The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 91, Issue 4

Selected Instructional Course Lecture | April 01, 2009

Joint and Long-Bone Gunshot Injuries

Paul J. Dougherty, MD¹; Rahul Vaidya, MD²; Craig D. Silverton, DO³; Craig Bartlett, MD⁴; Soheil Najibi, MD³

¹ Department of Orthopaedic Surgery, University of Michigan, 2912 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48103. E-mail address: pauldoug@med.umich.edu
² Detroit Receiving Hospital, 4201 Saint Antoine Street, Detroit, MI 48201
³ Henry Ford Hospital, 2799 West Grand Boulevard, K-12, Detroit, MI 48202
⁴ University of Vermont, 192 Tilley Drive, South Burlington, VT 05403

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Printed with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academy's Annual Meeting, will be available in March 2010 in Instructional Course Lectures, Volume 59. The complete volume can be ordered online at , or by calling 800-626-6726 (8 a.m.-5 p.m., Central time).

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

The Journal of Bone and Joint Surgery, Inc.

J Bone Joint Surg Am, 2009 Apr 01;91(4):980-997

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Extract

The care of patients with gunshot wounds can be clinically challenging as a result of the injury severity and systems-based factors, yet relatively few reports concerning the care of these patients have been written. To place the magnitude of the problem in perspective, it should be noted that there are 60,000 to 80,000 nonfatal gunshot wounds annually in the United States¹. In comparison, in the sixty-six months from March 19, 2003, through October 4, 2008, only 30,072 individuals sustained battlefield wounds during Operation Iraqi Freedom². Clearly, gunshot wounds are an enormous problem and orthopaedic surgeons should be aware of these injuries and their treatment.

Figures in this Article

Introduction

Prevalence

From 2001 to 2005, 1059 patients with a total of 1611 gunshot wounds were admitted to our institution (Henry Ford Hospital, Detroit, MI); 988 (61.3%) of these gunshot wounds were to the extremities. Five hundred and twenty-six wounds involved the lower extremity, and 462 involved the upper extremity. Ninety-eight injuries involved the spine, and an additional 525 did not involve the musculoskeletal system.

Similar to the situation in other urban trauma centers, 45.5% of patients who were admitted to the hospital had a fracture^3-5. Gunshot fractures are an important consideration for orthopaedic surgeons not only because of their frequency (Table I), but also because of the amount of resources that must be provided to care for each patient. The patients require longer hospital stays and use more resources than patients without fractures.

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TABLE I Gunshot Fractures Seen at Henry Ford Hospital, Detroit, Michigan, Between 2001 and 2005

	No.	%
Spine (cervical/thoracic/lumbar)	98	20.3
Clavicle	16	3.3
Scapula	12	2.5
Acetabulum	10	2.1
Hip	10	2.1
Pelvis	47	9.8
Humerus	42	8.7
Forearm	38	7.9
Hand	47	9.8
Femur	89	18.5
Patella	6	1.2
Tibia/fibula	50	10.4
Ankle	2	0.41
Foot	15	3.1
Total	482	100

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TABLE I Gunshot Fractures Seen at Henry Ford Hospital, Detroit, Michigan, Between 2001 and 2005

	No.	%
Spine (cervical/thoracic/lumbar)	98	20.3
Clavicle	16	3.3
Scapula	12	2.5
Acetabulum	10	2.1
Hip	10	2.1
Pelvis	47	9.8
Humerus	42	8.7
Forearm	38	7.9
Hand	47	9.8
Femur	89	18.5
Patella	6	1.2
Tibia/fibula	50	10.4
Ankle	2	0.41
Foot	15	3.1
Total	482	100

Joint Injury

Injuries into or near the joint have been common in our experience. The shoulder (the intra-articular region, proximal part of the humerus, clavicle, and scapula) has been the most common upper-extremity joint injured, with shoulder injuries accounting for 21.4% of all upper-extremity gunshot wounds between 2001 and 2005. In contrast, the wrist, the least injured upper-extremity joint, was involved 3.7% of the time (Table II). A lower percentage of lower-extremity injuries were intra-articular or near the joint; the knee was the most commonly injured joint (involved 9.5% of the time), while the ankle was the least commonly injured joint (involved 0.4% of the time) (Table III).

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TABLE II Periarticular Gunshot Wounds to Upper-Extremity Joints Seen at Henry Ford Hospital, Detroit, Michigan, Between 2001 and 2005

Upper-Extremity Joint	No.	%*
Shoulder	99	21.4
Elbow	47	10.2
Wrist	17	3.7

Based on the total number of upper-extremity gunshot wounds (462).

