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Gunshot Fractures to the Limbs: A Review of Fixation Methods

Background: The authors had intensive experience with gunshot fractures in wounded civilian and military in the war against organized crime in Rio de Janeiro. From the many difficulties and controversies, came the necessity to search for scientific evidence to establish management and treatment to these challenging injuries. Purpose: Make a revision about fixation methods in the management and treatment of gunshot fractures to the limbs. Material and methods/results: The author researched the combination of the terms "Fractures", "Gunshot", "Treatment", "Fixation" and "Orthopedic Surgery" in MEDLINE, PUBMED, SCIELO and LILACS. Conclusion: Gunshot fractures Grade Gustillo I and II can be treated with debridement plus immediately/early internal fixation; Fixation methods remain controversial in Gustillo III fractures. More high level studies are necessary to establish protocols in Gustillo III gunshot fractures. Citation: Mesquita CDR, Arcoverde LMG, Akerman MJP (2019) Gunshot Fractures to the Limbs: A Review of Fixation Methods. J Orthop Rheumatism 3(1):51-58 Mesquita et al. J Orthop Rheumatism 2019, 3(1):51-58 Open Access | Page 52 | of predisposing factors for deep infection in open fractures Noumi [10] performed in Japan, covering 89 exposed femoral fractures in 88 patients. The study took into account gender, age, Gustillo's classification, AO classification, fracture segment, time and method of intramedullary fixation (milled or unmurtened), debridement time (> or < 6h), polytrauma and floating knee. After evaluating these variables, the authors concluded that the only parameter that acts as predisposing factor of infection is the Gustillo classification (Table 1). Material and Methods The authors researched the combination of the terms "Fractures", "Gunshot", "Treatment" and "Orthopedic Surgery" in MEDLINE, PUBMED, SCIELO and LILACS. After this primary research, criteria for inclusion and exclusion were stablished: Inclusion criteria 1. Patients that were treated with gunshot injuries to the extremities and limbs 2. Clear description of the treatment in the surgical treatment of fractures by firearms. After the ABCDE Primary Evaluation and Trauma Management, one of the first steps in orthopedic assessment is to investigate the mechanism of trauma and observe the characteristics of the wounds. Historically, gunshot wounds are divided into high and low speed. Results of ballistic studies obtained in the literature have shown that the impact of the lesion on the tissue at the moment of impact, the anatomical site affected, the distance of the shot and the degree of bone comminution [5,6] are more important than the velocity to characterize the injuries. Fackler [5] observed that speed is only one of the severity factors of the lesion and is not considered a single criterion. Long [7] correlated the low speed lesions like Type Gustillo I Lesions and high speed lesions like Type Gustillo III. Classifying these lesions by high or low energy may not give the true dimension of severity and prognosis, with negative consequences for evaluation and treatment. Gustillo's classification for exposed fractures remains the ideal parameter for assessment of severity and prognosis of firearm fractures and should be used to the detriment of others in order to establish conducts in order to avoid serious complications such as infection [8,9]. In a multivariate study Table 1: Gustillo classification for open fractures. Gustillo and Anderson classification Grade I Clean skin opening of < 1 cm, usually from inside to outside; minimal muscle contusion; simple transverse or short oblique fractures Grade II Laceration > 1 cm long, with extensive soft tissue damage; minimal to moderate crushing component; simple transverse or short oblique fractures with minimal comminution. Grade III Extensive soft tissue damage, including muscles, skin and neurovascular structures: Often a high energy injury with severe crushing component. Grade IIIA Extensive soft tissue laceration, adequate bone coverage; segmental fractures, gunshot injuries, minimal periosteal stripping. Grade IIIB Extensive soft tissue injury with periosteal stripping and bone exposure requiring soft tissue flap closure; usually associated with massive contamination Grade IIIC Vascular injury requiring repair. Table 2: Gustillo I gunshot fractures. Author/Journal Population/anatomical