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Humeral Shaft Fractures Secondary to GSW

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Humeral Shaft Fractures Secondary to GSW Jeff Easom, D.O. Garden City Hospital GSW to Extremities Cost of 14 billion conservatively Fractures of humerus occur ... – PowerPoint PPT presentation

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Title: Humeral Shaft Fractures Secondary to GSW


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 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

4
Ballistics
  • Low velocity GSW - lt 1000ft/sec
  • High velocity GSW - gt2000ft/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 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

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
    (JBJS78-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 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.

25
Initial PE
  • NVI Left upper extremity
  • 1cm exit wound postero-lateral aspect LUE
  • AROM intact _at_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
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