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TABLE II Periarticular Gunshot Wounds to Upper-Extremity Joints Seen at Henry Ford Hospital, Detroit, Michigan, Between 2001 and 2005

Upper-Extremity Joint	No.	%*
Shoulder	99	21.4
Elbow	47	10.2
Wrist	17	3.7

Based on the total number of upper-extremity gunshot wounds (462).

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TABLE III Periarticular Gunshot Wounds to Lower-Extremity Joints Seen at Henry Ford Hospital, Detroit, Michigan, Between 2001 and 2005

Lower-Extremity Joint	No.	%*
Hip	20	3.8
Knee	50	9.5
Ankle	2	0.4

Based on the total number of lower-extremity gunshot wounds (526).

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TABLE III Periarticular Gunshot Wounds to Lower-Extremity Joints Seen at Henry Ford Hospital, Detroit, Michigan, Between 2001 and 2005

Lower-Extremity Joint	No.	%*
Hip	20	3.8
Knee	50	9.5
Ankle	2	0.4

Based on the total number of lower-extremity gunshot wounds (526).

An intra-articular injury is not always obvious; therefore, a gunshot wound near a major joint should be suspected of penetrating that joint. Joint penetration is an indication for surgical exploration of the joint, with copious lavage to remove debris and contaminants and, if indicated, stabilization of the fracture. Clues of joint penetration include air in the joint, an intra-articular hematoma, and an intra-articular fracture. Aspiration of the joint may be of benefit, as is injection of saline solution or methylene blue dye, but these methods are not always diagnostic. Treatment should be on the side of caution when joint penetration is suspected; it is recommended that whenever there is doubt about joint penetration the wound and joint be explored and débrided. There are two reasons to remove bullets and bullet fragments from the joint. First, a foreign body in the joint can cause mechanical trauma with subsequent arthritis and loss of function. Second, bullet lead in the joint is absorbed and can cause lead toxicity^3-5.

Arthroscopy has been used to manage penetrating joint injuries of the shoulder^5-7, elbow⁸, hip^9-16, and knee^17-23, but specific indications for this procedure have not been established and comparisons of arthroscopic and open exploration have not been done, to our knowledge. The advantages of arthroscopy are smaller incisions, potentially faster rehabilitation, and better visualization of the joint, while the disadvantages include prolonged time to set up, increased operative time, and the risk of compartment syndrome. Fluid extravasation has been reported to lead to death after a hip arthroscopy²⁴.

Shoulder

Our experience and the literature indicate that approximately 10% of all gunshot wounds of the extremities involve the shoulder. A minority (10%) of these shoulder injuries are intra-articular^7,25-27. Penetrating injuries of the upper extremity are commonly associated with other injuries, with 15% being associated with a vascular injury. While nerve injuries are less frequent, they are the most important determinant of long-term function of the limb^6,25-28.

A multiteam approach should be used. Orthopaedic, vascular, microvascular, and plastic surgery may be needed for patients with severely injured limbs. Proximal humeral and glenoid fractures may be present. Muscle-tendon units, ligaments, articular cartilage and labrum, and capsule may be involved and can be repaired at the time of the initial surgery in patients with a low-velocity gunshot wound.

While we are not aware of any direct comparisons of open and arthroscopic techniques for the management of these injuries, case reports support the use of both techniques^6,7,25,26. Fractures that are nondisplaced or easily reducible may be stabilized with arthroscopic techniques, whereas unstable fractures involving the articular surface require open reduction and internal fixation. Large osteochondral fragments can be stabilized with bioabsorbable pins, headless screws such as Herbert screws (Zimmer, Warsaw, Indiana), Acutrak screws (Acumed, Hillsboro, Oregon), or a combination of these devices (Figs. 1-A and 1-B). Small and nonviable fragments should be removed. The bullet and its fragments may be removed with use of arthroscopic or open techniques. In the presence of intra-articular fracture displacement, comminution, and/or metaphyseal-diaphyseal dissociation, an open technique through a deltopectoral approach is used to reconstruct the joint surface. Reconstruction of the humeral head is done with open reduction and internal fixation with use of bioabsorbable pins and screws and headless screws. Fractures of the surgical neck and shaft are managed with internal fixation with a locked plate and screws. Hemiarthroplasty is an option when the humeral head cannot be reconstructed. Complications include stiffness, infection, nonunion, malunion, hardware failure, compartment syndrome, and neurovascular injury.

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Fig. 1-A: Anteroposterior shoulder radiograph showing a proximal humeral and shoulder joint intra-articular fracture.

