Treating Gunshot Wounds In The Lower Extremity

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Author(s): 
Brandon R. James, DPM, Lawrence M. Fallat, DPM, FACFAS, and Pamela Morrison, DPM, FACFAS

   Although there is a possibility of lead toxicity from retained missile fragments anywhere within the body, it is unusual for lead absorption to occur in an extra-articular manner. When it comes to non-articular missile fragments, they do not require surgical removal and most often provide insignificant long-term complications.27 In addition, in cases of shotgun injuries, it may be impossible to remove all of the buckshot.

   However, lead becomes soluble in organic acids such as synovial fluid, producing increased blood lead concentrations.27 The symptoms of lead intoxication are vague and multiple organs can be affected. The symptoms often include fatigue, malaise, joint pain, headaches, nausea, vomiting, constipation and changes in memory, behavior and attention span.24-27 Consequently, when a lead fragment is within a joint, the excision of the fragment is essential.14 A clinician should suspect lead poisoning in a patient with microcytic anemia, basophilic stippling and abdominal pain.9,27

Case Study: When A Patient Shoots His Foot And Goes On To Amputation

A 42-year-old male presented to the emergency department after accidentally shooting himself in the left foot with a shotgun. His medical history was positive for bipolar disorder, chronic obstructive pulmonary disease and a previous drug overdose. His surgical history was positive for previous treatment of a gunshot wound to his left foot two years prior to the current injury. He was taking venlafaxine (Effexor, Pfizer), quetiapine (Seroquel, AstraZeneca), diazepam (Valium, Hoffman-LaRoche) and carisprodol (Soma), and had no allergies to medications.

   The initial evaluation revealed massive soft tissue damage to the dorsal and plantar aspect of his foot. The entry wound was located over the medial metatarsals and dorsalis pedis artery extending completely through the foot. The wounds consisted of irregular wound borders and devitalized tissue. Motor function and sensation were intact. The vascular exam indicated a capillary refill time of four seconds to the great toe. The patient graded his pain as 10 out of 10. Standard X-rays revealed comminution of the first and second metatarsals with most of the first metatarsal missing. There were also fractures of the third and fourth metatarsals, and proximal phalanges of the second, third and fourth toes. Numerous bone and missile fragments were scattered throughout the wound.

   The patient started on IV antibiotic prophylaxis and went to surgery four hours after the injury occurred. The procedure involved taking deep aerobic and anaerobic cultures. We debrided all devitalized tissue, removing small, loose fragments of bone, missile fragments, debris and hematoma. After performing power antibiotic irrigation, we inserted drains and applied retention sutures.

   Two days later, the patient went back to surgery. We performed further debridement and irrigation. There was no evidence of infection or ischemic changes. To stabilize the foot, we inserted Kirschner wires in the medullary canal of the second metatarsal and inserted an allogenic strut as a spacer where the first metatarsal would have been located. We used a Kirschner wire for stabilization.

   After one week, his left great toe became gangrenous and we proceeded to perform an amputation. We subsequently irrigated the wound and performed primary closure as the tissue was healthy. The patient discharged himself from the hospital against medical advice and was reluctant to return for any follow-up visits. One month later, he presented to the emergency department with a wound dehiscence and infection of his left foot. His white blood cell count was 13,000. We administered IV antibiotics and performed a midfoot amputation the next day.

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