extensive soft tissue stripping of fractures and increase the risk of infection. Therefore, surgical irrigation and gentle debridement is usually necessary to prevent infection (7). Further soft tissue stripping from bony fragments should be avoided to prevent devascularization. Yet, all free osseous fragments not essential to the stability of the bone or joints should be debrided since loss of blood supply to these fragments will lead to their necrosis and wound infection (7,16,18,21,22,29-31). High-energy wounds with extensive soft tissue damage should be treated with aggressive debridement of non-viable tissues. Since necrosis can evolve over 48 hours, return to the operating suite for repeat debridement is indicated. Once the wound is free of contamination, coverage can be considered (5,16,19,22,33).
Bone stabilization In contrast to long bone and major joint injuries, external fixation of the foot rarely provides sufficient stabilization for effective alignment and healing. The larger volume of articulating osseous segments in the foot leads to a higher probability of intra-articular fractures after any gunshot injury (Fig. 3). Therefore, limited internal fixation and percutaneous pin fixation may be required to optimize alignment (Fig. 4). Molinari and coworkers reviewed 121 low velocity gunshot fractures over a 10 year period. The total deep infection rate was 2.6% and nonunion rate was 3.3%. No significant difference was noted with respect to early versus delayed fixation of these open gunshot fractures (17). One must carefully assess the soft tissue envelope for the level of
Duvkin and Coughlin: Gunshot wounds of the foot contamination and necrosis to decide whether early versus delayed fixation will be tolerated by the patient.
Soft tissue coverage The discussion regarding closure or coverage should begin early in the course of treatment, but the final decision depends upon the full assessment of soft tissue damage. The choice of closure must proceed from the simple to the most complex. Primary closure of all surgically created incisions can be performed without hesitation as long as the foot compartment pressures remain low. Otherwise, primary closure is associated with increased complications and has been abandoned by some authors (31). Hoekstra noted infection in 25% of gunshot wounds undergoing delayed primary closure. Therefore, smaller gunshot wounds should be cleansed and allowed to heal by secondary intention. High energy wounds or those wounds untreated over 8 hours require more aggressive treatment and multiple debridements to prevent infection. Myocutaneous
Fig. 3: Intra-articular foreign bodies and articular fractures are frequently encountered in gunshot injury to the foot and ankle. This bullet protruded into the ankle mortise requiring open removal to prevent further articular damage with motion and weight-bearing. Injury 2997, Vol. 28, Suppl. 3
s-c9 flap coverage can be considered for the sensate foot with extensive soft tissue loss. Early consultation with a microvascular surgeon will allow for the optimal management of complex wounds (16, 33-36) (Fig. 5a,b). Bender reviewed 124 patients with high-energy shotgun injuries to the limbs. Twenty wounds required an average of 3 surgical debridements. Two patients had a delayed primary closure and two patients were allowed to granulate. Nine patients subsequently underwent skin grafting. Seven patients received myocutaneous flap coverage. Ten percent of the wounds to the lower limbs required a decompressive fasciotomy and six patients required amputation. This study demonstrated the variety of solutions to coverage problems in highenergy gunshot wounds (3). Early amputation must also be considered in the severely injured foot to prevent the significant morbidity associated with failed reconstruction. Unfortunately, no clear parameters for amputation yet exist. The only firm indication is loss of posterior tibia1 nerve function causing an insensate foot. The scoring systems used for the mangled limb have not been applied to severe gunshot
Fig. 4: Gunshot-induced fractures in the foot frequently require fixation for stability.
S-Cl0 fractures of the foot in a systematic way (33,34,37). Thus, clinical judgement remains as the most significant tool to decide between salvage or amputation. Fortunately, major advances in limb salvage in the last decade have improved the treatment and outcome of patients with severe injuries to the foot (34).
Mobilization/weight-bearing Early mobilization of the patient will prevent associated morbidities such as pulmonary complications, thromboembolic disease, or gastrointestinal disturbances. Specific mobilization of the injured foot and ankle is dependent on associated soft tissue constraints and fracture stabilization. Although weight-bearing will be dictated by the healing of fractures, early range of motion of the foot and ankle may prevent arthrofibrosis, oedema, and reflex sympathetic dystrophy leading to functional declines (l&38). Therefore,
reconstructive efforts must be motivated to provide enough internal stability to allow active or passive movement.
