Penetrating trauma has been increasing over recent years, especially here in sleepy St. Paul MN. On occasion, we all see patients who have sustained gunshots that have caused fractures. The persistent question has been: open fracture or not?
Do these patients need antibiotics? A wound washout? Are they at risk for lead poisoning? Unfortunately, there are no consistent answers in the textbooks. The orthopedic trauma group and MetroHealth in Cleveland sent surveys to 385 members of the Orthopedic Trauma Association (OTA) to see if there was some consensus.
A total of 173 of the surveys were completed, which is actually a very good success rate. About 72% were in practice at a Level I center, 18% at a Level II, and 10% at Level III/IV or non-trauma centers.
There was considerable heterogeneity among the responses. Here are the summaries for the specific questions asked:
How would you treat a gunshot injury near bone without fracture?
The majority of respondents recommended non-operative treatment and some form of antibiotics. However, there was no consensus regarding route of administration or duration. About 75% were in favor of a single dose of IV antibiotics, and half of those also recommended addition oral antibiotics. The presence of a retained bullet did not change management.
How would you treat a gunshot with a stable fracture to the fibula?
Three quarters of the respondents recommended the same management as above (IV antibiotics + oral), although about 10% would admit for IV antibiotics and 10% would do a washout or debridement. Only 7% recommended no antibiotics or debridement.
How would you treat a gunshot traversing the knee joint with a retained bullet?
About half stated they would explore the joint and the other half would not. Nearly all recommended antibiotics, with the majority in favor of a single dose IV followed by some duration of oral.
Is the union rate of a tibial shaft fracture from a gunshot treated surgically different than a non-gunshot fracture?
Half of the participants thought it would be the same, a quarter thought it would be higher, and a quarter lower.
What about a gunshot with a displaced tibia fracture without other skin wounds?
About half recommended fixation with irrigation and debridement with perioperative antibiotics. A quarter would do the same, but without the irrigation and debridement. About 10% would extend the antibiotic duration.
How would you handle a gunshot traversing bowel that results in a stable pelvic fracture?
There was no agreement here at all. The majority (61%) would not debride the fracture, but would recommend IV antibiotics. Most of those recommended at least 24 hours of coverage. The remaining surgeons recommended surgical debridement, and were evenly split over brief vs longer antibiotic duration.
Bottom line: This is a “How we do it study” that is based on science as interpreted by these orthopedic surgeons. In general, OTA members behave as if they consider gunshots to bone as open fractures. More than 90% recommend antibiotics any time a bullet touches the bone. But once the fracture requires operative management, it is treated like a non-gunshot fracture from the standpoint of debridement and antibiotics.
The most interesting part of this survey was the total lack of consistency in the answers. It is clear that there is wide variation in the practice patterns of these surgeons, which usually signifies a lack of good data pertaining to the problem.
In my next post, I’ll discuss the lead poisoning question I mentioned above.
Reference: Variation in treatment of low energy gunshot injuries – a survey of OTA members. Injury 49:570-574, 2018.
