Gunshot Wounds: Principles And Treatment
nng ioui atin cnt EduCo icaledMContinuing Medical EducationEducationalGoals:After completion ofthis CME, the readerwill:Gunshot Wounds:Principles andTreatmentHere’s an in-depth look at thesetraumatic injuries.1) Understand thedifferences betweenlow and high velocitygunshot wounds.2) Gain informationon treatment of gunshot wounds.3) Understand theGustilo classificationof compound fractures.By Ritchard Rosen, DPMWelcome to Podiatry Management’s CME Instructional program. Our journal has been approved as a sponsor of Continuing Medical Education by the Council on Podiatric Medical Education.You may enroll: 1) on a per issue basis (at 26.00 per topic) or 2) per year, for the special rate of 210 (you save 50).You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. You can also takethis and other exams on the Internet at www.podiatrym.com/cme.If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earnedcredits. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake thetest at no additional cost. A list of states currently honoring CPME approved credits is listed on pg. 156. Other than thoseentities currently accepting CPME-approved credit, Podiatry Management cannot guarantee that these CME credits will beacceptable by any state licensing agency, hospital, managed care organization or other entity. PM will, however, use itsbest efforts to ensure the widest acceptance of this program possible.This instructional CME program is designed to supplement, NOT replace, existing CME seminars. The goal ofthis program is to advance the knowledge of practicing podiatrists. We will endeavor to publish high quality manuscripts by noted authors and researchers. If you have any questions or comments about this program, you can writeor call us at: Podiatry Management, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us at bblock@podiatrym.com.Following this article, an answer sheet and full set of instructions are provided (pg. 156).—EditorCivilian injuries due to firearms are increasing in theUnited States.1, 2 As podiatric surgeons become moreinvolved with trauma, itis important to understand the principles and types of gunshot woundswe are faced with every day. Gunshot wound damage varies with thetype of weapon and caliber of thewww.podiatrym.comammunition as well as the distance amissile is shot from.Low Versus High Velocity GunshotWoundsGunshots are classified as highvelocity, low velocity, high energylow velocity shotgun and low energylow velocity gunshots. High velocityis seen in the military, and low veloc-ity is generally seen in civilian populations (Figure 1).A small entrance wound and alarge explosive exit wound is indicative of a high velocity projectilefired at close range. A small entrancewound with a small or no exit woundwith the missile retained within thehost’s tissue generally is indicativeContinued on page 150JUNE/JULY 2016 PODIATRY MANAGEMENT149
g nin atiouCMEtin ducnEolC icaedGunshot Wounds (from page 149)M150velocity projectiles, and therefore thenerves, skin, and subcutaneous fat.amount of tissue damage encounAlthough each structure is evaluated,of a low velocity bullet speed lesstered as well as the amount of conthe close proximity of all these structhan 2000 ft./sec (Figures 2,3).3tamination is much less than withtures in the foot requires knowledgethe military injuryof anatomy as well as function ofIn evaluating(Figure 4).5each of the above.and treating gunshotWhen confronting a gunshotwounds, the extentThe shotgun iswound, the following protocol shouldof the tissue damageanother type of inbe followed:caused by the bullet isjury encountered1) Take an adequate history. Itof utmost importance.in private practice.is important to ascertain if a “flashThe local effectsTissue damage isof missile injuriesdependentare:on the range1) Laceration andat which thecrushingshotgun is2) Production offired. 