Severe Hand Injuries Caused by a Mole Gun

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1 Originl Article DOI: /TurkJPlstSurg Severe Hnd Injuries Cused y Mole Gun Serdr Düzgün 1, Alpy Durn 2 1 Deprtment of Plstic nd Reconstructive Surgery, Gülhne Trining nd Reserch Hospitl, Ankr, Turkey 2 Deprtment of Plstic nd Reconstructive Surgery, Şnlıurf Trining nd Reserch Hospitl, Şnlıurf, Turkey 120 Astrct Ojective: Injuries y mole guns differ from other firerm injuries primrily ecuse they re close-rnge, low-energy injuries tht re highly contminted owing to contct with contminted surfces nd the presence of numerous residul foreign odies within the wound. The im of this rticle is to shre our surgicl experience regrding the repir of severe hnd injuries cused y mole guns. Mteril nd Methods: This retrospective study included 11 ptients with hnd injuries. Dt otined out the ptients, including ge, gender, dominnt or non-dominnt hnd, injuries to ll vitl structures, nd reconstructive procedures were ssessed, ctegorized, nd recorded. Results: Ten ptients hd defects in one or severl common digitl rnches of the medin nerve in res rnging from the distl prt of the crpl tunnel to the distl plmr crese. All ptients hd flexor nd extensor tendon injuries in ll fingers except for the first finger. Reconstruction of soft tissue nd skin defects ws crried out with n interpoltion flp plnned from rndom-sed supectorl-prumilicl region in five ptients, SCIA-sed groin flp in four ptients, reverse-rdil forerm flp in one ptient, nd n dipofscil flp plnned from the forerm in one ptient. Conclusion: Mole gun injuries typiclly include ll structures of the hnd, nd repir procedures involve every ntomic structure of the hnd. An erly nd effective surgicl opertion followed y prolonged nd effective physicl therpy protocols is vitl for regining the full spectrum of hnd functions. Keywords: Mole gun, hnd injury, flp, reconstruction, tendon, nerve INTRODUCTION A mole gun is simple ut effective firerm long used y frmers nd griculturl workers to kill nimls such s moles. This wepon hs sensitive trigger mechnism nd it works y rpid, high-velocity ejection of uckshot from the rrel fter gunpowder ignition. 1,2 In hnd injuries cused y mole guns, the victims indvertently suppose tht the gun hs lredy fired nd re injured y the shot when they hndle the gun ecuse of n overly sensitive trigger mechnism. Hnd injuries cused y mole guns re chrcterized y lrge tissue defects. Moreover, this dngerous wepon leds to oth functionl nd structurl dysfunction of the hnd. Hnd reconstruction following these injuries is prticulrly difficult, requiring multiple opertions t considerle cost. 3 Injuries y mole guns differ from other firerm injuries primrily ecuse they re close-rnge, low-energy injuries tht re highly contminted owing to contct with contminted surfces nd the presence of numerous residul foreign odies within the wound. Reconstruction of these injuries involves time-consuming, multi-stged procedures often with unstisfctory results. The im of this rticle is to shre Cite this rticle s: Düzgün S, Durn A. Severe Hnd Injuries Cused y Mole Gun. Turk J Plst Surg 2017; 25(3): Correspondence Author: Alpy Durn, MD E-mil: dr.lpydurn@hotmil.com Content of this journl is licensed under Cretive Commons Attriution-NonCommercil 4.0 Interntionl License. Received: Accepted:

