Humeral Shaft Fractures Secondary to GSW

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Humeral Shaft Fractures Secondary to GSW

• Jeff Easom, D.O.
• Garden City Hospital

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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
  

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Ballistics

• Destructive force directly proportional to KE (KE
  1/2 mv2)
• 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 _at_ close rangeten .22 cartridges

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Ballistics

• Low velocity GSW - lt 1000ft/sec
• High velocity GSW - gt2000ft/sec

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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.

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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

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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

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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

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• 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

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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

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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

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Part one cont.

• Injuries without s/s of vascular injury not
  investigated

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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

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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

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• 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.

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• Treatment of associated injuries gt DDU of
  proximate vessel gt 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

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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.

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• Group 4 - No unsuspected vascular injuries in
  group 4

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• 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.

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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
  (JBJS78-A,No.8,8/96

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• 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.

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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

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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.

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Surgical Management

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

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Initial PE

• NVI Left upper extremity
• 1cm exit wound postero-lateral aspect LUE
• AROM intact _at_wrist
• Active wrist extension

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ER Management

• Coaptation splint application
• Irrigation
• Tetanus
• ABX - IV Ancef

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Pre-op
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Pre-op
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Post-op Coaptation
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Post-op IM Nailing
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Two week f/u
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Two week f/u