Gunshot injuries in Central Europe - Epidemiology and outcome in Germany, Switzerland and Austria - an analysis based on the TraumaRegister DGU®.

BACKGROUND: Firearms are of special interest in trauma research due to high lethality and criminal value. Strong correlation between guns per capita and fire-arm related deaths has been shown. Most of existing literature regarding gun-shot fatalities are from the U.S. and data for Central Europe is lacking. Thus, the aim of this study was to assess the legal frameworks regarding gun-ownership in Germany (DE), Austria (A) and Switzerland (CH), and to retrospectively analyze data from the TraumaRegister DGU® regarding the epidemiology, injury severity, intention and outcome of gunshot-related deaths in these countries. METHODS: All patients from TR-DGU who sustained a gunshot injury in the time period from 1st January 2009 to 31st December 2019 were considered for analysis. Only cases admitted to level 1 or 2 trauma center in Germany, Switzerland, or Austria were included. Predicted mortality was calculated using the RISC-II. Further, the legal framework for firearm posession were explored. RESULTS: The legal frameworks do not differ significantly between the countries. However, only ex-military men from Switzerland are allowed to keep their automatic (military) weapon at home. We assessed 1312 gunshot fatalities (DE 1,099, A 111, CH 102) of which most were due to suspected suicide (A 72.1 %, CH 64.7 %, and DE 56.6 %, p = 0.003). Act of suspected violent crime or accidental gunshots were rare in all three countries. Amongst all gunshot fatalities, Austria showed the highest mean age (57.6 years), followed by DE (53.4 years) and CH (49.4 years; p < 0.01). Gunshot fatalities amongst all assessed countries due to suspected suicide showed a peak at the age of 60 years and above, whereas suspected violent crime delicts with gunshots were mainly seen in younger age groups. The highest mortality was found in suspected suicide cases, showing a mortality of 82.1 % (predicted 65.2 %) in Switzerland, 75.3 % (predicted 65.8 %) in Austria and 63.7 % (predicted 56.2 %) in Germany. CONCLUSION: Gunshot wounds are still rare in central Europe, but gunshot-related suicide rates are high. Gun ownership laws may have an impact on gunshot wounds due to suspected suicide. Injury patterns differ compared to countries where a high incidence of gun ownership is seen.

Analysis of social determinants of health on emergency department utilization by gunshot wound survivors after level 1 trauma center discharge.

Background: This project analyzed risk factors for emergency department (ED) utilization without readmission within 2 weeks post-discharge for survivors of gun violence. Methods: A hundred gun violence survivors admitted to a Level 1 trauma center were surveyed. Descriptive analyses and group comparisons were conducted between patients who did and did not use the ED. Factors analyzed are rooted in social determinants of health and clinical care related to the index hospitalization. Results: Of the 100 patients, 31 had an ED visit within 6 weeks, although most (87.1%) returned within 2 weeks of discharge. Factors significantly associated (p≤0.05) with a return ED visit included: not having an identified primary care provider, not having friends or family to count on for help, not having enough money to support themselves before return to work, and not feeling able to read discharge instructions. Conclusion: Lack of a primary care provider, low health literacy and social support were associated with increased ED visits without readmission post-discharge. Level of Evidence: Level III, Prognostic and Epidemiological.

Migration of Bullet Fragment 11 Years after Initial Gunshot Wound leads to Cervical Prevertebral Abscess: A Case Report.

Introduction: Literature showcases conflicting findings regarding the outcomes of ballistic fragment removal from the spine in gunshot wounds (GSW) patients. Further research in this area is needed to better comprehend the nuances of risks and benefits surrounding ballistic fragment removal from the spine in GSW patients. In this case report, we discuss the late-onset cervical prevertebral abscess which developed when a previously embedded bullet fragment migrated into the retropharyngeal space 11 years after an initial GSW. Case Report: A 29-year-old male sustained a gunshot wound to the face in 2011. He was stabilized with a posterior C3-C6 lateral mass instrumentation and fusion. There were no attempts to remove the bullet fragments. In 2023, the patient returned with worsening neck pain. Imaging demonstrated a retropharyngeal abscess with interval rotation of the ballistic fragment by 90°. An abscess was noted anterior to the cervical vertebrae with a freely mobile ballistic fragment within. Conclusion: This case highlights several questions: What is the criteria for radiographic surveillance of retained hardware? If there is documented movement, should this trigger further investigation? What complications can occur that warrant careful removal?