8 Firedshockwave and tematpointFigure 1: High velocity gunshot woundporary cavitationblank rangeLaceration and(less than 15crushing are the principle effects ofyards), the shotgun pellets arethe bullet passing through the tissueextremely lethal, and produceplanes and causing damage primarilyan extensive wound with subto the permanent cavity region of thestantial bone and soft tissuebullet track.3loss with comminution anddamage to the neurovascularTemporary cavitation is more ofFigure 2: Low velocity GSWstructures (Figures 5,6).4, 6, 8, 9a concern with high velocity wounds.Laceration and crushingare principles of Low velocity wounds.As the missile penetrates the tissueplanes, an extension of injury occursand expands the damage and sizeof the track greater than the size ofthe missile. The temporary track cancause damage at distances remoteto the original clinically observedtrack.3, 4, 9Most gunshot wounds encountered in private practice involve lowFired at long range, shotgun velocity diminishes andthe pellets disperse as theyreach their target. Subsequently, long range shotgun pelletscause minimal damage, andexperience has shown that Figure 3: High velocity GSWthese wounds sustained are ofbleed” has occurred. Flash bleed islittle sequella to the patient (Figure 7).rapid blood loss at the time of theinjury.Management of Gunshot Wounds2) Check vital signs.When encountering gunshot3) Inspect for burns to the tissue,wounds to the lower extremity, oneswelling, and pallor. These must bemust evaluate bones and joints, musnoted. Entrance and exit wounds mustcle, tendon units, vascular structures,be identified. If, however, there is noexit wound, imaging must be utilizedto identify the location of the bullet.4) Physical exam. Examinationby system must be performed (vascular, neurologic and musculoskeletal).BoneBy definition, a gunshot fractureis a high energy open fracture. Sev-Figure 4: Low velocity from distanceFigure 5: Shotgun, close rangeJUNE/JULY 2016 PODIATRY MANAGEMENTContinued on page 151www.podiatrym.com
Gunshot Wounds (from page 150)Stabilizing the Fracture is ofUtmost Importance (Figure 8).Stabilization options includesplints or cast or, usually, hardware such as external or internalfixation. The choice and timing ofnng ioui atin cnt EduCo icaledMCMEfollowed by copious irrigation and early fixation of thefracture (Figure 9, 10).eral studies demonstrated that theBerg, et al. in their study idenheat generated during firing does nottified that one-fifth of the fracturesmake the bullet sterile.15 Most lowwere treated by debridement onlyvelocity gunshot fractures resemblewithout hardwareGustilo and Anderfixation. These wereson grade I or II openfractures that arefracture due to theinherently stable orcomparatively milddo not require stato moderate soft tisbilization (e.g., fibsue damage.ula). Only 8% ofDefinitive treatthe fractures werement must be followtreated with openthe rules of treatingreduction and interopen fractures.nal fixation.14 TheseThe Gustiloopen fracture clasnumbers agree withsification systemthe report by Weilis the mo st c o m and co-authors.30 Asmonly used classireported before, inFigure 6: Shotgun, close range pellets remainFigure 7: Long range shotgunfication system for8 of the 12 fracturespelletsopen fractures. Ittreated with primathe stabilization method dependswas created by Ramon Gustilo andry external fixators, this was theon the fracture site, pattern andJ.T. Anderson, and then further exdefinitive treatment for union. Thiscomminution, the soft tissue injury,panded by Gustilo, Mendoza, andhigh percentage emphasizes theand the patient’s general condition.Williams. 10, 11, 12comminuted nature of the gunshotPrimary fixation is especially usefulfracture, type, and the tendency toin patients with multiple injuries,prefer a biological splint fixation,The Gustilo Classification is ascomplex ipsilateral extremity injumaintaining a fracture-healing envifollows:ries, severe injuries that require inronment.I Open fracture, clean wound,tensive wound care, open displacedwound 1 cm in length.intra-articular fractures, or openSkin Soft TissueII Open fracture, wound 1 cmfractures complicated by neurovasOrdog, et al. 18 retrospectivelybut 10 cm in length without excular damage.16tensive soft-tissue damage, flaps,reviewed 28,150 patients with gunavulsions.shot wounds; 60% of them wereGanocy and Lindsey 17 suggestIII Open fracture with extensivetreated as outpatients. Four pered a treatment protocol based onsoft-tissue laceration ( 10 cm),damage, or loss or an open segmental fracture. This type also inTemporary cavitation is more of a concerncludes open fractures caused byfarm injuries, fractures requiringwith high velocity wounds.vascular repair, or fractures thathave been open for eight hoursprior to treatment.IIIA Type III fracture