Well, it's 6.45, so we'll go ahead and get started. Thank you for everybody waking up early in the morning to learn with me about gunshot wounds. So, you know, why are we doing this? Why are we going through these cases? And you know, in February of 2020, this is an article that was in JAMA, the incidence in the United States, luckily, it's fallen back down again, but really rose sharply during the pandemic. It wasn't just in one location, it was kind of all over the country and all of the different states. And why it's near and dear to, you know, my heart and some of my colleagues is that we see about 27% of our total orthopedic consults are ballistic trauma. So we see a lot of it, and so I'm very excited to learn with everybody here from some of the experts in the field about, you know, what to do in certain situations, some background. So what are some of the objectives? So what are we going to go through today? So background on ballistic injuries and initial management, different ways for fixation in finger, hand, and elbow ballistic trauma. What are some of the options and fixation techniques? A little bit about ballistic nerve injuries and how to, you know, thinking about how to treat those, and then how to treat holes in the bone and bone void fillers, et cetera. So without further ado, I will exit out of there. Welcome Dr. Scott Tinsel. Good morning. Thank you. I just want to thank my colleague who retired yesterday, actually, from active duty, Leon Nesty, for his help with some of the slides. This was a slide from his picture, or from his PowerPoint, and I decided to use it because I thought it was kind of cool because you have the carpus on an x-ray with the gun, but I will tell you, just putting the gun in the PowerPoint seems somewhat gratuitous, and you know, I am in the military, and one of the hardest things that I had to deal with when I went to Afghanistan is you have to, you carry a gun all the time, you know, 24 hours a day, and I will tell you, I felt good at the end of the night when I was able to lock it away in the cabinet and know that I wasn't going to accidentally shoot myself or someone else. So clearly, I don't own a gun, and I'm not a big gun guy. All you really need to understand about ballistics is this equation, and we're not doing any projectile equations today. Honestly, the topic that I've been tasked with is, I think, fairly straightforward, and I think a few of the videos in about three minutes will explain most of it and show most of it. These are some data from a little while back now, but a lot of gunshot wounds involve the hand and the wrist, a lot from accidental discharges. There's a significant economic impact, and I think this third bullet here is what's really making the University of Chicago folks' lives a little bit miserable in their attempts to do good research on the topic. Eighty-five percent lost a follow-up before fracture healing, 26 lost with X-fixes and pins on their hands. So a huge percent of these people don't follow up, and that doesn't even touch on the nerve injuries that they're so interested in that take months and months and years to fully recover. So it's a really challenging field to study. I have a couple of cases mixed in here that this was a Marine with a low-velocity gunshot wound, but he accidentally discharged it, so it was very close to his hand, which increases the damage done. So this is a low-velocity gunshot wound, but in my hands, this is something that I would typically take to the operating room, and you can see that there's some combinated base fractures that are a little bit displaced here. So this is something that did end up going to the OR relatively quickly. This is another one. This is a high-velocity gunshot wound that showed up like this, so it had previously already been debrided. I think the key things are really the wound is what you should really be treating, not the term low- or high-velocity gunshot wound. So there's some numbers and data on the numbers, but it's really the wounds that you need to be treating and making that decision on whether you need to treat this open fracture as an open fracture or not. And I think out of the University of Chicago, there's a lot of data that is and will be coming out on whether these things need to go to the operating room acutely. So the basic numbers, so these are some numbers, less than 1,100 feet per second is a low-velocity gunshot wound. These are most of the handguns. They have significantly less kinetic energy. They have less yaw, so the bullet doesn't really flip. It just goes straight on through the tissue. So you have tissue destruction where the bullet goes through, but it doesn't create as big of a cavity, and it doesn't destroy as much tissue. The high-velocity gunshot wounds are more from 2,000 to 5,000 feet per second, and that's most of the modern rifles, and they have a tremendous amount of kinetic energy. And when they go into the tissue, they slow down so rapidly that they start flipping over, and they just create a much larger wave of tissue destruction. I thought this was an interesting number. Skin penetration happens at 150 to 170 feet per second, so much, much slower than even the low-velocity gunshot wounds. And you have damage in multiple ways. The passage of the bullet through the tissue, so that tearing of the tissue, and you get a secondary shock wave, and then you get that cavitation or the creation of this permanent cavity that occurs after the bullet goes through. When the bullet strikes the tissue, there's what we call a temporary cavity, which is essentially the stretching created by the vacuum that's created. And then there's a permanent cavity that's left from the bullet going through. The volume of this destruction can be anywhere 10 to 40 times the size of the bullet. And I'll show you these videos that really show this sort of undulation as the temporary cavity collapses and reforms. This is really, I think, the key to understanding all of this, this basic equation. But the first one here is a 9-millimeter bullet. And you can see that when you put this in at the 1180 feet per second, you get 355 foot-pounds of force. And then you go to some higher-velocity bullets, and you can see that you drastically increase the amount of energy imparted into the tissue just by increasing that velocity. And so the mass of the bullet's not as important as the velocity, just because that velocity is squared. As you increase the speed of this bullet, you really increase the tissue destruction. And that's what's been focused on in most of these rifles, is increasing the speed of these bullets. So here's sort of a couple images that show that. And so you can see the temporary cavity and the permanent cavity. Now if a nerve is in the trajectory of that permanent cavity, it's likely going to get transected. But if it's in that temporary cavity, you may just have a contusion to the nerve. And that's what's so hard to know about whether or not these nerves need to be explored or not. Here's a higher velocity. And you can see as the bullet's sort of exiting this gelatin here, it's totally 180 degrees flipped because that bullet is flipping through the tissue. So here's an image of a bullet going through gelatin at 1,000 feet per second, and then substantially higher at 2,800 feet per second. And