Skip to main content
SpringerLink
Log in

Versorgungsstrategien bei Schussverletzungen der Extremität

Treatment strategies for gunshot wounds of the extremities

  • CME Weiterbildung • Zertifizierte Fortbildung
  • Published:
Der Unfallchirurg Aims and scope Submit manuscript

Zusammenfassung

Chirurgen an städtischen Kliniken werden auch in Europa zunehmend mit Schussverletzungen konfrontiert. Schussfrakturen mit geringer Weichteildestruktion können gemäß geschlossener Frakturlehre versorgt werden. Stabile Frakturen sind durch funktionelle Schienung, instabile durch primär definitive Stabilisierung behandelbar. Die prophylaktische Antibiotikatherapie bei geringem Weichteilschaden wird kontrovers diskutiert. Schussfrakturen mit schwerer Weichteilschädigung werden gemäß offener Frakturlehre behandelt. Ein adäquates Wunddébridement und eine Stabilisierung durch Fixateur externe werden empfohlen. Eine i.v. Antibiotikaprophylaxe ist obligat, die Durchführung einer prophylaktischen Fasziotomie häufig indiziert. Im Rahmen der definitiven osteosynthetischen Versorgung muss die Notwendigkeit von autologem Knochenersatz bedacht werden. Schussverletzungen des Gelenks werden als offene Gelenkverletzungen behandelt und bedürfen einer ausführlichen Spülung, eines Débridements mit Projektilentfernung sowie einer antibiotischen Therapie.

Abstract

The incidence of gunshot wounds is increasing also in Europe and surgeons in urban trauma centers are more frequently confronted with this type of injury. Since there is no established treatment algorithm for gunshot injuries to the extremities, the surgeon should rely on established soft tissue injury and fracture protocols. Gunshot fractures with minor soft tissue destruction should be treated as closed fractures. The treatment of choice for unstable fractures is early internal stabilization, whereas stable fractures may be treated by functional bracing. The administration of an antibiotic prophylaxis for fractures with minor soft tissue injury is controversial. Gunshot fractures with major soft tissue injury should be treated as open fractures. Debridement of nonviable tissue and external fixation are recommended. Prophylactic intravenous antibiotics are mandatory and prophylactic fasciotomy is often required. Upon definitive internal stabilization, bone grafting should be considered since gunshot fractures are usually associated with a high degree of comminution. Articular gunshot injuries are treated as open joint injuries and require irrigation, debridement, foreign body removal and antibiotic prophylaxis.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3
Abb. 4
Abb. 5
Abb. 6
Abb. 7

Literatur

  1. Bartlett CS (2003) Clinical update: gunshot wound ballistics. Clin Orthop 408: 28–57

    Article  PubMed  Google Scholar 

  2. Bartlett CS, Helfet DL, Hausman MR et al. (2000) Ballistics and gunshot wounds: effects on musculoskeletal tissues. J Am Acad Orthop Surg 8: 21–36

    PubMed  CAS  Google Scholar 

  3. Cargile JS III, Hunt JL, Purdue GF (1992) Acute trauma of the femoral artery and vein. J Trauma 32: 364–370

    PubMed  Google Scholar 

  4. Coupland RM (1989) Technical aspects of war wound excision. Br J Surg 76: 663–667

    Article  PubMed  CAS  Google Scholar 

  5. Deitch EA, Grimes WR (1984) Experience with 112 shotgun wounds of the extremities. J Trauma 24: 600–603

    PubMed  CAS  Google Scholar 

  6. Dickey RL, Barnes BC, Kearns RJ et al. (1989) Efficacy of antibiotics in low-velocity gunshot fractures. J Orthop Trauma 3: 6–10

    Article  PubMed  CAS  Google Scholar 

  7. Dickson K, Watson TS, Haddad C et al. (2001) Outpatient management of low-velocity gunshot-induced fractures. Orthopedics 24: 951–954