with adcent had minor fractures not rethe final projectile location, the fracequate periosteal coverage of thequiring operative stabilization. Theture pattern, and the level of confracture bone despite the extensivepatients were treated with localtamination. In their opinion, stable,soft-tissue laceration or damage.wound debridement, irrigation, andnon-contaminated extra-articuIIIB Type III fracture with extenan antibiotic ointment. Only 1.8%lar gunshot wounds can be treatsive soft-tissue loss and periostealhad wound infections that responded non-operatively with antibioticsstripping and bone damage. This ised well to oral antibiotics withoutonly, whereas intra-articular prousually associated with massive conrequiring hospital admission. Injectiles should be removed, and untamination and will often need furtheir study of 163 patients with cistable fractures stabilized. For mostther soft-tissue coverage procedurevilian gunshot wounds, Brunnerhigh velocity injuries in the extrem(i.e., free or rotational flap).and Fallon 19 found no differencesities, external fixation is the treatIIIC Type III fracture associatedment of choice. The standard of carebetween patients who had debridewith an arterial injury requiring refor gunshot fractures is meticulousment and wound care and patientspair, irrespective of degree of soft-tisoperative debridement of all devitalwho had local wound care alone.sue injury.ized soft tissue and bone fragments,Continued on page 152www.podiatrym.comJUNE/JULY 2016 PODIATRY MANAGEMENT151
g nin atiouCMEtin ducnEolC icaedGunshot Wounds (from page 151)MNeither group received antibiotics, and both were treated as outpatients. The wounds were neitherclosed primarily nor did they havea delayed primary closure but wereleft to drain and close secondarily.152trauma in cases of an arteriovenousfistula. The presence of “hard signs”of arterial injury such as absentpulses, unequivocal signs of ischemia, profuse hemorrhage, and pulsating or expanding hematoma war-are obstruction, extravasation of contrast agent, early venous filling, irregularity of the vessel wall, a fillingdefect, and a false aneurysm. Thereis, however, a low yet measurablecomplication rate, with complicationsFired at point blank range(less than 15 yards),the shotgun pellets are extremely lethal.Vascular InjuriesVascular structures are frequently injured because of theirproximity to bone.20 A delay in thediagnosis or treatment can resultin a chronic debilitating handicapdue to ischemia and limb loss.Prompt restoration of blood flowis mandatory in traumatic peripheral arterial injuries. 21 Damage tovessels can result also in death dueto exsanguination. The damagemay result directly from the bullet,from secondary missiles such asrants urgent surgical intervention.23Furthermore, Berg and colleaguesidentified that arterial pressure indexis a sensitive tool for identifying avascular injury. According to theirprotocol, an arterial pressure indexratio of 0.9 or less warrants further investigation. For patients withequivocal findings of vascular inju-such as allergic reaction, renal failure, formation of a local hematoma,or a false aneurysm at the site ofcatheterization.Historically, angiography was theimaging modality of choice, but recent studies show that non-invasivestudies such as duplex Doppler ultrasonography are as sensitive as ar-Figure 8: Low velocityFigure 9: Initial stabilization with external fixatorFigure 10: Bone graft for reconstruction andlength of 1st metatarsalbone fragment, from cavitation, orshockwave effects. The injury tothe vessel can be occlusive (dueto transection or thrombosis of thevessel) or non-occlusive (an intimalflap tear or a pseudoaneurysm).Due to advances in diagnosisry such as diminished pulses, angiography yields the greatest benefit,particularly in avoiding unnecessarysurgery.14Angiography reduces unnecessary explorations for proximitywounds and can provide therapeu-Flash bleed is rapid blood loss at the timeof the injury.and treatment of vascular injuries,rates of amputation decreased dramatically, with limb salvage ratesexceeding 86%. 