Treatment of War Injuries of the Shoulder with External Fixators

Military Medicine, May 2005 by Davila, Slavko, Mikulic, Danko, Davila, Neda Jarza, Popovic, Ljiljana, Zupancic, Bozidar

In this retrospective study, 18 patients with war injuries of the shoulder were reviewed to evaluate the technical problems associated with external fixation and to analyze the incidence of infection and late functional results. The average patient age was 28.5 years. All patients were male. Thirteen patients had explosive wounds, whereas five wounds were caused by gunshot missiles. All injuries were extensive in terms of bone and soft tissue defects. Six patients presented with complex injuries involving neurovascular structures. Sixteen patients were treated with external fixation. Application of the proximal pins of the external fixator through the humeral head was possible in eight patients, the scapula served as the site of proximal fixation in four patients, only the clavicle was available for placement of pins in two patients, and both the scapula and the clavicle had to be pinned to achieve proximal stabilization in two patients. In two patients, fixation was not possible and early amputation was performed. Infection was eventually eradicated in all patients, allowing for adequate soft tissue coverage of the wounds. Analysis of functional results at an average of 6 years after the injury showed a considerable degree of functional deficit in most patients.

Introduction

In this retrospective study, we wished to investigate several aspects associated with management of war injuries of the shoulder, including technical difficulties of external fixation, the incidence of infection, and late functional results. We think that a better understanding of the underlying mechanisms and concepts can help surgeons during treatment of these often devastating injuries.

Gunshot wounds of the shoulder region are not uncommon and have been described by different authors. ' However, war injuries with high-velocity missiles (characterized by muzzle velocities exceeding 2,500 feet/s) present with additional intricate aspects, including extensive bone and soft tissue destruction, frequent damage of neurovascular structures, wound contamination, and high rates of infection.2-4 Because of these problems, patients with this type of injury were earlier frequently treated with immediate high-humeral amputation or shoulder joint disarticulation.

When dealing with injuries that involve neurovascular structures, clear priority should be given to vascular reconstruction, preferably using autologous venous grafts. Use of prosthetic materials should be avoided, because of the risk of infection.5 Repair of neural injuries can be performed as a delayed procedure, after the infection has been eradicated and the wound has healed.6

After the repair of vascular injuries and thorough soft tissue wound excision, bone stabilization can be started, with removal of all nonviable bone fragments, because they only predispose patients to later development of infection. There is no dispute that external fixation is the primary method of treatment for bone fixation of war injuries of the shoulder.7,8 However, the available literature does not provide clear guidelines concerning the exact placement of external fixator pins and proper construction of the external fixator apparatus in the setting of large bone defects of the shoulder and pectoral girdle. The attachment of the humerus to the scapula and clavicle involves principally soft tissues, and biomechanically secure, stable, external fixation of the proximal humerus should include proximal pin placement through the humeral head.9,10 If bone loss in the area of the humeral head is too extensive, then the acromial part of the scapula or the clavicle can be used instead. Placement of the distal pins usually does not cause technical difficulties. When there are sufficient bone and soft tissues, three (or, better, four) pins should be placed both proximally and distally.11,12 Unfortunately, in war injuries, the condition of the humeral head more often allows placement of only two pins.

Infection is another important aspect of war injuries. These wounds are highly contaminated, and observation of the principles of war surgery (immunization, antibiotic prophylaxis, radical wound excisions, and frequent wound dressings) is mandatory.13 The causative flora is variable, and both local and systemic measures are necessary to fight infection successfully.

We found no previous reports about the functional outcomes of war injuries of the shoulder. As for other war injuries that include extensive bone and soft tissue defects, functional results are not expected to be excellent and salvage of the extremity remains the main goal.

Methods

During the Croatian Homeland War (1991-1995), 1,643 patients with gunshot and explosive wounds were treated at the University Hospital Center Zagreb; 18(1.1%) of whom had a war injury of the shoulder. The average age of our patients was 28.5 years (range, 17-52 years). All patients were male. Thirteen (72.2%) patients had explosive wounds that resulted from shell fragments or mines, whereas five (27.8%) had gunshot injuries. Soft tissue injuries were extensive in all patients (Fig. 1). Six (33.3%) patients had sustained injuries of neurovascular structures (injuries to the axillary or brachial vessels in four patients, injury to the axillary nerve in three, and injury to the radial nerve in two).