    PubMed  CAS  Google Scholar 

  8. Dorlac WC, DeBakey ME, Holcomb JB et al. (2005) Mortality from isolated civilian penetrating extremity injury. J Trauma 59: 217–222

    PubMed  CAS  Google Scholar 

  9. Dugas R, D’Ambrosia R (1985) Civilian gunshot wounds. Orthopedics 8: 1121–1125

    PubMed  CAS  Google Scholar 

  10. Durham RM, Mistry BM, Mazuski JE et al. (1996) Outcome and utility of scoring systems in the management of the mangled extremity. Am J Surg 172: 569–573

    Article  PubMed  CAS  Google Scholar 

  11. Fackler ML (1998) Civilian gunshot wounds and ballistics: dispelling the myths. Emerg Med Clin North Am 16: 17–28

    Article  PubMed  CAS  Google Scholar 

  12. Feliciano DV, Herskowitz K, O’Gorman RB et al. (1988) Management of vascular injuries in the lower extremities. J Trauma 28: 319–328

    PubMed  CAS  Google Scholar 

  13. Granchi T, Schmittling Z, Vasquez J et al. (2000) Prolonged use of intraluminal arterial shunts without systemic anticoagulation. Am J Surg 180: 493–496

    Article  PubMed  CAS  Google Scholar 

  14. Gugala Z, Lindsey RW (2003) Classification of gunshot injuries in civilians. Clin Orthop 408: 65–81

    Article  PubMed  Google Scholar 

  15. Helfet DL, Howey T, Sanders R et al. (1990) Limb salvage versus amputation. Preliminary results of the mangled extremity severity score. Clin Orthop 256: 80–86

    PubMed  Google Scholar 

  16. Howe HR Jr, Poole GV Jr, Hansen KJ et al. (1987) Salvage of lower extremities following combined orthopedic and vascular trauma. A predictive salvage index. Am Surg 53: 205–208

    PubMed  Google Scholar 

  17. Johansen K, Daines M, Howey T et al. (1990) Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 30: 568–572

    PubMed  CAS  Google Scholar 

  18. Knapp TP, Patzakis MJ, Lee J et al. (1996) Comparison of intravenous and oral antibiotic therapy in the treatment of fractures caused by low-velocity gunshots. A prospective, randomized study of infection rates. J Bone Joint Am Surg 78: 1167–1171

    CAS  Google Scholar 

  19. Leonard MH (1969) The solution of lead by synovial fluid. Clin Orthop 64: 255–261

    PubMed  CAS  Google Scholar 

  20. Linden MA, Manton WI, Stewart RM et al. (1982) Lead poisoning from retained bullets. Pathogenesis, diagnosis, and management. Ann Surg 195: 305–313

    Article  PubMed  CAS  Google Scholar 

  21. Long WT, Brien EW, Boucree JB Jr et al. (1995) Management of civilian gunshot injuries to the hip. Orthop Clin North Am 26: 123–131

    PubMed  CAS  Google Scholar 

  22. Manton WI, Thal ER (1986) Lead poisoning from retained missiles. An experimental study. Ann Surg 204: 594–599

    Article  PubMed  CAS  Google Scholar 

  23. McNamara MG, Heckman JD, Corley FG (1994) Severe open fractures of the lower extremity: a retrospective evaluation of the mangled extremity severity score (MESS). J Orthop Trauma 8: 81–87

    Article  PubMed  CAS  Google Scholar 

  24. Najibi S, Dougherty PJ, Morandi M (2006) Management of gunshot wounds to the joints. Techn Orthop 21: 200–2004

    Article  Google Scholar 

  25. Norman J, Gahtan V, Franz M et al. (1995) Occult vascular injuries following gunshot wounds resulting in long bone fractures of the extremities. Am Surg 61: 146–150