so we're going to finish with a few videos in one quick case. But this first video here is just a nine millimeter round going through this gelatin. And you can see it goes right on straight through with a small temporary cavity and then that permanent cavity. Typically it's going to be a through and through unless it strikes bone. And then as opposed to a high velocity rifle where you see that this would obviously cause much more destruction to the body. Now a couple changing bullets also can change the destruction. And so both of these are technically low velocity or right in between with a shotgun at about 1,300 feet per second. But it really is important to treat the wound because this is a hollow point bullet and you'll see that it rapidly changes shape as it goes through and it creates a pretty large wave of destruction. So this is obviously going to cause a lot more tissue damage. And then the shotgun here, which again is low velocity and it doesn't penetrate as far so it's only four to six inches. But the sheer amount of destruction is unbelievable and I'll let this run for a few seconds because you'll see the tissue just completely or the gelatin completely torn up and almost just falling apart. And if you've seen any muscle that's been shot like this it's clearly very, very destructive. And so I'll finish with one case and this was a little bit of a deceiving case and it showed up like this to us at Bethesda and one of my colleagues who's a spine surgeon had done the original debridement. And I will say his debridement was okay but there was still tissue that needed to be debrided originally. This was a high velocity gunshot wound and it's a unique case because it's very surprising that this patient didn't need a free flap for soft tissue coverage. So it was very surprising, especially when you see the bone destruction. So he had about a 15 centimeter defect and there was substantial projectile and this was the bullet that broke apart in his arm. So we really expected much more soft tissue destruction from this high velocity injury and I guess the bone just took the brute of this injury. So after we fully debrided it and increased his wounds he had a pretty large defect of his radial nerve as well as his humerus. So it was about a 15 or so centimeter defect of his radial nerve. So we did a free vascular isofibular graft for him. A little bit of flexion on that x-ray there unfortunately but ultimately he went on to heal well. We did tendon transfers for his radial nerve and here he is after with really pretty good function in the long term. I'll show you his shoulder function here in a second. He went back to fighting. His biggest complaint was he had a little bit of decreased wrist extension strength, and so maybe I should have repaired that radial nerve, but it's a 15 centimeter defect, so I'm not sure he would have gotten the ECRL strength back like we talked about yesterday. Thank you. I hope that answers your question. Great, just as a reminder, if you want to submit any questions through the app, we can. Just one question, and what's the difference between damage in a self-inflicted kind of close to the body versus a shot from far away in terms of damage and everything like that? So I'm sure we'll see at some point, I'm sure we'll see at some point just a through and through gunshot wound with a tiny little hole. So frequently, if it doesn't strike a bone, it will just go through and through, create a very, very small entrance and exit wound. The closer you are, you're just absorbing more energy very, very closely as well as some of that residue that I think it might increase the risk of infection. So from very, very close range, they can obviously, they just impart a little bit more energy than a through and through gunshot wound from a further distance. And there are some, you can find anything on YouTube, but you can YouTube this, and they show some of the gelatin injuries from very, very close versus further away. In fact, one of the videos I was watching, the guy was injured because he was doing it from close range, and there was so much pushback that you can see why that would impart more energy. Great, thank you. Welcome, Dr. Katamika. Good morning, everyone. Thank you, Dr. Steppen, for inviting me for this very important ICL. My name is Megan Katamika, I'm at University of Chicago, and I'm gonna talk about some of the different approaches for dealing with ballistic injuries. Obviously, this has already been kind of discussed, but this, when you're dealing with gunshot wounds, this is basically gonna be a very different beast. And the biggest thing is understanding that energy is different than a simple fall from standing or going down a flight of stairs. This is a big burst of energy that's gonna affect not just the osseous structures, but also the soft tissue envelope and neurovascular structures. So when you start thinking about the injury, we have to get out of just looking at the trees, which is the osseous injury, and start looking at everything else in that envelope. So you start looking at the neurovascular status, you need to look at the nerves, you need to look at the arteries, and you also have to look at the soft tissue. Are you gonna need flaps? Are you gonna need to get other teams involved? Are you gonna have to get vascular involved? And is this gonna be a team sport, or is this gonna be just a simple structural fixation type situation? So the reason why I put this picture on there is because this is what we look at when we look at X-rays, but you gotta look at the patient to see what's going on from here to here and understand what else is happening to the patient. And it's important to know what tools you have in your toolbox. Sometimes you're gonna get creative, and I think a lot more times than not, you're gonna have to get creative, because plates aren't made for ballistic injuries, and this is where you start getting creative with external fixators, with wires, plates that are maybe for an ankle or for a wrist and you're using it on the elbow, et cetera. So when to wire? This is kind of a quick and dirty way of thinking about things, but when there's a large area of soft tissue injury, so I don't feel like I can make an incision there because I think that that tissue might be necrotic and I need to get some good lengthening. Also, if there's articular surface issues, or if it has a really good articular surface. So this is one of those examples where the articular surface is completely gone. This is also a horrible X-ray because this was a missed fracture that there was a through and through gunshot wound and we always have a rule that every gunshot wound gets X-rayed, because you don't know. You hope that it's just soft tissue sometimes, but this is one of the ones that was missed, and so this was seen actually on a forearm X-ray later on and intraoperatively is when they were diagnosed. So bone loss is not an issue in these cases. So remember with your, getting back to your AO with the K-wires, you're not gonna get that compression. So if you have bone losses in your case, then I would not push for a wire fixation. So for this patient, we're missing length. We need to get him out to length. We don't have a lot of bone stock here for a good plate and screws, and the articular surface is gone. So