22 In a Berg, et al.study, none of their patients required amputation—primary or delayed.14 Injuries can present acutelyor up to several months after thetic intervention such as stentingor embolization. In a study usingroutine arteriography, the negativesurgical exploration rate in patientswith “soft signs” of arterial injuryor with proximity wounds fell from84% to 2%.24Significant angiographic findingsJUNE/JULY 2016 PODIATRY MANAGEMENTteriography in most cases. In a studyby Knudson et al.,25 86 extremity injuries were assessed using color-flowduplex imaging. No missed arterialinjuries were found. Many centersnow successfully manage proximitywounds by repeated physical examination over a 24 hour period andreserve angiography only for thosepatients with abnormal physical findings or an arterial pressure index lessthan 0.9.26Norman and co-workers27 studied gunshot fractures to long bonesand concluded that routine use ofarteriography is not indicated unlessthere are abnormal findings on vascular examination. Many investigators still recommend that a gunshotwound in the immediate vicinity ofmajor vessels should be studied anContinued on page 153www.podiatrym.com
Gunshot Wounds (from page 152)giographically or explored surgically. Wound exploration involves lowmorbidity (3%) and is often a routinepart of wound management. Angiography can be used intra-operativelywith a fluoroscope. In our institution,we do not use angiography routinely,even in proximity wounds, but relyon serial physical examination of thelimb at risk.Limbs can tolerate warm ischemia time of up to six hours. Morethan six hours of ischemia will almost always result in muscle necrosis and possibly permanent damage.In patients with combined vascular and nerve injuries, prophylacticfasciotomy should be performed atthe time of arterial repair unlessa method for continuous pressuremeasurement is available. Sincemost vascular gunshot injuries involve damage to a segment of theartery, a temporary shunt, followedby prompt skeletal stabilization andthen a definite arterial repair shouldbe performed.14NervesNerves pass in close proximityto bones and vascular structures andand axonotmesis. Several studies addressed this issue. Omer29 reportedspontaneous recovery in 69% of patients with nerve injuries due to gunshot wounds between three and ninemonths after the injury.In light of the above literature,the podiatric surgeon should be familiar with anatomy and functionwww.podiatrym.comsyndrome must be identifiedin a timely fashion, and emergency fasciotomy is indicated.Tetanus prophylaxis is alwaysindicated: however, antibiotics prophylaxis is not essential for woundsthat are not grossly contaminated.Antibiotic coverage is, however, indicated for compound fractures.Gunshot wounds are generallynot closed by primary intention as they may beconsidered contaminated.prior to entering the surgical field.This brief summary should be kept inmind as you treat gunshot wounds:Surgical debridement and surgicalcleansing is always indicated in gunshot wounds.3Cleansing a wound involves copious irrigation at the entrance woundwith removal of surface debris. Probing the wound blindly should neverbe performed and extending the incision for visibility is not indicated.13Gunshot wounds are generallynot closed by primary intention asthey may be considered contami-Surgical debridement and surgical cleansing isalways indicated in gunshot wounds.are commonly injured when vascularinjury is present. In fact, a physical examination demonstrating acutenerve injury raises suspicion of vascular injury and usually warrants further investigation to rule out arterial injury. Concomitant arterial andnerve injury will most likely result ina non-functional limb.In a study by Visser, et al.28, only7% of patients with concomitantnerve and arterial injury had a normal functioning limb, despite successful vascular repair, as opposed to39% of patients with arterial injuryalone. Nerve injury presents clinically with hypoesthesia parasthesias,or paralysis. Spontaneous recoveryis usually expected in neuropraxianng ioui atin cnt EduCo icaledMCMEnated. Foreign bodies should be removed as long as excessive dissection is not required. Bullets are alsonot recommended to be excised ifextensive exploration is necessary.Stabilizing large fragments ofbone, whether with external fixationif there are large tissue defects, or byK-wire fixation, is indicated. (Figures11-18)In stable gunshot wounds wherethere is no damage to the vascularstatus, irrigate, splint, and observefor signs of infection. The patientmay be discharged from the emergency