2 our surgicl experience regrding the repir of such severe hnd injuries. MATERIAL AND METHODS The study ws conducted in complince with the Helsinki Declrtion nd fter informed consent ws otined from every ptient. This retrospective study included 11 ptients (eight mles nd three femles; verge ge: 42.5 yers; rnge: 23 to 70 yers) with hnd injuries. All injuries were indvertent self-inflicted gunshot wounds from very close rnge while hndling mole gun. Dt otined out the ptients, including ge, gender, dominnt or non-dominnt hnd, nd injuries to ll vitl structures, were ssessed, ctegorized, nd recorded. All hnd injuries hd n entry point on the plmr surfce nd n exit point on the dorsl surfce ccompnied y tendon, vessel, nerve, one, nd soft tissue injuries, nd skin defects of vrious sizes (Figure 1-3) Nine ptients hd right hnd injuries nd two hd left hnd injuries. Eight ptients were injured in the dominnt hnd. The injured ptients were first ssessed in the emergency deprtment. Becuse ll wounds presented contminted lst injuries, their mngement in the emergency deprtment included creful irrigtion nd deridement in order to remove necrotic mteril. Wounds were closed with single lyer of nitrofurzone nd rifmpicin-contining guze. All ptients received ppropritely positioned splints to mintin stility nd preserve circultion. None of the ptients hd circultory complictions. Becuse ll wounds were considered contminted, prenterl rod-spectrum first-genertion cephlosporin nd metronidzole tretment ws egun. Initil cre ws followed y surgicl reconstruction during the cute period. All ptients received their initil opertion within 24 to 72 hours (verge: 42 hours) of the gunshot wound. RESULTS Nine ptients hd defects in one or severl common digitl rnches of the medin nerve in res rnging from the dis- 121 c d Figure 1. -d. (-) Cse 1, dorsl nd volr spect of the right hnd with 4 th flexor digitorum superficilis tendon defect, 4 th metcrp defect, nd 3 rd common rnch of medin nerve defect. (c-d) Cse 9, dorsl nd volr spect of the left hnd with 3 rd flexor digitorum superficilis tendon defect, 3 rd metcrp defect, nd 3 rd common rnch of medin nerve defect

3 Figure 2.,. () Cse 2, volr spect of the injured right hnd with 3 rd nd 4 th flexor digitorum superficilis nd profundus tendon defect, 3 rd nd 4 th extensor digitorum comminis nd extensor digiti minimi tendon defect (distl of the uln), 4 th nd 5 th metcrp, os triquetrum, psiforme, os cpittum, os hmtum defect, nd 3 rd common rnch of the medin nerve motor rnch of the ulnr nerve. () Lte postopertive dorsl view of the hnd fter 6 months 122 Figure 3.,. () Preopertive x-ry of the 4 th metcrp defect. () Preopertive x-ry of the crpometcrpl one defect with foreign odies tl prt of the crpl tunnel to the distl plmr crese. One ptient hd defects involving the sensory rnches of oth ulnr nd medin nerves. One ptient hd no nerve injury. The ptient dt re summrized in Tle I. Autologous ilic one grft ws hrvested nd fixed with plte-screw to reconstruct one defects. Functionl rthrodesis (with plte-screw of the one grft) ws pplied to crpometcrpl joint defects in five ptients. Functionl rthrodesis with plte-screw ws pplied for defects in the 4 th nd 5 th metcrpl ones, crpl ones, nd the distl uln in one ptient. In the remining ptients, defects in the mid-neck region of the metcrpl one were repired with one grft using plte-screw. The plmris longus tendon ws generlly used for reconstruction of tendon defects. The flexor digitorum superficilis tendon of the fourth finger (which is conventionlly used for tendon trnsfer) ws not preferred ecuse it ws defective or injured in these ptients. In ptients hving no plmris longus tendon, the plntris tendon ws used s the donor tendon. Becuse one ptient lcked the plmris longus nd plntris tendons, the extensor tendon of the 3 rd toe ws used. Tht ptient ws re-operted on the 6 th dy post injury due to tendon rupture, which ws reconstructed using fsci lt tendon grft. Surl nerve grft ws used for the reconstruction of medin nd ulnr nerve defects. In postopertive 6 th month, repet intr-opertive exmintion of five ptients reveled tht the nerve grfts remined in excessively firotic tissues, nd thus neurolysis procedure ws performed, which proved unstisfctory. Reconstruction of soft tissue nd skin defects ws crried out with n interpoltion flp plnned from the rndom-sed supectorl-prumilicl region in five ptients, SCIAsed groin flp in four ptients, reverse-rdil forerm flp