Identifying mental health outcomes and evidence-based psychological interventions for supporting pediatric gunshot wound patients: A systematic review and proposed conceptual model.

BACKGROUND: Accidental and assault gunshot wounds (GSWs) are the second leading cause of injury in the United States for youth ages 1- to 17-years-old, resulting in significant negative effects on pediatric patients' mental health functioning. Despite the critical implications of GSWs, there has yet to be a systematic review synthesizing trends in mental health outcomes for pediatric patients; a gap the present review fills. Additionally, this review identifies evidence-based psychological interventions shown to be effective in the treatment of subclinical symptoms of psychological disorders in the general population. METHODS: A comprehensive search was conducted using five databases: American Psychological Association (APA) PsycInfo, APA PsycArticles, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Education Resource Information Center (ERIC), and Medical Literature Analysis and Retrieval Systems Online (MEDLINE). Twenty-two articles met inclusion criteria. RESULTS: Findings suggest pediatric GSW patients are at a significantly elevated risk for mental health disorders when compared to other- (e.g., motor vehicle collision) and non-injured youth. Disorders include post-traumatic stress, disruptive behavior, anxiety, depression, and substance use. Hospital-based violence intervention programs, cultivating supportive relationships with adults in one's community, and trauma-focused outpatient services were identified as effective interventions for treating subclinical psychological symptoms. CONCLUSIONS: Depicted in the proposed conceptual model, the present study delineates a direct association between pediatric GSWs and subsequent onset of mental health disorders. This relation is buffered by evidence-based psychological interventions targeting subclinical symptoms. Results suggest brief psychological interventions can help treat mental health challenges, minimizing risk for significant long-term concerns. Cultural adaptations to enhance the utility and accessibility of interventions for all patients are recommended.

Timing of surgical intervention in peripheral nerve injuries from gunshot wounds: Management and review of the literature.

Background: Gunshot wounds (GSWs) can result in various peripheral nerve injuries (PNIs), ranging from direct nerve transection to neuropraxia caused by the ballistic shockwave mechanism. PNIs from GSWs can be treated with either early or delayed intervention, with the literature supporting both approaches and sparking a debate between early and delayed intervention for PNIs from GSWs. Here, we present a case that underwent delayed exploration of the right common peroneal nerve after GSW and a literature review comparing early versus delayed intervention for PNIs from GSWs. Case Description: A 29-year-old male underwent right common peroneal nerve exploration 2 months after he sustained a GSW to the right lower extremity at the level of the fibular head tracking to the lateral malleolus. Initially, after the injury, he was offered supportive care. On evaluation, 1 month later, he reported a right-sided foot drop and paresthesias in the right lower extremity. A partial-thickness injury of the right peroneal nerve was seen on ultrasound, and a bullet fragment in the distal right lower extremity was revealed on computed tomography. The surgical intervention consisted of the right common peroneal nerve decompression proximally to distally and removal of the bullet fragment. Postoperatively, the patient did well with improvements in his right ankle dorsiflexion and plantar flexion seen at his 1.5-month follow-up visit. Conclusion: Many factors must be considered when treating PNIs from GSWs. For each case, clinical judgment, injury mechanism, and risk-benefit analysis must be evaluated to determine each patient's optimal treatment strategy.

Superficial Siderosis of the Central Nervous System: A Report of Two Cases With Spinal Pathology and a Review of the Literature.

Infratentorial superficial siderosis, characterized by hemosiderin deposition in the subpial layers of the brainstem, cerebellum, and spinal cord, is a rare progressive neurologic disorder. We present two cases of infratentorial superficial siderosis. Case 1 involves a 62-year-old female previously diagnosed with tethered cord syndrome and thoracic myelopathy, who, following 11 spinal surgeries, presented with worsening myelopathy, hearing loss, and cognitive impairment. Brain magnetic resonance imaging (MRI) revealed extensive superficial siderosis affecting the cerebellar vermis and bilateral cerebellar hemispheres. Case 2 is a 27-year-old male with a traumatic T4 spinal cord injury from a gunshot wound, complicated by a syrinx, experiencing persistent lower back pain and lower limb spasticity. MRI confirmed superficial siderosis in the spinal cord. This case report explores the clinical manifestations, imaging findings, management strategies, and prognosis of these cases. It also highlights the diverse clinical presentations and underlying etiologies of infratentorial superficial siderosis. It emphasizes the pivotal role of MRI with iron-sensitive sequences for definitive diagnosis. Furthermore, the management underscores the significance of a multidisciplinary team approach in providing comprehensive care for affected individuals.