Complications Studies of gunshot wounds to the foot have primarily used wound and fracture healing or infection rates as primary indicators of treatment outcome. No comprehensive reports of major complications are available. It is the authors’ opinion that complications related to gunshot wounds to the feet are much more common than the complications reported for gunshot injury to the limbs since the energy absorbed by the foot is concentrated in a discrete anatomical domain vital for functional ambulation. A partial list of complications seen in gunshot wounds to the foot is presented in Table 1.
Table 1: Complications
of gunshot wounds to the foot.
Infectious
l-14%
Osseous
delayed union malunion
Articular
arthritis arthrofibrosis
Soft tissue
ulceration keratoses contracture/toe
Neurovascular
Fig. Sa,b: a: This high-energy gunshot wound required multiple debridements after temporary fixation of fractures.
deformity
compartment syndrome ischaemia neuroma formation reflex sympathetic dystrophy chronic pain syndrome organic vs psychogenic
Conclusion
b: Soft tissue and bony injuries were treated with tricortical iliac bone graft, internal fixation, and myocutaneous free flap coverage.
Injuries due to firearms in the United States are increasing each year at a significant cost to society (1). Due to the high density of vital structures and articular relationships in the foot, gunshot wounds can lead to significant morbidity with long-term consequences -pain, deformity, and altered gait. The accurate assessment of the energy transmitted to the tissues will guide subsequent management. A methodical approach to initial care may optimize later reconstructive efforts by reducing the risk of infection and further injury to damaged tissues. A multispecialty approach to high-energy wounds can improve functional recovery of the injured foot.
Durkin and Coughlin: Gunshot wounds of the foot
S-Cl1 22. Swiontowski M. Criteria for bone debridement in massive lower limb trauma. Clin. Orthop. 1989;243:20-9.
References 1. Ryan M, Leighton T, Pianim N, Klein S , Bongard ical and economic consequences of gang-related ings. American Surgeon, 1993;59:831-3.
F. Medshoot-
2. Sinauer N, Annest J , Mercy J. Unintentional, nonfatal firearm-related injuries. A preventable public health burden. JAMA 1996;275:1740-3. 3. Bender J, Hoekstra S, Levison M. Improving outcome from extremity shotgun injury. Am. Surg. 1993;59:359-64. 4.
Billings J, Zimmerman M, Aurori B, Parsons J , Swan K. Gunshot wounds to the extremities. Experience of a level 1 trauma center. Orthop. Rev. 1991;20:519-24.
5. Boucree JJ, Gabriel to the foot. Orthop.
R , Lezine-Hanna J. Gunshot Clin. NA 1995;26:191-7.
6. Butler B , Wertheimer S. Close range shotgun the foot. J. Foot Surg. 1992;31:578-83.
wounds wounds
to
7. Geissler W, Teasedall R, Tomasin J , Hughes J. Management of low velocity gunshot-induced fractures. J. Orthop. Trauma 1990;4:39-41.
23. Myerson M , Manoli A. Compartment syndromes of the foot after calcaneal fractures. Clin. Orthop. 1993;142-50. 24. Fakhouri AJ , Manoli AD. Acute foot compartment dromes. J. Orthop. Trauma 1992;6:223-8.
syn-
25. Moed BR, Thorderson PK. Measurement of intracompartmental pressure: a comparison of the slit catheter, sideported needle, and simple needle. J. Bone Joint Surg. 1993;75A:231-5. 26. Finkelstein JA, Hunter GA, Hu RW. Lower limb compartment syndrome: course after delayed fasciotomy. J. Trauma 1996;40:342-4. 27. Steinberg BD, Gelberman RH. Evaluation of limb compartment with suspected increased interstitial pressure. Anoninvasive method for determining quantitative hardness. Clin. Orthop. 1994;248-53. 28. Ordog G, Wasserberger G, Balasubramanium maker W. Civilian gunshot wounds - outpatient ment. J. Trauma 1994;36:106-11.
S, Shoemanage-
8. Hampton 0. The indications for debridement of gunshot (bullet) wounds of the extremities in civilian practice. J. Trauma 1961;368-72.
29. Gustilo R , Anderson J. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones. Retrospective and prospective analysis. J. Bone Joint Surg. 1976;58A:453-8.
9. Hennessy M, Banks H, Leach R, Quigley T. Extremity gunshot wound and gunshot fracture in civilian practice. Clin Orthop. 1976;114:296-303.