at this point, I am not looking to recreate the articular surface. The biggest thing is to get that thumb out to length and hopefully when this heals, he'll have some good function, and probably will have some post-traumatic arthritis down the road. So we did, we got him out to length. We had one K-wire that was holding that length and one trying to get as many of the fragments together. We did open up this injury to try to get everything out of the joint as much as possible. Obviously, we are not going for perfect here. We're going for better. Suture fixation. I use a lot of sutures, especially around a plate to try to just bring a bag of bones together for better or for worse. So this is something I will not do by itself for the most part. And this is when I have a lot of combination and I don't feel like screw fixation's gonna happen. So I usually will take either a fiber wire or a really strong, larger gauge suture, and I will wrap it around using some, getting some of my sports techniques, sports knots to really capture this and bring it down to the plate. And just keep it in the general vicinity. Again, this is always an augment, not usually a solo fixation. And then when to plate. So you can do this for bone loss. And this is when you do a lot of bridging. Soft tissue envelope is around so that it is okay so that you can make an actual incision and you're not worried. This is also a great time if you need to explore nerves. This will help you because you can make, you can think about that with your approach. And then when you look at the bone itself, articular surface, if you need to do bridging of an articular surface, let that heal. If you have to go for staging, sometimes I'll use this as a, I'll bridge and then I'll go back for a fusion. I have a harder time getting these things to fuse first time around. I think that the injury hits a lot of the osseous cells. And so sometimes you need to do this in a staged fashion. Establishing length. And again, bone graft, which I'm gonna leave up to Dr. Strelzow who will be talking about that a little bit more later about how to fill these voids. So here's a patient that I was tricked on. You can see his X-ray here. There's just looks like it's a simple fracture, which if you know anything about gunshot wounds, they're never simple. And you can see the soft tissue air right there. So we went in and it turned out to be combinuted that here is a fracture extending into actually the radial neck into the head. So I went from making an anterior approach to having to go laterally and opening up the capsule. Here's our radial nerve right here. We had ended up first lagging this huge butterfly piece, which was what I thought this was connected to this, but it wasn't. So we had to use a different type of plate to get this length, which as you would probably guess, there's not a lot of radial neck plates that are this long. So we ended up using a Diametta plate, flipping it over, flattening out that curve that usually you use for a distal radius, and then placing it on. So the point of this is realizing, one, you can get tricked very easily with these fractures because there's usually a lot more extension of the combination than you think. Two, you may have to get a little crazy or a little bit more creative. Think of it either way. And figure out what's gonna work best for you so that you can get the fixation you need. Again, we don't make plates for ballistic injuries, so this is when you get a little artistic. So when to use X-Fix. I've actually used more X-Fix in the last 10 years than I have when I was with my training. So this is a lot of stage decision-making. This is when you have multiple teams involved. You're talking about flat fixation. You're gonna need to get vascular involved because there's vascular status issues. Huge defects that you're not really sure how you're gonna deal with that quite yet, especially if it's in the middle of the night. You need to get some stability and then start planning, calling some mentors, trying to figure out what the next step is. This is a patient that had a neurovascular injury with his gunshot wound. Let's go the other way. And here's another one, very similar, where basically half of the olecranon is gone. This whole articular surface is gone. Here is the cornoid up here anteriorly, and then obviously the extension of this. And you can see that there's soft tissue error right here. He ended up having a neurovascular compromise with a pulseless arm, so this had to be staged. The first was just getting an X-Fix on, and then you can see these staples, and then this myriad of little staples from a vascular who first did a staged shunt and then eventually did a bypass. So this kind of complicates things because now I have an X-Fix on, and this patient is now on anticoagulation, and there is a very scary vascular repair on the anterior aspect of the elbow. So operating, and you're scared about plunging with your drill, about your K-wires and everything, and you don't even want to go anterior. I at this point was like, okay, I'm just going posterior. You can't use a tourniquet. So it becomes a very difficult situation, and that's when you have to really be communicating with your team. We ended up fixing this as much as we could. Here's just some of the steps. I didn't want to belabor this too much, but obviously getting the steps of that articular surface, and then we were able to plate it, and then we did everything posteriorly to avoid anything that had to be involved with these clips. And then last but not least, don't forget the power of subtraction, so amputation. We don't like to talk about it, but it happens. And this is usually what I do as a staging decision. I don't do it when they come into the ED unless there's like a neurovascular issue. So a lot of these gunshot wounds, they will miss the vascular structures sometimes, and then you can do this in a staged procedure where you can talk to the patient and being like, look, we're probably gonna have to do some type of amputation. These are your options, or we can do a fusion, et cetera. And I find that I do, for some reason, this MCP of the middle, I have a lot of these. I'm not really sure if just the South Side of Chicago is really good at aiming for the MCP of the middle finger, but this becomes a discussion of, Dr. Strozzo's nodding because he's dealt with this pain. And it becomes a discussion, do you want to fuse an MCP, or do you want to subtract the digit? And that becomes a question of function. Patients usually can't wrap their head around it the day of coming in, in the ED, because they just got shot and are traumatized. But generally, once they have like an X-Fix or a plate on, they understand the functional loss of that finger, and it helps them with that decision making of, okay, I want to have a ray resection, or I want to have this just fused in this position. So I do think that the best thing in my hands is to give them that opportunity to see how their hand is going to be different, and then make an educated decision on their own. So here's one where we ended up doing an external fixator on a 15-year-old. So his physis were half taken out. This physis is pretty much gone, this one's partially gone. We staged it, I gave him about six weeks to see how much of this is gonna