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Fig. 1-B: Radiograph made after treatment with open reduction and internal fixation.

Elbow

The incidence of gunshot wounds to the elbow may be underestimated in the literature^8,25,28-32. If the proximal part of the forearm (proximal part of the radius or proximal part of the ulna) and the distal part of the arm (distal part of the humerus) are included as part of the elbow, then the rate is higher than has been reported. On the basis of these criteria, we have found that gunshot wounds to the elbow account for 4.8% of all extremity gunshot wounds and 10.2% of upper-extremity gunshot wounds. Associated injuries include nerve injuries and arterial and venous injuries.

Initial management includes vascular repair, irrigation and débridement, and stabilization with a bridging external fixator (Figs. 2-A and 2-B). Definitive treatment may involve a combination of various techniques, including internal (Figs. 3-A and 3-B) and/or hinged external fixation.

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Fig. 2-A Fig. 2-B: Figs. 2-A and 2-B Anteroposterior (Fig. 2-A) and lateral (Fig. 2-B) radiographs showing an intra-articular distal humeral fracture stabilized with a spanning external fixator of the elbow. This approach allowed staged reconstruction of the joint. A standard construct is to span the joint with two pins in the humerus and two pins in the ulna. This may be modified depending on the degree of fracture comminution and bone loss at the joint.

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Fig. 3-A Fig. 3-B: Anteroposterior (Fig. 3-A) and lateral (Fig. 3-B) radiographs showing definitive open reduction and internal fixation, through a transolecranon approach, of the distal humeral fracture shown in Figures 2-A and 2-B.

Complications include stiffness, malunion, nonunion, infection, and nerve injury. A severely injured joint may be salvaged with a compression plate arthrodesis of the elbow³² or with arthroplasty³¹. Young, active patients are not good candidates for elbow arthroplasty. When such patients have an arthritic and painful elbow, an arthrodesis may be considered³². A loose bullet in the elbow joint is an indication for arthroscopic irrigation, débridement, and bullet removal⁸.

Wrist

In our experience from 2001 through 2005, gunshot wounds to the wrist accounted for 1.7% of all extremity gunshot wounds and 3.7% of all upper-extremity gunshot wounds. Associated injuries include fractures, neurovascular injuries, and tendon ruptures. Fractures are very common in patients with a gunshot wound to the wrist and may involve the distal parts of the radius and ulna, the carpus, or both. Initial management includes irrigation and débridement, vascular repair if necessary, and spanning external fixation. A free flap or skin graft may be necessary to cover soft-tissue defects caused by high-energy gunshot wounds. Nerve repair, tendon repair, or reconstruction can be achieved after the initial irrigation and fracture stabilization. The role of arthroscopy in the treatment of gunshot wounds to the wrist is not clear, and, because the majority of these injuries involve unstable fractures of the distal part of the radius and/or the carpus, open treatment is usually required.

Hip

We have found gunshot wounds to the hip joint to account for 2% of all extremity gunshot wounds and 4% of lower-extremity gunshot wounds. If nonarticular wounds to the hip region are included, these proportions increase to 9% and 17%, respectively^{9-16,24,25,33-38}.

The recognition of an intra-articular injury is based on radiographic and computed tomography findings (Figs. 4-A and 4-B). In the absence of a fracture, or when radiographs are inconclusive, a fluoroscopically assisted arthrogram is the most sensitive test to detect violation of the joint³⁹.

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Fig. 4-A: Anteroposterior pelvic radiograph showing the intra-articular location of a bullet.

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Fig. 4-B: Computerized axial tomography scan of the hips, showing the bullet imbedded in the femoral neck.

When an associated injury to the femoral artery is suspected, an arteriogram is indicated. When a vascular injury is present, an emergent repair or bypass is necessary.

Transabdominal gunshot wounds to the hip pose a particularly difficult problem. The current recommendation for treatment of hip joint violation with a transabdominal bullet is emergent irrigation and débridement and fracture stabilization in addition to antibiotic prophylaxis. Transpelvic bullets that traverse the urinary bladder require urologic assessment and primary bladder repair. Urinary diversion may be necessary to avoid infection or fistula formation^36,39.

