Chapter 11: Gunshot and Wartime Injuries

Paul J. Dougherty, Romney C. Andersen, Soheil Najibi

Chapter Outline

Introduction

Gunshot injuries remain a significant part of the workload for some urban trauma centers in the United States and are also common in war-torn regions throughout the world. The purpose of this chapter is to review the epidemiology, pathophysiology, and treatment of gunshot wounds and war injuries. This chapter is intended not only to assist those who evaluate gunshot wounds as a major part of their practice but also orthopedic surgeons who occasionally see patients with such injuries. 

Nonmilitary and Military Weapons

Weapons that are used in nonmilitary and military settings differ. Firearms seen in nonmilitary settings include handguns, rifles, and shotguns.8,33,81,83,142 Conventional military weapons can be divided into the categories of small arms and explosive munitions. Small arms consist of pistols, rifles, and machine guns. Explosive munitions consist of artillery, grenades, bombs, mortars, land mines, and improvised explosive devices (IEDs). Armored vehicle crew casualties represent a special subgroup of injuries seen in those who work and fight in and around armored vehicles. 

Small Arms

Small arms are weapons that fire a bullet from a rifled barrel to a target. The bullet is usually contained in a cartridge consisting of powder, a primer, and a cartridge case all in one unit (Fig. 11-1). Handguns and rifles are classified by the diameter (size) of the barrel (9 mm, 0.45 inch, 7.62 mm). Handguns used by the military are the same as used those by civilian police and others in regard to size, shape, and caliber. They are usually semiautomatic, which means a bullet is fired every time the trigger is pulled and as long as there is ammunition in the weapon’s magazine.8,33,81 
Figure 11-1
Schematic drawing of a cartridge.
 
An entire cartridge is made up of the cartridge case, the bullet, a primer, and powder. When struck, the primer initiates powder burning, generating the pressure to propel the bullet in flight.
An entire cartridge is made up of the cartridge case, the bullet, a primer, and powder. When struck, the primer initiates powder burning, generating the pressure to propel the bullet in flight.
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Figure 11-1
Schematic drawing of a cartridge.
An entire cartridge is made up of the cartridge case, the bullet, a primer, and powder. When struck, the primer initiates powder burning, generating the pressure to propel the bullet in flight.
An entire cartridge is made up of the cartridge case, the bullet, a primer, and powder. When struck, the primer initiates powder burning, generating the pressure to propel the bullet in flight.
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Handguns are the most common firearms associated with nonmilitary injuries. A handgun is intended to be fired over a short range and is small. Two types of handguns are most commonly seen: Pistols and revolvers (Fig. 11-2A). A pistol has a magazine that contains cartridges, which are fed (or cycled) into the barrel every time the trigger is pulled (Fig. 11-2B). Revolvers contain cylinders with chambers that contain cartridges. The cylinder rotates so that a cartridge is aligned to the barrel when the trigger is pulled.81,142 
Figure 11-2
Types of handgun.
 
