The bullet ripped through the cellphone, held up as the only defense against an armed intruder.
Its path then continued through the wrist, pulverizing bone
and ligaments, before exiting the forearm shredding tendons creating an exit wound
three times the size of the entrance. Transported to a trauma center, the patient
was evaluated and discharged in a splint with instructions to follow-up with an
orthopedic surgeon, hopefully with additional expertise in hand and wrist surgery.
Despite the penetrating trauma seen on exam and x-rays, the only DCO, or “damage
control orthopedic” care rendered that evening was a dressing and a splint due
to the strain the COVID-19 crisis had placed this hospital under. A crisis now
flipping the switch on traditional triage protocols. Penetrating trauma taking
a backseat to a public health effort to control the spread of, and treat those
affect by, a highly contagious virus.
Fortunately, the patient and their employer where strong advocates
for definitive care. Unable to see her assigned treating physician, the patient
presented to the office, was evaluated, and immediately deemed an urgent/emergent
case with x-rays confirming the presence of foreign material throughout the
zone of injury and fractured bones in close proximity to large entrance and
Decision for Anesthesia
Given the timing and emergent nature of the procedure, a
consultant anesthesiologist was not available. A regional forearm block was decided
upon to control the pain of the wound exploration and cleaning which was
required. Ultrasound images assisted with needle placement to deliver anesthetic
around the median, radial, and ulnar nerves proximal to the zone of injury. Once
regional anesthesia was established, the surgery revealed that the bullet path not
only contained fracture fragments, ligament disruptions, and shredded tendons, but
also pieces of clothing, cell phone case, and electronic components from a
smartphone. All were meticulously removed. Gross contamination was removed by direct
visualization and the aid of real-time x-ray. Microscopic contamination was diluted
through subsequent irrigations and debridement. Joints were relocated and
stabilized, and soft tissue coverage was obtained. The complexity of the tendon
injuries was deemed to require direct repair, reconstruction, and probable tendon
transfers. A transfer of care to a board-certified, fellowship-trained, hand
surgeon was arranged.
Ultimately, there is hope that the patient will regain good function
in the hand despite the severe trauma it sustained. What we must remember from this
case and others like it during this pandemic, is that while COVID-19 has put a
back-breaking strain on our healthcare system, doctors, nurses, first
responders, and the many others who are supporting this heroic effort to
control it, treat it, and prevent the spread, life is still happening. People
are still being assaulted, children are still falling off bikes, and knives are
still falling onto feet and cutting tendons during this crisis. None immediately
life-threatening, but without proper urgent care, possibly limb threatening.
Orthopedic surgeons, myself included, may have less perceived
use treating those unfortunate enough to be infected by COVID-19. It has been twenty-three
years since this orthopedist “managed” a patient on a ventilator in a Surgical
Intensive Care Unit as an intern; however, we must not forget the limb
threatening implications for many as we focus on the life threatening issues of
those caught in the grip of this pandemic.
Need for Damage Control Orthopedics
While not all orthopedic surgeons treat severe acute trauma
regularly, all of us are familiar with DCO, or Damage Control Orthopedics.
Stabilize the injury, clean the contamination, and cover the wound if possible.
Do everything possible to help, but most importantly, “do no harm”.
The Coronavirus pandemic is unlike a traditional battle
where trauma surgeons are at the forefront. In the ABC’s of a patient in
extremis, those providers who excel in the treatment of “Airway” and ”Breathing”
are at the forefront; however, let us still devote care and resources to
treating urgent and emergent limb threatening injuries, even if it means an
orthopedic surgeon performs his own regional anesthesia to stabilize and clean
As Orthopedic surgeons, let’s focus presently on DCO. Get in,
get out, and then get out of the way.