Nonmilitary and Military Weapons
Armored Vehicle Crew Casualties
Nonmilitary Gunshot Wounds
Overview of Battle Casualties
Soft Tissue Wound Management
Skeletal Muscle Injuries
Authors’ Preferred Method of Treatment
Antibiotic Recommendations for Nonmilitary Gunshot Wounds
Pathophysiology of Lead Toxicity
Principles of Management
Recommended Treatment for a Suspected Elbow Joint Injury
Long Bone Fractures
Authors’ Preferred Method of Treatment (Military-Related Injuries)
NA, not available; NR, not reported; RPG, rocket propelled grenade.
The authors’ current antibiotic recommendations (Table 11-5) for nonmilitary gunshot wounds are dependent on injury severity. Isolated perforating wounds of the soft tissue only without vascular injury, or those patients with isolated simple fractures, may be treated initially with a first-generation cephalosporin. This applies to those who are treated as either inpatients or outpatients. Those with more extensive injuries with soft tissue loss may benefit from the addition of an aminoglycoside. For patients who are allergic to penicillin, clindamycin or vancomycin is used.
If cephalosporin or penicillin allergy, consider clindamycin (600 mg IV BID) or vancomycin (dosing per individual patient).
Recommended treatment for patients with a suspected elbow joint injury from a gunshot wound is open irrigation and debridement of the joint, and removal of foreign material, bullet fragments, or small loose bone fragments, if present. Initial stabilization of the elbow following a fracture of the distal humerus, the proximal radius, or proximal ulna can be done with a splint. With more comminuted fractures, use of external fixation spanning the elbow can be utilized temporarily. After stabilization, CT will aid in assessment of the fracture and the elbow joint for definitive fracture fixation (Fig. 11-26A–D). In unstable fracture-dislocations, urgent internal fixation of the fractures may be necessary, alone or in addition to spanning external fixation of the joint.18
Definitive treatment may involve a combination of various techniques, including internal fixation and/or hinged external fixation (Fig. 11-26E–F). Salvage of a severely injured joint may be achieved with compression plate arthrodesis of the elbow101 or, in elderly low demand patients arthroplasty could be used.30 Young and active patients are not good candidates for elbow arthroplasty. In one study, intermediate-range follow-up of 8 to 12 years postarthroplasty showed a five of seven (71%) failure rate. Arthrodesis may be indicated for a nonsalvagable elbow joint in which there is good distal limb function. This is particularly true if the patient is young, has reasonable bone stock, poor soft tissue coverage, and is free of infection.101 Complications of elbow gunshot wounds include stiffness, malunion, nonunion, infection, and nerve injury.115 In a cohort of 44 patients at the author’s institution, 4 died of other injuries and 6 were lost to follow-up. Of the remaining 34 patients, 19 (56%) patients had nerve injuries. The nerve injuries included 8 ulnar, 11 radial, and 2 median nerve injuries. Two patients had combined injuries. Two nerves (one radial and one ulnar) were repaired with partial return of function. Two complete radial nerve injuries were treated with tendon transfers. Four patients (12%) had brachial artery injury that required repair. Four patients (12%) developed deep infections requiring irrigation and debridement in the operating room. Three patients required secondary bone grafting to achieve bony union of the fracture.
Blast injuries and combat-related gunshot wounds are generally more contaminated than similar injuries seem in the civilian sector and an increased focus on adequate debridement is necessary. Blast injuries in particular are much more highly contaminated as significant quantities of foreign material is driven deep into the soft tissues. The Emergency War Surgery Handbook specifically recommends early aggressive debridement and advises against early closure of wounds. The nature of the blast injury frequently makes tissue friable and wounds tend to progress for many days after the initial injury. Frequent debridements every other day until wounds are stable and clean are the mainstay of treatment. Long bone fixation in an austere setting is also avoided and external fixation should be used not only for damage control but rather as a stabilizing frame to aid in transfer of rewounded soldier to a stable medical environment. Definitive stabilization varies little from civilian standards; however, higher grade tibia fractures are less likely to become infected when utilizing circular external fixation.82 Soft tissue management is also frequently a challenge requiring large soft tissue transfers. Not infrequently the extremity injury is so great that patients choose elective amputation. As prosthesis improves and the care of the amputee has improved, small improvements in outcomes have been seen with amputation compared to limb salvage.145