Open fractures: the management of firearm missle fractures of the extremites

A prospective study of civilian firearm missile fractures during a three years period from July 1996 to June 1999 was conducted at Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania, to identify the specific problems of firearm injuries and their treatment in our civilian society. Patients with firearm missile injuries to the extremities admitted and managed at Muhimbili Orthopaedic Institute, in Dar es Salaam, Tanzania between July 1996 and June 1999. Objectives of the study were as follows;1. To identify specific problems of firearm injuries and their treatment in our civilian society: 2. To compare the clinical and functional results for plaster cast, skeletal traction, external fixation and screw fixation treatments for the various types of open firearm missile fractures to the extremities. 3. To compare the complications and the complication rates of the named firearm open fracture injuring agents and of the mentioned types of treatment. All the patients admitted to the Muhimbiii Orthopaedic Institute with open firearm missile fractures to the extremities requiring surgical debridement and stabilization were entered into the study. Patients with firearm injuries to other parts of the body other than the extremities were excluded from the study. Forty eight long bone open fractures caused by firearm missiles to the extremities in 40 patients were treated during this period. A male predominance was evident with a male to female ratio of 19:1. The age range was between 18 and 70 years with a mean of 29.5 years. The injuries were inflicted by rifle bullets in 18 patients (45%), shotgun shots in 8 patients (20%), pistol bullets in 8 patients (20%), landmine shrapnel fragments in 3 patients (7.5%) and a terrorist bomb explosion in 3 patients (7.5%). The most frequently injured bones were the femur in 20 patients (50%) and the tibia in 13 patients (32.5%). Thirty four of the fractures (70.8%) were Type III while 13 (27.1%) were type II by Gustilo classification. Associated injuries were present in 13 patients with scalp lacerations in 3 patients, penetrating chest injury with haemothorax in 2 patients, abdominal injury with gut perforation in 2 patients and superficial burns to the body in 2 patients.There was one irreparable axillary artery injury resulting in an above elbow amputation. Thirty three patients (82.5%) arrived to hospital within 24 hours of injury and underwent primary surgery by wound debridement and stabilization. Seven patients arrived to hospital more than 24 hours after injury and underwent secondary surgery. Treatment: Treatment with plaster cast, skeletal traction using a Braun's splint, external fixation with a Tanzfix or a tubular AO external fixator, miniexternal fixator and cancellous screw fixation was used, depending on what was judged to be the most suitable option from the available facilities at the time of treatment. Stabilization was achieved by skeletal traction in 15 patients (37.5%), plaster of Paris in 17 patients (42.5%), screw fixation in one patient {2.5%), external fixation in 7 patients (17.5%). Amputation was done in three patients {7.5%): two primary and one secondary. The immediate post-operative course was uneventful in 37 patients while 3 polytrauma patients from a bomb explosion died within 24 hours of admission, one patient died due to septicaemia, one due to haemorrhagic shock and one died of associated abdominal injuries. Assessment of outcome: Clinical outcome assessment included fracture union, average duration to fracture healing or union, average hospital stay, functional results, average time to return to work and the complication rate of each method of treatment and of each injuring agent. Follow up averaged 9 months (range 6-12 months). Results: At the end of the study 29 patients (72.5%) had healed and six patients (15%) died. Patients treated by plaster cast took longer time to heal (25 weeks), had poorer functional results and took on average longer time to return to work (15 months) as compared to the other treatment groups. The gross complication rate was also high at (60.4%) in the 4 types of treatment, the highest being in the treatment with casting (37.5%) and the lowest in the treatment with external fixation (7.5%). Fractures secondary to shrapnel and rifle injuries had worse prognosis as compared with fractures secondary to pistol shot injuries. Treatment with skeletal traction had better clinical results than the plaster cast treatment. The average healing time was the same at 25 weeks but the functional results were better and 75% of the patients returned to work in an average time of 15 months. The complication rate in this group was 60.4%. There were six deaths in all constituting 15% of the patients. Three deaths were due to severe polytrauma, one was due to associated abdominal injuries, one death was due to haemorrhagic shock and one was due to septicaemia. The two patients who died from severe polytrauma were among the 6 patients treated by external fixation. All the 4 surviving patients healed within an average tune of 1 6 weeks with good functional results. All of them returned to work within an average time of 10 months. The most common comp,ication was infection in 16 patients constituting 40% of the cases. Conclusion: It is concluded that firearm missile injuries, as it has been shown in many other societies, are on the increase even in our traditionally peaceful country. The treatment problems are immense given the limited resources and options of treatment and stabilization in our hospitals. It is also concluded that the external fixator should continue to be the treatment of choice for severe grade III open firearm missile fractures of the extremities secondary to high-velocity mechanism. Non-operative treatment with plaster cast and skeletal traction can be used for selected stable, non-displaced fractures secondary to lowvelocity mechanism. Appropriate preventive measures of firearm injuries should include restriction of the availability of firearms to the public and a broadbased approach to the current unemployment problem. The ongoing peace initiatives currently taking place in and around our geographical region should be given all the necessary support to end the violence among the warring factions and ethnic groups in our region.