A: A 9-mm Browing P-35 pistol used in several countries as the military handgun. It is also available to the nonmilitary market. This firearm was first produced in the 1930s. B: Revolver; the cylinder rotates to align with the barrel for each cartridge.
A: A 9-mm Browing P-35 pistol used in several countries as the military handgun. It is also available to the nonmilitary market. This firearm was first produced in the 1930s. B: Revolver; the cylinder rotates to align with the barrel for each cartridge.
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Figure 11-2
Types of handgun.
A: A 9-mm Browing P-35 pistol used in several countries as the military handgun. It is also available to the nonmilitary market. This firearm was first produced in the 1930s. B: Revolver; the cylinder rotates to align with the barrel for each cartridge.
A: A 9-mm Browing P-35 pistol used in several countries as the military handgun. It is also available to the nonmilitary market. This firearm was first produced in the 1930s. B: Revolver; the cylinder rotates to align with the barrel for each cartridge.
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Rifles are shoulder-fired weapons that are intended to strike a target farther away from the shooter than a handgun or shotgun can (Fig. 11-3). In general, the barrel is longer and has rifling to impart a spin on the bullet. Rifling consists of spiral grooves that line the barrel, engaging the bullet and causing it to spin on the longitudinal axis lending gyroscopic stability in air. The bullets fired from rifles are more aerodynamic in shape than those fired from pistols, leading to more accurate bullet flight. Bullets for nonmilitary rifles may have an open tip or “soft nose” to allow for expansion of the bullet when striking the target. Military bullets have complete metal jacketing to limit deformation or fragmentation, which decreases wound damage. Machine guns are intended to fire in the full automatic mode; this occurs when repeated shots are fired as long as the trigger is held down, as opposed to the semiautomatic fire described earlier. Machine guns generally weigh more than rifles and are installed onto vehicles and aircraft.86,142 
Figure 11-3
M16 series military rifles (from top to bottom): M16A1, M16A2, M4A1, and M16A4.
Rockwood-ch011-image003.png
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Modern military rifles are most often “assault rifles” and have the ability to fire in both fully automatic and semiautomatic modes. In an effort to reduce recoil, cartridges used in these weapons are not the full-powered rifle cartridges seen in civilian hunting rifles or in military weapons of the first half of the 20th century.130,142 Shotguns are shoulder-fired weapons that have a smooth barrel (Fig. 11-4). Shotgun gauge sizes are inversely proportional to the diameter of the barrel. The gauge expresses the inverse of the size of a lead sphere able to be fired from the shotgun. For example, a 12-gauge shotgun can shoot a 1/12-lb lead sphere, while a 20-gauge shotgun can shoot a 1/20-lb lead sphere. This is why it is not intuitive that a “12-gauge” shotgun is more lethal than a “20-gauge” shotgun. Although shotguns are able to fire a solid lead sphere and a number of other types of rounds most often shotguns fire multiple projectiles, called pellets, which vary in size from 0.012 to 0.36 inch. The pellets are often contained in a cup or wad that keeps them together and pushes the shot out of the barrel (Fig. 11-5). The pellets begin to spread the farther they move as they exit the barrel.83,136 The spread of the pellet shot over a given distance is dependent on the size of the shot, the length of the barrel, and the degree of “choke” on the barrel. Choke is a constriction at the end of the barrel that will cause less spread of the shot over a given distance. A standard measure of choke is the amount of pellets that are put into a circle at 40 yards. A full choke should put 70% of its pellets into the circle, whereas an “improved cylinder” choke should put 50%. When within a few feet of the barrel, the spread of the shot is negligible.8,83 
Figure 11-4
Barrel types: Smoothbore (shotgun) and rifled.
 
The smoothbore barrel is commonly used for shotguns, whereas a rifled barrel is used in both rifles and handguns.
The smoothbore barrel is commonly used for shotguns, whereas a rifled barrel is used in both rifles and handguns.
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Figure 11-4
Barrel types: Smoothbore (shotgun) and rifled.
The smoothbore barrel is commonly used for shotguns, whereas a rifled barrel is used in both rifles and handguns.
The smoothbore barrel is commonly used for shotguns, whereas a rifled barrel is used in both rifles and handguns.
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Figure 11-5
Shotgun shell.
 
A shotgun shell consists of the primer, powder, wad, and shot. All of this is contained in the shell casing. When powder burning is initiated by the primer, the wadding propels the shot down the barrel and into free flight.
A shotgun shell consists of the primer, powder, wad, and shot. All of this is contained in the shell casing. When powder burning is initiated by the primer, the wadding propels the shot down the barrel and into free flight.
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Figure 11-5
Shotgun shell.
A shotgun shell consists of the primer, powder, wad, and shot. All of this is contained in the shell casing. When powder burning is initiated by the primer, the wadding propels the shot down the barrel and into free flight.
A shotgun shell consists of the primer, powder, wad, and shot. All of this is contained in the shell casing. When powder burning is initiated by the primer, the wadding propels the shot down the barrel and into free flight.
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Explosive Munitions

Explosive munitions include artillery, grenades, mortars, land mines, bombs, and IEDs.8,34 They are the most common agents for wounding soldiers on a battlefield, beginning with World War I (1914 to 1918), when artillery became more common on the battlefield. Table 11-1 describes the relative proportion of different types of weapons that generated casualties on the battlefield from various wars during the 20th and 21st centuries. 
 