    PubMed  CAS  Google Scholar 

  26. Omer GE Jr (1974) Injuries to nerves of the upper extremity. J Bone Joint Surg Am 56: 1615–1624

    PubMed  Google Scholar 

  27. Ordog GJ, Sheppard GF, Wasserberger JS et al. (1993) Infection in minor gunshot wounds. J Trauma 34: 358–365

    Article  PubMed  CAS  Google Scholar 

  28. Ordog GJ, Wasserberger J, Balasubramanium S et al. (1994) Civilian gunshot wounds – outpatient management. J Trauma 36: 106–111

    PubMed  CAS  Google Scholar 

  29. Patton JH Jr (2006) Treatment of civilian gunshot wounds: a trauma surgeon’s perspective. Techn Orthop 21: 162–171

    Article  Google Scholar 

  30. Patzakis MJ, Harvey JP Jr, Ivler D (1974) The role of antibiotics in the management of open fractures. J Bone Joint Surg Am 56: 532–541

    PubMed  CAS  Google Scholar 

  31. Persad IJ, Reddy RS, Saunders MA et al. (2006) Gunshot injuries to the extremities: experience of a U.K. trauma centre. Injury 36: 407–411

    Article  Google Scholar 

  32. Rhee J, Martin R (1997) The management of retained bullets in the limbs. Injury 28: S-C23–S-C28

    Article  Google Scholar 

  33. Simpson BM, Wilson RH, Grant RE (2003) Antibiotic therapy in gunshot wound injuries. Clin Orthop 408: 82–85

    Article  PubMed  Google Scholar 

  34. Tarkin IS, Hatzidakis A, Hoxie SC et al. (2003) Arthroscopic treatment of gunshot wounds to the shoulder. Arthroscopy 19: 85–89

    PubMed  Google Scholar 

  35. Thoresby FP, Darlow HM (1967) The mechanisms of primary infection of bullet wounds. Br J Surg 54: 359–361

    Article  PubMed  CAS  Google Scholar 

  36. Volgas DA, Stannard JP, Alonso JE (2005) Current orthopaedic treatment of ballistic injuries. Injury 36: 380–386

    Article  PubMed  Google Scholar 

  37. Williams AB, Luchette FA, Papaconstantinou HT et al. (1997) The effect of early versus late fasciotomy in the management of extremity trauma. Surgery 122: 861–866

    Article  PubMed  CAS  Google Scholar 

  38. Wolf AW, Benson DR, Shoji H et al. (1987) Autosterilization in low-velocity bullets. J Trauma 18: 63

    Article  Google Scholar 

  39. Zinman C, Norman D, Hamoud K et al. (1997) External fixation for severe open fractures of the humerus caused by missiles. J Orthop Trauma 11: 536–539

    Article  PubMed  CAS  Google Scholar 

Download references

Interessenkonflikt

Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.

Author information

Authors and Affiliations

  1. Klinik für Unfallchirurgie, Städtisches Klinikum Braunschweig, Freisestraße 9, 38118 , Braunschweig, Deutschland

    P. Kobbe & H. Reilmann

  2. Department of Orthopaedic Surgery, Division of Trauma, University of Pittsburgh, Pittsburgh, USA

    P. Kobbe, I.S. Tarkin, C. Tzioupis & H.-C. Pape

  3. Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Hannover, Deutschland

    M. Frink

  4. Klinik für Unfallchirurgie, Universitätsklinikum Essen, Essen, Deutschland

    R. Oberbeck & D. Nast-Kolb

Authors
  1. P. Kobbe
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. M. Frink
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. R. Oberbeck
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. I.S. Tarkin
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. C. Tzioupis
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. D. Nast-Kolb
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. H.-C. Pape
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. H. Reilmann
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to P. Kobbe.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Kobbe, P., Frink, M., Oberbeck, R. et al. Versorgungsstrategien bei Schussverletzungen der Extremität. Unfallchirurg 111, 247–255 (2008). https://doi.org/10.1007/s00113-008-1436-6

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00113-008-1436-6

Schlüsselwörter

Keywords

Search

Navigation