High Velocity Gunshot Fractures of Humerus: Results of Primary Plate Osteosynthesis

Abstract

Background: High velocity gunshot fractures usually seen in conflict zones, often mandate external fixation due to delayed presentation and associated contamination. In the presented observational study, we managed high velocity gunshot fractures of humerus with adequate debridement and primary plate osteosynthesis under controlled conditions with gratifying results.

Material and methods: Eighteen consecutive cases of fracture of the humerus secondary to high velocity gunshot wounds with ages ranging from 28 to 45 years reporting within 6 h of the initial injury formed our study group. Immediate debridement, lavage and primary plate osteosynthesis was carried out following hemodynamic stabilisation and intravenous antibiotics. All the cases were followed up at 2, 4, 6 months, 1 year and then annual follow-up including telephonic follow-up for six patients.

Results: Fifteen cases of Gustillo Anderson type III A, two of type III B and one of type III C were managed with primary plate osteosynthesis. Brachial artery injury was addressed immediately, however injured radial nerve ends were tagged. Five cases showed delayed/non-union and were managed with decortication and autologous bone grafting. Two cases of deep infection could be managed with implant retention till union. The implants were removed following fracture consolidation. All the fractures united and no patient was left with sequelae of chronic infection.

Conclusion: Timely presentation of high velocity gunshot fractures of humerus teamed up with adequate debridement, soft tissue management and primary plate osteosynthesis can offer satisfactory outcomes. Associated vascular injury needs immediate attention. Nerve injuries can be addressed in a staged procedure. Our results have been satisfactory and add to the scant literature available on the subject, however further studies are warranted.

Keywords: Gunshot; Humerus; Internal fixation; Open fracture.

Fig. 1

Gunshot fracture of humerus distal diaphysis injuring brachial artery. a Preoperative image, b preoperative radiograph, c postoperative radiograph

Fig. 2

Gunshot fracture of proximal shaft of humerus. a Wound of entry in close vicinity to neurovascular bundle, b wound of exit, c preoperative radiograph, d postoperative radiograph

Fig. 3

Gunshot fracture of proximal and diaphyseal humerus. a Preoperative radiograph showing comminuted fracture humeral head and diaphyseal fracture. b The entry wound before debridement, c the retrieved bullet, d humerus head fragments excised in piece-meal, e postoperative radiograph

Fig. 4

Two years follow-up of the case shown in Fig. 1 above. a Radiograph showing consolidated fracture, b–d show well-taken up split thickness graft with no deformity and satisfactory range of motion at elbow and shoulder joint

Fig. 5

30 months follow-up of the case shown in Fig. 3 above. a Healed surgical scar, b radiograph showing consolidated diaphyseal fracture with absent humeral head, c active abduction of 40°, d assisted abduction full range, e passive flexion of 120°, f active extension of 30°, g active internal rotation near full range, h active external rotation 50°