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American Association for Hand Surgery
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Theme: Inclusion and Collaboration Theme: Inclusion and Collaboration

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Gunshot sounds involving the hand have low infection rates after instrumentation
Leahthan Faye Domeshek, MD; Carrie Bettlach, FNP; Austin Ha, MD; Moore M. Amy, MD
Washington University, St. Louis, MO

Introduction:
Gunshot wounds involving the hand can lead to significant morbidity especially when fractures of the metacarpals and phalanges result. These injuries often include bony destruction and large soft tissue defects. Infection risk is a concern especially when bony defects require instrumentation in the setting of poor soft tissue quality. The goal of our study was to examine the efficacies of our management of metacarpal and phalangeal fractures resulting from gunshot wounds to the hand. Specifically, we examined complications including infection and unanticipated reoperation after instrumentation.

Materials & Methods:
Charts of all patients who presented to the emergency room with gunshot wounds from 2010 to 2017 were reviewed. Only those patients who were treated by the Plastic Surgery service for metacarpal and/or phalangeal fractures resulting from their wounds were included. Data collected included mechanism of injury, use of antibiotics, surgical vs nonsurgical management, and occurrence of infection or other complication after instrumentation.

Results:
Of 1599 patient charts that were initially reviewed, 103 patients met inclusion criteria, presenting with 133 fractures. Thirty-three percent of patients presented with self-inflicted wounds. Eighty-two percent of patients received antibiotics on presentation, and an additional 13% who did not, were discharged from the emergency department with an oral antibiotic prescription. A variety of fixation methods were utilized for treatment. Thirty-three percent of patients were treated nonoperatively. Nearly 17% of patients elected for revision or ray amputation either primarily or after failed alternative management. Four patients (4%) developed infections postoperatively. Of these four patients, three were treated operatively (two required removal of hardware, the third, who had received a revision amputation at the time of injury required removal of retained shrapnel). The fourth patient had developed a pin site infection, which was successfully with oral antibiotics and pin removal. Average duration of follow up was 80 days; half of the patients who had planned removal of hardware (k-wires or external fixators) in clinic did not follow up subsequent to removal.

Conclusions:
Metacarpal and phalangeal fractures resulting from gunshot wounds can cause significant bony and soft tissue destruction. Infection is rare after instrumentation when patients receive antibiotics and irrigation shortly after sustaining injury. Follow-up in this patient population is poor, and long term ability to assess functional outcomes or return to work could not be adequately assessed.


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