department. In unstable orvascular compromised patients, exploration is indicated immediately.In gunshot wounds, compartmentSummary Civilian gunshot wounds aregenerally low velocity, resulting inlaceration and crushing damage tothe bullet track. Low velocity, smallentrance and small exit wounds canlead to simple fractures or to comminution. Treatment should consist ofdebridement and stabilization, andthe bullet may or may not be excised. In military practice, high velocity wounds cause temporary cavitation and severe loss of soft tissue. Close range shot gun blastsalso cause massive damage and arefraught with a large degree of contamination. Surgical debridement is imperative due to cavitation and retainedforeign bodies. The judgment of the initialtreating podiatric surgeon is of utmost importance. Adhering to theprinciples of treatment previouslyidentified will benefit the prognosisof the patient. Aggressive yet prudent judgment and treatment are the best waysto approach a gunshot wound.Case 1: Low Velocity GunshotWoundA 46-year old male presented tothe emergency department with a lowvelocity gunshot wound. A small entrance wound was noted on the dorsalaspect of the foot. X-rays revealed acomminuted fracture of the 2nd metatarsal. The wound was debrided andthe fragments of bone were irrigatedwith copious amounts of saline. AnContinued on page 154JUNE/JULY 2016 PODIATRY MANAGEMENT153
g nin atiouCMEtin ducnEolC icaedGunshot Wounds (from page 153)Mexternal fixation was placed acrossthe fracture site to maintain osseouslength. After a few weeks, the fracturesite was resected and a bone graftwas placed within the fracture fragments. A K-wire was used to transfixthe bone graft and the external fixation remained for 8 additional weeks(Figures 11—Figure 18). PMgunshot wounds and gunshot fracture incivilian practice. Clin. Orthop. 114:296,1976.4Demuth, W.E. and Smith, J.M. Highvelocity bullet wounds of muscle andbone: the basis of rational early treatment.J. Trauma 6:744, 1966.pp 242-247, Wiley, New York, 1984.8Demuth, W.E. the mechanism oofshotgun wounds. J Trauma 11:219, 1971.9Anania, W.A., Rosen, R.C., Giuffre,A. M. Gunshot wounds ot the lower extremity: Principales and Treatment. J FootSurg 26, number 3,228, 1987.Spontaneous recovery is usually expected inneuropraxia and axonotmesis.ReferencesRyan, M., Leighton, T., Pianism,N., Klein, S., Bongard, F. Medical andeconomic consequences of gang relatedshootings. American surgeon, 59, 831833, 1993.2Sinauer, N., Annest, J., Mercy, J.,Unintentional nongatal firearm relatedinjuries. A preventable public health burden. JAMA, 275. Pp 1740-1743. 1996.3Hennessy, M.J., Banks,H.H.,Leach, R.B. and Quigley, T.B. Extremity5Marcus, N.A., Blair, W.F., Schuk,J.M., and Omer, G.E. Low velocity gunshot wounds to the extremities. J Trauma20:2016, 1980.6Wolf, W., Benson,D.R.,Shoji, H, Hoeprich, P, and Gilmore, A., Autosterilization in low velocity bullets. J. Trauma18:63, 1978.7May, H.L. (ed) Emergency Medicine,Figure 11: Low velocity GSWFigure 12: Low velocity compound fracture1154Figure 13: Stabilization with external fixatorFigure 14: Stabilization with external fixatorFigure 16: Bone Graft for reconstructionFigure 17: Bone Graft for reconstructionJUNE/JULY 2016 PODIATRY MANAGEMENT10Thomas P. Rüedi; Richard E. Buckley; Christopher G. Moran (2007). AOprinciples of fracture management, Volume 1. Thieme. p. Page 96. ISBN 3-13117442-0.11Gustilo RB, Anderson JT. Prevention of infection in the treatment of onethousand and twenty-five open fracturesof long bones: Retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58:453–8.12Gustilo RB, Mendoza RM, WilliamsDN. Problems in the management of typeIII (severe) open fractures: A new classification of type III open fractures. J Trauma. 1984; 24:742–6.).13Brettler, D., Sedlin,E.D., and Mendler, D.G. Conservative treatment of lowvelocity gunshot wounds. Clin. Orthop140:26, 1979.Continued on page 155Figure 15: Debridement of wound and irrigationof fracture siteFigure 18: Bone graft with fixationwww.podiatrym.com