heal, how much of that physis was still there. His fingers started becoming more and more, as you can see, it's starting to become a little bit more crooked, as he's still growing from here, but not over from here. He decided that he wanted to go for a ray resection, did not show up the day of surgery, so he is floating around, ignoring my phone calls, with one of our external fixators on the south side of Chicago. So if you see him, that's my work. Yeah, tell him to come to clinic. So in conclusion, gunshot wounds just behave differently. It's a different beast, it doesn't follow classification, so don't get out your ortho bullets or whatever you're using to get your classifications to help you with decision making, it's not. You need to see the patient, you need to look at the patient, you need to make decisions about the soft tissue, the neurovascular status, and the bony injury, and expect the unexpected. Thank you. All right, thank you, that was wonderful. All right, thank you, that was wonderful. So next we're gonna talk a little bit about ballistic nerve injuries with Dr. Nelly. All right, good morning everyone, thanks for joining us. I'm Julia Nelly, I'm at the University of Missouri, and I have the distinct pleasure of talking about something we don't have a good answer for. So here we go. Here are my disclosures, and the objective of the next 10 minutes is to understand the types of nerve injuries associated with ballistic trauma, which most of us probably are very familiar with, describe some of the challenges of trying to determine when do we intervene on these and when do we not, and hopefully develop an algorithm that may be helpful for folks. So we all know these classifications of peripheral nerve injury, right? If you're above that yellow line, they're probably gonna get better. Between the yellow and the red, a little bit unknown. If you're in that red zone, below the red line, they're gonna need some sort of surgical intervention for their nerve, for them to have a chance of recovery. Right, so as Dr. Tintle expertly described for us, the weapon type matters, right? That permanent cavity and the temporary cavity are different between a low-velocity weapon and missile versus the high-velocity. We know that there's gonna be more energy being imparted if the missile is rotating or flipping through the tissue. I don't know about you, but most of my patients aren't able to tell me which one they got shot with unless they're the ones who accidentally shot themselves, because there are some handguns out there that are actually high-velocity weapons, and then there are some rifles that are actually considered low-velocity. So while we use this terminology to describe these injuries, it's not always clinically applicable because we just don't know. So let's talk about some of the classic teaching that we all hear about. Aren't most of the ballistic injuries, peripheral nerve injuries, neuropraxic, right? What are the mechanisms that can injure the nerve in a ballistic injury? And again, Dr. Tintle went through some of this. It can be direct trauma from the bullet, the thermal and shockwave damage. It can be laceration secondary to the fractures that can occur. There can be compression due to swelling. There can be subacute scar formation. All of these things can impact the nerve. And if we look at the literature, what we see out there is that you can have laceration rates as high as 62% in patients who have a high-velocity ballistic injury, and as low as 8% in the low-velocity ballistic injuries. So they're a little bit all over the map. And again, shotguns are unique, especially if they're in close range, as you saw in that video. But what are we all taught, right? That there's an expectation of expectant management for three months with these, right? Because we know that 70% of them can have spontaneous recovery. And one of the biggest or largest studies of this was by Dr. Omer in the Vietnam era. He was stationed at Brooke Army Medical Center. And he found that 70% of patients with a ballistic peripheral nerve injury recovered within three to nine months. He saw that the recovery rates were similar between a high-velocity and low-velocity ballistic injury. And then he also had this subset, though, that was really interesting, that they underwent exploration because they had wounds that necessitated it, and ended up undergoing repair of their peripheral nerve injury. 67 of those he had 12-month data on. And what he found was only 25% had good clinical function. The 75% of those that were deemed successful or having some good clinical function were done within three to six months of the injury, as opposed to being done later than that. So we have some indication early on that getting these done sooner rather than later can make a difference. And of course, the University of Chicago group shows us that in the lower extremity, again, that 70-ish range, 70% range of patients can have functional recovery at final follow-up in peripheral nerve injury in the lower extremity. But when we look at upper extremity, the results aren't as good because we see that there's improvement in 68% around a year, but only 24% at an average of a year had full recovery, right? So there's some damage that is not recoverable. So for me, that leaves me asking a few questions about what we're taught, right? What happens, we know that 70% are gonna get better, but what happens about that 30%? Are there any predictive factors we can look towards to say, hey, you're probably gonna fall in this 30% group and I need to do something early? Because if we do need to intervene, can we make our interventions, or can we get our interventions to have a more positive outcome, better than 25% getting good clinical function, which does not necessarily mean, in the literature, does not necessarily mean full recovery. So how do we predict it, right? So a panel in 2017 found that 27 patients with a nerve palsy after a ballistic injury had a nerve laceration, so 27% of these. Again, fitting those numbers that we've been seeing for several years, fracture in one study increased the likelihood of having a nerve injury, but in this panel study where they actually went in and explored 59 of the nerves, they did not find that to hold true. And they described this may be just a limitation of numbers, but I thought 59 explorations was pretty reasonable. And of course, there tends to be an association with vascular injury with these peripheral nerve lacerations. You can see in that bottom right photo, if you can see this fantastic vascular reconstruction right here, and then this is the nerve that had a full laceration in it that's getting trimmed back to healthy ends so we can reconstruct it right there. These nerve vascular structures are in close proximity, so it makes sense that if the artery is lacerated, the nerve may be as well. The next question that often comes up is don't we need to wait because we have to understand the zone of injury? Do we need to wait to intervene? Again, the classic teaching is you gotta wait three to four weeks in a setting, even in a setting of a known transaction so the zone of injury can fully demarcate. If we look in the literature about that, too, it's a little, the information's a little bit mixed, right? So there's a group out of France that