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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 24  |  Issue : 2  |  Page : 100-106

Prospective analysis of extremity gunshot injuries treated in a Nigerian regional trauma center


1 Department of Orthopaedic Surgery, National Orthopaedic Hospital, Enugu, Enugu State, Nigeria
2 Department of Surgery, Ebonyi State University and Federal Teaching Hospital, Abakaliki, Ebony, Nigeria
3 Department of Surgery, College of Medicine, University of Nigeria, Ituku-Ozalla, Enugu, Nigeria

Date of Web Publication18-Nov-2019

Correspondence Address:
Dr. Ndubuisi O Onyemaechi
Department of Surgery, College of Medicine, University of Nigeria, Ituku-Ozalla, Enugu State.
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmh.IJMH_27_19

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  Abstract 

Background: Extremity gunshot injuries are a common cause of morbidity and mortality in our environment. They pose a management challenge because of the complex soft tissue and bony injuries. Objectives: The objectives of this study was to determine the pattern and treatment outcomes of these injuries in our setting. Materials and Methods: This was a prospective study of extremity gunshot injuries treated at National Orthopaedic Hospital, Enugu, Nigeria over a 12-month period. Results: Fifty-five patients were studied, with a mean age of 36.9 ± 13.39 years and a male-to-female ratio of 8.2:1. The two top causes of gunshot injuries were armed robbery (41; 74.5%) and assaults/communal clash (6; 10.9%), and the most common type of gun was the rifle (21; 38.2%). Gunshot fracture was the commonest type of injury among the patients (39, 70.9%). Only 34.5.1% of our patients presented to hospital within the first 6h. Secondary wound closure was the commonest method of wound cover. Majority of the gunshot fractures were treated non-operatively. The duration of hospitalization ranged from 2 days to 13 weeks with a mean duration of 4.9 weeks. Late presentation, presence of fracture, and wound infection were associated with prolonged hospital stay. Outcome of treatment was good in 80% of patients and the mortality rate was 1.8%. Conclusion: The young adult males are more involved in extremity gunshot injuries. The fracture rate of these injuries is high with associated increased morbidity. Effective control measures aimed at reducing the incidence of gunshot injuries will reduce the negative socioeconomic impact of these injuries.

Keywords: Extremities, gunshot injury, Nigeria, pattern, treatment outcome


How to cite this article:
Lasebikan OA, Omoke NI, Onyemaechi NO, Iyidobi EC, Anetekhai WI. Prospective analysis of extremity gunshot injuries treated in a Nigerian regional trauma center. Int J Med Health Dev 2019;24:100-6

How to cite this URL:
Lasebikan OA, Omoke NI, Onyemaechi NO, Iyidobi EC, Anetekhai WI. Prospective analysis of extremity gunshot injuries treated in a Nigerian regional trauma center. Int J Med Health Dev [serial online] 2019 [cited 2019 Dec 15];24:100-6. Available from: http://www.ijmhdev.com/text.asp?2019/24/2/100/271090




  Key Messages: Top


Armed robbery attacks and assaults were the most common causes of extremity gunshot injuries in our environment.

The lower extremities were more commonly involved with the thigh being the most affected sites. Gunshot fractures and soft issue injuries were the most common types of injuries.

Judicious management of gunshot wounds is very critical for good clinical outcome. Majority of the gunshot fractures were managed non-operatively with good results. Late presentation, gunshot fractures, and wound infection were associated with prolonged hospital stay, whereas wound infection was associated with high energy and massive wounds, and late presentation.


  Introduction Top


Injuries represent 12% of the global disease burden and the third most common cause of death globally.[1] Gunshot injuries (GSIs) contribute significantly to the global disease burden arising from injuries.[2] Globally, the incidence of GSIs has been on the increase.[3] In both military and civilian settings, GSIs cause significant morbidity and mortality on the victims. In Nigeria, GSIs are the third leading cause of injury after road traffic crashes and falls, and the second leading cause of injury-related deaths.[4] Majority of gunshot victims are male young adults who are the active and productive age group of the society.[4],[5],[6] This has both public health implications and negative impact on the economy of a country.

