This article discusses contemporary management strategies for gunshot-related fractures with special attention paid to the initial evaluation, role of debridement, principles of fixation, need and duration of antibiotic therapy, and management of sequelae. Pertinent sequelae detailed are fractures associated with vascular injury, compartment syndrome, massive loss of soft tissue and bone, nerve injury, and lead toxicity.
Key points
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Initial assessment should begin with Advanced Trauma Life Support principles, inspection of soft-tissue damage and contamination, a thorough neurovascular examination, local wound care, imaging, and fracture stabilization.
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High-risk wounds are those involving high-energy weapons, delayed presentation, large soft-tissue deficits, multiple projectiles, exposed bone, and those occurring on a battlefield or farm environment.
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Most low-risk gunshot fractures can be treated similarly to closed fractures. Stable injuries can be treated with cast immobilization, antibiotics, and daily wound care.
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Operative intervention is indicated for unstable fracture patterns, wounds with exposed bone, high-risk wounds, associated vascular injury, or associated compartment syndrome.
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Bullet tracts do not decompress compartments, and compartment syndrome should be managed with full-length fasciotomies.
Introduction
Nonfatal gunshot injuries are a common problem, estimated to occur approximately 60,000 to 80,000 times per year in the United States. Several studies have reported that roughly half of all hospital admissions for gunshot wounds require fracture care, underscoring the importance of the orthopedic surgeon in the overall management of these patients. Gunshot missiles most commonly penetrate the bones of the spine, femur, tibia and fibula, hand, and forearm, and may acutely result in life-threatening or limb-threatening injuries. Furthermore, despite appropriate initial treatment, early and late sequelae such as compartment syndrome, nerve palsy, bone and soft-tissue deficits, and lead toxicity may additionally incur a significant morbidity in this population. The purpose of this review is to discuss contemporary management strategies for gunshot-related fractures, with special attention paid to the initial evaluation, role of debridement, principles of fixation, need and duration of antibiotic therapy, and management of sequelae.
Initial evaluation
The Advanced Trauma Life Support (ATLS) protocol should be the initial priority in a gunshot-wound victim. After primary stabilization, a history and secondary survey should be performed by the orthopedic surgeon. The patient or law enforcement officers may provide clues relating to the weapon involved in the shooting. Shotguns are considered low-velocity weapons but with a high injury potential as a result of multiple, high-mass projectiles. More extensive tissue damage is associated with multiple shots, close range, higher-velocity weapons, and expanding missiles (eg, hollow-point ammunition) ( Figs. 1 and 2 ). Although forensic science can help to determine entry versus exit wounds, ammunition type by examination of wounds, and the position of the patient at the time of missile entry, it is not the job, nor within the scope of expertise, of the treating physician to attempt to establish these facts. The forensic information is generally not helpful for treating the patient at hand. Furthermore, these conclusions can be erroneous, leading to legal confusion in later criminal proceedings.
The patient should be fully exposed and examined for wounds, and the anatomic structures in the trajectory of each bullet wound should be evaluated thoroughly. The appearance of the limb should be inspected for color, soft-tissue damage, gross contamination, compartment swelling, joint effusion, and the presence of exposed bone fragments. Wounds presenting with pulsatile bleeding and/or diminished distal pulses should raise suspicion for vascular injury, and may require emergent surgical exploration. Even in the presence of normal pulses, one should consider checking an ankle-brachial index on all gunshot-related injuries of the extremities, and obtain angiography or ultrasonic vascular testing for ratios less than 0.9. A thorough neurologic examination, including testing with pinprick for sharp/dull sensation, should also be documented as a baseline. All wounds can be labeled with a metallic marker for easier identification on radiographs, and all missiles should then be accounted for either with a retained bullet fragment or an exit wound. Characterization of periarticular or perivascular injuries may be enhanced via computed tomography (CT). All wounds are then copiously irrigated and dressed; the authors generally pack small wounds daily with ¼-inch iodinated gauze strips, and dress larger wounds with iodinated vaseline gauze sheets. Tetanus prophylaxis is considered in all patients with an unknown immunization status. Fractures are reduced and stabilized with padded plaster splints. Fractures involving retained fragments in the hip joint or fractures of the femur that cannot be immediately treated are stabilized with skeletal traction via distal transosseous pins.
