Simultaneous, Asymmetrical, Comminuted and Bilateral Ballistic Fractures by Multiple Gunshot Wounds and a Review of Its Literature: A Case Report in Chad

Although open leg fractures are very common in orthopedics and traumatology, bilateral open leg fractures are extremely rare and are usually associated with an increased risk of complications. We report a case of a simultaneous, asymmetrical, comminuted and bilateral open fracture of the tibia and fibula by a firearm that occurred during an escape attempt in a 29-year-old prisoner. The pre-operative radiological assessment found an open fracture of both legs of the ballistic type;multiple traumatic gunshot wounds with a narrow entry hole and a wide exit hole. Early surgical intervention of intravenous antibiotics, tetanus prophylaxis and open fracture irrigation and debridement was performed within the 6 hour rule. The treatment consisted of a posterior splint followed by trimming andosteosynthesis using a FESSA external fixator from the military health service. A second operation was not needed. Evolution was favorable with ambulation starting from the 45th day. Simultaneous and bilateral tibia-fibula fractures by a firearm are exceptional, therefore, the treatment was surgical with the pre-operative and post-operative protocols well managed.

Surgical treatment for rabbits' femoral arteries subjected to gunshot wounds combining with seawater immersion

Objective: To investigate the surgical treatment methods and evaluate the outcome of gunshot wounds combining with seawater immersion in rabbits’ femoral arteries. Methods: One hundred healthy New Zealand white rabbits (either sex, 3.14 kg± 0.61 kg in weight) were randomly divided into a seawater immersion group (n=50) and a simple injury group (n=50). The unilateral femoral arteries of all the rabbits were injured by 0.38 g steel spheres with velocity of 600-800 m/s fired by a 7.62 mm rifle. The rabbits in the seawater immersion group were immersed in seawater (saline content of 2.54%, pH 8.2- 8.4, and at 21℃) for 60 minutes but those in the simple injury group were not. After the injured segment (observed by naked eyes) of the femoral artery was excised, the blood flow restoration was reconstructed by direct end-to-end anastomosis, reversed autogenous venous grafting or cryopreserved arterial allografting, according to the length of the arterial defects. At 24 hours, and 7, 14 and 21 days after operation, the blood flow was examined. Operative exploration was performed for the animals with partly or fully obstructed blood flow. The tissues around the anastomosis sites and the grafts were harvested for pathological observation under a light microscope and an electron microscope. Results: In the rabbits with completely transected injury, the unobstructed rates in the first 3 weeks after operation were 80.00% in the seawater immersion group and 86.67% in the single injury group, and no significant difference was found between the two groups (P> 0.1). In the rabbits with arterial contusion injury, the unobstructed rates in the first 3 weeks after operation were 86.67% in the seawater immersion group and 82.35% in the single injury group, and no significant difference was found between the two groups (P> 0.1). Most thrombosis occurred in the first operative week. Atypical endothelial cells were detected at the anastomosis sites at the first operative week, and the anastomosis sites were lined with endothelial cells in 3 weeks postoperatively. Conclusions: During the surgical treatment for gunshot wounds combining with seawater immersion, resection of the grossly-injured artery and routine artery reconstruction can obtain satisfactory outcome. Homologous artery is a kind of vascular graft with certain applied value.

Pathological study of rabbits' femoral arteries subjected to gunshot wounds combining with seawater immersion

Objective: To investigate pathological characteristics of gunshot wounds concomitant seawater immersion in rabbits’ femoral arteries. Methods: Thirty rabbits were divided randomly into 3 groups: simple gunshot-wound group (Group I, n=10), gunshot wound with seawater immersion for 30 mins (Group II, n=10), and 60 mins group (Group III, n=10). Femoral arteries were impacted by (0.38 g) steel spheres fired with a (7.62 mm) rifle. After being wounded, rabbits in Groups II and III were immersed in seawater for 30 or 60 mins, but those in Group I were not. At 2, 4, 6, 8, 12 hours following injury, a 40 mm segment of the artery on each side of the gunshot point were excised and observed by light and electron microscopy. Results: The patterns of arterial injuries were mainly contusion and transection. Completely transected artery was classified as primary-wound-tract area, contused area and shocked area. Compared with those in Group I, the primary-wound-tract and contused areas in Group II manifested obvious swelling in the arterial wall especially at the outside 2/3 of the media. Vacuolar structures were often seen in smooth muscle cells of the media. Intercellular space among the smooth muscle cells were filled with homogeneous acidophilic substances. Deep rugae among endothelial cells flattened or rugal folds lost their longitudinal orientation, and marked fibrin and platelet deposition were noticed. No significant difference was detected between Group II and III. The pathological changes in the shocked area were similar in 3 groups. Conclusions: For gunshot wounds concomitant seawater immersion in rabbits’ femoral arteries, there was a marked swelling of cells and intercellular space in primary-wound-tract area and contusion area. The influence of these pathological changes on surgical reparation deservers further study.