30. Gustilo R, Merkow R, Templeman D. The management open fractures. J. Bone Joint Surg. 1990;72A:299-303.
10. Howland W , Ritchey S. Gunshot fractures in civilian tice. J. Bone Joint Surg. 1971;53A:47-53. 11. Hull J. Management of gunshot ties. J. Trauma 1976;40:193-7.
fractures
prac-
of the extremi-
12. Sergi A, Acello A. Gunshot wounds to the foot and ankle. Clin. Pod. Med. Surg. 1995;12:689-702. 13. Stucky W, Loder R. Extremity gunshot wounds J. Ped. Orthop. 1991;11:64-71.
in children.
14. Barach E, Tomlarovich B , Nowak R. Ballistics. A pathophysiologic examination of the wounding mechanisms of firearms: Part 1. J. Trauma, 1986;26:225-35. 15. Barach E, Tomlarovich B , Nowak R. Ballistics. A pathophysiologic examination of the wounding mechanisms of firearms: Part 2. J. Trauma, 1986;26:374-83. 16. Hoekstra S, Bender J, Levison M. The management of large soft-tissue defects following close-range shotgun injury. J. Trauma 1990;30:1489-93. 17. Molinari R, Yang E, Strauss E, Einhorn nal fixation in low-velocity extremity Contemp. Orthop. 1994;29:335-9.
T. Timing of intergunshot fractures.
18. Morgan M, Spencer A, Hershey F. Debridement of civilian gunshot wounds of soft tissue. J. Trauma 1961;354-360. 19. O’Sullivan S, O’Shaughnessy shotgun injuries sustained 1996;27:63-7. 20. Scully R. An evaluation ing viability of muscle 1956;73:1031.
31. Patzakis M , Wilkins J. Factors influencing infection rates in open fracture wounds. Clin. Orthop., 1989;243:36-40. 32. Patzakis M, Harvey J, Ivier D. The role of antibiotics management of open fractures. J. Bone Joint 1974;58A:453-8.
in the Surg.
33. Poole G, Agnew S, Griswold J, Rhodes R. The mangled lower extremity: can salvage be predicted. American Surgeon 1994;60:50-5. 34. Vasconez H, Nicholls l? Management of extremity injuries with external fixator or Ilizarov devices. Cooperative effort between orthopedic and plastic surgeons. Clin. Plast. Surg. 1991;18:505-13. 35. Gould J, Shi S. Free vascularized soft tissue flaps for coverage of the foot and ankle. Clin. Orthop. 1995;314:26-36. 36. Galumbeck M, Freeman B. Arterialized venous flaps for reconstructing soft-tissue defects of the extremities. Plast. Reconstr. Surg. 1994;94:997-1002. 37. McNamara M, Heckman J, Corley F. Severe open fractures of the lower extremity: A retrospective evaluation of the Mangled Extremity Severity Score (MESS). J. Orthop. Trauma 1994;8:81-7. 38. Seale K. Reflex Sympathetic Dystrophy tremity. Clin. Orthop. 1989;243:80-7
of the lower
ex-
M, O’Connor T. Accidental in game-shooting. Injury
of surgeon’s criteria for determinduring debridement. Arch. Surg.
21. Thorsby F , Darlow H. The mechanism of primary infection in bullet wounds. J. Bone Joint Surg., 1967;54A: 359-62.
Injury 1997, Vol. 28, Suppl. 3
of
Address correspondence and reprint requests to: Robert C Durkin MD, Department of Orthopaedic Surgery, University of California, San Francisco, 500 Parnassus Avenue, MU-320 W, San Francisco, CA 94143-0728, (415) 476-1166, (415) 476-1304 fax
Management
Robert C Durkin,
of gunshot wounds
MDl, R Richard Coughlin,
of the foot
MD2
1 Resident, Department of Orthopaedic Surgery, University of California, San Francisco 2 Assistant Clinical Professor, Department of Orthopaedic Surgery, San Francisco General Hospital
Summary1 Civilian injuries due to firearms are increasing in the United States (1,Z). Criminal violence has sharply increased the incidence of high-velocity wounds in civilian practice (1). Gunshot wounds of the foot represent a special circumstance of the broad spectrum of firearm injuries. A fundamental understanding of the wounding mechanisms involving energy transfer is paramount to effective management. Furthermore, adequate care of the gunshot wound of the foot requires careful consideration of its unique anatomical constraints and of the biomechanical issues regarding weight-bearing and the gait cycle to ensure functional recovery. The purpose of this article is to review an approach to the care of gunshot wounds of the foot based on the literature and the authors’ experience treating these injuries at San Francisco General Hospital. Keywords: management,
gunshot wounds, foot, fracture, surgical internal fixation, orthopaedic surgery
Introduction Civilian injuries due to firearms are increasing in the United States (1,2). Fifty percent of American homes are estimated to contain a firearm. This leads to over 17,000 unintentional injuries annually. Often, these injuries are self-inflicted and caused by low muzzle velocity handguns (2-13). Criminal violence has sharply increased the