nng ioui atin cnt EduCo icaledMCMEGunshot Wounds (from page 154)14Burg,A., Nachum, G, Salai, M,Haviv,B., Heller,S., Velkes,S. and Dudkiewicz, I. Treating Civilian Gunshotwounds to the extremities in a level 1trauma center: Our experience and recommendations. IMAJ VOL 11 september2009, p 546-551.15Wolf AW, Benson DR, Shoji H. Autosterilization in low-velocity bullets .JTrauma 1978; 18: 63.16Anderson JT, Gustilo RB. Immediate internal fixation in open fractures.Orthop Clin North Am 1980; 11: 569-78.17Ganocy K 2nd, Lindsey RW. Themanagement of civilian intraarticular gunshot wounds: treatment considerationsand proposal of a classification .system.Injury 1998; 29 Suppl 1: SA1-6.18Ordog GJ, Wasserberger JS, Balasubramanium S. Civilian gunshot wounds.outpatient management. J Trauma 1994;36: 106-111.19Brunner RG, Fallon WF. A prospective, randomized clinical trial of wounddebridement versus conservative woundcare in soft-tissue injury from .civiliangunshot wounds. Am Surg 1990; 2: 104-7.20Saletta JD, Freeark RJ. Vascularinjuries associated with fractures. OrthopClin .North Am 1970; 1: 93-721Perry MD, Thal ER, Shires GT.Management of arterial injuries. Am Surg.1971; 173: 403.22Adinolfi MF, Hardin WD, O’Connell RC, Kerstein MD. Amputations after.vascular trauma in civilians. South Med J1983; 76: 1241-3.23Smith RF, Elliott JP, Hageman JH.Acute penetrating arterial injuries of the .neckand limbs. Arch Surg 1974; 109: 198-205.24Reid JDS. Assessment of proximityof a wound to major vascular structures.as an indication for arteriography. ArchSurg 1988; 123: 942-6.25Knudson MM, Lewis FR, AtkinsonK, Neuhaus A. The role of duplex .ultrasound arterial imaging in patients withpenetrating extremity trauma .Arch Surg1993; 128: 1033-7.26Levy BA, Zlowodzki MP, Graves M,Cole PA. Screening for extremity arterial.injury with the arterial pressure index.Am J Emerg Med 2005; 23(5): 689-95.27Norman J, Gahtan V, Franz M,Bramson R. Occult vascular injuries following gunshot wounds resulting in longbone fractures of the extremities.Am Surg .1995; 61: 146-50.28Visser PA, Hemreck AS, PierceGE. Prognosis of nerve injuries incurred.during acute trauma to peripheral arteries. Am J Surg 1980; 140: 596-9.29Omer GE Jr. Acute management ofperipheral nerve injuries. Hand Clin 1986.2: 19.30Weil YA, Petrov K, Liebergall M,Mintz Y, Mosheiff R. Long bone fractures.caused by penetrating injuries in terroristattacks. J Trauma 2007; 62: 909-12.Dr. Rosen is chief ofpodiatric surgery atHoly Name MedicalCenter in Teaneck, NJ.He is adjunct faculty atUMDNJ-Newark andAssociate Clinical faculty at Touro College ofOsteopathic Medicine.He has been in privatepractice at Northeast Podiatry Group for thepast 28 years and is active in teaching residentsat UMDNJ, Holy Name Medical Center andEnglewood Medical Center.CME EXAMINATIONSee answer sheet on pagE 157.1) Temporary cavitation is an importanteffect of:A) Low velocity woundsB) High velocity woundsC) ShotgunsD) 22 gauge bullet4) Shotgun injuries:A) Are lethal at less than 15 yardsB) Are lethal at greater than 15 yardsC) Cause minimal damage at less than 15 yardsD) Cause maximum damage from greaterthan 15 yards2) Laceration and crushing are principlesof:A) Low velocity woundsB) High velocity woundsC) ShotgunD) 22 gauge bullet5) With Gunshot wounds, surgical debridementand surgical cleansing is:A) Always indicatedB) Never indicatedC) Sometimes indicatedD) Dependent on injury3) “Flash Bleed” refers to:A) Bleeding from the woundB) Rapid blood loss at time of injuryC) Rapid blood loss after delayD) Bleeding upon wound inspection6) Gunshot wounds are considered:A) ContaminatedB) CleanC) DirtyD) SterileContinued on page 156www.podiatrym.comJUNE/JULY 2016 PODIATRY MANAGEMENT155
g nin atioutin ducnECo icaledMCME EXAMINATION7) Laceration and CrushingA) Cause damage distant to the track ofthe bulletB) Cause major tissue lossC) Cause damage confined to thepermanent cavityD) Cause damage at the entrance orexit only8) Prophylactic antibioticsA) Are never essential to gunshotwoundsB) Are indicated for compound fracturesC) Should be determined by the surgeonD) B and C1569) Which of the following is not related tolow velocity injuries?A) Bullet speed is less than2000 ft/secB) Small entrance woundC) Bullet speed is greater than2000 ft/secD) Small exit wound10) Spontaneous recovery of nerves isexpected inA) neuropraxiaB) axonotmesisC) neurotmesisD) A and BPM’sCME ProgramWelcome to the innovative Continuing EducationProgram brought to you by Podiatry ManagementMagazine. Our journal has been approved as asponsor of Continuing Medical Education by theCouncil on Podiatric Medical Education.Now it’s even easier and more convenient toenroll in