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Importance of injury severity in the choice of treatment and its impact on prognosis in gunshot fractures

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European Journal of Trauma and Emergency Surgery Aims and scope Submit manuscript

Abstract

Purpose

The management of femur and tibia fractures resulting from gunshot injuries is a challenge for orthopedic surgeons. One-stage and two-stage treatments are applied according to the anatomical location and severity of the injury. In this study, the importance of injury severity and anatomical location was evaluated in the choice of treatment method and its impact on prognosis in cases of lower extremity gunshot fractures.

Methods

A total of 124 patients who met the study criteria were evaluated. They were grouped separately according to the anatomical location of the injury (femur, n = 73; tibia, n = 51) and the surgical method (one-stage, n = 77; two-stage, n = 47). The demographic characteristics of the patients, fracture classification, presence of neurological or vascular damage at the time of diagnosis, anatomical location of the injury, surgical procedure, and follow-up time were recorded. The time of union and the presence of malunion were evaluated radiologically. Finally, patients were assessed clinically with the New Injury Severity Score (NISS) and leg length discrepancy (LLD) calculated through measurements made on lower extremity orthoroentgenograms.

Results

The rate of vascular injury and the number of Gustilo-Anderson type IIIB and IIIC cases were significantly higher in the two-stage treatment group (p = 0.001 and p = 0.000, respectively). The infection rate was also higher in the two-stage group; therefore, time to union was significantly longer (p = 0.004 and p = 0.05, respectively). LLD was higher among patients who received two-stage treatment (p = 0.015). According to the NISS scale used in clinical assessment, better scores were obtained for the one-stage group (p = 0.002). In comparisons made according to anatomical location, no significant difference was found between femur and tibia injuries.

Conclusion

Regardless of anatomical location and treatment method, injuries of higher severity such as Gustilo-Anderson type IIIB and IIIC are correlated with higher rates of complications such as vascular injury, postoperative infection, delayed union, and LLD. Furthermore, in cases of severe injuries, a two-stage approach is commonly favored.

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References

  1. Bäckman PB, Riddez L, Adamsson L, Wahlgren CM. Epidemiology of firearm injuries in a Scandinavian trauma center. Eur J Trauma Emerg Surg. 2020;46(3):641–7.

    Article  PubMed  Google Scholar 

  2. Krug EG, Sharma GK, Lozano R. The global burden of injuries. Am J Public Health. 2000;90(4):523–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Cook A, Osler T, Hosmer D, Glance L, Rogers F, Gross B, Garcia-Filion P, Malhotra A. Gunshot wounds resulting in hospitalization in the United States: 2004–2013. Injury. 2017;48(3):621–7.

    Article  PubMed  Google Scholar 

  4. Fowler KA, Dahlberg LL, Haileyesus T, Annest JL. Firearm injuries in the United States. Prev Med. 2015;79:5–14.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Dougherty PJ, Vaidya R, Silverton CD, Bartlett C, Najibi S. Joint and long-bone gunshot injuries. J Bone Joint Surg Am. 2009;91(4):980–97.

    PubMed  Google Scholar 

  6. Court-Brown CM, Rimmer S, Prakash U, McQueen MM. The epidemiology of open long bone fractures. Injury. 1998;29(7):529–34.

    Article  CAS  PubMed  Google Scholar 

  7. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58(4):453–8.

    Article  CAS  PubMed  Google Scholar 

  8. Gustilo RB, Mendoza RM, Williams DN. Problems in management of type III (severe) open fractures: a new classifcation of type III open fractures. J Trauma. 1984;24(8):742–6.

    Article  CAS  PubMed  Google Scholar 

  9. Nguyen MP, Savakus JC, O’Donnell JA, Prayson NF, Reich MS, Golob JF Jr, McDonald AA, Como JJ, Vallier HA. Infection rates and treatment of low-velocity extremity gunshot injuries. J Orthop Trauma. 2017;31(6):326–9.

    Article  PubMed  Google Scholar 

  10. Davidovitch RI, Elkhechen RJ, Romo S, Walsh M, Egol KA. Open reduction with internal fixation versus limited internal fixation and external fixation for high grade pilon fractures (OTA type 43C). Foot Ankle Int. 2011;32(10):955–61.

    Article  PubMed  Google Scholar 

  11. Bacon S, Smith WR, Morgan SJ, Hasenboehler E, Philips G, Williams A, Ziran BH, Stahel PF. A retrospective analysis of comminuted intra-articular fractures of the tibial plafond: open reduction and internal fixation ver-sus external Ilizarov fixation. Injury. 2008;39(2):196–202.

    Article  PubMed  Google Scholar 

  12. Corrales LA, Morshed S, Bhandari M, Miclau T 3rd. Variability in the assessment of fracture-healing in orthopaedic trauma studies. J Bone Joint Surg Am. 2008;90(9):1862–8.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Sarmiento A, Sobol PA, Sew Hoy AL, Ross SD, Racette WL, Tarr RR. Prefabricated functional braces for the treatment of fractures of the tibial diaphysis. J Bone Joint Surg Am. 1984;66(9):1328–39.