Management and outcomes of cerebrovascular injuries after gunshot wounds to the cervical spine.

STUDY DESIGN: This study was a multicenter retrospective analysis of cervical spine gunshot wound (GSW) patients. OBJECTIVE: The present study was conducted to evaluate the management and outcomes of vascular injuries following GSW involving the cervical spine. SUMMARY OF BACKGROUND DATA: Gunshot wounds (GSW) injuring the cervical spine are associated with high rates of vascular injury. METHODS: Charts of patients with GSW involving the cervical spine at two Level 1 trauma centers were reviewed from 2010 to 2021 for demographics, injury characteristics, management and follow-up. Statistical analysis included T tests and ANOVA for comparisons of continuous variables and chi-square testing for categorical variables, non-parametric tests were used when indicated. Beta-binomial models were used to estimate the probabilities outcomes. Bayesian regression models were utilized to compute risk ratios (RR) and their 95 % confidence intervals (CI) to enhance the inferential robustness. RESULTS: 40 patients with cervical spine GSW and associated cerebrovascular injury were included in our analysis. 15 % of patients had Biffl grade (BG) V injuries, 50 % grade IV, and 35 % grade III-I. Angiography was performed in 35 % of patients. 5 of these patients (BG V-III) required endovascular treatment for pseudoaneurysm obliteration or parent vessel sacrifice. 7 patients (22 %) showed evidence of progression. 70 % of patients were placed on antiplatelet therapy for stroke prevention. Bayesian regression models with a skeptical prior for cerebral ischemia revealed a mean RR of 4.82 (95 % CI 1.02-14.48) in the BG V group, 0.75 (95 % CI 0.13-2.26) in the BG IV group, and 0.61 (95 % CI 0.06-2.01) in the combined BG III-I group. For demise the mean RR was 3.41 (95 % CI 0.58-10.65) in the BG V group and 1.69 (95 % CI 0.29-5.97) in the BG IV group. In the high BG (V, IV) group, 54.55 % of patients treated with antiplatelet therapy had complications. None of the patients that were treated with antiplatelet therapy in the low BG (III-I) group had complications. CONCLUSIONS: Cervical spine GSWs are associated with high-grade vascular injuries and may require early endovascular intervention. Additionally, a high rate of injury progression was seen on follow up imaging, requiring subsequent intervention. Reintervention and demise were common and observed in high BG (V, IV) groups. The incidence of stroke was low, especially in low BG (I-III) groups, suggesting that daily aspirin prophylaxis is adequate for long-term stroke prevention.

A decade long overview of damage control laparotomy for abdominal gunshot wounds.

PURPOSE: Over the last three decades, damage control laparotomy (DCL) has become important in the management of abdominal gunshot wounds (GSW). This paper reviews the experience of a single institution over a decade with the use of DCL for GSW of the abdomen. METHODS: Longitudinal data (2013-2022) was collected from the Hybrid Electronic Medical Registry database to identify all patients with an abdominal GSW over the study period. The data was stratified based on patients who underwent DCL and those who did not. Descriptive analysis was completed to summarise the raw data. Univariate and multivariate analysis was completed to identify variables associated with undergoing DCL. RESULTS: There were 135 patients (32%) who underwent DCL and 290 patients (68%) who did not. Colonic, small bowel, mesenteric, hepatic, pancreatic and intra-abdominal vessel injuries were associated with the need for DCL (P<0.05). In total, 85 of the 135 (63%) patients who underwent DCL required more than one damage control technique. There were 45 (33%) mortalities in the DCL group compared to 16 mortalities (6%) in the non-DCL group (P<0.001). CONCLUSION: One third of patients who underwent a laparotomy following a gunshot wound to the abdomen had a DCL. The indications for DCL include both physiological criteria and injury patterns. DCL is associated with significant morbidity and mortality. Efforts need to be directed towards refining the indications for DCL in this group of patients to prevent inappropriate application of this potentially lifesaving technique.