Table 11-1
Casualty Generation by Weapon
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Table 11-1
Casualty Generation by Weapon
Wounding Agent World War I Bougainville Campaign, Solomon Islands (World War II) Vietnam Conflict (Wound Data and Munitions Effectiveness Team [WDMET]) Wars in Afghanistan and Iraq
Bullet 28.06% 34% 30% 12.8%
Mortar NR 39.5% 19% NR
IED/Booby trap/land mine NA 1.9% 17% 74.3%
Hand grenade 1.21% 12.7% 11% 0.2%
Artillery 70.4% 11% 3% 8.3%
RPGa NA NA 12% 4.4%
 

NA, not available; NR, not reported; RPG, rocket propelled grenade.

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Explosive munitions wound via one or more of four mechanisms: Ballistic, blast, thermal, or translational (Fig. 11-6). Ballistic injuries occur from fragments of exploding munitions or from material around the explosive device. Blast injuries occur because of a transient blast wave caused by the exploding munitions. Thermal injuries are caused by a transient increase in local temperature as a result of the explosion. Translational injuries are caused by a person being propelled and sustaining blunt trauma due to the explosion. Patients often sustain closed injuries as the result of these translational injuries. 
Figure 11-6
Mechanisms of injury explosive munition.
 
The three mechanisms of injury are ballistic, blast, and thermal. The ballistic effects take place much farther away from the explosion compared with blast or thermal effects.
The three mechanisms of injury are ballistic, blast, and thermal. The ballistic effects take place much farther away from the explosion compared with blast or thermal effects.
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Figure 11-6
Mechanisms of injury explosive munition.
The three mechanisms of injury are ballistic, blast, and thermal. The ballistic effects take place much farther away from the explosion compared with blast or thermal effects.
The three mechanisms of injury are ballistic, blast, and thermal. The ballistic effects take place much farther away from the explosion compared with blast or thermal effects.
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Explosive, ballistic, and thermal injuries are similar to those seen with civilian injuries; however, the blast mechanism is unique to military injuries. The blast and thermal effects occur relatively close to the exploding munitions, whereas ballistic injuries can also occur farther from the device.12,34,118 The distances from the munitions that the various effects may be seen (ballistic, blast, thermal) will vary with the type of device and the environment. An explosion in a confined space, for example, will increase the effects of blast overpressure. Someone who is wounded closer to the exploding munitions may have combined ballistic, thermal, and blast effects compared with someone farther away. A typical mortar shell, when detonated in an open area, might have thermal effects within a few feet of detonation. The blast or pressure wave may cause ear injury within 30 feet. Fragments; however, can still cause injury at greater than 100 yards from detonation. 
Blast injuries tend to have large soft tissue wounds associated with fractures. The rate of infection is significantly higher in blast-induced injuries than blunt injuries. This is due to the “outside in” mechanism of a blast versus the typical “inside out” mechanism of a blunt injury. In blunt fractures, the bone frequently breaks and the sharp edge of the bone lacerates the skin exposing the fracture to contamination—“inside out.” A blast injury on the other hand has significant amounts of foreign material deposited deep into tissue both surrounding and at the fracture site—“outside in.” 
Artillery includes cannons that fire large projectiles for a greater range. The projectiles may be antivehicle, contain white phosphorus, or be explosive filled. The diameter of US military artillery cannon barrels ranges in size from 105 mm to 8 inches. The explosive-filled projectiles are most often used against infantry soldiers. When detonated, they produce fragments of varying shape and size, which cause wounds. The fragments produced depend on the casing of the artillery round. Modern artillery casings break up to produce more uniform fragments over a given area. The fragments may range from a few milligrams to several grams in weight. After detonation, fragments may initially travel at several thousand meters per second. This initial velocity rapidly decreases because of the irregular shape of the fragments.8,12,34,118 
Grenades are small explosive-filled devices that may be thrown or fired from a special launcher (Fig. 11-7). Grenades may produce smoke for signaling or be designed to disable destroy tanks or soldiers. As with artillery shells, the type of fragment produced is dependent on the composition of the container. Most modern grenades have a notched or prefragmented casing that produces fragments of a uniform size when detonated.8,12,34,118 
Figure 11-7
Grenade.
 
