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THE APPROACH TO MANAGING TRANS-PELVIC GUNSHOT WOUNDS



Abstract

Between June 1998 and April 2006, 93 patients with trans-pelvic gunshot injuries were admitted to our hospital. Initially the management was done by general surgeons, without any orthopaedic consultation. Later a good working relationship between general surgeons and orthopaedic surgeons developed, and good co-operation was achieved.

We felt it was important to determine the direction of the bullet tract. A detailed history was taken to try and position the assailant, and the action taken by the victim. We tried to establish the number of shots that were fired, and whether any pervious gunshot injury had been sustained. We then drew an imaginary straight line between the entry and exit wound, in order to try and determine the anatomical structures that were likely to be injured by the bullet.

When x-rays were not helpful in identifying the bony injury, then a CT scan with 3D reconstruction was performed. Contrast studies such as a sinogram, a cystogram and intravenous pyelogram, combined with contrast CT, was also helpful in determining the bullet tract.

At laparotomy the entire bullet tract has to be debrided. All injured viscera are repaired, and the abdominal cavity thoroughly washed out. Any extra-peritoneal rectal injury requires a proximal colostomy, and rectal stump washout. All bullets lodged near or into a joint must be removed early, within 4 days of injury. We feel that using antibiotics alone for contaminated bullet tracts, without debriding the tract and removing the bullet from bone, does not prevent sepsis.

Correspondence should be addressed to: Léana Fourie, CEO SAOA, PO Box 12918, Brandhof 9324 South Africa.