Civilian gunshot wounds to the head:a case report,clinical management,and literature review

Background:Civilian gunshot wounds to the head refer to brain injury caused by projectiles such as gun projectiles and various fragments generated by explosives in a power launch or explosion.Gunshot wounds to the head are the deadliest of all gun injuries.According to literature statistics,the survival rate of patients with gunshot wounds to the head is only 9%.Due to the strict management of various types of firearms,they rarely occur,so the injury mechanism,injury and trauma analysis,clinical management,and surgical standards are almost entirely based on military experience,and there are few related reports,especially of the head,in which an individual suffered a fatal blow more than once in a short time.We report a case with a return to almost complete recovery despite the patient suffering two gunshot injuries to the head in a short period of time.Case presentations:We present a case of a 53-year-old man who suffered two gunshot injuries to the head under unknown circumstances.On initial presentation,the patient had a Glasgow Coma Scale score of 6,was unable to communicate,and had loss of consciousness.The first bullet penetrated the right frontal area and finally reached the right occipital lobe.When the patient reflexively shielded his head with his hand,the second bullet passed through the patient’s right palm bone,entered the right frontotemporal area,and came to rest deep in the lateral sulcus.The patient had a cerebral hernia when he was admitted to the hospital and immediately entered the operating room for rescue after a computed tomography scan.After two foreign body removals and skull repair,the patient recovered completely.Conclusions:Gunshot wounds to the head have a high mortality rate and usually require aggressive management.Evaluation of most gunshot injuries requires extremely fast imaging examination upon arrival at the hospital,followed by proactive treatment against infection,seizure,and increased intracranial pressure.Surgical intervention is usually necessary,and its key points include the timing,method,and scope of the operation.

Masquelet technique in military practice:specificities and future directions for combat-related bone defect reconstruction

Because of its simplicity,reliability,and replicability,the Masquelet induced membrane technique(IMT)has become one of the preferred methods for critical bone defect reconstruction in extremities.Although it is now used worldwide,few studies have been published about IMT in military practice.Bone reconstruction is particularly challenging in this context of care due to extensive soft-tissue injury,early wound infection,and even delayed management in austere conditions.Based on our clinical expertise,recent research,and a literature analysis,this narrative review provides an overview of the IMT application to combat-related bone defects.It presents technical specificities and future developments aiming to optimize IMT outcomes,including for the management of massive multi-tissue defects or bone reconstruction performed in the field with limited resources.

Evaluation of follow-up and long-term outcomes of gunshot and stab wounds in a French civilian population

Purpose The data concerning long-term follow-up and outcomes of penetrating trauma are poorly detailed in the literature.The main objective of our study was to analyze the hospital and extra-hospital follow-up of penetrating trauma victims and to evaluate the late complications and long-term consequences of these traumas.Methods This work was a retrospective longitudinal monocentric observational study conducted at Laveran Military Hospital,from January 2007 to January 2017.All patients hospitalized for gunshot wound or stab wound management during this period were identified via a retrospective systematic query in the hospital information system using the ICD-10 codes.Epidemiological data,traumatism characteristics,hospital management,follow-up and traumatism consequences(i.e.,persistent disability)were analyzed.To improve evaluation of traumatism long-term consequences,extra-hospital follow-up data from general physicians(GP)were collected by phone call.During this interview,9 closed questions were asked to the GP.The survey evaluated:the date of the last consultation related to injury with the GP,the specific follow-up carried out by the GP,traumatism consequences,and recurrence of traumatism.Descriptive,univariate and multivariate with regression analysis were used for statistical analysis.Results A total number of 165 patients were included.Median(Q1,Q3)of hospital follow-up was 28(4,66)days.One hundred one patients(61.2%)went to their one-month consultation at hospital.GP follow-up was achieved for 76 patients(55.2%).Median(Q1,Q3)of GP follow-up was 47(21,75)months.Twenty-four patients(14.5%)have been totally lost to follow up.The overall follow-up identified 54 patients(32.7%)with long-term consequences,20 being psychiatric disorders and 30 organic injuries.Organic consequences were mainly peripheral nerve damages(n=20;12.1%).Most of the psychiatric consequences were diagnosed during GP follow-up(n=14;70%).Seventeen cases(10.3%)of recurrence were found and late mortality occurred in 4 patients(2.4%).High injury severity score,older age and gunshot wound were significantly linked to long-term consequences.Data collection and analysis were carried out in accordance with MR004 reference methodology.Conclusion This study showed a high rate of long-term consequences among patients managed for penetrating injury.If all organic lesions are diagnosed during hospital follow-up and jointly managed by hospital and extra-hospital physicians,most socio-psychiatric consequences were detected and followed by extra-hospital workers.However,for half of the patients,the extra-hospital follow-up could not be assessed.Thus,these consequences are very probably underestimated.It appears imperative to strengthen the compliance and adherence of these patients to the care network.Awareness and involvement of medical,paramedical teams and GP role seems essential to screen and manage these consequences.

