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GUNSHOT WOUNDS

Introduction

Gunshot wounds to the hand and wrist are common injuries seen both in military conflict and civilian life. These injuries may result from either intentional or inadvertent discharge of a firearm and can cause varying degrees of damage depending on the type and velocity of the projectile, as well as the location of the wound. After a gunshot wound to the hand, the patient will typically experience pain, deformity, and loss of hand function, and prompt medical attention is crucial. Conservative management, including local wound care, prophylactic antibiotics, and splinting/casting may be appropriate in select low-velocity gunshot wounds, but surgical intervention is often necessary. Surgical treatment will typically begin with early, aggressive debridement and may be followed with other procedures such as open reduction and internal or external fixation, bone grafting, wound closure, digital amputation or major reconstructions for bone loss for example.1,2

Pathophysiology

  • A gunshot wound to the hand results from a bullet or other projectile object being fired from a gun—accidentally or intentionally—and striking any region of the patient’s hand or wrist; the projectile object may either exit through or remain in the hand after the incident, and the amount of subsequent damage is determined by the location of the wound and the type and velocity of the projectile
  • Gunshot wounds are generally classified as low velocity, intermediate velocity, or high velocity.  Velocity is calculated by measuring speed of the bullet as it leaves the muzzle of the gun.
    • Low velocity (<350 m/s): most handguns, except for magnums
    • Intermediate velocity (350-500 m/s): shotgun blasts
      • Close-range shotgun injuries can increase risk for wound contamination or infection and the pellets act like a single bullet at very close range.
  • High velocity (>600 m/s): military assault and hunting rifles
    • High risk of infection
    • The higher the velocity of the projectile, the more severe the injury and the higher the risk for contamination due to a greater degree of energy transfer and the blast effect 

Incidence and Related Conditions

  • Each year, approximately 32,000 people die and 67,000 are injured from firearm-related incidents, including assaults, acts of self-harm, and accidents3
    • >70% of unintentional gunshot wounds and 45% of intentional gunshot wounds involve the extremities4
    • Of the patients who receive medical treatment for unintentional gunshot injuries, 34% involve the arm or hand3
    • Plumbism, i.e. lead poisoning
    • Neurotoxicity
ICD-10 Codes

  • GUNSHOT WOUNDS

    Diagnostic Guide Name

    GUNSHOT WOUNDS

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    GUNSHOT WOUNDS (PUNCTURE)    
    FOREARM    
    - WITH FOREIGN BODY S51.842_S51.841_ 
    - WITHOUT FOREIGN BODY S51.832_S51.841_ 
    WRIST    
    - WITH FOREIGN BODY S61.542_S61.541_ 
    - WITHOUT FOREIGN BODY S61.532_S61.531_ 
    HAND    
    - WITH FOREIGN BODY S61.442_S61.441_ 
    - WITHOUT FOREIGN BODY S61.432_S61.431_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S51 AND S61
    A - Initial Encounter
    D - Subsequent Routine Healing
    S - Sequela

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Gunshot Wounds
  • Gunshot wound left hand. Accidental wound from a handgun fired at a very close range.
    Gunshot wound left hand. Accidental wound from a handgun fired at a very close range.
  • Note the small entry wound (circle 1) and the large area of potential blast effect (circle 2)
    Note the small entry wound (circle 1) and the large area of potential blast effect (circle 2)
  • Note the comparably large exit wound caused by the bullet, blast effect and secondary missiles i.e. metacarpal bone fragments
    Note the comparably large exit wound caused by the bullet, blast effect and secondary missiles i.e. metacarpal bone fragments
Symptoms
History of a Gunshot
Pain and welling
Deformity
Abnormal hand function
Typical History