looked at sciatic nerve partial transactions in a porcine model. They created that injury and then looked at the intact portion of the sciatic nerve and found that there was no center line grade two, three, or four injury at 24 hours. So they are suggesting that you don't have to wait a tremendous amount of time because potentially, if there's something that's still intact, it may be viable. However, a group out of China looked at a canine model where they didn't actually create a ballistic injury to the sciatic nerve just near it and both high velocity and low velocity wounds and they found that the injury findings, both histologically and looking at neurotransmitters were more pronounced in that high velocity group than the low velocity group up to 10 days. So they're saying you need to wait because you can't fully understand the zone of injury right away. We also hear often that we need to wait until valerian degeneration has completed to be able to identify what is the zone of injury. And again, the literature out there is really, there's no consensus as to how that can help us. So why intervene early? We can decrease the gap. We can prevent retraction of those nerves. We know if we wait until three weeks, there are gonna be approximately 8% loss of the total nerve length and that puts us potentially in the range of needing a reconstruction. So one of the ways we can deal with this is if we're intervening early or at least identifying the nerve injury early, you can put sutures in the proximal distal end and hold them out to length if the soft tissues are not ready for a nerve repair reconstruction. And we know that primary repair within two to three weeks results in superior outcomes compared to secondary repair or reconstruction. However, we also know if we have to wait because soft tissue issues, infection, they went down the path of monitoring, we can get more successful outcomes if nerve repairs or reconstructions are done within those three to four months as opposed to waiting six months or beyond. And this may be due to this large reduction in axonal numbers growing out distally after that three-month mark and changes in the Schwann cells as well. And then finally, it's a lot harder to go in after something is really fibrous and scarred in, right? That hostile environment becomes more hostile the longer we wait. And as Dr. Konteminka mentioned, it's not a lot of fun to be messing around around one of those vascular reconstructions in a bed of scar. And this was already touched on as well. We can't overlook those social factors, right? Some of these folks don't come back. And this was a study done in St. Louis where they looked at 17 pediatric patients with gunshot wounds. And they underwent exploration at their initial presentation because they had nerve deficits. And why were they doing that? They had found that only 8% of the patients who lived in an urban setting followed up. And for any sort of even just follow-up care. And so they posited that the morbidity of a nerve exploration was less than the morbidity associated with missing the transection and never seeing them come back again for any sort of treatment. So we have a few controversies. How do we work this through into a practical algorithm? And this is kind of how I think about these things. If there's a large soft tissue defect, they're gonna have to go to the OR. So look at the nerve if they have a peripheral nerve, clinical findings of injury. If there's a laceration detected and the soft tissue is not ready for any sort of nerve repair reconstruction and you think that you're gonna need a nerve graft, I still try to maintain the length by putting an epineural suture in each end and maintaining that tension across the nerve so it doesn't continue to retract. Then I plan for a repair reconstruction at the time of definitive closure, whatever that means. But trying to do that within the first two to three weeks if possible. Okay, so let's say, let's go down that right side now. Say there is not a large soft tissue defect. Is there a fracture that requires fixation and they have clinical findings of nerve injury? If they're going to the OR, I like to be looking at that nerve. Similarly, if they have a vascular injury, they're gonna be going to the OR, I like to look at the nerve and still going down that path of maintaining it out to length and then dealing with it once the soft tissue is allowed. So what if they don't have any of those things? They don't have a big soft tissue defect, they don't have a fracture that requires fixation, they're not going to the OR with vascular, then waiting for an EMG and getting an EMG at five to six weeks is what I like to do. Also monitoring their clinical improvement because that can get me in that window of if they're not improving, then I can repair, we can probably reconstruct at that point and explore within the first two to three months. So is there anything on the horizon that might help us and give us more clarity to this? So 4-Aminopyridine is a medication currently being used for multiple sclerosis patients to increase their walking performance. John Alfaro and his group is looking at this in an animal model and what they're finding is that they can have transient restoration of conduction of a nerve if a nerve is injured but it's in continuity. And so this may give us a way to diagnose these type of nerve injuries and guide interventions. And you've heard a lot, I think, about PEG fusion potentially at this meeting in the last few years, but if that ends up being translated to human use and clinical use, we do know that intervening early for that is gonna be necessary and so that may guide what we're doing for these potential ballistic peripheral nerve injuries as well. So here again, those objectives and thanks so much for your time. Thank you. Wonderful, that was, thank you, that was awesome. That nice little algorithm slide was really cool, I'll have to have him send that to me. Dr. Strelzow's gonna come up and talk a little bit about holes in the bone and best way to fill them if necessary. Thanks, Jeff. Thanks for inviting me to speak. I get probably the easiest talk because as you'll see, there's not much you have to do actually with holes, but why not, let's go through it. So you've heard a little bit about how to manage them from a fixation perspective, but what happens when you've got a big hole or even a small hole and what should you do with them? Do I need more metal, do I need less metal if I've got a hole in a bone? And then hopefully some tricks to help you in the upper extremity. Now I'm gonna caveat everything I'm about to say with its upper extremity. The lower extremity is very different and appears to behave differently with respect to the holes around fractures. You've heard a lot about this. There's really a paucity of good literature and the vast majority of it is military and so it doesn't really apply when you're starting to see low energy or low velocity fractures. You've seen lots about high velocity and low velocity, so I'm gonna skip through that and really get to the crux of what we hope to talk about. So this is a sort of standard University of Chicago patient. He was shot I think 14 times. We'll concentrate on his upper extremity. So here's the injury to him. He's sort of got a, I don't know