Multi-institutional review of characteristics and management of gunshot wounds to the spine.

BACKGROUND CONTEXT: Gunshot wounds (GSWs) to the vertebral column represent an important cause of morbidity and mortality in the United States, constituting approximately 20% of all spinal injuries. The management of these injuries is an understudied and controversial topic, given its heterogeneity and lack of follow-up data. PURPOSE: To characterize the management and follow-up of GSWs to the spine. STUDY DESIGN/SETTING: A multi-institutional retrospective review of the experience of two urban Level 1 trauma centers. PATIENT SAMPLE: Patients with GSWs to the spine between 2010-2021. OUTCOME MEASURES: Measures included work status, follow-up healthcare utilization, and pain management were collected. METHODS: Charts were reviewed for demographics, injury characteristics, surgery and medical management, and follow-up. Statistical analysis included T-tests and ANOVA for comparisons of continuous variables and chi-square testing for categorical variables. All statistics were performed on SPSS v24 (IBM, Armonk, NY). RESULTS: A total of 271 patients were included for analysis. The average age was 28 years old, 82.7% of patients were black, 90% were male, and 76.4% had Medicare/Medicaid. The thoracic spine (35%) was most commonly injured followed by lumbar (33.9%) and cervical (25.6%). Cervical GSW was associated with higher mortality (p<.001); 8.7% of patients developed subsequent osteomyelitis/discitis, 71.3% received prophylactic antibiotics, and 56.1% of cervical GSW had a confirmed vertebral or carotid artery injury. ASIA scores at presentation were most commonly A (26.9%), D (20.7%), or E (19.6%), followed by C (7.4%) and B (6.6%). 18.8% of patients were unable to be assessed at presentation. ASIA score declined in only 2 patients, while 15.5% improved over their hospital stay. Those who improved were more likely to have ASIA B injury (p<.001). Overall, 9.2% of patients underwent spinal surgery. Of these, 33% presented as ASIA A, 21% as ASIA B, 29% as ASIA C, and 13% as ASIA D. Surgery was not associated with an improvement in ASIA score. CONCLUSIONS: Given the ubiquitous and heterogeneous experience with GSWs to the spine, rigorous attempts should be made to define this population and its clinical and surgical outcomes. Here, we present an analysis of 11 years of patients presenting to two large trauma centers to elucidate patterns in presentation, management, and follow-up. We highlight that GSWs to the cervical spine are most often seen in young black male patients. They were associated with high mortality and high rates of injury to vertebral arteries and that surgical intervention did not alter rates of discitis/osteomyelitis or propensity for neurologic recovery; moreover, there was no incidence of delayed spinal instability in the study population.

The April Revolution and the Sense of Place in Medical Space: Focusing on Major Hospitals in Downtown Seoul.

This article focuses on the medical activities conducted by major hospitals in downtown Seoul during the April Revolution in 1960, examining their experiential context and significance. The influx of guns and bullets into Korean society following the liberation in 1945 intertwined with the political and social conflicts of the period, resulting in numerous assassinations, crimes, and terrorism. Gunshot wounds were traumas that became a part of the everyday life of Koreans, as well as scars which reflected their historical contexts. At the same time, the frequent occurrence of gunshot wounds led to the development of medical capacities to treat them. The Korean surgical academia expanded its technical foundation with experiences during and after the Korean War. This progress was particularly noticeable in areas closely related to gunshot wounds, such as craniotomy, thoracotomy, vascular anastomosis, debridement, anesthesia, and blood transfusion. Major hospitals in downtown Seoul served as medical spaces where these experimental and technical foundations were concentrated, allowing them to minimize the death toll despite the massive gunfire by the National Police in April 1960. Thus, the aftermath of the epidemic of gunshots resulted in a rather paradoxical outcome. This development became a resource for doctors and nurses, who added their revolutionary implications in reconstructing the experience of April 1960 in their various memoirs and reports. While memoirs reorganized general medical activities, portraying injured patients as participants in the revolution, reports provided forensic descriptions and interpretations of the deaths, giving authority to the main narrative of the revolution. As the interpretations and significance based on historical contexts gained prominence, major hospitals in downtown Seoul also developed a sense of place closely associated with the revolution.

