How Long Does A Gunshot Wound To The Leg Take To Heal

Explanation

Projectiles create direct and indirect injuries. Straight is caused by the wound crenel produced past the projectile'southward size and shape. Indirect comes from the temporary crenel produced as tissue expands away from the bullet path. The crenel expands then collapses.

Fractures can be caused by this indirect cavitation with wedge shape fractures caused by bending away from projectile. Wear can increase the size and depth of the cavity. These videos show the cavity expansion and then collapse based on the differences in depression vs. high velocity.

Low free energy example:

https://www.youtube.com/watch?v=NvYWWwylz-I

High energy example:

https://youtu.be/zG48pgYe-Is?t=814

Initial evaluation:

Just like any distracting injuries, do a full ortho exam on these patients. Exist sure to focus on the joint above and below the area of the injured area.

CT scan to evaluate nearby joints, frequently helpful to eval the articulation above and below

Kinetic energy = 1/2MV^2 (Velocity is the greatest contributor to energy)

Because velocity is the greatest factor in kinetic energy, firearms are classified by velocity:

Loftier velocity = high free energy ( >two,000 feet per second )

Rifles
Shotguns when within 10 feet (wadding from cartridge can get embedded in the torso causing infections, have a high suspicion for it)

270 Winchester. FPS >2900. Varies based on the bullet grain (mass of the bullet).

Depression velocity = usually lower to medium free energy ( <2,000 feet per second )

Handguns

High energy projectiles are linked to a higher risk of infection (41 percent vs. only ix.5 for low-free energy) creating larger temporary cavities and soft-tissue injuries.

Treatment:

Loftier energy
- Antibiotics
  - Ancef
  - Keep 1st generation cephalosporin 1-3 days postal service injury
  - Recommends against safety use of aminoglycosides or penicillin
- Surgery
  - Irrigation, debridement, delayed wound closure typically 3-5 days after injury
Low energy
- Antibiotics
  - OTA survey showed that 86% provide routine ancef
- Surgery
  - If intra-articular bullet fragments
    - Prevents synovitis, joint destruction, elevated lead levels
  - Wound is part of dissection field for fixation
  - Show of meaning soft-tissue damage
- No surgery
  - Entry and exit wounds have low incidence of infection (2 pct)
  - Routine surgical debridement is non recommended for arthrotomies without retained fragments or fractures that do not require fixation
    - Though there is common meniscus and chondral damage that may crave arthroscopic treatment subsequently

Unique scenarios

Acetabular and pelvic ring injuries when projectile violated the bowel
- Routine fracture debridement has unproven effectiveness in these pelvic injuries
- Injection rates are high with or without bony debridement

Here are the answers to the higher up questions.

How would you describe this fracture?

AP view of a femur in a skeletally mature individual showing a distal third comminuted fracture with likely bullet fragments

What was the velocity of the projectile, high or low?

Likely High free energy, >2,000 feet per second (FPS)

Any more than imaging that you would want to get?

CT browse right lower extremity (RLE). Involving correct knee and hip to evaluate the joints.

How would you manage this injury in the trauma bay?

Ideally become supplies needed ahead of fourth dimension
- Basin, sterile saline, sterile gauze, kerlix (gauze roll), acewrap, traction pin supplies (if needed, not in this case), splint supplies (long posterior leg splint in this case)
Let the gen surg team do their ABCs, master and secondary exams (you should practise the rectal examination if covering spine)
I usually spring to "C" considering I consider the pelvis to be role of circulation because in that location can be life-threatening claret loss
Do a full exam neck to toes
- Look for whatever area of open skin, be on high alert because it is sometimes easy to miss open fractures and arthrotomies (open joints)
- Palpate for pain (tin can aid find fractures)
- Bank check Motility (helps find joint dislocations)
- Motor and sensory (reflexes if covering spine)
- Vascular (if abnormal consider checking indicate with doppler and ABIs)
Gild xrays for whatsoever expanse of concern: Skin abrasions/bruising, Hurting, motion abnormality, (it is okay to over 10-ray, minimal radiation, cheap, and y'all don't desire to miss annihilation)
- You can society long bone xrays to help survey joints if in a hurry (femurs, tibia/fibula, forearm, humerus). If you call back a articulation is involved, only go the joint specific xray.
- You tin find fractures underlying mild abrasions (more likely in loftier energy mechanisms)
Wash off debris and exam more closely with sterile saline
Embrace with sterile saline soaked gauze
Add more absorbent gauze, kerlix, and ace wrap
Splint

What would you practice in the operating room?

What would you do with the bullet fragments?
- Leave bullet fragments, unless they are in the joint, in the path of dissection, in the spinal canal, or sometimes if likely to crusade irritation (superficial)
What type of fixation would you employ and what type of bone healing?
- secondary bone healing with a retrograde or anterograde femur nail
What parameters are essential to restore in the operating room and how would you assess them?
- Restore length, rotation, alignment (compare with xrays of other side, line upwardly cortical diameters, check both legs if other side isn't covered past drapes)
- Check femoral neck under fluoro (femoral neck fractures are common in higher energy femoral shaft fractures)
- Check knee joint ligaments (ligamentous knee injuries are mutual in high energy injuries, trying to get one while the patient is awake is likely non obtainable)