what you wanna call it, a parry elbow disaster from two bullets. And you think, okay, well there doesn't appear to be a lot of bone there. What am I gonna do with it? He went to the operating room with the trauma surgeons. They did a shunt, which is always obviously a limb salvage situation. The problem with that is, as you heard earlier, now there's no tourniquet. You're probably going through either a bed or some part of the bed that has a shunt and a whole bunch of combat gauze as our general surgeons like to use around these large injuries. And you're kind of considering, how the heck am I gonna reconstruct this? As you kind of zoom in and try and get a better idea, because this is often the x-ray that you get, you really, you start to appreciate just how much bone is missing. What you can't appreciate here is the soft tissue wound, and this patient had a relatively large, we're gonna say exit wound, although I caution you, if you are seeing a lot of gunshot wounds, not to use the word entry and exit wound. You are not a ballistic expert, and that can be a problem if you ever get deposed in a court of law with respect to a gun-related injury. You heard about the tools you have, okay? So the tools are all the things you just heard about, and it's how you're gonna use those to really be successful. We typically get to be very creative with our fixation strategies because the bone, we're not going for anatomic fixation, right? If you go back to that x-ray, there's no way you're gonna make that look like it was never broken, so you do what you can to make it as functional for this patient as possible. We talked about that bone and that void, so how are you gonna fill it? Well, you go back to your sort of basics of bone void fillers, and you think, well, these are the properties I want, right? These are the classic properties of a bone graft. Osteoinductive, well, how am I gonna induce the bone to do what I want it to do, which is heal? How am I gonna give it the cells to be able to get there? How am I gonna support the void if I need to support the void? This is typically using a structural or cortical graft. And then last but not least, you're giving it the structure, or as I like to say on the micro scale, you're basically giving it the apartment block, and you need to fill the apartment block with renters. These are synthetic options for voids, and then if you really wanna go down the graft substitute train, there's a whole host of them. And I'm sure as you probably have experienced, the orthobiologic sphere is chocker-blocked with people. You'll have your rep du jour will come in and say, hey, I've got this fancy product that's gonna make everything better. I would caution you, particularly around ballistics, that you probably don't need any of those fancy things, but certainly they're available. And if you're interested and wanna play with them, I don't think that there's enough data to tell you that they're useful or not useful in your particular patient. They all have benefits, and they all have downsides. Certainly when you start to look at that slide that told you what the principles are of bone void, think about why you are filling a hole, right? So do I need something structural? That'll dictate the type of potential graft you may use if you're not going to use autograft. The, our experience certainly at the University of Chicago is at least initially to stay away from autograft. Again, these are probably patients who are high risk of infection, particularly the patient that I just showed you with large multiple injuries. And so putting a large structural autograft in that in the acute setting, probably not in your best interest or the patient's. So definitely if you're thinking about a structural graft, calcium phosphates are sort of your classic go-to. If you're looking for something that's a little bit better absorbed, you may think about something like a calcium sulfate or the mixed agents where you've got a hybrid, calcium sulfate, calcium phosphate. One of the nice things about calcium sulfate is it can be used for some antibiotic depo. It can give you some higher elution, which can be nice. The downside of that is if you've got a nice big open wound, you may find that nice milky solution leaking out of a wound at two to five weeks, which makes everyone pause for a moment and say, do we need antibiotics? So just give you a couple of cases to try and show you how and when we use it. This is a young female patient came in after multiple gunshots. She also had some injuries to her abdomen, but these were the ones that we were involved with. Certainly for her tibia there, that was treated non-operatively. We're pretty aggressive with non-operative management of long bones that have cortical integrity maintained. And then when you get to the wrist here, you obviously notice a retained fragment, but on top of that, a pretty comminuted distal radius. The CT scan, I will echo something that Dr. Kontemeka said, which is you will always be surprised at how bad these are when you get to the operating room. Do not trust your CT, do not trust your X-ray. This CT makes it look, hey, that's gonna be a chip shot, nice dorsal big fragment. When you get in there, I can promise you that is not the way it ends up looking, and suddenly you'll find fracture lines in all kinds of weird directions that just don't make sense. But this particular patient, pretty comminuted radial styloid type fracture pattern because of where it is, because of the ability for us to get length, alignment, and rotation, we did not use anything. You don't need anything. And I would suggest that for the vast majority, that's the case. If we go back to our young gentleman that we started with, certainly, again, trying to figure out what to do with that void. Well, intraoperatively, you can see the large void that we did have extending a long way down his metaphysis at the ulna. This is one instance where, because of the brachial artery injury, because of the large soft tissue void, we ended up doing a radial flap for him as well. Because of the large, again, exit wound, but please don't use that, you'll notice that I filled it in. What I chose to use here was a mixture of calcium phosphate, hydroxyapatite, and calcium sulfate, and I off-labeled, again, off-labeled, used some vancomycin in that, which I mix on the back table, which provides me some bone graft, but it also provides me a structural support, because you can see just how long that segment is unsupported. And then with the antibiotic elution as well, you kind of get the best of all worlds. And he went on to do quite well at the six-month mark when he returned, sadly, for another injury. Another example, this is a 25-year-old, pretty classic through and through for the humeral shaft. Isolated injury, radial nerve is out. He's a gentleman, because he was a paraplegic from a GSW to the spine at the same time, we elected to fix him normally, to be honest. I would have left that non-operatively if it was an isolated injury. Went in, had a look at the radial nerve. Nerve was intact, it was heavily contused, but was sitting there. We elected to plate him a little bit differently. He, because of the location of the wound, we actually sort of did a medial approach to the humerus, which was fun. And he did well, his nerve