4 Tle I. Ptient dt Injured Dominnt Tendon Nerve Bone Skin nd soft- Reconstructıve Age hnd hnd defect defect defect tissue defect procedure 1 23 Right Right 4 th FDS 3 rd Common rnch 4 th Metcrp Plmr region 3 1 cm Rndom-sed of medin nerve Dorsl region 4 4 cm interpoltion flp 2 26 Right Right 4-5 FDP-FDS 3 rd Common rnch of Distl of uln Plmr region 4 3 cm Rndom-sed 4-5 EDC medin nerve motor 4 th 5 th Metcrp Dorsl region 4 3 cm interpoltion flp 5 th EDM rnch of ulnr nerve os triquetrum-psiforme cpittum-hmtum 3 32 Right Right 5 th FDS-FDP - 5 th Metcrp Plmr region 2 2 cm SCIA-sed groin flp 5 th EDC Dorsl region 5 4 cm 4 33 Right Right 2 nd FDS 2 nd Common rnch 2 nd - 3 rd Metcrp Plmr region 2 2 cm Reverse rdil forerm flp 2 nd EDC-EIP of medin nerve Dorsl region 6 3 cm 5 37 Left Right 4 th FDS-FDP 3 rd Common rnch 4 th Metcrp Plmr region 2 1 cm Rndom-sed of medin nerve Dorsl region 5 4 cm interpoltion flp 6 41 Right Right 3 rd FDP 2 nd Common rnch 3 rd Metcrp Plmr region 3 1 cm SCIA-sed groin flp of medin nerve Dorsl region 5 5 cm Right Right 4 th FDS-FDP 3 rd Common rnch 3 rd - 4 th Metcrp Plmr region 2 1 cm Rndom-sed 4 th EDC of medin nerve Dorsl regıon 3 3cm interpoltion flp 8 49 Right Right 2 nd FDP 2 nd - 3 rd Common rnch 2 nd - 3 rd Metcrp Plmr region 2 1 cm SCIA-sed groin flp 3 rd FDS-FDP of medin nerve Dorsl region 4 4 cm 3 rd EDC 9 54 Left Right 3 FDP 3 rd Common rnch 3 rd Metcrp Plmr region 3 1 cm SCIA-sed groin flp of medin nerve Dorsl region 5 3 cm Right Left 3 FDS-FDP 3 rd Common rnch 3 rd - 4 th Metcrp Plmr region 3 2 cm Adipofscil turnover flp of medin nerve Dorsl region 6 4 cm Right Right 2-3 FDS-FDP 3 rd Common rnch 2 nd Metcrp Plmr region 2 1 cm Rndom-sed of medin nerve Dorsl region 5 3 cm interpoltion flp FDP: flexor digitorum profundus; FDS: flexor digitorum superficilis; EDC: extensor digitorum communis; EIP: extensor indicis proprius; SCIA: superficil circumflex ilic rtery Figure 4.,. () Cse 4, preopertive mrkings of reverse rdil forerm flp. () Lte postopertive view of the flp fter 6 months (Figure 4) in one ptient, nd n dipofscil flp plnned from the forerm in one ptient. None of the ptients experienced prolem regrding flp circultion, nd no flps were lost. Reconstruction with free flp ws not plnned in ny of these ptients owing to the high proility of diffuse endothelil injury-thromus ecuse the recipient vessels were in the injury zone. Furthermore, reconstruction of the defective region with more relile flp together with erly physiotherpy hstened return to work. Due to strict dherence to the rules of urgent deridement nd dministrtion of prenterl wide-spectrum ntiiotics, none of our ptients hs suffered n infection to dte. DISCUSSION Injuries y mole gun re low-energy injuries, ut they differ from other firerm injuries in tht they occur t closernge nd re contminted wounds. 1-4 The most import-

5 124 nt feture of mole gun injuries is the high rte of tendon, nerve, one, nd extensive soft tissue-skin defects s result of the close-rnge nture of the injury. 5 After such n injury, multi-stge reconstruction is needed to regin hnd functionlity. All ptients in our clinic underwent surgery within 72 hours of their injury. All frctures were repired with plte nd screw, while ony defects were repired using one grfts in the sme session. Although delyed grft pplictions re preferle in contminted wounds, intensive nd effective ntiiotic use long with erly use of one grfting in the sme opertive session prevented infection nd one loss. Furthermore, coupled with erly physiotherpy, this method proved eneficil in ensuring the ptient s erly return to norml lifestyle. 6 In this study, reconstruction of one nd soft tissue defects ws performed much erlier thn in previous studies. 