In recently published reports, extremity gunshot wound accounted for over 50% of GSIs treated in civilian trauma setting of developing countries.[3],[6] Thus, GSIs to the extremities are common and may result in complex soft tissue and bony injuries. The extent of tissue injury depends on several factors such as the bullet’s diameter or caliber, the shape of the bullet, as well as its velocity, weight, and tumbling characteristics. A good knowledge of the current concepts of wound ballistics, the pathology of soft-tissue wounds, and fractures is important for effective management of GSIs of the extremities.[7]

The management of these injuries remains a major challenge to trauma surgeons globally. In many developing countries where the trauma systems are poorly developed, with poor access to health care, the challenges of management of extremity GSIs are enormous. Previous studies report that the management of extremities GSI in Nigeria is often associated with significant morbidity and mortality.[8],[9] The variations in pattern and outcome of extremity GSI in previous reports underscores the importance of a prospective data in our setting that can facilitate preventive strategies and optimum care of the victims. The aim of this study was to determine the pattern of presentation and outcome of treatment of extremity GSIs in our setting and to propose a protocol for management.


  Materials and Methods Top


Study design and setting

This was a 12-month prospective study of all patients who presented to the emergency unit of National Orthopaedic Hospital, Enugu, Nigeria with extremity GSIs from January 1 to December 31, 2007. Twelve months were used for patient recruitment and each of the patients was followed up for one year to determine the outcome of treatment. National Orthopaedic Hospital, Enugu, Nigeria is a regional trauma center located in Southeast Nigeria. It receives trauma referrals from the five southeast states of Nigeria and the neighboring states of the South-South and North Central regions of Nigeria. The research and ethics committee of National Orthopaedic Hospital, Enugu, Nigeria approved the study protocol.

Study population and data collection

All the patients who sustained GSI to any of the extremities admitted during the study period were recruited for the study. Patients who sustained GSIs to other parts of the body in addition to the extremities were also included. However, only data from the extremity injuries were used in this study. Informed consent was obtained from the patients or from parents/guardians of those less than 18 years on admission. Patients who declined consent and those who did not complete their treatment were excluded from the study. All the patients were admitted into the Accident and Emergency (A&E) unit of the hospital and were resuscitated promptly using the advanced trauma life support (ATLS) protocol. Although in the A&E unit patients’ wounds were assessed, parenteral prophylactic antibiotics commenced and tetanus toxoid immunization given. All the gunshot wounds were debrided within 6–8 h of admission and where necessary initial skeletal stabilization was carried out. Patients were either discharged from the A&E unit or admitted to the high-dependency unit, or the surgical wards depending on the severity of the injuries. The wound classification was carried out using the International Committee of the Red Cross (ICRC) wound classification. A detailed history, thorough clinical examination, and radiological assessments were carried out on all the patients. Information obtained on admission included the following: the sociodemographic profile of the patients, cause of the GSI, range of shot, type of gun used, part of the body affected, injuries sustained, and injury-arrival interval. The treatment given to the patient, the duration of hospitalization, and outcome of the treatment and complications after a one-year follow-up from time of discharge were retrieved from the patients’ medical records. The parameters used in assessing outcomes were as follows: complete wound healing; presence of wound complications; clinical and radiological evidence of fracture healing; presence of complications of fracture healing; and presence of functional disability and death. A data collection form was used to collate the data.

Statistical analysis

Analysis of the data was performed using the Statistical Package for the Social Sciences software version 22.0 (SPSS, Chicago, IL). Frequency table, cross-tabulation, and Pearson’s chi-squared test of significance were also used for the analysis. Comparison of two means was done using the Student’s t-test. Statistical significance was set at P < 0.05.


  Results Top


A total of 55 patients with 63 injuries were studied. The age of the patients ranged from 2 to 67 years with a mean age of 36.9 ± 13.39 years. The incidence of gunshot to the extremities rose to a peak in the third decade of life, and then decreased with increasing age [Figure 1]. There were 49 (89.1%) males and 6 (10.9%) females giving male-to-female ratio of 8.2:1.
Figure 1: Distribution of gunshot injury to the extremities by age and sex

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The two top causes of GSI to the extremities were armed robbery (41; 74.5%) and assaults/communal clash (6; 10.9%), and the most common type of gun was the rifle (21; 38.2%) followed by shot guns (18; 32.7%) as shown in [Table 1]. Rifles and shot gun were used in 15 (36.6%) and 13 (31.7%) cases of armed robbery, respectively. A rifle and a shotgun were used in each of the 2 (33.3%) cases of assault/communal clashes observed. Forty-eight (87.3%) patients were shot at close range and there was presence of exit wound in 42 (76, 3%) patients. Majority of patients presented with high energy and massive wound (based on ICRC classification of gunshot wounds) as shown in [Table 1].
Table 1: Pathomechanism of gunshot injuries (n = 55)

