MILITARY MEDICINE, 175, 3:206. 2010

Shotgun Injury to the Arm: A Staged Protocol forUpper Limb Salvage

Darabos Nikica, MD, PhD*; Cesáreo Marijan, MDf; Grgurovic Denis, MDf;Rutic Zeljko, MDf; Darabos Anela, MDt; Kenneth Egol, MD, PhD§

ABSTRACT Low-energy shotgun fracrures involving the arm are complex injuries. Previously published reports haveemphasized various problems associated with these injuries. This case report describes a low-energy shotgun woundmanaged by a staged treatment protocol involving: ( 1 ) a spanning external ñxator and immediate soft tissue management,followed by (2) osteosynthesis and autogenous bone grafting and (3) epineural suturing of injured radial nerve, with asuccessful outcome. Although adequate debridement of the fracture and soft tissue wound is the key lo open fracturemanagement, some difference of opinion exists with regard to the timing of bone reconstruction and grafting. In severetype III open fractures, or in wounds that are marginal, it may be best to delay cancellous bone gratting until soft tissuehasstabilizedfollowingacute trauma when the risk of infection has been minimized. If early coverage of vital structuresis not possible, local or remote flap coverage may be necessary.

INTRODUCTIONShotgun wound fractures in general fall within two catego-ries: low-energy (<200 ft/sec) shotgun wounds, which arecommon in civilian criminal activity and high-energy ballisticO200 ft/sec) injuries, which are associated with missiles andother weapons of war. Despite surgeons* best efforts at limhsalvage, these injuries may result in extremity amputation.A tiumber of strategies for the management of complex boneand soft tissue injuries associated with severe traumas havebeen reported, '"̂

This case report describes a low-energy shotgun woundmanaged by a staged treatment proKKol involving a span-ning external tixator and soft tissue management, followedby osteosynthesis and acute bone grafting with a successfuloutcome.

Case ReportA 60-year-old, left hand-dominant male received a low-energy shotgun wound of the left arm while serving in themilitary. The weapon was a Zastava M75 16 gauge shotgun,fired from a close range, at a distance of about 20 cm. Thewound was highly contaminated with an approximately 10-cmzone of injury and resultant bone and soft tissue loss (Fig. 1 ).

•University Clinic for Traumatology. Medical School, University ofZagreb, Draskoviceva 19, ! 0000 Zagreb. Croatia.

i-Department of Traumatology. Varazdin General Hospital, 1. Mestrovica 1.42000 Varazdin, Croatia.

tThe Scientific Unit, Varazdin General Hospital, I, Mestrovica 1. 42000Varazdin. Croatia.

§Departmeni of Orthopedic Surgery, NYU Hospital for Joint Diseases.301 E. 17th Street, New York, NY 10016.

Previous presentation: Osteosynthesis and Trauma Care (OTC) Foundationmeeting, St. Petersburg, Russia. 2007; OTC fellowship. New York. 2008.

Investigation with the human subject reported in the article was performedwith informed consent and following all the guidelines for investigation withhuman subjects required by the instilutifMi(s) wiih which all the authors areaffiliated.

The patient received first generation cephalosporin and teta-nus prophylaxis in the emergency department and was indi-cated for surgical intervention. Systolic blood pressure waslower than 90 mmHg, but the hand was warm and well per-fused. There were no hard signs of brachial artery injury, butthe patient was noted to have diminished distal pulses. Therewas no clinical evidence or laboratory evidence of dissemi-nated intravascular coagulation (DIC). There was a lesion ofthe radial nerve.

Following a complete trauma work up, the patient wasbrought to the operating room where he underwent his firstin a series of planned operative interventions. Upon furtherexploration, the patient was noted to have the following neuralinjuries: traumatic laceration of cutaneus branches of the axil-lary nerve, 1 -cm-long defect of the radial nerve, absence of theposterior cutaneus nerve of the arm and motor branches to thelong, lateral, and medial triceps muscle. The bone injury wa.sclassified as a comminuted fracture of the proximal third ofhumérus. There were many free devitalized bone fragments,which were debrided. There was approximately 10 cm ofhumeral bone defect following debridement, which was typedas a IIIB according to Gustillo's Classification,'"" The softtissue loss included the following: the lateral head of tricepsbrachii muscle, almost all of biceps brachii, brachialis, andcoracobrachialis muscles with their concomitant arterovenoussupply, covering soft tissue and skin of anterior and posteriorparts of the upper arm. The status of deep brachial vesselsand of the ulnar and median nerves was confirmed intact. Thewound was further classified as E30. X30, CI, F2, VO, M2according to the Red Cross wound classification."'^ Mangledextremity severity score (MESS) was 7.'^

Initial operative treatment included: (1) irrigation and ini-tial radical debridement of the wound, (2) bone stabilizationwith an external fixator adjusted to .shorten the upper arm andthereby clo.se the gap/prevent tension on future neural anas-tomosis, and (3) epineural suturing of the radial nerve. Acute

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FIGURE 2. Shotgun injury of arm after first operation: anterior aspect.

