Wednesday, November 6, 2002
509

Fracture Management of Gunshot Wounds to the Hand

Mark Kiehn, MD, Karol Gutowski, MD, and Amitabha Mitra, MD.

Introduction: Management of gunshot wounds (GSW) to the hand, based on military experience, emphasized aggressive soft tissue debridement and delayed fracture fixation. Civilian GSW are predominantly low velocity injuries with less tissue destruction, which may allow for less aggressive debridement and early fracture fixation. The purpose of this study was to evaluate the results of early definitive treatment of hand GSW fractures and patient compliance to determine the benefits of this treatment strategy for an inner-city trauma-patient population. Methods: Chart review of patients with GSW hand fractures at an urban, level-1 trauma center from January 1989 to December 1998. Results: Seventy-two patients with 98 fractures were treated. The majority of fractures occurred in the metacarpals, proximal phalanges, and metacarpophylangeal joints. Wounds were cleansed and minimally debrided and intravenous antibiotics were administered. The average time from injury to surgery was 2 days. Fixation techniques included K-wires (33), splinting/casting (29), internal plates (16), external fixation (12), and other techniques (4). Two in-patient and 4 post-hospital infections were diagnosed. There were no cases of osteomyelitis and no infection required fixation device removal. All infections were limited to superficial soft tissues and resolved with antibiotics. Twenty-eight patients (39%), most commonly splint/cast (12) and K-wire (14), were lost to follow-up upon discharge from the hospital and only 11 patients (15%) continued follow-up until the final wound healing and conclusion of hand therapy. Conclusions: Conservative debridement and early fixation of civilian GSW hand fractures was associated with few infections, which were limited to soft tissues, resolved with antibiotics, and did not require hardware removal. Poor patient follow-up should be anticipated for the urban hand-GSW patient. Adjustments in treatment strategy should be considered to reduce treatment-related complications and optimize outcomes for these patients.
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