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The gunshots involved the lower and upper extremities in 34 (61.8%) and 21 (38.2%) patients, respectively. Three (5.5%) of the victims were multiply injured; each of them sustained injury in the upper extremity in addition to back, neck, and chest injuries, respectively. Armed robbery and assault accounted for two and one of these multiple injured cases, respectively. All the six gunshots by the military and police involved the lower extremities, whereas 24 (58.5%) and 17 (41.5%) of the gunshots by armed robbers involved the lower and upper extremities, respectively (P = 0.359). The rates of injury in the upper and lower extremities caused by assault and self-inflicted gunshot were the same. Seventeen (81.0%) of the injuries in the upper extremity were caused by armed robbery. The distribution of the anatomical sites of the extremities involved in GSI is shown in [Figure 2]. The thigh and the forearm were the top two sites affected, and injuries in the right extremities outnumbered those in the left by a ratio of 1.3:1.
Figure 2: The distribution of the anatomical sites of the extremities involved in GSI

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The distribution of the types of injuries is shown in [Table 2]. Thirty-nine (61.9%) of the patients had open fractures, and 25 (25.4%) had soft-tissue injuries only. There were three (4.8%) vascular injuries and five (7.9%) nerve injuries. The femur was the most common site of gunshot fracture (13; 33.3%). Other sites of fractures were tibia/fibula (4; 10.3%), humerus (5; 12.8%), foot (7; 17.9%), hand (3; 7.7%), radius/ulna (5; 12.8%), and clavicle (2; 5.1%). There was significant correlation between the incidence of gunshot fractures and the type of gun used and type of gunshot. The incidence of fracture was 90.5% in rifle-related injuries as compared with 72.2% and 36.4% in shot gun and hand gun injuries, respectively (P = 0.013). The rates of fractures in high- and low-velocity GSIs were 81.6% and 41.7%, respectively. There was no significant correlation between the range of gunshot and incidence of fractures (P = 0.409).
Table 2: Types of injuries

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The injury-arrival interval ranged from 1 h to 32 days, with a mean of 49h. Nineteen patients (34.5%) presented within the first 6 h of the injury. Only 23 patients (41.8%) received prehospital treatment before presentation. Using our treatment protocol, seven patients (12.7%) who had simple puncture/penetrating injuries were treated by judicious wound debridement and dressing and discharged from the A&E unit. Forty-eight patients (87.3%) were admitted to the surgical ward for further treatment after initial resuscitation. The treatment protocol used in the management of the patients is shown in [Figure 3]. All these patients underwent wound exploration and judicious serial debridement with copious lavage using normal saline. The methods of wound cover were as follows: primary closure 1 (2.1%), delayed primary closure 6 (12.5%), secondary closure 25 (52.1%), secondary intention 8 (16.7%), split skin grafting 6 (12.5%), and flap cover 2 (4.2%). Only 5 of the 39 patients with fractures had open reduction and internal fixation. Other definitive fracture treatment methods are shown in [Table 3]. Three patients (5.5%) had compartment syndrome of the extremities for which fasciotomy was done.
Figure 3: Treatment protocol

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,
Table 3: Definitive fracture treatment method

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The duration of hospitalization ranged from 2 days to 13 weeks with a mean duration of 4.9 weeks. Late presentation, presence of gunshot fracture, and wound infection were associated with prolonged hospital stay (P = 0.001). The mean duration of hospital stay for patients with soft-tissue injuries only and patients with gunshot fracture was 16 days and 7.5 weeks, respectively The difference in mean was significant (P = 0.001). Wound infection (17; 30.9%) was the most common complication observed [Table 4]. Wound infection was associated with high energy and massive wounds, and late presentation (P = 0.01). Forty-four patients (80%) recovered fully following treatment, 10 (18.2%) had disabilities, and 1 (1.8%) died. The only patient that died (1.8%) presented on the seventh day of injury with overwhelming sepsis.
Table 4: Complications of extremity gunshot injuries (n = 54)

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  Discussion Top


Extremity GSIs in civilian trauma setting are a common emergency in our region. In this study, the most common victims were the young active males and this is similar to findings in previous studies.[4],[5],[6],[10] Male youths are often the perpetrators of violent crimes, civil conflicts and armed robbery, and more vulnerable to GSIs. The economic losses associated with this pattern of injuries further compounds the morbidity and mortality of extremity GSIs. Armed robbery was noted to be the leading cause of GSIs. The increasing incidence of GSIs resulting from armed robbery attacks has been reported in many studies.[5],[6],[10],[11],[12] This may be associated with the high rate of unemployment and rising poverty level in Nigeria.

