Hand Injuries and Firearms
Hand injuries come in all flavors. Knives, motor blocks, sheet metal, augers, alligators, lawn mowers and – guns. The latter type of hand injuries (also called ballistic injuries) is something I started to see only once I moved to the US, where firearms are more widespread among civilians resulting not only in frequent accidental hand injuries, but in my pinion also in a higher frequency of use during altercations and assaults.
Ballistic Hand Injuries in Times of War
Logically, the phenomenon plagued hand surgeons most during times of armed conflicts. World War II, the Korean and Vietnam war and recently the conflicts in Iraq and Afghanistan influenced the way hand surgeons think about these types of injury.
Some say the principles of treatment are forgotten soon after each armed conflict and have to be rediscovered during the next. My personal journey into this phenomenon was profoundly influenced by the writings from the Vietnam era, which I found easy to transpose into a civilian’s world while obtaining functional results reliably.
Principles of Treatment of Ballistic Hand Injuries
The basic principles of treatment for these types of hand injuries are as follows:
- Emergent initial debridement and skeletal fixation, vascular repairs, antibiotic treatment
- Open wound treatment, repeated irrigation and debridement
- Delayed wound closure
- Secondary skeletal and other reconstructions
The main objective is prevention of infection and preservation of as much hand function as possible after these hand injuries. The “Vietnam strategy” was pioneered (among others) by Brown and Jabalay, whose papers based on their war experience represent timeless wisdom.
It should be noted that none of the initial operating room sessions require any exotic fracture fixation hardware or high tech equipment. After all, this strategy was actually executed numerous times under very unfavorable circumstances (think MASH) and still worked. However, considerable surgical judgement and an in depth knowledge of anatomy paired with near perfect surgical technique are indispensable. These early stages mostly determine the final outcome.
More complex secondary reconstructions can then be performed more or less at leisure while creating the most favorable environment in terms of equipment and availability of technical expertise possible. The most frequent type of secondary procedures are bone grafts for definitive skeletal reconstruction and scar revisions.
The following lecture was given as one of my visiting scholar’s lectures at 6th People’s Hospital in Shanghai in 2008 (leaving out most of the gruesome intraoperative photographs):Hand Injuries by Civilian Firearms