Gunshot wounds to the hand: An Urban Level-I Trauma Center Ten Year Experience
Clifford Pereira, MD, FRCS(Eng)1, J. Brian Boyd, MD FRCS FRCSC FACS1, Mark Gelfand, MD2, Brant Putnam, MD1.
1Harbor UCLA Medical Center, Torrance, CA, USA, 2UCLA, Los Angeles, CA, USA.
PURPOSE: Gunshot wounds (GSWs) to the hand are an increasing occurrence in our inner cities. When they occur, they can constitute a significant reconstructive challenge. We present our ten year experience at an urban level I trauma center.
METHODS: A retrospective review was performed on all patients admitted to Harbor UCLA with GSWs to the extremities between January 1997 and January 2007. Patients who had sustained GSWs to the hand and wrist needing operative intervention were selected for this study.
RESULTS: Between 1997 and 2007, a total of 1358 patients were admitted to the Harbor-UCLA ER having sustained GSWs to the upper and lower extremities; and, of these, 1306 survived. Of the survivors, 62 patients (55 males, 7 females) sustained GSWs to their hand and wrist requiring operative intervention. None died within a month of the incident. Their mean age was 25.1 (±10.2) years, most presenting within a few hours of the injury. Only 2 cases presented after 24 hours. Surprisingly, 97% had received multiple low velocity gun shot wounds: over 50% in other extremities and 30% in the abdomen. Mean length of hospital stay was 5.0 (±5.1) days, with 9.7 % cases requiring ICU stay. Mean length of ICU stay was 3.3 (±1.4) days. The wrist joint was involved in only 2 cases, one of which required a proximal row carpectomy and wrist fusion. Most fractures of the small bones of the hand were comminuted, requiring iliac crest bone grafts in two cases, and arthrodesis in one. Tendon injuries requiring repair occurred in 16% cases with equal extensor and flexor tendon involvement. There were 7 nerve injuries at the level of the wrist, 5 of which were neuropraxias and two were lacerations. Both nerve lacerations (1 ulnar nerve and 1 median nerve) were repaired primarily at the first operation. Vascular injuries to the radial or ulnar artery at the level of the wrist occurred in 3 cases, all of which required reversed saphenous vein interpositional grafts for repair. Only one patient required amputation of an involved finger. Free flaps were used in only once case (a free parascapular flap to the wrist).
CONCLUSION: In the urban setting, GSWs to the hand and wrist are invariably a component of multiple low velocity missile wounds (aka handgun injuries) received by a single patient. Most of these are associated with comminuted fractures that rarely require bone grafts, fusion or amputation. Vascular injuries occur rarely, but when they do, they require interpositional vein grafts due to loss of length. Very few patients require complex free tissue transfers, and surprisingly few sustain nerve or tendon injuries. In fact, only 2 of 62 sustained lacerations to nerves.