1 Abstracts in German, French, Italian, Spanish and Japanese are printed at the end of this supplement.
incidence of high-velocity wounds in civilian practice (1). One can no longer assume a civilian gunshot wound is of the low-velocity nature, therefore more active intervention by the surgeon is warranted. A fundamental understanding of the wounding mechanisms involved in three types of gunshot injuries - low-velocity, highvelocity, and shotgun - is paramount to effective care. More importantly, the energy transferred to a tissue is equal to the difference in kinetic energy of a bullet on entering and exiting a tissue (Fig. 1). Several authors state that the dissipation of energy is directly related to mass and velocity of a bullet and directly related to the density, tensile strength, and amount of tissue involved. Furthermore, the energy transferred is inversely related to the aerodynamics of the bullet path (5,12,14,15). The salient aspects of ballistics have been described in several excellent reviews (14,15). Gunshot wounds to the foot represent a special circumstance of the broad spectrum of firearm injuries. Despite a multitude of articles outlining the care of gunshot wounds to the limbs, (3,4,7-13,16-21) few authors discuss gunshot-induced injury to the foot (5,6,12). In addition, no prospective or randomized studies of treatment protocols have been reported. Functional outcomes have not been addressed, rather, numerous studies describe wound and fracture healing as study endpoints. Clearly, the foot sustaining a gunshot injury requires special consideration for full functional recovery. An understanding of the anatomy, biomechanics, and function of the foot is important to the management of gunshot wounds to the foot. The increased density of neurovascular structures, the large number of discrete
Durkin and Coughlin: Gunshot wounds of the foot articular relationships, and the limited volume of the foot in 8 fascial compartments allow for only limited deformation of tissues prior to severe injury. The proportion of bone to soft-tissue is high in the foot with a thin envelope dorsally. Therefore, it is not suprising that Boucree et al. (5) report fractures in more than 80% of patients (Fig. 2). Any missile entering the foot will strike a variety of structures before exiting, thereby generating a large number of secondary missiles. For this reason, the standard classification of wounds according to muzzle velocity used so often in the leg and thigh is less valid in the foot. Even low-velocity superficial wounds can lead to long-term sequelae -pain, deformity, and altered gait. In the normal gait cycle, the human foot must support body weight, adapt to the ground surface and absorb the energy of footstrike, and efficiently transfer muscle energy for locomotion. This function depends on painless mobile joint mechanics. Alteration of this intricate relationship will significantly affect functional outcome. Adequate care of the gunshot wound to the foot requires careful consideration of its unique anatomical constraints to ensure functional recovery. The purpose of this article is to review an approach to the care of gunshot wounds of the foot based on the literature and the authors’ experience treating these injuries at San Francisco General Hospital.
Initial
treatment
The patient with a gunshot wound to the foot should inspected carefully and the soft tissue defect should characterized and documented in the medical record photograph or drawing to assist in subsequent care.
be be by An
Fig. 2: The proportion of bone to soft tissue is high in the foot leading to a high incidence of osseous injury with gunshot wounds. initial assessment of the extent of devitalization of tissue can also be made at this time. However, the full extent of tissue damage may take up to 72 hours to evolve (11,22). The limb must be palpated for crepitance indicative of fracture, for masses suggestive of foreign bodies, and for overall stability of the osseous and soft
Fig. la,b: The energy transferred to the tissues of the foot is equal to the difference in kinetic energy of the bullet on entering and exiting. Secondary projectiles due to bullet fragmentation and tissue interaction lead to further injury. Injury 1997, Vol. 28, Suppl. 3
S-C8 tissue envelope. An assessment of vascularity is also made by direct palpation of peripheral pulses, nail-bed capillary refill times, and doppler ultrasound of peripheral vessels. Multiplanar reontgenograms are important to obtain while the patient is stabilized but prior to the application of dressings or casts that would impair the quality of the radiograph. Compartment syndrome can be difficult to diagnose after trauma to the foot since the patient frequently has severe pain and the compartments are difficult to evaluate by manual palpation (23,24). Pain out of proportion to the insult is an early sign of increased compartment pressure. Injuries to the forefoot make passive flexion tests less useful. Direct measurement of compartmental pressures in the foot using a slit catheter may help to confirm the diagnosis (25). Normal compartment pressures are in the range of 4-5 mmHg. Elevation of the compartment pressure so that the difference between diastolic blood pressure and compartment pressure is less than 30 mmHg is suggestive of compartment syndrome and warrants a decompressive fasciotomy
(23,25-27). The initial treatment in the emergency room should include lavage of the soft tissue wounds and tract. Superficial debridement of grossly contaminated tissue with foreign material such as wadding or clothing is indicated. Routine coring of the skin wound and missile tract is not necessary; but should be reserved for those wounds demonstrating significant tissue devitalization (9-11). A sterile dressing should be applied with a temporary splint.