In a case series of fifty-three gunshot wounds to the hip, Long et al.³⁹ found the entry site to be the buttock in thirty-two patients, the anterior aspect of the thigh or inguinal area in thirteen, the lateral aspect of the hip in six, and the lower part of the abdomen in two. The authors recommended antibiotic therapy (a three-day course of Ancef [cefazolin] and gentamicin) without an arthrotomy if the injury was caused by a low-energy gunshot, the injury is not transabdominal, the bullet is not in communication with synovial fluid, and there is a stable fracture that does not require internal fixation. Fifteen of the fifty-three patients met these criteria and were treated without an arthrotomy. Septic arthritis did not develop in any of these fifteen patients. An arthrotomy was performed in hips with extensive comminution and/or transabdominal injury. An infection developed in six of the fifty-three hips, and four of the six patients with an infection had a transabdominal injury. One of the infections was associated with a missed bullet in the hip joint and one, with a missed displaced femoral neck fracture.

The recommended treatment of the fractures is open reduction and internal fixation (Figs. 5-A and 5-B). Hip arthroplasty or arthrodesis is not recommended in the acute setting. When there is severe comminution and adequate bone is not available for internal fixation, resection arthroplasty may be done³⁹. Complications of gunshot wounds to the hip include arthrosis, infection, fistula formation, nonunion, malunion, and osteonecrosis³⁹.

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Fig. 5-A: Anteroposterior pelvic radiograph showing a gunshot femoral neck fracture.

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Fig. 5-B: Radiograph made after treatment of the femoral neck fracture with a compression screw and side plate.

Bullets can be removed by means of arthrotomy³⁹ or arthroscopy^{9,10,12-15,24}. Hip arthroscopy requires special equipment, including a fracture table and fluoroscopy, as well as experience with the technique. Intra-abdominal fluid extravasation and abdominal compartment syndrome have been reported after hip arthroscopy for the treatment of a gunshot wound to the hip²⁴. In the presence of an acetabular fracture, extreme care must be taken to measure the arthroscopy fluid inflow and outflow. If the inflow and outflow are not balanced, it is likely that fluid is extravasating into the pelvis and abdomen, and the procedure should be stopped²⁴.

Knee

Our experience has been that 5% of all extremity gunshot wounds and 9.5% of all lower-extremity gunshot wounds involve the knee region (with or without an open joint injury and with or without a fracture). The literature suggests that 5% of all extremity gunshot wounds and 10% of lower-extremity gunshot wounds involve the knee^17,18,20,40.

Perry et al.⁴⁰ reported on sixty-four gunshot fractures of the knee. These included thirty-seven intra-articular fractures and twenty-seven extra-articular fractures. There were twenty-nine femoral, twenty-nine tibial, and nine patellar fractures. Twenty-three patients had an arteriogram because a vascular injury was suspected, and six of these arteriograms were positive. All of the knees with a positive arteriogram were explored, and five of the six limbs required vascular repair. Of the five injuries that required vascular repair, one involved the common popliteal artery; one, a branch of the common femoral artery; two, both the peroneal and the posterior tibial arteries; and one, the superficial femoral artery. Only two patients had a nerve injury, which involved the peroneal nerve in both. Two infections were reported.

Spanning external fixation of the joint is recommended when there is a severely comminuted and unstable fracture about the knee. Multiple irrigation and débridement procedures and a delayed closure may be necessary for patients with extensive soft-tissue injury. Delayed reconstruction of the joint may be undertaken once the soft tissues have healed.

Acute reconstruction of knee ligaments is not recommended for patients with an unstable fracture or associated injuries. In these cases, a delayed reconstruction may be undertaken after fracture-healing and rehabilitation. Meniscal tears and large osteochondral fragments may be fixed acutely.

Tornetta and Hui reported on the role of arthroscopy in managing gunshot wounds of the knee¹⁸. Of thirty-three patients who had an arthroscopic examination after sustaining a gunshot wound to the knee, five had a chondral injury, fourteen had a meniscal injury, and five had intra-articular debris that had not been seen on radiographs. On the basis of these findings, we recommend diagnostic arthroscopy and arthroscopic-assisted bullet removal and irrigation and débridement for the treatment of gunshot wounds that involve the knee. In the presence of a meniscal tear or an osteochondral fragment, acute repair can be performed arthroscopically by an experienced arthroscopist. Problems with arthroscopy of the knee include fluid extravasation and compartment syndrome.

Ankle

In our experience, 0.4% of gunshot wounds to the lower extremity have involved the ankle. Treatment has varied from spanning external fixation or internal fixation for a low-velocity injury to arthrodesis or amputation for a high-velocity injury^41,42. The role of arthroscopy is limited to bullet removal and irrigation and débridement of the joint, in the absence of an unstable fracture.