FIGURE 1. X-Ray after admission.

bone grafting of the defect was deferred due to the risk ofwound infection. The wound was packed open to be changeddaily with normal saline wet to dry dressings (Fig. 2).

The patient received a repeated treatment of irrigation anddebridement on hospital days 2,4. and 6 post trauma. On day 7post trauma with no signs of infection, defitiitive bone fixationwas performed, which consisted of the removal of the externalfixator and intramedullary unreamed nailing. ín addition, cor-ticocancellous bone autografting was performed along withdefinitive wound coverage using a muscle flap of long andmedial heads of triceps brachii and STSG (Figs. 3 and 4).

Three months following the injury there was no sign of infec-tion, but the patient had not shown any radiographie progression FIGURE 3. X-Ray after second operation.

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FIGURE 4. Shotgun injury after second operation; lateral aspect.

toward bone union and was indicated for further surgery. Thepatient underwent a third operation, which included anotherautogenous bone graft to the bone defect site.

At 6 months post-trauma radiographs showed signs of boneunion. The circulation to the hand was maintained and therewere no signs of infection. The neurologic status improvedwith almost full radial motor reinervation. The shoulder hadlimited abduction for one-half of movement, elevation, andexternal rotation for one-third of movements and terminalreduction of internal rotation; elbow extension and rotationswere limiled in terminal movements and flexion for one-thirdof movement, whereas there was tio limitation in wrist move-ments (according to the opposite site). The range of shoulder,elbow, and wrist motions improved and became functional(Figs. 5, 6, and 7j. There were persistent paresthesias in the

FIGURE 5. Functional status 6 months post-trauma A.

distribution of the superficial radial nerve in the hand andfingers. The restilts of electromyoneurography revealed adiminution of motor units in the foreatrn caused by the lossof muscular masses. One year post injury, the radiographsshowed a qualitative bone union (Fig. 8). The clinical statusof the patient wa.s unchanged and he returned to his duty.

DISCUSSION -Low-energy shotgun fractures involving the arm are complexinjuries. Previously published reports have emphasized vari-ous problems associated with these injuries.'"*

This case report presents a staged management for the treat-ment of a complex upper extremity shotgun wound involv-ing bone, muscle, and nerve tissue. Despite a MESS scoreof 7 points the patient would not consider the possibility ofamputation, and limb salvage was undertaken. The success inthis case is another example of the problem associated withassigning risk for amputation, rather than treating each sit-uation individually. For the surgeon, many of the dilemmasconcerning if, when, and where to amputate, as well as otherissues related to this treatment have diminished by utilizingmodern supportive measures.'^

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FIGURE 6. Funetional status 6 tnonths post-trauma B.

FIGURE 7. Functional status 6 months post-trauma C.

Bullets fired from low-energy weapons tend to result inminimal tissue cavitations as compared to higher-energy weap-ons. Stable, extra-articular fracture patterns seen with theseinjuries may require only local irrigation and debridement

FIGURE 8. X-Ray I year post trauma.

with splinting or bracing vs. internal fixation at the surgeon'sdiscretion. However, all patients who sustain these injuriesshould receive tetanus prophylaxis and short-term intravenousantihiotics.**'*"'

Elstrom et al.'^ suggest that extemal fixation alone isadequate for undisplaced fractures associated with shotgunwounds. As to displaced fractures., these authors reported thatdelayed (7 to 14 days) primary internal fixation following theinitial phase of wound healing had proven benign, and led toresults that were superior to those obtained from other formsof treatment."-'"

Soft tissue management of these injuries is controver-sial.-"-' The timing of definitive closure depends on manyfactors including the amount of initial contamination, theavailability of local soft tissue and of technical expertise.Failure to perform an adequate, wide surgical debridementis the main cause of associated post injury wound infection

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and abscess fonnation.- Whether a wound has been appro-priately debrided requires substantial experience and properjudgment. Because of the difficulty in determining viabilityof the surrounding soft tissue envelope, surgeon^ often chooseto perform repeat irrigation and debridement until all tissueviability within the zone of injury is declared as it was donein this ca.se.