Role of debridement
The common myth that bullets fired from a gun are sterile has been disproved in several studies. Bacteria and clothing debris are commonly translocated into the wound from the blast effect, and cause contamination. However, despite the fact that many surgeons consider the wound contamination to be similar to that of open fractures, current evidence has demonstrated that not all wounds require debridement as is done for open fractures. For example, Dickey and colleagues presented a prospective randomized trial of 73 patients with stable, nonoperatively managed gunshot-related fractures, and noted similar infection rates between those with and without antibiotic prophylaxis. Knapp and colleagues reported on 222 stable long-bone fractures treated nonoperatively, and similarly found no difference in infection rates between those treated with intravenous or oral antibiotics. The authors’ preference for stable low-energy gunshot fractures without exposed bone is to allow the wounds to close by secondary intention via daily packing changes; additionally, a 5-day course of an oral first-generation cephalosporin as prophylaxis is prescribed, because of the unknown degree of initial contamination and the potential for poorer personal hygiene in the urban population. Stable fractures of the tibia and humerus, for example, can be placed into an appropriately molded cast or splint with a window to allow for wound care. Unstable fractures are treated using operative principles similar to those for closed fractures ( Figs. 3 and 4 ).
It is important to bear in mind that the aforementioned studies are reports of low-risk bullet wounds; that is, low-velocity handgun injuries resulting in mildly comminuted fractures in urban environments. On the other hand, surgical debridement of gunshot wounds still has a role in high-risk wounds, which need to be evaluated on an individual basis. Those wounds involving high-energy weapons (military rifles or shotguns), delayed presentation, large soft-tissue deficits, and multiple projectiles, and those occurring on a battlefield or farm environment carry an increased risk of infection, and such wounds should be managed operatively. From their experience the authors also argue that even low-velocity gunshot fractures over subcutaneous bones, such as the clavicle or tibia, would also benefit from surgical debridement and coverage of the exposed bone ( Fig. 5 ).
The key principle of gunshot-wound debridement is removal of necrotic and contaminated tissue. High-energy wounds with extensive soft-tissue damage require debridement of devitalized tissue, and the “4 Cs” (color, capacity to bleed, consistency, contractility) have been recommended as a guide to determine muscle tissue viability. Shotgun injuries possess a dual infection risk in that large, soft-tissue damage may be accompanied by contaminated shotgun wadding or the plastic shell. An attempt should be made to remove these gross materials along with any obvious pellets, but an exhaustive search to remove each individual pellet is likely to cause unnecessary secondary injury. Debridement may also be performed during fixation of unstable fractures. If implanting hardware, the bullet tract can be excised with an elliptical incision and closed primarily after a thorough debridement and irrigation.
Transabdominal gunshot wounds that are associated with fractures of the spine, pelvis, and proximal femur represent a unique concern, as the presence of free intestinal contents increases the risk for infection. Although fractures to the spine with concurrent viscus perforation may lead to meningitis, vertebral osteomyelitis, or abscess formation, the current evidence suggests that bony debridement is not necessary if broad-spectrum antibiosis is continued for 7 to 14 days. Furthermore, extraction of retained bullets has not been proved to decrease the risk of infection, and should only be reserved for deteriorating neurologic function, acute lead toxicity, or location in an intervertebral disk space causing mechanical symptoms. Similar findings have been observed in the pelvis and hip joints. In a review at the authors’ institution, 84 patients with gunshot-related pelvic fractures were studied. Perforated viscus injury was seen in 50 patients, hip joint involvement in 15 patients, and sacroiliac joint injury in 3 patients. Only 1 patient experienced an infection from a transcolonic missile that resulted in a retained fragment in the hip joint, and that patient was treated with an initial debridement. The investigators concluded that extra-articular fractures, even in the presence of intestinal injury, did not require orthopedic debridement. Several other studies have corroborated a similar conclusion that debridement should be reserved only for intra-articular violation from a transabdominal bullet or for any trajectory injury with retained joint fragments.