Using the ICRC wound classification, we noted that majority (74.5%) of the wounds were high-energy injuries. This may be explained by the observation that assault rifles were the commonest type of gun and the range of shot was close in majority (87.3%) of the cases. The incidence of high-energy GSI in this study is higher than that reported in other studies, where low-energy injuries were predominant.[3],[5],[10] This relatively higher incidence may be attributed to the proliferation of high-velocity arms and increased level of politically motivated violence associated with general elections in Nigeria. Preelection and postelection violence were witnessed across Nigeria during the study period.

The lower limbs were more injured in about 61.8% of patients. This agrees with reports from previous studies in our environment.[5],[10],[13] The involvement of only the lower extremity in gunshot by the law enforcement agents suggests that the intention was to demobilize rather than kill the victim. The upper extremity may be hit either by a direct shot or in attempt to ward off a shot targeted to the head chest and abdomen. In this study, the involvement of the upper and lower extremity in armed-robbery-related GSIs suggests the intention in over a third of cases was to kill the victim. The right extremity predominance observed in [Figure 2] suggests that the victims were shot in the right extremity to demobilize the more likely dominant extremity. The thigh was the commonest anatomical site of injury as was also reported in other studies.[10],[11]

The incidence of gunshot fractures tends to vary among studies. We noted a gunshot fracture rate of 61.9% in this study. Chalya et al.[3] in Tanzania; Dada and Awoyomi[5] in Lagos Nigeria; and Odatuwa-Omagbemi et al.[13] in Warri Nigeria reported the incidence of 45.7%, 37%, and 52%, respectively. Obalum et al.[14] in Lagos reported an incidence of 35%. The relatively high rate of fractures in this study may be because of the higher incidence of high-energy injuries we observed.

Only 34.5% of our patients presented to hospital within the first 6h. A greater proportion of patients in other studies presented to hospital within the first 6h. Omoke in Abakaliki,[10] Onumiya in Irrua,[6] and Abbas in Maiduguri[12] reported the incidence of 72.4%, 64.5%, and 47.8%, respectively. The reason for the late presentation in our study may be that whereas the other studies included patients who sustained GSI to other parts of the body such as head, abdomen, and chest, our study was predominantly on extremity GSIs. GSIs to the head, abdomen, and chest usually cause more serious injuries and will compel early presentation to hospital. However, patients with extremity injuries may seek treatment elsewhere including traditional bone setting centers before presenting to hospital. We also noted that the patients with more severe injuries presented earlier to hospital than those with less-severe injuries.

All the patients had wound exploration and debridement with copious normal saline lavage. Majority of the gunshot wounds were closed secondarily. Because of the late presentation of our patients, majority of the gunshot wounds were either contaminated or infected at presentation and thus could not be closed primarily. Primary wound closure was done on only one patient who had a minor wound from a low-energy injury and presented within 6 h of injury with good outcome. In our environment with the peculiarity of late presentations, we recommend delayed primary and secondary wound closure of gunshot wounds to prevent wound complications.

Majority of the gunshot fractures in our study were treated non-operatively. Manipulation under anesthesia (MUA) with casting was the commonest technique used in the fracture treatment. The presence of contaminated wounds in majority of the patients precluded internal fixation which was carried out in only five patients with low-energy fractures as recommended by our treatment protocol. Three patients developed gangrene from associated vascular complications and had amputation. This is similar to the figures in previous reports.[10] The tibia and forearm fractures were predominantly treated by MUA with casting and external fixators, whereas the femoral fractures were treated predominantly by skeletal traction and open reduction and internal fixation. External fixation was used for initial skeletal stabilization. Thereafter, the patients were treated definitively with cast. Delayed open reduction and internal fixation was carried out in some cases of high-energy fractures after satisfactory wound cover and initial external fixation. Emergency fasciotomy was carried out in three patients who developed compartment syndrome.

The mean duration of hospitalization in our study of 4.9 weeks is significantly longer than 16 and 13 days, respectively, in a Nigerian and Finnish study, respectively.[10],[15] We also noted that patients with only soft-tissue injuries had a significantly shorter hospital stay than those with associated fractures. Patients with gunshot fractures have been reported to have a significantly longer hospital stay.[11],[16] This may explain the longer mean duration of hospitalization in our study because majority of the patients had gunshot fractures.