Lead Toxicity

Lead toxicity can occur with retained bullet fragments, most commonly when they are within the synovial fluid^3-5,43-63. Lead becomes soluble in organic acids, such as synovial fluid, producing increased blood lead concentrations³. Another mechanism by which lead is introduced into the bloodstream is phagocytosis by macrophages. While routine removal of bullets or their fragments is not recommended unless they are within a synovial fluid cavity, the possibility of lead toxicity from retained bullets anywhere should be remembered^{3,4,44-47,51-57,61,64-66}.

Approximately 90% to 95% of lead is stored in bone, taking the place of calcium in the calcium hydroxyapatite^3,64. The half-life of lead in bone is twenty to thirty years^4,51,57,61. Its blood half-life is approximately thirty days, and excretion is through the biliary and renal systems. Hypermetabolic states can mobilize bone stores and increase the blood lead concentration, causing a patient to become symptomatic. Hypermetabolic states can occur with fractures, surgery, alcohol use, diabetic ketoacidosis, pregnancy, infection, hyperthyroidism, Paget disease, neoplasia, and the use of medications or recreational drugs.

Surgeons should be aware of the symptoms of lead toxicity⁵⁰. These symptoms are vague, and multiple organs can be affected. Because of this, the diagnosis of lead toxicity is often delayed. Patients with lead toxicity most often present with symptoms such as fatigue, malaise, abdominal complaints (pain, nausea, vomiting, and/or constipation), headache, or joint pain. Patients can also have difficulty with memory, attention span, and behavior. Signs of lead toxicity include microcytic hypochromic anemia, encephalopathy, peripheral nerve changes due to demyelination of motor axons, and chronic renal failure. Later encephalopathic findings may be cerebral edema and seizures.

Lead toxicity should be suspected if the patient is found to have microcytic anemia or symptoms such as persistent abdominal pain. A whole blood lead concentration should be assessed to confirm the diagnosis.

Long-Bone Fractures

Humerus

Gunshot fractures to the humeral diaphysis occur less commonly than do those of the femur and tibia (Table I)^67-70. Nerve injuries are relatively common in patients who sustain gunshot wounds of the humerus and are more common with distal injuries than with proximal injuries^30,69,71-75.

We are not aware of any prospective studies comparing the various methods of treatment of humeral fractures, and the management of these injuries is controversial^{28,30,68,72-76}. We recommend a fracture brace or coaptation splint when there is minimal soft-tissue injury and the fracture can be held in alignment by these means. However, proximal or very distal fractures are often not amenable to this method of care^68,69.

External fixation has been used for patients with more extensive injuries, such as battlefield wounds. Zinman et al.⁷⁴ reported on twenty-six Israeli war casualties who had external fixation of an open humeral fracture. A monolateral external fixator was used, and resulted in union, in fifteen patients, whereas compression plate fixation was used in five patients and a cast was utilized for six. Five of the six patients treated with a cast had a delayed union, and four were subsequently treated with plate fixation and bone-grafting. Fifteen patients had a total of twenty nerve injuries. One of the injuries involved the radial nerve and was due to distal, lateral pin placement. There were four brachial and two radial artery repairs. Twenty-three patients were followed for a mean of 6.5 years after the injury. The authors reported that the result was excellent in fourteen patients, good in four, fair in three, and poor in two. All fractures eventually healed. The authors concluded that external fixation was the best treatment for patients with a severe open injury secondary to a war wound as it stabilized the fracture while allowing access for wound care. They recommended that an open method be used to place lateral pins in the distal part of the humerus, in order to avoid radial nerve injury, with percutaneous placement reserved for posteriorly placed pins.

In 1995, Keller⁷³ reported a study of thirty-seven refugees who had been treated for a gunshot fracture of the humerus at a Red Cross Hospital on the Sudanese border. The patients were seen at an average of 9.5 days after the injury, at which time thirty-three of the wounds were infected. Eight patients had a nerve palsy. Twenty-three patients were treated with a plaster-of-Paris splint, seven were treated with external fixation, and seven were treated with skeletal traction. The average duration of the immobilization with the plaster-of-Paris splint was 35.8 days, and twenty-one of the twenty-three fractures so treated were adequately aligned. Four of the patients had an average of two operations. The seven patients treated with external fixation had the frame in place for an average of 46.3 days, and four of the fractures were adequately aligned. Five of the seven did not unite and required a total of eleven operations. Of the seven patients treated with traction, which was maintained for an average of 27.7 days, five obtained union. There were six reoperations in three of the seven patients. Although the patients treated with the splint had the best results, the groups were not comparable because those treated with external fixation or traction had more severe injuries.