Intra-articular retained fragments represent an undisputed surgical indication ( Fig. 6 ). Regardless of the joint, metallic fragments can lead to irreversible mechanical disruption of articular cartilage and/or lead toxicity. Otherwise, bullet extraction is usually not indicated unless it is retained within a synovial joint, is associated with acute lead toxicity, or positioned in a painful anatomic region such as the subcutaneous tissue, the foot, or the hand. Bullets retained in the foot are especially not well tolerated during weight-bearing activities, and a similar argument can be made for bullets lodged within the hand that cause discomfort with dexterous activities.
Principles of fixation
Gunshot projectiles cause fractures via 3 mechanisms: (1) direct crushing of tissue, (2) the sonic wave, and (3) the temporary cavity. The degree of energy transfer often causes significant comminution, which complicates operative planning and outcomes. In general, the operative fixation principles follow those of nonpenetrating trauma, but a brief review by anatomic region is given here.
Articular Injury
Chondral injuries can be managed by arthroscopic or open approaches. Arthroscopy allows for greater visualization of the joint surfaces, but an open arthrotomy may be necessary for more complex reconstructions. If an arthroscopic method is chosen, care should be taken to monitor the adjacent compartments (including the retroperitoneal space and abdomen for hip arthroscopy), as fluid may extravasate from the spaces between fracture fragments, causing compartment syndrome and possibly death. Regardless of the method, gross contaminants, bullet fragments, and/or small loose bodies may cause posttraumatic arthritis and should be removed from the joint. Acutely, large osteochondral fragments can be repaired with headless compression screws, and small defects can be treated with debridement and microfracture. Severely comminuted joints or those with advanced degenerative disease may benefit from delayed hemiarthroplasty or total joint arthroplasty.
Extra-Articular Injury
Upper extremity
Fractures of the proximal humerus and humeral shaft can often be managed nonoperatively, similarly to closed fractures. The usual indications for repair of the proximal humerus apply (ie, displacement of 1 cm or angulation of 45°), and may be repaired via plating, pinning, or nailing, depending on the surgeon’s preference. Fractures of the humeral shaft can be treated with plating, nailing, or external fixation, although recent meta-analyses suggest that the rates of reoperation are lower for plating. Fractures with significant comminution can be bridged with locked plates, and those with significant bone loss may require an additional procedure such as wave plating with cancellous bone graft, vascularized fibular graft, titanium mesh cage with bone graft, or bone transport with an Ilizarov frame. Fractures of the distal humerus are more challenging to reconstruct, and posttraumatic stiffness often complicates these injuries. Typically the medial and lateral columns are fixed with 3.5-mm plates, which may need to be augmented with bone graft (tricortical iliac crest or cancellous with a bridge plate). External fixation may initially be required if irreparable comminution or excessive swelling is present. At the proximal ulna, surgery is often required to reestablish articular congruity and early motion. Open reduction and internal fixation is often the treatment of choice, but severe comminution may require external fixation or excision with triceps advancement. For late complications of stiffness or pain, arthrodesis or total elbow arthroplasty are salvage options, and whole-elbow allografting may reestablish bone stock if an insufficient amount precludes these procedures. Nondisplaced fractures of the forearm can be managed expectantly with local wound care, but operative management of displaced forearm fractures has been shown to have superior outcomes. Finally, the challenge with gunshot fractures to the hand lies in managing the multiple tissue injuries. For example, a tendon injury would require early motion, but a nerve injury would ideally require immobilization. Another example of conflicting rehabilitation protocols is seen with a concomitant flexor and extensor tendon injury. The authors’ preference is to allow motion of the tendons if a tensionless repair can be achieved on the nerves; in the case of concomitant flexor and extensor injury, the flexor tendon protocol takes precedence, as revision repair of the extensor tendon is less complicated. Unstable fractures of the metacarpals and phalanges require rigid fixation to allow early motion, which may be accomplished by plates or miniature external fixators. Large soft-tissue defects can be managed with limited debridement; questionable tissue should actually be initially left behind, as the hand possesses a unique regeneration potential. In a study by Pereira and colleagues, 55 complex hand injuries from gunshots were reviewed; 44 required primary closure, 4 required local rotational flaps, 1 required a free flap, and 1 required a digital amputation. Although 61% had good subjective functional scores, 65% still reported being “disabled from work.”