Cranial trauma in handgun executions: Circumferential delamination defect and its relationship with contact/close-range shooting.

Skeletal evidence usually constitutes the only source of information to interpret lesion patterns that help to clarify the circumstances surrounding death. The examination and interpretation of bone trauma are essential to the application and utility of anthropology as a forensic science. When discussing the effect of gunshot wounds in bone, it becomes imperative to differentiate between short and long-distance injuries based on clear, distinct, and observable signs. To contribute to the debate, our focus is directed toward the external analysis of the so-called circumferential delamination defect (CDD) as an observable proxy for close-range shooting (≤30 cm) and contact gunshot wounds in the skull. In the context of known extrajudicial killings, in which the perpetrators used short 9 × 19 FMJ ammunition in a close-range shooting, instances of CDD have been documented. Empirical evidence reinforcing the causal relationship between CDD and close-range shootings is presented. Elements' characteristics of firearm residues were also found in remains buried for up to 30 years. Primarily, this work shows that the concentrations of gunshot residues (Pb, Ba, and Sb) resemble those observed in fresh corpses with the same gunshot wound (GSW). Moreover, the correlation observed between CDD and gunshot residues, where the likelihood of CDD increases the closer to the head and the more perpendicular the shot angle is, reinforces CDD as a pivotal discriminatory factor in the skeletal evidence of short-range or contact shot. This research contributes to the field of forensic anthropology by providing fundamental insights into the etiology of CDD and its practical application.

Shots fired: evaluation of vascular injury, compartment syndrome, and transfusion rates among civilian ballistic orthopaedic fracture patients presenting to two Level I trauma centres.

PURPOSE: This study investigates baseline patient demographics and predictors of vascular injury, blood transfusion, and compartment syndrome in patients with orthopaedic fractures secondary to GSWs at two high-volume Level I trauma centres. METHODS: A retrospective chart review of all GSW-related trauma patients at two Level I trauma centres between July 2019 and September 2021 was conducted. Chi-squared and two-tailed independent t tests were used for data analysis, and logistic regression with odds ratios (OR) determined predictors of primary outcomes. RESULTS: Among 478 GSW patients, 94 (19.7%) sustained 130 orthopaedic fractures, most commonly at the lower extremity (77.7%). Orthopaedic fracture patients showed significantly higher rates of vascular injury (29.8 vs. 4.7%, p < 0.001), transfusion (27.7 vs. 12.8%, p = 0.006), and compartment syndrome (3.2 vs. 0.3%, p = 0.011) compared to non-orthopaedic injury patients. Univariable analysis identified ankle (OR = 47.50, p < 0.001) and hip/femur fractures (OR = 5.31, p < 0.001) as predictors of vascular injury. Multivariable logistic regression revealed lower extremity vascular injury (OR = 54.69, p = 0.006) and anatomic fracture sites of the humerus (OR = 15.17, p = 0.008), clavicle/scapula (OR = 11.30, p = 0.009), and acetabulum/pelvis (OR = 7.17, p = 0.025) as predictors of blood transfusion. Univariable analysis showed lower extremity vascular injury (OR = 30.14, p = 0.007) as a predictor of compartment syndrome. CONCLUSION: These findings underscore the importance of diagnosing and managing vascular injuries and compartment syndrome in GSW-related orthopaedic fractures, emphasizing the necessity for targeted transfusion strategies in such cases.

Robot-assisted thoracoscopic repair of tracheal gunshot wound.

A 23-year-old man suffered two gunshot wounds and upon arrival to the emergency room was found on imaging to have a large pneumothorax with considerable subcutaneous emphysema. Intubation and placement of bilateral chest tubes did not improve the patient's oxygenation; bronchoscopy revealed a 1 cm tracheal defect in the membranous wall 4 cm proximal to the carina. The patient underwent robot-assisted primary repair of the tracheal injury with a #3-0 PDS Stratafix barbed suture buttressed with an intercostal muscle flap. The patient was discharged in good condition on post-operative day 17, with follow-up bronchoscopy showing complete healing of the trachea.

Evaluation of Self-Inflicted versus Non-Self-Inflicted Gunshot Wounds and Associated Injuries Involving the Hand and Upper Extremity.