Hall and Pankovich⁷¹ treated eighty-nine humeral fractures with Ender nailing; twenty-two of these fractures were due to gunshot wounds, and four of the twenty-two were due to shotgun wounds. The authors reported good results. As is the case with other traumatic indications, Ender nailing for treatment of humeral fractures has been replaced with conventional intramedullary nailing. It remains to be seen whether intramedullary nailing or plate fixation is best for unstable or more extensive injuries.

The use of a functional brace, after a short time in a coaptation splint, for the treatment of simple fractures with minimal soft-tissue disruption yields acceptable results⁶⁸ (Figs. 6-A and 6-B). We and others recommend a spanning external fixator to provide initial stabilization for patients with more extensive injuries, such as those resulting from a short-range shotgun blast³⁵ (Fig. 7). The use of a small-pin external fixator for patients with extensive comminution and soft-tissue injury has been reported to have a good success rate²⁸. When both the limb and the patient have become stable, planning for fracture stabilization and soft-tissue coverage can be done. The use of a cage with allograft⁷⁷ or a fibular osteoseptocutaneous flap⁷⁷ has been described for the treatment of skeletal defects.

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Fig. 6-A: Anteroposterior radiograph of a gunshot fracture of the humerus treated with a coaptation splint.

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Fig. 6-B: The gunshot fracture after four months in a functional brace.

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Fig. 7: Anteroposterior radiograph showing a gunshot fracture of the humerus treated with external fixation.

Forearm

There are relatively few reports describing care of gunshot wounds to the forearm^78-91. Nerve injury is commonly associated with gunshot wounds to the forearm, and there is a 10% prevalence of compartment syndrome^84,86,88. The goals of fracture care are to restore forearm length and alignment as well as radial bow.

Elstrom et al.⁹² treated twenty-nine fractures of the radius and/or ulna in the 1970s. Fifteen patients were treated with a cast or with the pins-and-plaster technique. A nonunion developed in three of these patients, and a malunion developed in another three. Six displaced and comminuted fractures were treated with delayed open reduction and internal fixation, and none of them went on to malunion or nonunion. This suggests that open reduction and internal fixation may be safely used if the soft tissues are healthy.

External fixation is recommended for treatment of a displaced or comminuted forearm fracture that is unstable and associated with severe soft-tissue injury. Has et al.⁹³ reported a 10.3% infection rate following external fixation for treatment of upper-extremity war injuries, primarily those resulting from explosive munitions.

Care for a diaphyseal forearm fracture depends on the severity of both the soft-tissue and the osseous injury, just as it does when the open forearm fracture is not caused by a firearm⁷⁸. Patients with a relatively stable fracture of the ulna and minimal soft-tissue trauma may be treated with application of a cast after appropriate wound treatment (Fig. 8). Displaced fractures should be treated with open reduction and internal fixation when the soft tissues permit (Figs. 9-A and 9-B).

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Fig. 8: Anteroposterior radiograph showing an ulnar shaft fracture treated with local wound care and a splint followed by a fracture brace. The fracture healed uneventfully.

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Fig. 9-A: Anteroposterior radiograph showing a comminuted ulnar shaft fracture.

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Fig. 9-B: Radiograph made after treatment of the ulnar shaft fracture with open reduction and internal fixation.

Initial stabilization with external fixation should be used for patients with bone loss when both forearm bones are involved. If just the radius or the ulna is involved, splinting may be all that is required. A soft-tissue antibiotic-impregnated spacer may be used for initial care of the void⁷⁹. A second-stage procedure to reconstruct bone defects should be done once the limb is stable. External fixation may also be used for patients with severe soft-tissue injury, such as those who have sustained a shotgun blast to the forearm. Initial stabilization with an external fixator allows staged bone and soft-tissue reconstruction. Autologous bone-grafting to fill defects has been described^79,80,84, whereas we are not aware of any reports on the use of allograft and bioactive substances such as bone morphogenetic protein (BMP) or demineralized bone matrix for reconstruction of a post-gunshot forearm defect.

A salvage procedure may be performed, by creating a "single-bone forearm," for the treatment of unreconstructable bone loss or osteomyelitis⁸⁷. The proximal part of the ulna needs to be preserved to achieve a stable elbow, and the single bone based on the proximal part of the ulna does not allow pronation or supination.

Femur

Diaphyseal femoral fractures are the most common long-bone fractures associated with gunshot wounds^38,70,94-101 (Table I). Prior to approximately twenty years ago, balanced skeletal traction was the mainstay of care for femoral fractures in war or peace¹⁰². Initial stabilization with traction is commonly used today as a temporary means of stabilization until more definitive care can be provided¹⁰³.

