Tratamiento de las fracturas por herida de arma de fuego: revisión bibliográfica sistematizada / Treatment of gunshot wound fractures: systematic review of the literature / Tratamento de fraturas por arma de fogo: revisão bibliográfica sistematizada

Introducción: Las fracturas por heridas de arma de fuego son un motivo de consulta habitual en nuestro país. Existe gran variabilidad de conductas respecto a su tratamiento. El objetivo principal de este trabajo es analizar los distintos tratamientos y sus indicaciones. Materiales: Se realizó una revisión sistematizada de la literatura en las bases de datos Pubmed y Scielo. Se incluyeron artículos con fracturas por herida de arma de fuego en miembros superiores e inferiores, excluyendo la mano. Se analizó: tratamiento (ortopédico o quirúrgico), debridamiento, antibioticoterapia y complicaciones. Resultados: Se obtuvieron 19 artículos que cumplían los criterios de inclusión y exclusión. Los artículos tuvieron un Nivel de Evidencia tipo 2b, 3 y 4. Conclusiones: Los artículos analizados tienen un bajo nivel de evidencia. La fijación quirúrgica es variable y depende de la topografía ósea, la lesión de partes blandas y las lesiones asociadas. El debridamiento profundo está relacionado con mayores índices de infección. Las fracturas estables de tratamiento ortopédico no deberían debridarse ya que aumenta los índices de infección. Debería realizarse antibioticoterapia intravenosa inicial en todos los pacientes, la terapia posterior es discutida.

Introduction: Fractures due to gunshot wounds are a common reason for consultation in our country. There is great variability of conduct regarding its treatment. The main objective of this work is to analyze the different treatments and their indications. Materials: A systematic review of the literature was carried out in the Pubmed and Scielo databases. Articles with fractures due to gunshot wounds in the upper and lower limbs (excluding the hand) were included. We analyzed: treatment (orthopedic or surgical), debridement, antibiotic therapy and complications. Results: 19 articles were obtained that met the inclusion and exclusion criteria. The articles had a Level of Evidence type 2b, 3 and 4. Conclusions: The articles analyzed have a low level of evidence. Surgical fixation is variable and depends on bone topography, soft tissue injury, and associated injuries. Deep debridement is associated with higher rates of infection. Stable orthopedically treated fractures should not be debrided as this increases infection rates. Initial intravenous antibiotic therapy should be performed in all patients, subsequent therapy is discussed.

Introdução: As fraturas por ferimentos por arma de fogo são motivo comum de consulta em nosso país. Há grande variabilidade de conduta quanto ao seu tratamento. O objetivo principal deste trabalho é analisar os diferentes tratamentos e suas indicações. Materiais: Foi realizada revisão sistemática da literatura nas bases de dados Pubmed e Scielo. Foram incluídos artigos com fraturas por arma de fogo em membros superiores e inferiores, excluindo a mão. Foram analisados: tratamento (ortopédico ou cirúrgico), desbridamento, antibioticoterapia e complicações. Resultados: foram obtidos 19 artigos que atenderam aos critérios de inclusão e exclusão. Os artigos tinham Nível de Evidência tipo 2b, 3 e 4. Conclusões: Os artigos analisados ​​apresentam baixo nível de evidência. A fixação cirúrgica é variável e depende da topografia óssea, lesão de tecidos moles e lesões associadas. O desbridamento profundo está associado a maiores taxas de infecção. Fraturas estáveis ​​tratadas ortopedicamente não devem ser desbridadas, pois isso aumenta as taxas de infecção. A antibioticoterapia intravenosa inicial deve ser realizada em todos os pacientes, a terapia subsequente é discutida.

Ultrasound Diagnosis of Either an Occult or Missed Fracture of an Extremity in Pediatric-Aged Children

OBJECTIVE: To report and assess the usefulness of ultrasound (US) findings for occult fractures of growing bones. MATERIALS AND METHODS: For six years, US scans were performed in children younger than 15 years who were referred with trauma-related local pain and swelling of the extremities. As a routine US examination, the soft tissue, bones, and adjacent joints were examined in the area of discomfort, in addition to the asymptomatic contralateral extremity for comparison. Twenty-five occult fractures in 25 children (age range, five months-15 years; average age, 7.7 years) were confirmed by initial and follow-up radiograms, additional imaging studies, and clinical observation longer than three weeks. RESULTS: The most common site of occult fractures was the elbow (n = 9, 36%), followed by the knee (n = 7, 28%), ischium (n = 4, 16%), distal fibula (n = 3, 12%), proximal femur (n = 1, 4%), and humeral shaft (n = 1, 4%). On the retrograde review of the routine radiographs, 13 out of the 25 cases showed no bone abnormalities except for various soft tissue swelling. For the US findings, cortical discontinuity (direct sign of a fracture) was clearly visualized in 23 cases (92%) and was questionable in two (8%). As auxiliary US findings (indirect signs of a fracture), step-off deformities, tiny avulsed bone fragments, double-line appearance of cortical margins, and diffuse irregularity of the bone surfaces were identified. CONCLUSION: Performing US for soft tissue and bone surfaces with pain and swelling, with or without trauma history in the extremities, is important for diagnosing occult or missed fractures of immature bones in pediatric-aged children.

Condrodiastasis y transporte óseo simultáneos para formación de hueso único como alternativa de reconstrucción por trauma severo de antebrazo en niños: reporte de un caso / Chondrodiatasis and bone simultaneous transport for formation of one-bone as reconstruction alternative for severe trauma of forearm in children: report of a case

Los defectos post traumáticos severos de miembros superiores en niños son infrecuentes y cuando ocurren involucran mecanismos de alta energía. Se realiza estudio descriptivo, sobre preescolar masculino, 7 años, indígena, quien presentó trauma severo en antebrazo derecho con fractura abierta III b y pérdida de 2/3 distales del cúbito y 2/3 proximales del radio con preservación de placa de crecimiento de éste último. Planteamos como objetivo preservar el miembro, mantener longitud axial y su máxima función realizando la reconstrucción de antebrazo por condrodiastasis del radio y transporte óseo del cúbito simultáneamente utilizando fijador externo llizarov. Logramos alargamiento de 2,5 cms. en radio y 3 cms. en cubito con la consolidación de ambos para la formación de un hueso único radio-cubito, conservando los movimientos intrínsecos de la mano, el crecimiento epifisiario, la flexo-extensión de codo y muñeca con abolición de pronosupinación. Concluimos que la cirugía reconstructiva con formación de hueso único mediante técnicas combinadas de alargamiento óseo es una opción terapéutica eficaz para el manejo del trauma complejo del antebrazo con pérdida de hueso en niños.

Severe post-traumatic defects in the upper limbs of children are rather rare and when they happen they involve mechanisms of high energy. Material and methods descriptive and prospective study about indigenous masculine, 7 years, who present severe trauma in right forearm with open fracture III b and loss of 2/3 distal of the ulna and 2/3 proximal of the radio with preservation of plate of growth. We outline as objective to preserve the limb, to maintain axial longitude and their maximun function carrying out the forearm reconstruction simultaneously for chondrodiatasis of the radio and bone transport of the ulna using external fixation llizarov. We achieved lengthening of 2,5 cm. in radio and 3 cm. in ulna with thinks about the consolidation of both for the formation of a one-bone radio-ulna, conserving the intrinsic movements of the hand, the epiphyseal growth, the elbow flexo-extension and wrist with pronosupination abolition. WE concluded that the reconstructive surgery with formation of one-bone mediating combined techniques of bone lengthening is a therapeutic effective option for the hadling of the complex trauma of the forearm with bone loss in children.