ä Despite an increasing rate of civilian low-velocity gunshot injuries, there remains a lack of evidence-based treatment standards.ä Most low-velocity gunshot-induced fractures of the extremity can be managed similarly to non-gunshot-induced fractures, with the goals of restoring function and minimizing complications.ä There are a limited number of high-quality studies to support the use of prophylactic antibiotics for nonoperatively treated gunshot wounds.ä Intra-articular retained bullets should be removed, while prophylactic irrigation and debridement for a transarticular bullet is not routinely warranted for infection prevention.ä Much of the literature on low-velocity gunshot wounds is Level-III or IV evidence, warranting the need for higherpowered, randomized, prospective investigations.Gun violence and firearm injuries are serious public health problems in the United States. Civilian gunshot wounds (GSWs) are associated with substantial morbidity, mortality, and socioeconomic consequences. The incidence of nonfatal GSWs continues to increase in the United States, with an estimated 535,150 nonfatal GSWs between 2014 to 2018, increasing approximately 41% over the previous 5 years 1 . GSWs have increased from eighth to sixth among the most common causes of nonfatal violence-related emergency department visits 1 . Nonfatal GSWs disproportionately impact males, members of racial and/or ethnic minorities, and those under the age of 35 years 2 . Urban areas remain the predominant center of injury, with most gun violence concentrated among high-risk populations 3 . These injuries have profound economic impact, with the cost of care in the U.S. exceeding $2.7 billion annually 4 .The military experience has provided the basis for highvelocity GSW management. However, most GSWs presenting to civilian medical facilities are caused by low-velocity handguns 5 . Despite the increasing frequency of civilian GSWs, the management of these injuries is debated 4,[6][7][8][9] . The present review focuses on the current best evidence on the management of low-velocity GSWs to an extremity in the civilian population. GSWs to the spine and high-velocity GSWs are not discussed. Historical Perspective and BallisticsPrior to the 17th century, bacteria were unknown and infection from GSWs was thought to be secondary to gunpowder poisoning. During that era, standard of care was bullet removal and cautery 10 . Although wartime data have provided foundational principles for the treatment of high-velocity GSWs, there are distinct differences in the management of civilian lowvelocity GSWs. By definition, low-velocity bullets travel <2,000 ft/s (610 m/s) (while high-velocity bullets travel >2,000 ft/s). Bullet properties (mass and shape), travel characteristics (yaw, tumble, and velocity), impact characteristics (pass-through Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article...
Background: Tibial plateau fractures account for approximately 1% to 2% of fractures in adults 1 . These fractures exhibit a bimodal distribution as highenergy fractures in young patients and low-energy fragility fractures in elderly patients. The goal of operative treatment is restoration of joint stability, limb alignment, and articular surface congruity while minimizing complications such as stiffness, infection, and posttraumatic osteoarthritis. Open reduction and internal fixation with direct visualization of the articular reduction or indirect evaluation with fluoroscopy has traditionally been the standard treatment for displaced tibial plateau fractures. However, there has been concern regarding inadequate visualization of the articular surface with open tibial plateau fracture fixation, contributing to a fivefold increase in conversion to total knee arthroplasty 2 . In addition, the risk of wound complications and infection has been reported to be as high as 12% 3,4 .Knee arthroscopy with percutaneous, cannulated screw fixation provides a less invasive procedure with excellent visualization of the articular surface and allows for accurate reduction and fracture fixation compared with traditional open reduction and internal fixation techniques 1 . Recent studies of arthroscopically assisted percutaneous screw fixation of tibial plateau fractures have reported excellent early clinical and radiographic outcomes and low complication rates 3,5,6 . Description: This technique involves the use of both arthroscopy and fluoroscopy to facilitate reduction and fixation of the tibial plateau fracture. Through a minimally invasive technique, the depressed articular joint surface is targeted with use of preoperative computed tomography (CT) scans and intraoperative biplanar fluoroscopy. Reduction is then directly visualized with arthroscopy and fixation is performed with use of fluoroscopy. Lastly, restoration of the articular surface is confirmed with use of arthroscopy after definitive fixation. Modifications can be made as needed.Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSEST/A372).
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