This cutaway illustrates the casing, which is composed of notched wire, producing fragments when detonated. The powder is stored in the casing and is ignited by the detonator.
This cutaway illustrates the casing, which is composed of notched wire, producing fragments when detonated. The powder is stored in the casing and is ignited by the detonator.
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Figure 11-7
Grenade.
This cutaway illustrates the casing, which is composed of notched wire, producing fragments when detonated. The powder is stored in the casing and is ignited by the detonator.
This cutaway illustrates the casing, which is composed of notched wire, producing fragments when detonated. The powder is stored in the casing and is ignited by the detonator.
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Mortars are weapons that have barrels aimed at a high arc to produce indirect fire. Projectiles fired from mortars may produce smoke, white phosphorus, or explosive fragments. These weapons are smaller and are more limited in range compared with the cannon. As with the other weapons described earlier, fragments produced by the explosive shells vary with the composition of the shell’s casing.8,9,12 
Land mines may be one of two major types: Antipersonnel or antivehicle. Antipersonnel land mines are those intended to injure individual soldiers. Antivehicle land mines are intended to destroy or disable vehicles, such as tanks. Antipersonnel land mines are classified by the US Army as static, bounding, or horizontal spray (Fig. 11-8). Another category, unconventional or improvised devices, will be handled separately in this section. Currently, there is much concern about land mines throughout the world because of vast land-mined tracts that remain from conflicts in Asia, Africa, and the Balkans. Estimates vary, but between 70 and 100 million land mines remain in place, which, until removed, will continue to be a hazard to those living or working in the area (Fig. 11-9).1,7,8,12,34,110,118 
Figure 11-8
Antipersonnel land mines.
 
This illustrates the types of manufactured antipersonnel land mines seen throughout the world. A static mine is tripped when a person steps on the mine. A bounding mine, when tripped, propels an explosive device to about waist high and then detonates. The horizontal spray mine directs multiple small fragments in one direction when tripped.
This illustrates the types of manufactured antipersonnel land mines seen throughout the world. A static mine is tripped when a person steps on the mine. A bounding mine, when tripped, propels an explosive device to about waist high and then detonates. The horizontal spray mine directs multiple small fragments in one direction when tripped.
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Figure 11-8
Antipersonnel land mines.
This illustrates the types of manufactured antipersonnel land mines seen throughout the world. A static mine is tripped when a person steps on the mine. A bounding mine, when tripped, propels an explosive device to about waist high and then detonates. The horizontal spray mine directs multiple small fragments in one direction when tripped.
This illustrates the types of manufactured antipersonnel land mines seen throughout the world. A static mine is tripped when a person steps on the mine. A bounding mine, when tripped, propels an explosive device to about waist high and then detonates. The horizontal spray mine directs multiple small fragments in one direction when tripped.
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Figure 11-9
Small static land mine.
 
Note the small size of this land mine compared with a hand. These are usually made of minimal metal components to avoid detection.
Note the small size of this land mine compared with a hand. These are usually made of minimal metal components to avoid detection.
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Figure 11-9
Small static land mine.
Note the small size of this land mine compared with a hand. These are usually made of minimal metal components to avoid detection.
Note the small size of this land mine compared with a hand. These are usually made of minimal metal components to avoid detection.
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Static land mines are those that are laid on top of the ground or buried in soil and are detonated when someone steps on the device, and are the most common type of mine. They contain a small amount of explosive (100 to 200 g) and produce a characteristic pattern of injury (Fig. 11-10).110 Soviet surgeons obtained considerable experience with land mines during the war in Afghanistan (1979 to 1988), which prompted them to conduct both laboratory and clinical investigations on the mechanism of injury. Injuries produced by static land mines are primarily to the lower extremity (Fig. 11-11). There are three areas of injury—there is an area of mangling or avulsion (traumatic amputation), which occurs at the midfoot or distal tibia. There is a second area in which the soft tissues are separated from bone along fascial planes in the leg (brisant). This area is a tidewater area in terms of tissue survival; the tissue is compromised, but it may heal. Third, more proximally at or above the knee, injuries may occur from fragments or debris propelled from the land mine but not necessarily from direct effects of the blast itself. The degree of injury is dependent on the size and shape of the individual’s limb, the type of footwear and clothing worn, the amount and type of soil overlying the land mine, and the size of the land mine.1,110 
Figure 11-10
This photograph is of a foot injured by a small planted land mine.
 