Orthopedic costs associated with gunshot wounds (GSWs) totaled approximately USD 510 million from 2005 to 2014. Previous studies have identified differences in injuries associated with self-inflicted (SI) GSWs; however, there remains a gap in understanding injury patterns. This study aims to expand upon the current literature and shed light on injury patterns and outcomes associated with SI vs. non-self-inflicted (NSI) GSWs. This is a retrospective cohort study of upper extremity GSWs from January 2012 to December 2022. Data were analyzed using the two-sample t-test, Pearson's chi-squared test, and Fisher's exact test. SI GSWs tended to be high-velocity GSWs and occurred more often in distal locations compared to NSI GSWs (p = 0.0014 and p < 0.0001, respectively). SI GSWs were associated with higher Gustilo-Anderson (GA) and Tscherne classifications (p < 0.0001 and p = 0.0048, respectively) and with a greater frequency of neurovascular damage (p = 0.0048). There was no difference in fracture rate or need for operative intervention between the groups. GA and Tscherne classifications were associated with the need for and type of surgery (p < 0.0001), with a higher classification being associated with more intricate operative intervention; however, GSW velocity was not associated with operative need (p = 0.42). Our findings demonstrate that velocity, wound grading systems, and other factors are associated with the manner in which GSWs to the upper extremity are inflicted and may thus have potential for use in the prediction of injury patterns and planning of trauma management and surgical intervention.

Attempted repair of chest wall injury following penetrating injury with surgical stabilization rib and autologous bone graft: A case report.

Rib fractures are one of the most common injuries following blunt trauma. When associated with penetrating trauma, the projectile velocity and immense energy transfer cause significant rib fracture displacement and fragmentation. As a result, these patients are potentially exposed to an even higher risk of complications compared to those seen in more simple rib fractures. Unfortunately, there is limited research regarding technical considerations for surgical stabilization of rib fractures (SSRF) in severely displaced rib fractures with bone loss following penetrating injury. We present the case of a 21-year-old male gunshot wound victim with severely displaced and comminuted rib fractures in which we utilized an autologous bone graft bridge during SSRF to enhance fracture unionization, chest wall stability, and cosmesis. Unfortunately, the bone graft failed to incorporate into surrounding tissue.

Bronchial artery embolization for the treatment of delayed massive hemoptysis due to a retained bullet.

Bronchial artery embolization is a feasible option for treating hemoptysis caused by foreign objects in patients who are not candidates for surgery.

Exploration of the right peroneal nerve after a gunshot wound.

Background: Gunshot wounds (GSWs) often result in neuropraxia or a mixed injury pattern rather than direct nerve transection. There is still debate between early and delayed intervention for the optimal treatment of intact nerves following GSWs. Early intervention may prevent the formation of dense scar tissue, and delayed intervention allows for the zone of injury to be fully demarcated for optimal treatment planning. Here, we present the case of a 29-year-old male who underwent exploration of the right common peroneal nerve after a GSW. Case Description: A 29-year-old male presented for evaluation of a GSW to the right lower extremity at the level of the fibular head he sustained 2 months prior. Following his injury, he was immediately evaluated in the emergency department and offered supportive care. He reported paresthesias in the right lower extremity and a right-sided foot drop. Computed tomography demonstrated a bullet fragment in the distal right lower extremity, and ultrasound revealed a partial thickness injury in the right peroneal nerve. Exploration of the right common peroneal nerve and bullet fragment was recommended. The bullet fragment was removed from the distal right lower extremity in one piece. Following this, the right common peroneal nerve was decompressed proximally to distally, with scar tissue encountered distally. Postoperatively, the patient did well, ambulating shortly after surgery, and at 3 weeks postoperative, he was ambulating without difficulty. Conclusion: Clinical judgment and risk-benefit analysis of each patient must be made individually to determine the most optimal treatment method following GSWs.

Penile Fracture Secondary to Gunshot Injury: A Multidisciplinary Approach and Exceptional Surgical Management in an Uncommon Case.