Pellet Embolization after Subclavian Artery Injury:A Case Report

Acute upper limb ischemia caused by a gunshot penetrating vascular injury and subsequent arterial embolization by foreign body is uncommon in everyday practice and is associated with high morbidity/mortality rates, especially with emergency surgery. We present the case of a 72-year old male who attempted suicide using a gun. A gunshot entry wound was evident in the right upper chest region with no pellet exit wound. Radial pulses were palpable bilaterally. Angiography revealed right subclavian artery direct injury and pellet embolization to the brachial artery. The patient underwent open surgery, with reversed saphenous vein interposition graft to replace subclavian artery defect. A pellet was removed by a separate arteriotomy in the brachial artery. Associated injuries were clavicle-comminuted fracture and subclavian vein injury. The patient remained well 5 months later with no reported complications. In conclusions, the presence of radial pulses alone on clinical exam cannot rule out the presence of a significant vascular injury.

Terrorist attacks:cutaneous patterns of gunshot and secondary blast injuries

Terrorist attacks have been on the rise.During the recent terrorist attacks in France,terrorists perpetrated their acts using weapons of war,as well as explosive charges.These two modes of action,when combined,can create skin lesions with similar macroscopic appearances,which can sometimes go unnoticed because of body fragmentation.A total of 68 autopsies,83 external examinations,140 standard radiographic examinations,and 49 computed tomography(CT)scans were performed over 7 days during the 2015 terrorist attacks in France.Bodies were injured by firearms and shrapnel-like projectiles.We analysed the clinical findings for the secondary blast cutaneous lesions from the explosive devices and compared these lesions with ballistic-related lesions to highlight that patterns can be macroscopically similar on external examination.Secondary blast injuries are characterised by penetrating trauma associated with materials added to explosive systems that are propelled by explosive air movement.These injuries are caused most often by small,shrapnel-like metallic objects,such as nails and bolts.Propulsion causes ballistic-type injuries that must be recognised and distinguished from those caused by firearm projectiles.Differentiating between these lesions is very difficult when using conventional criteria(size,shape,number and distribution on the body)with only external examination of corpses.This is why the particularities of these lesions must be further illustrated and then confirmed by complete autopsies and radiological and anatomopathological examinations.

Adrenal gland injury due to gunshot

Adrenal gland trauma is a rare phenomenon, due to the small size and retroperitoneal location of the organ. The majority of adrenal gland trauma is due to blunt force injury and is only rarely encountered due to the penetrating mechanisms. A 20-year-old male sustained a gunshot wound to the left abdomen. Upon exploration, he was found to have a through and through injury to the left adrenal gland, among other injuries. Injury to the adrenal gland due to penetrating trauma is exceptionally rare. The principles of management are to control bleeding from the gland with debridement and hemostasis rather than attempt to resect the entire organ. The management of a penetrating injury to the adrenal gland is straightforward and should not be a contributor to a patient’s morbidity or mortality.

Gunshot （Pellets） injury to the maxillofacial complex： a case report

Gunshot injuries are rather serious but uncommon type of trauma in India. A 45-year-old male was presented with gunshot （pellets） embedded in the maxillofacial area for 22 years. There is no consensus in the literature whether to attempt their removal or leave them in situ. Our patient had no long-term sequela like infection, fistula formation, carcinogenesis or metal poisoning to date except for chill feeling on cold days. Management of this patient presented a dilemma in treatment in view of the effects of foreign bodies in the maxillofacial area.

Mandible prognathism saved a life： a case report

An unusual case of a suicidal firearm injury is presented, in which the victim placed the gun under his chin and fired. However, none of the vital structures of the head and face were injured because the victim＇s chin was considerably anterior to other facial structures as a result of a class Ⅲ facial deformity. This resulted in thetrajectory of the bullet being anterior to vital facial structures and not causing injury to those structures.