Gunshot wounds are rarely injuries that present to a podiatric practice, but they do occur and they can affect the lower extremities. However, when dealt with by a podiatrist, it’s typically in the hospital setting, where the Podiatrist has been called in during the middle of the night to see a patient in the emergency room. Hopefully this type of injury is not one that you can relate to, but as we are tackling uncommon injuries and diagnoses this month I thought it fitting to discuss this type of injury. We will only scratch the surface in discussing such injuries with the hope that you’ll never need to know the rest!
When a patient presents with a gunshot wound/injury, as Podiatrist’s we will interview the patient to determine how the injury occurred, but the answer is usually unimportant and unrelated to the treatment protocol that will be followed; the opposite of how we handle most other injuries where the mechanism is extremely important. With gunshot wounds, there’s been an injury, the damage needs to be assessed, we need to determine if the bullet or any pieces of the bullet remain in the patient, and construct a course of treatment.
Assessing the damage. Typically the emergency room doctors will treat any injuries, in addition to the gunshot wound that are life-threatening to the patient or need immediate attention. This includes a complete workup of the patient to determine if they have stable vital signs (heart rate, blood pressure etc) and any injuries to their head, abdomen, chest etc. Once any initial threat to the patient is dismissed, the Podiatrist is called in and needs to assess any damage specific to the area of injury. In past blogs we’ve talked about compartment syndrome and neurovascular compromise, and those are the two most important things that will be immediately deciphered. Does the patient have pulses to the foot below the level of injury? Is the sensation in the foot the same in comparison to the non-injured foot, below the level of the injury? Has the injury in some way blocked blood flow and/or caused compression or severance of any nerves in the foot. If the answer to any of these questions is yes, the situation becomes more urgent. If the answer to all questions is no, then the situation is less urgent, but still needs significant evaluation and treatment.
Where’s the bullet? A bullet and any pieces that may remain from the bullet (if there are any) will show up on x-ray. Therefore, x-rays in the area of interest are routinely performed on patients with gunshot injuries/wounds. Once it is determined that there are no pieces of the bullet remaining in the patient, treatment can progress. If the bullet is lodged or if there are pieces present, the location needs to be determined, as it will affect treatment. As a general rule, and for simplicity purposes if the bullet is lodged securely in the bone without fracture to the bone, it is left alone. If the bullet is in the surrounding tissues, it is typically removed and all pieces if accessible through the open wound are removed. If pieces are not accessible, they are left alone.
What’s the next step? Gunshot wounds, independent of a graze vs penetrating vs through and through injury need to be cleansed thoroughly once the initial damage has been assessed and all immediate concerns such as compartment syndrome and vascular compromises have been handled. Thorough cleaning entails a trip to the operating room where all dirt and debris brought into the area by the bullet are removed with high-pressure application of sterile solution, decreasing the risk of infection. Depending on the Podiatrist’s experience, the type of wound, and the surrounding skin, the wound may or may not be initially closed with sutures. Often times, the wound must be left open and allowed to fill in with new skin and tissue on it’s own because the edges of the affected area can not be brought back together.
Gunshot wounds are uncommon injuries and are complicated in their treatment. The Podiatrist must ask him/herself numerous questions to determine the best course of treatment for each individual patient so that they are given the best chance at a complete recovery. Although this is a simplistic view of what Podiatrists are faced with when dealing with this type of injury, it does provide some insight.
Steer clear of flying bullets and you’ll never need to see this information utilized first hand!