External fixation has been used for open fractures on the battlefield. Reis et al.⁷⁰ reported on nineteen femoral fractures that were initially treated with external fixation with the intention to use this method until bone union occurred. Six patients had conversion to a cast brace because of pin-track infection, and five others had open reduction and internal fixation. Fourteen of the femora were treated with bone-grafting. The authors noted that no additional procedures were done until the limb was free of obvious infection. The average time to union was nineteen weeks. External fixation is now more commonly used for patients who are physiologically unable to undergo more extensive surgery^99,104. The use of temporary external fixation as a bridge from the injury to the definitive fracture stabilization has become a popular means of initially stabilizing the fracture.

Intramedullary Nailing

Use of intramedullary nailing to treat patients with a malunion, nonunion, or infection after a fracture secondary to a gunshot wound in the United States began after World War II^105-107. Wiss et al.¹⁰¹ retrospectively reviewed the cases of seventy-seven patients who had sustained a gunshot femoral fracture; fifty-six of these patients had adequate records for follow-up. The patients were initially treated with skeletal traction for ten to fourteen days, and intramedullary nailing was performed when the wound tract had healed. No deep wound infections were reported. The average time to union was just over five months, and the average duration of follow-up was sixteen months. Five patients had a limb-length discrepancy of >1 cm, one patient had angulation of 15°, and one had a clinically relevant rotational deformity. Five of the fifty-six patients required vascular repair in addition to the treatment of the femoral fracture. The authors also reported an associated sciatic nerve injury in three patients, one of whom had a return of function, one of whom had partial return, and one of whom had no return of function. Two patients had a peroneal nerve palsy, and one of them had a return of function.

Hollmann and Horowitz⁹⁷ reported on twenty-six patients who had sustained a fracture as a result of a "low-velocity" gunshot wound and were treated with intramedullary nailing at an average of nine days after the injury. Nineteen of the patients (two treated with open nailing and seventeen treated with closed nailing) were followed until union, which occurred at an average of four and one-half months after the injury.

Bergman et al.⁹⁵ reviewed the cases of sixty-five patients with a gunshot femoral fracture. The patients were treated with reamed intramedullary nailing at an average of two days (range, zero to fourteen days) after the injury, and they were followed for an average of two years (range, 9.5 months to six years). All fractures healed, at an average of just over four months (range, thirteen to thirty-one weeks). Two patients had persistent drainage, which resolved within three weeks while they were being treated with antibiotics.

Tornetta and Tiburzi¹⁰⁰ reported on fifty-five patients with a gunshot femoral fracture. Thirty-eight were treated with intramedullary nailing and were followed for an average of two years (range, fourteen to thirty-six months). The average time to union was two months (range, five to twenty-two weeks).

In a study by Nicholas and McCoy¹⁰⁸, twelve patients with a total of fourteen femoral fractures were treated with immediate intramedullary nailing (performed less than eight hours after the injury). Three patients had vascular repair, and two patients had a sciatic nerve injury. The average time to union was five and one-half months (range, three to eight months). None of the patients had an infection.

Retrograde nailing has become a popular technique for the treatment of diaphyseal femoral fractures, particularly those near the knee. Initially, it was thought that this approach should not be used for an open fracture because of the risk of knee infection, but we believe that two reports^109,110 demonstrated that intramedullary nailing may be done safely, with a minimal risk of infection, in patients with a gunshot femoral fracture. We recently reported on a series of 196 gunshot femoral fractures, of which fifty-six were treated with retrograde nailing¹¹¹. There was no increased rate of infection, at either the fracture site or the knee joint, associated with this method of treatment (Figs. 10-A and 10-B).

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Fig. 10-A Fig. 10-B: Fig. 10-A Anteroposterior radiograph showing a diaphyseal femoral fracture, which was subsequently treated with immediate retrograde intramedullary nailing. Fig. 10-B Postoperative radiograph showing excellent fracture alignment.

Compartment syndrome is an infrequent complication of femoral shaft fractures^112,113. We found that three of 102 patients treated for a diaphyseal femoral gunshot wound between 2001 and 2006 at our institution had the diagnosis of thigh compartment syndrome.

Tibia

Tibial fractures are the second most frequent long-bone fractures resulting from a gunshot wound (Table I). A variety of methods have been reported for the treatment of these fractures, including the use of a cast or a fracture brace, external fixation, and intramedullary nailing.

