Treating Gunshot Wounds In The Lower Extremity

Brandon R. James, DPM, Lawrence M. Fallat, DPM, FACFAS, and Pamela Morrison, DPM, FACFAS

   Tissue characteristics also affect the injury pattern. Tissues that have more elasticity and relatively low density such as skin can be spared from serious injury with gunshot wounds.9,13,14 In contrast, dense organs with less elasticity such as bone absorb more energy, resulting in more damage. When a missile strikes bone, fracture, missile deformation, missile fragmentation and secondary missile production may all occur.7 The high ratio of bone to soft tissue within the foot and ankle is the main reason missile injuries are so devastating to this region.

Keys To Initial Documentation And Management Of Injuries

Although accidental gunshot wounds are common, when evaluating these wounds, it is necessary to document injuries objectively and clearly.17 Although emergency physicians typically manage these wounds, a detailed description of the wound is important. Incorrect documentation can have medicolegal implications. Accordingly, one should refrain from opinion on and differentiation of entry or exit wounds.17 Instead, note the size, shape, anatomic location and associated findings including powder or soot burns.17

   The distance from the end of the barrel to the target is typically less than three feet if a powder burn is visible.3 Photographing the wound may prove to be useful. If one must remove clothing from a victim, avoid disturbing any missile holes in shoes or clothing. One should save all missile fragments, document them and handle them with care.17

   The management of a firearm injury to the lower extremity is an emergency but comes secondary to treatment of the patient as a whole.18 After stabilizing the wound, one should obtain an accurate history if possible. The history should include the type and caliber of missile, the type of weapon used, the distance from the weapon to the patient and the position of the victim when the incident occurred.3

A Guide To Injury Assessment

Firearm injuries are unique because of the variability of action and anatomy involved. The victim’s clinical examination will reveal skin wounds and the approximate location of fractures. One must determine the patient’s distal neurovascular status as soon as possible. Clinically, if one suspects vascular insult because of the inability to palpate pulses, a white or blue discoloration of the skin or excessive bleeding, then angiography may be beneficial.
Compartment syndrome may also occur with gunshot wounds. If the physician suspects increased compartment pressures, take measurements and if the pressures are elevated, perform an appropriate fasciotomy as a medical emergency.

   Flush the gunshot wound with sterile saline and do a preliminary cleaning of the wound. Then take anaerobic and aerobic wound cultures, and consider appropriate routine tetanus prophylaxis.3 One needs to ensure immediate hemorrhage control and stabilization of the lower limb before taking radiographs.18 Radiographs allow for identification of gas, fractures, bone fragments, the extent of soft tissue injury, the location of retained missiles and other retained foreign bodies such as fragments of sock and shoe material.

   At this stage in treatment, clinicians can make a judgment as to the probable degree of energy transfer within the wound. Peripheral nerve damage can be difficult to evaluate initially. Due to tissue damage and pain, the patient may be unwilling to attempt to move his or her foot to evaluate motor function and assist in the determination of sensation. As with vascular evaluation, the physician may have an index of suspicion of nerve damage based on the proximity of the wound to the peripheral nerves.

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