Antibiotics The use of antibiotics for gunshot wounds of the feet remains controversial. In earlier literature concerning gunshot fractures of the limbs, culture and routine antibiotic prophylaxis were not recommended (8-10,18). Ordog et al. reviewed the outpatient management of civilian gunshot wounds at a major county hospital in Los Angeles, California, over a 4 year period (28). Approximately 28,000 patients with superficial soft tissue gunshot wounds were seen during the study period with 16,000 (60%) treated as outpatients. Fractures were excluded from the study group. Interestingly, while less than 5% of the patients received antibiotics, only 1.8% developed wound infections. Approximately three percent of injuries involved the foot. Geissler et al. demonstrated that a single intramuscular injection of a long-acting third-generation cephalosporin (Cefonicid 1 gm) prevented infection as well as a 48 hour regimen of intravenous antibiotics in two groups of patients sustaining low-velocity gunshot fractures (7). Hull suggested that antibiotics were necessary for 24 - 48 hours only if internal fixation was used (11). In contrast, other authors recommend 2-3 days of
intravenous first-generation cephalosporin for gunshot wounds to the foot (5,12,29,30). Patzakis et al. demonstrated a clear benefit of intravenous administration of a first-generation cephalosporin over no antibiotics in gunshot wounds to the limbs. In a separate study, this author observed half the infection rate in open fractures treated with antibiotics within 3 hours of injury in comparison to injuries where antibiotics were delayed for over 3 hours (31,32).
Operative
debridement
A thorough assessment of the soft tissue contamination and vascularity is imperative. Classically, surgical debridement was recommended for high-energy wounds to the limbs only (4,8,10). Morgan reviewed 40 low energy, lower limb gunshot wounds managed with 5 days of antibiotics without debridement. Despite 17 patients with fevers >102 “F, none became infected or required re-admission, antibiotics, or surgical procedures (18). Caution, however, must be exercised in the foot where the ratio of bone to soft tissue is high. Even low velocity missiles can cause extensive soft tissue stripping of fractures and increase the risk of infection. Therefore, surgical irrigation and gentle debridement is usually necessary to prevent infection (7). Further soft tissue stripping from bony fragments should be avoided to prevent devascularization. Yet, all free osseous fragments not essential to the stability of the bone or joints should be debrided since loss of blood supply to these fragments will lead to their necrosis and wound infection (7,16,18,21,22,29-31). High-energy wounds with extensive soft tissue damage should be treated with aggressive debridement of non-viable tissues. Since necrosis can evolve over 48 hours, return to the operating suite for repeat debridement is indicated. Once the wound is free of contamination, coverage can be considered (5,16,19,22,33).
Bone stabilization In contrast to long bone and major joint injuries, external fixation of the foot rarely provides sufficient stabilization for effective alignment and healing. The larger volume of articulating osseous segments in the foot leads to a higher probability of intra-articular fractures after any gunshot injury (Fig. 3). Therefore, limited internal fixation and percutaneous pin fixation may be required to optimize alignment (Fig. 4). Molinari and coworkers reviewed 121 low velocity gunshot fractures over a 10 year period. The total deep infection rate was 2.6% and nonunion rate was 3.3%. No significant difference was noted with respect to early versus delayed fixation of these open gunshot fractures (17). One must carefully assess the soft tissue envelope for the level of
Duvkin and Coughlin: Gunshot wounds of the foot contamination and necrosis to decide whether early versus delayed fixation will be tolerated by the patient.