recovered, and we did not use graft, okay? So there's another example of where the vast majority of upper extremity fractures appear to heal when they're low velocity or low energy injuries. We are, I think it's this month or next month, hopefully you'll see that in JHS. Our union rate was actually equivalent to closed injuries for the same fracture pattern and same classification. So again, probably don't need many of them. Many bone grafts, for example, probably don't need many of them, many bone graft fillers. One question that always comes up is what do you do about antibiotics and what do you do about IND? Traditionally, we're all taught, right? Open wounds, you're gonna take them to the OR, you're gonna debride them. Again, for low energy urban style ballistic injuries, the vast majority of these probably do not need to go to the OR and probably do not need a formal IND. That's been shown in now multiple studies. And so for the vast majority of these, we are not going in and doing anything. Obviously, if you're gonna fix the bone, it's an opportunity to give it a wash. You'll notice we take most of the loose fragments, you give it a couple of squirts of saline and most of the debris kind of washes out of the wound because of the heavy fragmentation you get. Certainly looking for devascularized tissue and devascularized bone, you saw those wonderful videos of how impactful that shock wave can be. In terms of joints, through and through arthrotomies, we do nothing for. We let them go. We actually do not even give them antibiotics at this point. If you have a through and through with a retained metallic foreign body in the joint, those are ones you're gonna go and take the fragments, the bullet fragments out or the metallic foreign bodies out. And then the nerves, yeah, I mean, this is one of my heavy interests because I don't know what to do with them. And having explored and not explored them, I still don't understand why they get injured. Certainly there's some data that's very conflicted because our data did not show it, but historically there was some data showing that the more comminuted fracture patterns, the more bony fragments you had, the higher likelihood of a nerve laceration. That has not been our experience and our study would contradict that. However, when you do go in there, it's amazing. The ones that I have seen that are transected do seem to be like a bony fragment that's transected it. And I've only ever seen one which was exactly like your x-ray to the palm, the hand, where it was a through and through. The bullet clearly just took the median nerve out, but it seems to be pretty rare. Last but not least, a very similar injury. Here's a heavily comminuted proximal ulna again. Young gentleman with another brachial artery injury, unfortunately. You can see the bone void again. Looks almost identical to our other patient, right? Big, soft tissue exposure to try and get down there, unfortunately. But you can see the hole in the bone, right? Nice, big, big hole. When you get to the operating room, there's just nothing there to use. And so, again, another opportunity to use something. This is, again, another one where I used a mixture of some calcium phosphate and calcium sulfate. I like to put some vancomycin in that solution just because I think it can't hurt. These wounds are, in theory, dirty. And so, it healed nicely. That's them at a year coming back for follow-up. Well, I think this is my last case. So, 43-year-old, forearm, isolated forearm injury. Pretty decent-sized bone void comes in. We actually just plated it. We didn't do anything for that. That void came in at eight months for an unrelated injury. That's relatively filled in, although not healed. But clinically, very happy. You wouldn't know that he has a, probably a nonunion if I CT'd it, but he was not interested in me doing anything for it, so we left it. So, again, do you need to fill him? Probably not. The vast majority of these seem to do very well in the upper extremity without anything. But, again, low velocity, and it depends on the size of the void. Hopefully, that helps. That's just a summary of most of what you've already heard. So, thanks. Do you wanna stay up? Yeah. All right. There are a few questions I'm gonna try to answer if the moderators maybe can come up, and we'll have, like, five minutes or six minutes to do a case or two, maybe. So, if, question for you, Dr. Strausel, what are you doing for your antibiotic prophylaxis in a low-velocity, say, hand gunshot wound that comes in with a ballistic injury? Our data would say you don't need to do anything. So, there's a couple nice studies looking at low velocity for upper and lower extremity. If you give them a single dose, you're absolutely fine, but they don't even actually need the single dose of antibiotics. And what are you doing if you're putting implants in? Are you worried about anything like that afterwards? The exact same thing. They get a single dose, the pre-op dose. If they're going to the OR, they get a single ANSEF dose and discharge without anything. Perfect. All right, so we'll start with a, there's one other question. Does anyone have experience with joint replacement in MCP or PIP gunshot wounds? And I'll say a lot of them aren't coming back, so you don't know what the future lies, and their fingers are extremely stiff. And so, I don't know how much improvement, I don't think pain is usually the issue. They usually actually do end up with a stable finger. So, I don't know if anyone has any other experience than that. I would urge you not to do it primarily, to do an arthroplasty, just because they haven't gotten stiff, usually at that point they're just unstable. We have a series of war-injured patients where less than 10, but about 10 MPs that we used, some sort of tended interposition arthroplasty, and they got about 45 degrees of motion and were relatively pain-free, but that was with about five-year follow-up. So, long-term, they may certainly need something else. Yeah, I was gonna say the same thing. I've had actually two military gentlemen, two Marines that had injuries to the fourth and fifth metacarpals through the joints, and actually the vast majority of them don't look at the X-ray. If you get them to heal, they're actually pretty happy. And even if the X-ray looks terrible at the joint, they seem to function. So, I'd try and avoid it if I could. And then one last question before we get to the case. Any thoughts on intramedullary fixation in the hand humerus arm with the comminution? And I'll say that I think it's great for the metacarpals. Recently I had a case with all four of them going across and putting as many intramedullary screws as possible to, you know, both for the soft tissues and span the comminution, and it worked well. So, I don't know if either of you or any of you have experience with that. So, I don't, for the forearm specifically, I don't like the intramedullary fixation. We've had folks that did use it a lot in the war, and what I've found is at least more problems down the road because I've seen a lack of an anatomic reduction of the radius, which has really led to significant problems at the DREJ, and just made everything more complicated. And the thought, I think, by using the nail was to, you know, they would not use the nail, they would