    Article  CAS  PubMed  Google Scholar 

  14. Patel I, Young J, Washington A, Vaidya R. Malunion of the tibia: a systematic review. Medicina (Kaunas). 2022;58(3):389.

    Article  PubMed  Google Scholar 

  15. Su CA, Nguyen MP, O’Donnell JA, Vallier HA. Outcomes of tibia shaft fractures caused by low energy gunshot wounds. Injury. 2018;49(7):1348–52.

    Article  PubMed  Google Scholar 

  16. Campbell S, Dhyani J, Greenberg P, Ahmed N. Outcomes in patients with late debridement of open long bone fractures of the lower extremities in penetrating trauma: a retrospective review of the National Trauma Data Bank. Eur J Orthop Surg Traumatol. 2020;30(6):1075–81.

    Article  PubMed  Google Scholar 

  17. Siracuse JJ, Farber A, Cheng TW, Jones DW, Kalesan B. Lower extremity vascular injuries caused by firearms have a higher risk of amputation and death compared with non-firearm penetrating trauma. J Vasc Surg. 2020;72(4):1298-304.e1.

    Article  PubMed  Google Scholar 

  18. Mullenix PS, Steele SR, Andersen CA, Starnes BW, Salim A, Martin MJ. Limb salvage and outcomes among patients with traumatic popliteal vascular injury: an analysis of the National Trauma Data Bank. J Vasc Surg. 2006;44(1):94–100.

    Article  PubMed  Google Scholar 

  19. Knapp TP, Patzakis MJ, Lee J, Seipel PR, Abdollahi K, Reisch RB. Comparison of intravenous and oral antibiotic therapy in the treatment of fractures caused by low-velocity gunshots. J Bone Joint Surg Am. 1996;78(8):1167–71.

    Article  CAS  PubMed  Google Scholar 

  20. Mills L, Tsang J, Hopper G, Keenan G, Simpson AH. The multifactorial aetiology of fracture nonunion and the importance of searching for latent infection. Bone Joint Res. 2016;5(10):512–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Winquist RA, Hansen ST Jr, Clawson DK. Closed intramedullary nailing of femoral shaft fractures. J Bone Joint Surg Am. 1984;66(4):529–39.

    Article  CAS  PubMed  Google Scholar 

  22. Harris I, Hatfield A, Walton J. Assessing leg length discrepancy after femoral fracture: clinical examination or computed tomography? ANZ J Surg. 2005;75(5):319–21.

    Article  PubMed  Google Scholar 

  23. Vaidya R, Anderson B, Elbanna A, Colen R, Hoard D, Sethi A. CT scanogram for limb length discrepancy in comminuted femoral shaft fractures following IM nailing. Injury. 2012;43(7):1176–81.

    Article  PubMed  Google Scholar 

  24. Andalib A, Sheikhbahaei E, Andalib Z, Tahririan MA. Effectiveness of minimally invasive plate osteosynthesis (MIPO) on comminuted tibial or femoral fractures. Arch Bone Jt Surg. 2017;5(5):290–5.

    PubMed  PubMed Central  Google Scholar 

  25. Osler T, Baker SP, Long W. A modification of the injury severity score that both improves accuracy and simplifies scoring. J Trauma. 1997;43(6):922–5.

    Article  CAS  PubMed  Google Scholar 

  26. Penn-Barwell JG, Sargeant ID. Severe Lower Extremity Combat Trauma (SeLECT) Study Group Gun-shot injuries in UK military casualties - features associated with wound severity. Injury. 2016;47(5):1067–71.

    Article  PubMed  Google Scholar 

  27. Harwood PJ, Giannoudis PV, Probst C, Van Griensven M, Krettek C, Pape HC. Polytrauma Study Group of the German Trauma Society. Which AIS based scoring system is the best predictor of outcome in orthopaedic blunt trauma patients. J Trauma. 2006;60(2):334–40.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Orthopaedics and Traumatology, Gazi Yaşargil Training and Research Hospital, Ankara, Turkey

    Okan Ateş & Cahit Ancar

  2. Department of Orthopaedics and Traumatology, Ankara Yıldırım Beyazıt University, Ankara, Turkey

    Ceyhun Çağlar

Authors
  1. Okan Ateş
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  2. Cahit Ancar
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Correspondence to Ceyhun Çağlar.

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Ethics committee approval was obtained from our institution.

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Informed consent forms were obtained from all patients for both their participation in the study and for publications.

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The authors declare no competing interests.

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Ateş, O., Ancar, C. & Çağlar, C. Importance of injury severity in the choice of treatment and its impact on prognosis in gunshot fractures. Eur J Trauma Emerg Surg (2024). https://doi.org/10.1007/s00068-024-02495-x

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