Best Practices for Orthopaedic Treatment of Pediatric Gunshot Injuries

Abstract

Gun injuries arise from increased access to firearms across the U.S. More firearm injuries are presenting to emergency departments and non-trauma centers. Most are treated with antibiotics, bedside I&D, and non-operative stabilization for simple wounds of <1 cm without contamination and stable fracture patterns. More complex injuries (usually caused by high-velocity weapons) with larger soft tissue defects with contamination, bone loss, operative fracture patterns, intraarticular projectiles, vascular injuries, compartment syndromes, and nerve injuries warrant IV antibiotics and further treatment in the operating room. Only 28% of nerve injuries regain function. Loss to follow-up is high (43%). Growth arrest and lead toxicity are long-term sequelae that must be monitored-the new CDC acceptable blood lead level is <3.5 μg/dL. Gun injuries are now the leading cause of death in children. Evaluation of the child's environment and access to guns and education is important for preventing future injuries on an individual level; however, research and legislation are needed to decrease this epidemic of gun violence injuring and killing children today.

Key concepts: •Gun injuries are currently the leading cause of death in children.•Gun injuries with minimal soft tissue damage and contamination can be treated in the emergency room with bedside debridement, oral antibiotics, and splinting.•Gun injuries with large soft tissue defects, contamination, bone loss, operative fracture patterns, intraarticular projectiles, vascular injuries, compartment syndromes, and nerve injuries warrant further treatment in the operating room and IV antibiotics.•Children with gun injuries involving the physis should be followed for growth arrests and those with retained bullet fragments close to bone or joints for lead toxicity.•Education, research, and legislation are necessary to protect children from gun injuries.

Figure 1

Timeframe of pediatric gun injuries studied by 5-year intervals. From 2005-2009 is the most studied timeframe, including 50,600 patients in this review.

Figure 2

A 2-year-old shot with a pellet gun. A) Clinical image of the entrance wound on her forearm. B) Radiographs demonstrating retained pellet posterior to her humerus.

Figure 3

3D CT scan A) anterior view and B) posterior view of a left distal humerus fracture due to gunshot through a car with an ulnar nerve injury.

Figure 4

Decision chart for Initial Evaluation of Pediatric Gun injuries of the Extremity.

Figure 5

Gunshot though a knee. A) AP and B) Lateral radiograph of a knee after gunshot injury with fracture visible on the AP and air visible on the lateral. CT (C and D) further demonstrate air in the joint and fracture.

Figure 6

Firearm injury with a rifle with multiple bullet fragments on radiograph A) and large soft tissue defect B). Further evaluation revealed a large sciatic nerve transection. He underwent multiple wound debridement’s prior to undergoing nerve grafting (arrow) C).

Figure 7

Traumatic amputation of the great toe in a 2-year- old.

Figure 8

This 14-year-old is at risk for elevated lead levels if fragments are not removed due to fragmentation of the bullet, close to bone, and length of exposure to the lead-containing fragments.

Figure 9

School gunfire, injuries, and deaths from 2013 to 2022.39 There is an increase in gunfire, injuries, and death after 2020 with the increase in gun availability.