PM’s CE program!You can now enroll at any time during the yearand submit eligible exams at any time during yourenrollment period.PM enrollees are entitled to submit ten examspublished during their consecutive, twelve–monthenrollment period. Your enrollment period beginswith the month payment is received. For example,if your payment is received on November 1, 2014,your enrollment is valid through October 31, 2015.If you’re not enrolled, you may also submit anyexam(s) published in PM magazine within the pasttwelve months. CME articles and examinationquestions from past issues of Podiatry Management can be found on the Internet at http://www.podiatrym.com/cme. Each lesson is approved for 1.5 hours continuing education contacthours. Please read the testing, grading and paymentinstructions to decide which method of participation is best for you.Please call (631) 563-1604 if you have any questions. A personal operator will be happy to assist you.Each of the 10 lessons will count as 1.5 credits;thus a maximum of 15 CME credits may be earnedduring any 12-month period. You may select any 10in a 24-month period.The Podiatry Management Magazine CMEprogram is approved by the Council on PodiatricEducation in all states where credits in instructionalmedia are accepted. This article is approved for1.5 Continuing Education Contact Hours (or 0.15CEU’s) for each examination successfully completed.Home Study CME credits nowaccepted in PennsylvaniaContinued on page 156JUNE/JULY 2016 PODIATRY MANAGEMENT
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wound debridement, irrigation, and an antibiotic ointment. Only 1.8% had wound infections that respond-ed well to oral antibiotics without requiring hospital admission. In their study of 163 patients with ci-vilian gunshot wounds, Brunner and Fallon19 found no differences between patients who had
In addition to the foregoing autopsy report, Dr. ROSE furnished six pages of Xerox copies of the following: 1 permit for autopsy 1 gunshot wound chart 1 body diagram head 1 body diagram surgical wounds 1 body diagram gunshot wound 1 bcrly diagram entrance gunshot wounds ---7111.ectrostatic copies have been made of the six pages of
from hard-to-heal wounds. All wounds were located on lower limbs, as per the study’s inclusion criteria. The wounds’ characteristics are listed in Table 3. Overall, 31 wounds were treated with a mean dressing change every 3 days. During the 8-week follow-up, nine
Maher and Hoerr Forensic Comparison of Simultaneous Recordings of Gunshots AES 147th Convention, New York, USA, 2019 October 16-19 Page 2 of 8 Analysis of gunshot sounds can involve a variety of audio forensic procedures [4] . Gunshot forensic audio examiners may be tempted to treat gunshot acoustical
Integra Wound Matrix and Integra Flowable Wound Matrix for the management of wounds including p and full-thickness wounds, pressure ulcers, venous ulcers, diabetic ulcers, chronic vascular ulcers, tunneled/undermined wounds, surgical wounds (e.g., donor sites/grafts, post-Mohs surgery, post-las
The third paper, Economic burden of hard-to-heal wounds by Romanelli, Vuerstaek, Rogers, Armstrong and Apelqvist, examines the potential cost implications of hard-to-heal wounds in different countries. The significant economic burden of these complex wounds relates mainly to extended time to healing and to associated complications.
inated wounds require more irrigation. Primary closure is considered in relatively clean bite wounds or wounds that canbecleansede ectively.Othersarebesttreatedbydelayed primary closure. Head and neck wounds have a very low infection risk [ ,
60%–100% of non-healing wounds. While the role that biofilm play in the chronicity of wounds is still in infancy, it is becoming widely accepted that hard-to-heal wounds contain biofilm — and that somehow their presence delays or prevents healing. Management of biofilm in chronic wounds is rapidly becoming a primary objective of wound care.
Accounting Paper 1 You do not need any other materials. Pearson Edexcel International GCSE Turn over . 2 *P48370A0220* SECTION A Answer ALL questions. Some questions must be answered with a cross in a box . If you change your mind about an answer, put a line through the box and then mark your new answer with a cross . 1 A business sells goods for cash. What are the entries in the books of the .