Lower extremity
Most civilian handgun injuries to the femur result in mild to moderately comminuted fractures with a low degree of soft-tissue loss. In such cases, standard reamed intramedullary nailing techniques are generally preferred, and have been shown to have outcomes comparable with those of closed fractures. In higher-energy wounds with extensive loss of bone and soft tissue, external fixation may be used either as a temporary measure until adequate soft-tissue coverage can be achieved, or as a definitive treatment. External fixation may be necessary in a critically injured patient who requires a “damage control” approach. In study by Mack and colleagues, provisional external fixation was required in 39 of 41 open proximal femur fractures in the combat setting. In their study, blast wounds and high-energy gunshot wounds were responsible for 71% and 20% of the fractures, respectively, and reoperation for complications was required in 56% of patients, with infection being the most common indication. In general, the external fixation is exchanged within 2 weeks of its application for a static locked intramedullary nail, but the fixator may be used definitively in cases with severe bone loss by converting it to a ring construct for bone transport. Distal femoral shaft and supracondylar fractures can similarly be stabilized with intramedullary nailing, albeit in a retrograde direction. Distal femur periarticular plates are another option, and are more appropriate for fractures with intra-articular extension. Fractures of the tibia metaphysis and shaft are treated similarly to those of the femur, except that low-energy shaft fractures can effectively be treated with casting and wound care. Often an intact fibula maintains length and the ability to perform straight leg raise, which can mislead initial responders. Fractures with inadequate alignment are preferably treated with static locked intramedullary nails, although no prospective or retrospective trials examining exclusively gunshot-related fractures exist. Periarticular fractures are best managed with anatomic reduction of the joint fragments and rigid fixation with plate-and-screw constructs. Bone graft or substitutes may be necessary to fill structural voids. In either the shaft or periarticular regions, excessive soft-tissue swelling or deficits can be managed with bridging external fixation devices, which may be used temporarily or definitively. Fractures of the foot are often treated nonoperatively with weight bearing as tolerated, as long as the bullet has been removed. These patients often experience stiffness, but the degree to which this occurs is usually not disabling.
Spine and pelvis
Gunshot fractures to the spine are common but infrequently require surgical fixation. Unless the bullet has a transverse trajectory across both facets or unless the bullet is large in comparison with a small spine (such as in a child), the spine usually remains stable. Although not originally designed for penetrating trauma, some spine surgeons use the 3-column model of Denis to guide treatment. In the cervical spine, if 1 column is disrupted then a C-collar is applied, but if 2 or more are disrupted then the patient is placed in halo traction. In the thoracic and lumbar spine, if 1 column is disrupted then observation is warranted, but if 2 or more columns are involved then a thoracolumbar spinal orthosis (TLSO) can be worn by the patient when out of bed. Alternatively, in unstable patterns such as disruption of 2 or more columns or bilateral facet destruction, short-segment posterior spinal fusion allows early rehabilitation and mobilization. Unstable fractures of the pelvis are rare. External fixation or plate-and-screw constructs may be used to stabilize an anteriorly or posteriorly disrupted pelvic ring.
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