The routine use of antibiotic bead pouches first and morerecently, negative pressure vacuum assisted closure may havemade acute closure of the wound less necessary than in thepast. Delayed wound closure at the time of repeated debri-dement is safe, effective, and involves less risk.-' Vacuum-assisted closure appears to be a viable adjunct to the treatmentof open high-energy injuries. This device, however, does notreplace the need for formal debridement of necrotic tissue,but it may avoid the need for a free tissue transfer in somepatients with large traumatic wounds.-'' The case for a delayedwound closure is made on the basis of several parameters ihatinclude: surgical team availability, the condition of the patient,and adequate infonned consent.-^ Delayed wound closure isthe rule, whereas emergency free tissue transfer is an excep-tion in major trauma centers around the world.-''

More rapid closure of these wounds is a possibility nowa-days. Modern techniques of wound debridemenl and itnme-diate administration of antibiotics have made immediatewound closure predictably safer.^' European surgeons haveadvocated an early "'fix and flap*" practice that has yieldedgood results, with lower rates of infection than those thatoccurred with standard staged soft-tissue recoastruction pro-cedures.-** Furthermore, a staged wound closure requires asecond surgery, which is costly and may often be avoided.'''Complications are more likely to occur when there is a delaybetween the time of injury and the initial treatment. The devel-opment of infection in minor shotgun wound injuries is anunusual occurrence when these injuries are limited to the softtissue structures. Additionally, wound debridement and anti-biotics are often unnecessary in minor uncomplicated shotgunwounds, but may be beneficial in patients who have sustainedmultiple injuries, gross wound contamination, significant tis-sue devitalization, large wounds, or delay in treatmeni.-"* "'

Deitch et al.^' conclude that the major cause of a pro-longed hospital stay in these patients is the presence of amajor soft tissue injury, whereas the presence or absence ofa neural injury is the most important determinate of whetheran extremity would be functional. It appears that neither skel-etal nor vascular injuries result in long-term extremity disabil-ity following such injuries." They recommend an aggressiveoperative approach toward early wound closure to decreasehospitalización time. Furthermore, these authors also believethat the presence or absence of neurologic injury in patients isan important component of their long-term management."

One study has shown that liberal use of arteriography andfasciotomy. eariy fracture stabilization, repair of all signifi-cant vascular injuries, and early coverage of vital structuresall contribute to a successful outcome in patients with extrem-

ity gunshot wounds."' In our case we chose not to performarteriography de.spite the proximity of the blast to the brachialartery and the presence of distal diminished pulses becauseof the persistence of a well-perfused hand and the absence ofvascular hard signs.

The initial indication for external fixation in the treat-ment of this fracture was the large, soft tissue wound associ-ated with the missile, including that requiring neurovascularrepair. Theoretically, fixaior causes limited damage to theremaining blood supply of the bone and does not interferewith neurovascular repair or with postoperative wound care.Rates of deep infection vary dramatically and are probablyrelated to the degree of underlying soft tissue injury ratherthan to the implant. Functional results following external fixa-tion for select fractures, though, appear to be as good as thoseof intramedullary or plate fixation. The incidence of nonunionin cases of externally fixed upper extremity fractures variesfrom 5 to 62%.-'-" Early autogenous iliac crest bone graftingmay be indicated to reduce the rate of nonunion in patientswith extensive soft tissue injury, bone loss, or no evidence ofradiographie union at 3 months. ' '"

For definitive fracture fixation we chose intramedullary fix-atioti. Interlocking humeral nails allow for fixation of segmen-tai or .severely comminuted fractures. Union rates with thesedevices aie in the 92 to 100% range, with an average time ofhealing between 6 and 13 weeks."*•''"-

Our goals in treatment of this particular case were to pre-vent infection, achieve bone union in good alignment, andrestore the limb function. A continuous course of antibiot-ics is usually indicated in more extensive severe type III openwounds, until a successful wound closure. Multiple irrigationand debridements were repeated at 36- to48-h intervals until aclean, completely viable wound was present. Our early autog-enous bone graft did not prove detrimental, although one maysuppose its failure on placement into a host bed that was stillin a highly inflammatory state. In severe type III open frac-tures, or in wounds that are marginal, it may be best to delaycancellous bone grafting until soft tissue has stabilized froman acute trauma, after the risk of infection has been minimizedand the early inflammatory stages are passed. Definitive softtissue coverage., however, should be performed as soon aspossible.

CONCLUSIONAn adequate debridement is the key to open fracture manage-ment. Stabilization in this case was obtained by initial externalfixation followed by unreamed nailing. The common denomi-nator for success in these ca.ses is early coverage of vital stnic-tures (nerve, vessel, and bone). Type Illb injuries by definitiondefy the ability to be closed primarily. If early coverage ofvital structures is not possible, local or remote nap coveragemay be necessary. With severe injuries, including specificindications such as a dysvascular limb or uncontrolled infec-tion, consideration must be directed to the possibility of early

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amputation, rather than to a series of unsuccessful reconstruc-tive procedures.

ACKNOWLEDGMENTSWe thank Vora Srsan Zivanovic (Depanment of General Surgery andTraumaiology, General Hospiia! Varazdinl. The source of all funding for thestudy liai been obtained by the National Health Insurance. No benefits in anyform have been received or will be received from a commercial party relateddirectly or indirectly to the subject of this article. Dr. Egol receives researchsupport from Stryker, Synthes and Bioniet.

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