Fracture bracing has been used in both war and peace since World War I. Delbet¹¹⁴ fashioned a walking brace to treat fractures of the tibia during World War I. Dehne et al.¹¹⁴ popularized the use of nonoperative ambulatory treatment of tibial fractures during the 1950s. This treatment was also developed by Sarmiento et al.⁸⁹ in the 1960s and has been a treatment method for a variety of both open and closed tibial fractures.

Witschi and Omer¹¹⁵ reported the results of ambulatory treatment with a cast followed by fracture bracing in a series of eighty-four patients who had sustained a tibial fracture secondary to a missile injury. All of the fractures had some comminution. Despite this, the authors reported <1 cm of shortening in forty-eight of fifty-eight patients with an isolated injury and only 1 cm of shortening in the ten additional patients. Osteomyelitis, which prolonged the time to union, developed in seven patients. Brown and Urban¹¹⁶ reported on sixty patients with a total of sixty-three war-related tibial fractures that were treated with a fracture brace. The fractures healed in an average of four and a half months. Shortening averaged 9 mm (range, 2 to 38 mm). Twenty-seven of the fractures had no shortening. Four of the sixty-three patients had persistent drainage. Sarmiento et al.⁸⁹ reported on thirty-two gunshot tibial fractures treated with a fracture brace. One fracture did not heal, but the average time to union of the others was four months.

Leffers and Chandler¹¹⁷ reviewed the cases of forty patients with a total of forty-one tibial fractures due to gunshot wounds. Thirty-five fractures were treated initially with a cast and then with a fracture brace. Because of their severity, five fractures were initially treated with external fixation, and then a functional brace was applied within the first two months. One patient was treated with pins and plaster. The fractures that were treated initially with a cast healed in an average of three months, whereas those that were initially treated with external fixation healed in an average of five months. Eight patients had persistent wound drainage, and two had a surgical procedure to care for the wound. It should be noted that these forty patients accounted for less than one-third of the patients with gunshot-associated tibial fractures who had been seen at the authors' institution.

Ferraro and Zinar¹¹⁸ reported on ninety of 133 patients with a tibial fracture due to a gunshot wound who had been treated at Harbor/UCLA Medical Center. Fracture stabilization was achieved with a long leg cast in fifty-eight patients, external fixation was used for seventeen, and unreamed intramedullary nailing was performed in fifteen. The authors found that fractures classified as Winquist Grade zero, one, or two healed within three months. In the group classified as Winquist Grade three, four, or five, those treated with intramedullary nailing healed at an average of four months and those treated with external fixation healed at an average of six and one-half months.

Brien et al.¹¹⁹ recommended a treatment algorithm based on both soft-tissue and bone injury. For stable fractures with minimal soft-tissue disruption, they recommended antibiotics and cast treatment. For "unstable" fractures, the recommended treatment was reamed intramedullary nailing, unreamed intramedullary nailing, or external fixation, depending on the degree of soft-tissue disruption. The authors recommended the use of small-pin fixators for tibial metaphyseal fractures. It should be noted that the authors did not precisely define "stable" or "unstable" fractures¹¹⁹.

Presently, treatment of gunshot fractures of the tibial shaft depends on the amount of bone comminution and the degree of soft-tissue injury. Patients who have a tibial shaft fracture with minimal comminution, soft-tissue injury, displacement, or angulation may be treated successfully with local wound care in the emergency department and application of a cast, followed by a functional brace.

While we are not aware of any large clinical series in which the use of intramedullary nailing for the treatment of gunshot fractures was evaluated, it appears that more comminuted fractures are better managed with intramedullary nail fixation. If there is major soft-tissue injury requiring a soft-tissue transfer, consideration should be given to the use of external fixation until the soft tissues are reconstructed, at which point the fixator may be removed and an intramedullary nail can be inserted.

Overview

Gunshot injuries remain a major clinical problem for orthopaedic surgeons, particularly when the treatment of inner-city trauma is a major part of their practice. Additional research is needed to evaluate outcomes of gunshot fractures and joint injuries. The use of more modern fixation techniques developed since the 1980s has not been well documented for patients with humeral or tibial fractures. Likewise, prevention of arthritis, joint stiffness, infection, and lead toxicity are major concerns in the treatment of patients with gunshot joint injuries, and prevention of these complications should remain a focus of the treatment team.

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Topics

fracture ; gunshot wounds ; external fixation devices ; intramedullary nailing ; long bone

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Paul J. Dougherty, Rahul Vaidya, Craig D. Silverton, Craig Bartlett, Soheil Najibi; Joint and Long-Bone Gunshot Injuries. The Journal of Bone & Joint Surgery. 2009 Apr;91(4):980-997.

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