Wound infection was the commonest complication observed. This is similar to reports from other studies.[3],[10] In a recently published report, presence of exit wound (perforating wound) and fracture were identified as independent risk factors for civilian gunshot wound infection.[17] Thus, in this study that had fracture and exit wound in over sixty and seventy percent of the cases, respectively, the high rate of wound infection observed was not a surprise. Wound infection rate correlated positively with the severity of the wounds. This is because the more severe wounds are more likely to be contaminated with a higher risk of infection. We also noted that patients who had wound infection stayed significantly longer in hospital than those who did not. This suggests that wound infection in GSIs increases the morbidity and cost of treatment of these injuries. Therefore, measures aimed at preventing and controlling wound infections in GSIs will improve the outcome of these injuries.

Majority of the patients (80%) in this study recovered fully following treatment. Disabilities were noted in 18.2% of patients. These were the patients who had amputation, severe nerve injuries, and significant limb shortening. The mortality rate of 1.8% is similar to that in other published reports worldwide.[3],[6],[11],[18],[19]


  Limitations of the Study Top


The limitation of this study is in being a hospital-based single center and a cross-sectional one. The data may not be a representation of the entire population. Although the study was carried out between 2007 and 2008, we do not think that the delay in the reporting will affect the validity of the findings.


  Conclusion Top


Extremity GSI is an important cause of trauma-related morbidity and mortality in our environment. It is often a complex injury that tasks the skills of the attending surgeon. This demands good knowledge and understanding of the principles of ballistic injuries and energy transfer to soft tissue and bone by the trauma surgeon. Established treatment guidelines for high- and low-energy injuries should be followed strictly for good outcomes. Effective crime control by the law enforcement agencies and government legislation to control arms proliferation in our region may reduce the incidence of GSIs. This may also reduce the medical, social, and economic burden of these injuries.


  Recommendation Top


We recommend that primary wound closure could be carried out after wound debridement in low-energy gunshot wounds that present within 6 h of the injury. However, in high-energy injuries and those presenting after 6h, delayed primary closure and secondary closure are recommended. Massive gunshot wounds should be treated by serial debridement followed by split skin grafting or flap cover. Low-energy gunshot fractures may be treated by open reduction and internal fixation after achieving wound cover. However, high-energy gunshot fractures are preferably treated by external fixation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Pedan M, McGee K, Sharma G. The Injury Chart Book: A Graphical overview of the global Burden of injuries. Geneva, Switzerland: World Health Organization; 2002. Available from http://www.whqlidoc.who.int/Publications/924156220x.pdf. [Last accessed on 2018 Jun 30].  Back to cited text no. 1
    
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Richmond TS, Cheney R, Schwab CW. The global burden of non-conflict related firearm mortality. Inj Prev 2005;11:348-52.  Back to cited text no. 2
    
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Chalya PL, Mchembe M, Gilyoma JM, Mabula JB, Kanumba ES. Gunshot injuries: A Tanzanian experience in a teaching hospital in the Lake Zone. East Cent Afr J Surg 2011;16:19-25.  Back to cited text no. 3
    
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Solagberu BA. Epidemiology and outcome of gunshot injuries in a civilian population in West Africa. Eur J Trauma 2003;29:92-6.  Back to cited text no. 8
    
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Odatuwa-Omagbemi DO, Adiki TO. Pattern and presentation of extremity gunshot injuries in Warri, Nigeria. Niger Health J 2013;13:85-90.  Back to cited text no. 13
    
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Obalum DC, Giwa SO, Ogo CN. Pattern of extremity gunshot injuries seen in Lagos University Teaching Hospital, Lagos, Nigeria. Niger Q J Hosp Med 2007;17:140-3.  Back to cited text no. 14
    
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Annest JL, Mercy JA, Gibson DR, Ryan GW. National estimates of nonfatal firearm-related injuries: Beyond the tip of the iceberg. JAMA 1995;273:1749-54.  Back to cited text no. 15
    
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Burg A, Nachum G, Salai M, Haviv B, Heller S, Velkes S, et al. Treating civilian gunshot wounds to the extremities in a level 1 trauma center: Our experience and recommendations. Isr Med Assoc J 2009;11:546-51.  Back to cited text no. 16
    
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Davis M, Kevin M, Glickman E. Inner-city gunshot wound—10 years on. Injury 2011;42:488-91.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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