1,3 In ddition, one, tendon, nerve, nd soft tissue-skin defects were repired in the sme opertive session. Although injuries to sustntil numer of significnt structures of the hnd produce unstisfctory results to some extent, performing pproprite reconstructive steps in the shortest time period is of utmost importnce. Reconstruction using free flp ws not plnned in ny of the ptients, since their injuries were lst nd urn injuries tht involved the vessels of the recipient region. In ddition, ecuse the region ws sujected to high-energy trum, there ws diffuse endothelil injury with high proility of thromus formtion due to severe edem tht developed on the 2 nd dy. Locl flps nd interpoltion flps re preferred for repir of skin nd soft tissue defects, ecuse they re felt to e sfer. 7 No complictions developed in ptients in whom locl nd interpoltion flps were pplied. A dely procedure (eginning on the 9 th dy) ws performed in ptients receiving n interpoltion flp, nd the flps were detched on the 15 th dy. In summry, our tretment protocol for mole gun injuries includes urgent surgicl deridement nd dministrtion of prenterl rod-spectrum ntiiotics due to the contminted nture of these wounds. They usully occur in persons working in frms, fields, or grdens in rurl res. Victims sometimes suffer irreversile disilities nd my need longterm rehilittion. Moreover, severe infections my result owing to the contminted nture of these injuries. Therefore, urgent irrigtion of the wound, nd deridement of ll necrotic tissue, uckshot, nd foreign nd contminted ojects is criticl in preventing infections efore proceeding with reconstruction. 8,9 Ptients usully undergo surgery within 72 hours for closure of one, tendon, nerve, nd soft tissue-skin defects. Repir of ll ville defects is completed in the sme session, nd the ptients re dmitted to hospitl for prolonged period (usully 21 dys) nd receive ctive nd pssive exercise progrms, prffin ths, hot nd cold ths, nd nti-edem therpy. This is followed y ctive nd pssive exercise progrms t home for three months. CONCLUSION Injuries y mole gun re chrcterized y severe hnd injuries tht differ from other firerm injuries primrily ecuse they re close-rnge, low-energy injuries tht re highly contminted. Such injuries typiclly ffect ll structures of the hnd, nd repir procedures involve every ntomic structure of the hnd. An erly nd effective surgicl opertion followed y prolonged nd effective physicl therpy protocols is vitl for regining the full spectrum of hnd functions. Ethics Committee Approvl: Authors declred tht the reserch ws conducted ccording to the principles of the World Medicl Assocition Declrtion of Helsinki Ethicl Principles for Medicl Reserch Involving Humn Sujects (mended in Octoer 2013). Informed Consent: Written informed consent ws otined from the ptients for the puliction of this study. Peer-review: Externlly peer-reviewed. Author contriutions: Concept - S.D.; Design - S.D.; Supervision - S.D., A.D.; Resource - S.D,A.D., X; Mterils - S.D.; Dt Collection nd/or Processing - S.D., A.D.; Anlysis nd/or Interprettion - A.D.; Literture Serch - S.D., A.D.; Writing Mnuscript - S.D.; Criticl Reviews - S.D., A.D Conflict of Interest: No conflicts of interest were declred y the uthors. Finncil Disclosure: The uthors declred tht this study hs received no finncil support. REFERENCES 1. Keskin M, Beydes T, Tosun Z, Svci N. Close rnge gunshot injuries of the hnd with the "mole gun". J Trum 2009; 67(1): Uner HB, Gurpinr SS, Ckir I. Mole gun-n unusul firerm, cse note. Forensic Sci Int 2001; 118: Demirci S, Gunydin G, Dogn KH, Erkol Z. Deths cused y mole guns: three cse reports. Int J Legl Med 2008; 122: Fckler ML, Burkhlter WE. Hnd nd forerm injuries from penetrting projectiles. J Hnd Surg Am 1992; 17A: Wilson RH. Gunshots to the hnd nd upper extremity. 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