Penile fractures happen when the tunica albuginea is forcefully torn during intense sexual activity or vigorous masturbation. Gunshot-induced cases are extremely rare. Diagnosis, often requiring surgical exploration, poses challenges due to the condition's rarity and severity. We report a complex case of a patient with multiple gunshot wounds, highlighting the need for a multidisciplinary approach for abdominal and genitourinary regions. A 24-year-old male presented to the emergency department with multiple gunshot wounds to the anterior thoracic and abdominal walls, inguinal region, penis, and lower extremities. Despite multiple gunshot wounds, the patient maintained hemodynamic stability during physical examination. No imaging study was performed since surgical management was decided due to the presence of hematemesis. During exploratory laparotomy, a 2 cm stomach lesion was found and repaired by the general surgery team. Urology then addressed genital trauma, identifying and fixing a 1 cm tunica albuginea defect in each corpora cavernosa, achieving bilateral penile fracture repair. The patient was discharged after eight days of hospitalization, with adequate oral intake and urinating. Fifty-two days later, he persists with mild erectile dysfunction (International Index of Erectile Function-5 score: 17 points). This unique case involving a gunshot-induced penile fracture alongside abdominal and several other injuries was successfully managed through a multidisciplinary approach. As these lesions are rare, prompt treatment with standardized surgical procedures for civilian cases is crucial for optimal outcomes.

Spinal gunshot wounds: A retrospective, multicenter, cohort study. / [Artículo traducido] Lesiones vertebrales por proyectil de arma de fuego: estudio de cohorte retrospectivo, multicéntrico.

INTRODUCTION AND OBJECTIVE: To describe the demographic and clinical characteristics and treatment of patients with spinal gunshot wounds across Latin America. MATERIAL AND METHODS: Retrospective, multicenter cohort study of patients treated for gunshot wounds to the spine spanning 12 institutions across Latin America between January 2015 and January 2022. Demographic and clinical data were recorded, including the time of injury, initial assessment, characteristics of the vertebral gunshot injury, and treatment. RESULTS: Data on 423 patients with spinal gunshot injuries were extracted from institutions in Mexico (82%), Argentina, Brazil, Colombia, and Venezuela. Patients were predominantly male civilians in low-risk-of-violence professions, and of lower/middle social status, and a sizeable majority of gunshots were from low-energy firearms. Vertebral injuries mainly affected the thoracic and lumbar spine. Neurological injury was documented in 320 (76%) patients, with spinal cord injuries in 269 (63%). Treatment was largely conservative, with just 90 (21%) patients treated surgically, principally using posterior open midline approach to the spine (79; 87%). Injury features distinguishing surgical from non-surgical cases were neurological compromise (P = 0.004), canal compromise (P < 0.001), dirty wounds (P < 0.001), bullet or bone fragment remains in the spinal canal (P < 0.001) and injury pattern (P < 0.001). After a multivariate analysis through a binary logistic regression model, the aforementioned variables remained statistically significant except neurological compromise. CONCLUSIONS: In this multicenter study of spinal gunshot victims, most were treated non-surgically, despite neurological injury in 76% and spinal injury in 63% of patients.

Brachial Gunshot Wounds: Injury Patterns and Considerations for Managing the Abnormal Neurological Examination.

BACKGROUND: Nerve injuries from gunshot wounds (GSWs) to the upper arm can cause significant morbidity and loss of function. However, indications for surgical exploration and nerve reconstruction remain unclear as both low- and high-grade injuries can present with an abnormal neurological examination. METHODS: Adult patients presenting with a history of isolated GSW to the upper arm between 2010 and 2019 at a single urban level 1 trauma center were screened for inclusion in this retrospective study. Patient demographics, neurological examination findings, concurrent injuries, and intraoperative findings were gathered. Bivariate analysis was performed to characterize factors associated with nerve injuries. RESULTS: There were 139 adult patients with isolated brachial GSWs, and 49 patients (35%) presented with an abnormal neurological examination and significantly associated with concurrent humerus fractures (39% vs 21%, P = .026) and brachial artery injuries (31% vs 2%, P < .001). Thirty of these 49 patients were operatively explored. Fifteen patients were found to have observed nerve injuries during operative exploration including 8 patients with nerve transections. The radial nerve was the most commonly transected nerve (6), and among the 16 contused nerves, the median (8) was most common. CONCLUSION: Nerve injury from upper arm GSWs is common with directly traumatized nerves confirmed in at least 39% and nerve transection in at least 16% of patients with an abnormal neurological examination. Timely referral to a hand and/or peripheral nerve surgeon for close clinical follow-up, appropriate diagnosis, and any necessary surgical reconstruction with nerve grafts, tendon transfers, and nerve transfers is recommended.