The typical patient is a 27-year old male who was shot on the palmar side of his right hand during a robbery. The man had his hands raised in submission during the incident, but the assailant still fired his handgun once at point blank range. The bullet entered and exited the center of the victim’s right hand through the metacarpals, resulting in comminuted fractures of several bones in the region and causing him severe pain and disability.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals
  • Preserve tissue
  • Prevent infection
  • Repair and reconstruct the hand
  • Return hand function
Conservative
  • Local wound care
    • Indicated for low-velocity/energy gunshot wounds with no bone involvement and clean wound edges
  • Prophylactic antibiotic therapy
    • Use of antibiotics after gunshot wounds is controversial, but it is considered the preferred treatment for open fractures, when the wound appears to be grossly contaminated or the extent of contamination is unclear, and for high-velocity/energy gunshot wounds
    • Debate regarding antibiotic usage applies particularly to low-velocity/energy gunshot wounds and a lack of data supporting their effectiveness in this capacity1
    • Delay in antibiotic administration can significantly increase the risk for infection
    • Cephalosporin
      • Recommended for intra-articular wounds and those resulting from high-velocity/energy weapons or shotguns
      • Should be administered intravenously for at least 48 hours as prophylactic treatment
    • Gentamicin
      • Should be added if there is a cavitary lesion or soft tissue defect
  • Splinting/casting
    • Alternative intervention when internal fixation is inappropriate if it can provide adequate fracture stabilization and opportunities for wound care5
  • Hand rehabilitation
    • Typically needed after surgery
    • Splinting is followed by passive flexion-extension exercises when soft-tissue swelling dissipates, with a rapid return to active motion usually within 3 weeks
    • Generally consists of 3 phases: early (protective), intermediate (mobilization), and late (strengthening)6
Operative
  • Surgery is typically indicated if there is considerable tissue damage, major vascular injury, progressive neurologic deficit, obvious contamination, joint involvement, compartment syndrome, unstable fractures, tendon injuries, superficial fragments in the palm, and when patients present more than eight hours after the incident1
  • Initial surgery should be conservative and focus on preserving and protecting vital structures, restoring viability, and preventing sepsis6
  • Surgical debridement
    • Should begin as early as possible and include aggressive debridement of all devitalized tissue2
    • Combining early local debridement with splinting and early active motion may be sufficient for wounds resulting from low-velocity/energy trauma without damage to anatomical structures2
  • Open reduction and internal or external fixation
    • Indicated for unstable or operative fracture patterns after low-velocity/energy gunshot wounds
    • Distal interphalangeal (DIP) joints are more suited to rigid cross-joint immobilization for primary arthrodesis, whereas in proximal interphalangeal (PIP) and metacarpophalangeal (MP) joints, secondary reconstruction to retain motion is preferred
    • Noncomminuted fragments that can be reduced easily should be rigidly fixed, or external fixation with distraction will stabilize the joint and allow for recovery free of joint-reactive forces
  • Bone grafting
    • Bone grafts from the distal radius or iliac crest can be used to replace segmental bone loss
  • Primary or secondary wound closure
    • Depending on the type of injury and degree of contamination, wounds should either be closed immediately or left open to heal by secondary intention1
  • Amputation
    • Early removal of a digit is recommended when 4 of the 6 basic components of the finger or thumb (ie, bone, joint, skin, tendon, nerve, vessel) are injured6
    • Amputation is also preferred if a severe injury to a low-value finger such as the little finger is sustained
  • Hand fasciotomy if intrinsic compartment syndromes is present or developing.
Treatment Photos and Diagrams
Gunshot Wound Treatment
  • Gunshot wound after irrigation, debridement, soft tissue repair and ORIF of multiple fractures
    Gunshot wound after irrigation, debridement, soft tissue repair and ORIF of multiple fractures
  • Dorsal wound closure after irrigation, debridement, soft tissue repair and ORIF of multiple fractures
    Dorsal wound closure after irrigation, debridement, soft tissue repair and ORIF of multiple fractures
  • Palm wound closure after irrigation, debridement, soft tissue repair and ORIF of multiple fractures
    Palm wound closure after irrigation, debridement, soft tissue repair and ORIF of multiple fractures
Complications
  • Infection
  • Ischemia
  • Edema
  • Hematoma
  • Wound-healing problems
  • Decreasing range of motion
Outcomes
  • Early mobilization combined with early debridement, stabilization, and repair with appropriate antibiotic coverage has been found to result in low infection rates, faster rehabilitation, and an improved quality of life; this treatment course gives patients the best chance for a full functional recovery especially after low velocity gunshots.1
  • Bone grafting has been shown to be a relatively safe procedure with low complication rates for gunshot wounds, so long as the wounds are not infected, even though some bone graft resorption has been reported1
Key Educational Points
  • Early aggressive surgical debridement and repair followed by timely postoperative rehabilitation is critical to achieve joint mobility, tendon excursion, edema control, and ultimately good hand function2
  • Combined or complex injuries sustained from a gunshot wound can be difficult to manage, since different tissue types may require contrasting modes of treatment2
  • Debriding questionably ischemic tissues at the time of injury is often unnecessary and detrimental because of the abundant blood supply to the hand and dense concentration of structures vital to upper limb function2,6
  • Reconstructing a severely damaged digit may result in a chronically stiff and painful finger that impedes hand function; amputation may therefore be required in these cases6
References

Cited

  1. Turker T, Capdarest-Arest N. Management of gunshot wounds to the hand: a literature review. J Hand Surg Am 2013;38(8):1641-50. PMID: 23561721
  2. Pereira C, Boyd JB, Olsavsky A, et al. Outcomes of complex gunshot wounds to the hand and wrist: a 10-year level I urban trauma center experience. Ann Plast Surg 2012;68(4):374-7. PMID: 22421482
  3. Fowler KA, Dahlberg LL, Haileyesus T, Annest JL. Firearm injuries in the United States. Prev Med 2015;79:5-14. PMID: 26116133
  4. Gotsch KE, Annest JL, Mercy JA, et al. Surveillance for fatal and nonfatal firearm-related injuries: United States, 1993-1998. MMWR 2001;50:1–32.
  5. Kiehn MW, Mitra A, Gutowski KA. Fracture management of civilian gunshot wounds to the hand. Plast Reconstr Surg 2005;115(2):478-81. PMID: 15692353
  6. Eardley WG, Stewart MP. Early management of ballistic hand trauma. J Am Acad Orthop Surg 2010;18(2):118-26. PMID: 20118328

New Article

  • Fowler KA, Dahlberg LL, Haileyesus T, Annest JL. Firearm injuries in the United States. Prev Med 2015;79:5-14. PMID: 26116133

Reviews

  1. Turker T, Capdarest-Arest N. Management of gunshot wounds to the hand: a literature review. J Hand Surg Am 2013;38(8):1641-50. PMID: 23561721
  2. Eardley WG, Stewart MP. Early management of ballistic hand trauma. J Am Acad Orthop Surg 2010;18(2):118-26. PMID: 20118328

Classics

  1. Duncan J, Kettelkamp DB. Low-velocity gunshot wounds of the hand. Arch Surg 1974;109(3):395-7. PMID: 4853046
  2. Granberry WM. Gunshot wounds of the hand. Hand 1973;5(3):220-8. PMID: 4583858
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