Soft tissue coverage The discussion regarding closure or coverage should begin early in the course of treatment, but the final decision depends upon the full assessment of soft tissue damage. The choice of closure must proceed from the simple to the most complex. Primary closure of all surgically created incisions can be performed without hesitation as long as the foot compartment pressures remain low. Otherwise, primary closure is associated with increased complications and has been abandoned by some authors (31). Hoekstra noted infection in 25% of gunshot wounds undergoing delayed primary closure. Therefore, smaller gunshot wounds should be cleansed and allowed to heal by secondary intention. High energy wounds or those wounds untreated over 8 hours require more aggressive treatment and multiple debridements to prevent infection. Myocutaneous
Fig. 3: Intra-articular foreign bodies and articular fractures are frequently encountered in gunshot injury to the foot and ankle. This bullet protruded into the ankle mortise requiring open removal to prevent further articular damage with motion and weight-bearing. Injury 2997, Vol. 28, Suppl. 3
s-c9 flap coverage can be considered for the sensate foot with extensive soft tissue loss. Early consultation with a microvascular surgeon will allow for the optimal management of complex wounds (16, 33-36) (Fig. 5a,b). Bender reviewed 124 patients with high-energy shotgun injuries to the limbs. Twenty wounds required an average of 3 surgical debridements. Two patients had a delayed primary closure and two patients were allowed to granulate. Nine patients subsequently underwent skin grafting. Seven patients received myocutaneous flap coverage. Ten percent of the wounds to the lower limbs required a decompressive fasciotomy and six patients required amputation. This study demonstrated the variety of solutions to coverage problems in highenergy gunshot wounds (3). Early amputation must also be considered in the severely injured foot to prevent the significant morbidity associated with failed reconstruction. Unfortunately, no clear parameters for amputation yet exist. The only firm indication is loss of posterior tibia1 nerve function causing an insensate foot. The scoring systems used for the mangled limb have not been applied to severe gunshot
Fig. 4: Gunshot-induced fractures in the foot frequently require fixation for stability.
S-Cl0 fractures of the foot in a systematic way (33,34,37). Thus, clinical judgement remains as the most significant tool to decide between salvage or amputation. Fortunately, major advances in limb salvage in the last decade have improved the treatment and outcome of patients with severe injuries to the foot (34).
Mobilization/weight-bearing Early mobilization of the patient will prevent associated morbidities such as pulmonary complications, thromboembolic disease, or gastrointestinal disturbances. Specific mobilization of the injured foot and ankle is dependent on associated soft tissue constraints and fracture stabilization. Although weight-bearing will be dictated by the healing of fractures, early range of motion of the foot and ankle may prevent arthrofibrosis, oedema, and reflex sympathetic dystrophy leading to functional declines (l&38). Therefore,
reconstructive efforts must be motivated to provide enough internal stability to allow active or passive movement.
Complications Studies of gunshot wounds to the foot have primarily used wound and fracture healing or infection rates as primary indicators of treatment outcome. No comprehensive reports of major complications are available. It is the authors’ opinion that complications related to gunshot wounds to the feet are much more common than the complications reported for gunshot injury to the limbs since the energy absorbed by the foot is concentrated in a discrete anatomical domain vital for functional ambulation. A partial list of complications seen in gunshot wounds to the foot is presented in Table 1.
Table 1: Complications
of gunshot wounds to the foot.
Infectious
l-14%
Osseous
delayed union malunion
Articular
arthritis arthrofibrosis
Soft tissue
ulceration keratoses contracture/toe
Neurovascular
Fig. Sa,b: a: This high-energy gunshot wound required multiple debridements after temporary fixation of fractures.
deformity
compartment syndrome ischaemia neuroma formation reflex sympathetic dystrophy chronic pain syndrome organic vs psychogenic
Conclusion
b: Soft tissue and bony injuries were treated with tricortical iliac bone graft, internal fixation, and myocutaneous free flap coverage.
Injuries due to firearms in the United States are increasing each year at a significant cost to society (1). Due to the high density of vital structures and articular relationships in the foot, gunshot wounds can lead to significant morbidity with long-term consequences -pain, deformity, and altered gait. The accurate assessment of the energy transmitted to the tissues will guide subsequent management. A methodical approach to initial care may optimize later reconstructive efforts by reducing the risk of infection and further injury to damaged tissues. A multispecialty approach to high-energy wounds can improve functional recovery of the injured foot.
Durkin and Coughlin: Gunshot wounds of the foot
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Injury 1997, Vol. 28, Suppl. 3
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Address correspondence and reprint requests to: Robert C Durkin MD, Department of Orthopaedic Surgery, University of California, San Francisco, 500 Parnassus Avenue, MU-320 W, San Francisco, CA 94143-0728, (415) 476-1166, (415) 476-1304 fax