not do a flap, they would do a skin graft and try to avoid the big dissection. And then the whole problem just gets so complicated down the road when you have the bones healed, it's not anatomic, they still need a flap now for their nerve reconstructions, and really they just should have, you know, done a flap early on. So, I would much rather put a big plate and get it perfect, and then do what you need to do for the soft tissues, yeah. For the metacarpal fractures with bone loss, I've had some success doing a staged induced membrane and then putting an intramedullary screw with that so you can preserve the articular surface, go in and put bone graft in after you remove your antibiotic cement, and then intramedullary screw through all three segments of that with some reasonable success with that. Of course, they're gonna have stiffness by nature of the injury, I think, too, but that's one other way to do intramedullary fixation. Well, I was just gonna say, we should write up, we have a series of, I think, 10 or 12 humeral shaft fractures with brachial artery injuries that we've used humeral nails for, which is a nice option, because, you know, they do these massive explorations, our vascular and trauma service, so you end up with a huge wound, you just don't wanna either operate through or operate beside, so the humeral fixation can be very helpful, and then we're toying with an IRB for, there's now like some two companies, I think, that have locked ulnar nails that with proximal and distal locking options, which I think would be actually a pretty interesting study that I have to get off the ground, but that would be helpful for the ulna. Definitely, I think it makes sense for the ulna. So quickly, I know that we have like a minute or two, so this is a 16-year-old male with a gunshot wound. Multiple gunshot wounds, but this is the only bony injury to the left upper extremity. There's some kind of weird exam with some decreased sensation over the median nerve. It's hard to tell. She does feel something. She's limited by pain, and so we've learned, you know, we're not doing any prophylaxis for antibiotics here. You know, what are we thinking in terms of, relatively straightforward fixation, in terms of timing, are we worried about the nerve? Everyone tells us that ballistic injuries are a neuropraxia. She's got some median nerve function intact. Dr. Nolley, any thoughts on that? What is that retained fragment doing with her skin? First question. It's tented, but it was taken out in the ED. Ah, okay, took away our opportunity to go to the operating room for that. Yeah, I mean, with a patient like this, I think getting them stabilized and closure reduced, have a splint in place, and re-examine in a week is reasonable if they have some intact median nerve function. It's not somebody I would rush off to the OR to be looking for nerve laceration. However, with what looks like the trajectory of that, the median nerve is certainly right in that pathway. Yeah, that's exactly what we ended up doing. She was initially treated in the ED. The wounds were washed out, left open, because they were small wounds, and exactly, I think you hit it on the head, we saw her back in the clinic a week later. Basically, the exam's unchanged. Still not really able to move her thumb, but she's not really moving her hand in general. Sensations decrease, something is a little bit weird. And is there anything, what are you consenting for? Is there anything specific? You're gonna obviously view the nerve, I'm assuming, during this fixation. Yeah, yeah, certainly. I am consenting for nerve repair versus reconstruction. I have the discussion, I always have the discussion with the patient, allograft versus autograft. If it's mixed motor sensory, young patient, I'm leaning a little bit more towards autograft still. But I have lots of young patients who will not consent to that, or their parents, I guess, because you would have a parent consenting, and they won't consent for that because of the donor site morbidity. So being prepared for both of those situations. There is a group out of France that are talking about putting, in order to decrease the need for an allograft or autograft and enable primary repair, putting extremities at higher flexion angles so that you can do a primary repair, holding them there for six weeks, and then starting to move them after that. And so that would be something that I think is really intriguing. I don't do that currently. I don't know if you all are doing that at all, but. Yeah, I heard that discussion. Worry about full flexion, obviously, but maybe a little bit to get a primary nerve repair makes some sense. Also, maybe a carpal tunnel release to help you get a little bit of that tension off the nerve as well. Yeah, and releasing the next side of potential compression, certainly. So to go our pretty straightforward fixation as the size of the bony defect or injury is always bigger than you think. Once you get it out to length, there's a gap, but again, not really necessary for bone void filler there. And so this is the nerve. It's kind of strange, and it really speaks to the fact that it's kind of a weird exam, right? It's partially intact. It's halfway cut. What is going on there? And so just for the interest in time, internal dissection and grafting, and she was consented for all of this. The thing is, if she didn't have that fracture, we probably would have followed her. We would have been three to six months down the road if she followed up again. And so I think she was actually lucky to have a fracture. And you say, well, are these partial injuries common? A month later, almost didn't follow up after three months, but the fracture healed. Are these common? Is that like a one-off case? So a month later, same almost exact case, pretty straightforward fracture fixation, explored the median nerve with a similar, and there's a partial injury to the median nerve. And it was a similar kind of strange exam. And again, another person that, if this went to a trauma surgeon, they probably wouldn't have explored the median nerve and went to look at that. And so explaining that these do happen. And then if they don't have a bony injury and that do follow up. I was just gonna say, trauma surgeon what? Yeah. Wow, I was waiting. That hurt, that cut me deep. You are a hand surgeon. You're like right there. You are a hand surgeon. And if they don't have a bony injury and they do follow up, it is actually much harder to deal with. This is an ulnar nerve that I explored probably at six to nine months afterwards. And what do you do with this massive neuroma? There's some fibers going through, what to cut out, what not to cut out. I think it becomes a more difficult problem. So obviously we're still searching for, if ultrasound is gonna give us some better information, what is it gonna give us the information that's gonna help us decide whether to go in or not for these injuries. But I think that we're, I have more cases, but I think that we're out of time. So in the interest of everyone's time, I'll let you guys go. Perfect, yeah. Thank you.

managing gunshot wounds

ballistic injuries

upper extremities

orthopedic consults

fixation techniques

bullet nerve injuries

bone void fillers

individualized treatment plans

antibiotic prophylaxis

joint injuries