The mine was under the forefoot and the patient had footwear.
The mine was under the forefoot and the patient had footwear.
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Figure 11-10
This photograph is of a foot injured by a small planted land mine.
The mine was under the forefoot and the patient had footwear.
The mine was under the forefoot and the patient had footwear.
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Figure 11-11
Small static land mine injury.
 
This illustrates the three areas of injury sustained from a small static land mine. First, there is an area of avulsion or amputation; second, there is an area of soft tissue stripping where tissue may or may not survive. Third, proximal to this area, there may be fragment wounds from debris or the land mine, or injury from the fast translation of being propelled upward from the land mine itself.
This illustrates the three areas of injury sustained from a small static land mine. First, there is an area of avulsion or amputation; second, there is an area of soft tissue stripping where tissue may or may not survive. Third, proximal to this area, there may be fragment wounds from debris or the land mine, or injury from the fast translation of being propelled upward from the land mine itself.
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Figure 11-11
Small static land mine injury.
This illustrates the three areas of injury sustained from a small static land mine. First, there is an area of avulsion or amputation; second, there is an area of soft tissue stripping where tissue may or may not survive. Third, proximal to this area, there may be fragment wounds from debris or the land mine, or injury from the fast translation of being propelled upward from the land mine itself.
This illustrates the three areas of injury sustained from a small static land mine. First, there is an area of avulsion or amputation; second, there is an area of soft tissue stripping where tissue may or may not survive. Third, proximal to this area, there may be fragment wounds from debris or the land mine, or injury from the fast translation of being propelled upward from the land mine itself.
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Bounding mines are land mines that, when tripped, propel a small grenade-like device to about 1 to 2 m in height. The device then explodes, producing multiple small fragment wounds similar in nature to those produced by grenades.110 
Horizontal spray land mines are mines that, when tripped, fire fragments in one direction. These land mines may be used to protect a perimeter or during an ambush. The Claymore mine is an example of this type of mine. It fires about 700 steel balls that weigh 10 grains each in one direction. The weapons produce multiple fragment wounds to exposed personnel nearby (Fig. 11-12).110 
Figure 11-12
Claymore mine injury.
 
This photograph illustrates multiple small fragment wounds of a thigh from a patient injured by a Claymore mine.
This photograph illustrates multiple small fragment wounds of a thigh from a patient injured by a Claymore mine.
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Figure 11-12
Claymore mine injury.
This photograph illustrates multiple small fragment wounds of a thigh from a patient injured by a Claymore mine.
This photograph illustrates multiple small fragment wounds of a thigh from a patient injured by a Claymore mine.
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Unconventional or improvised devices are another category of land mine. These mines are fabricated out of another piece of ordnance, such as a grenade or mortar shell. They are designed to detonate when a person steps on the device, a person pulls a tripwire, or the device is triggered remotely by radio or control wires. These devices may be made out of locally available materials as well. They vary in construction from smaller antipersonnel devices to large explosive devices with several kilograms of explosive to disable or destroy vehicles (Fig. 11-13). 
Figure 11-13
Improvised explosive device (IED).
 
This illustrates an IED (“booby trap”) made from a grenade that is inserted into a can. When the wire is tripped, the grenade explodes. This drawing is taken from a World War II British Commando manual. IEDs are the most common type of land mine or booby trap seen in the Vietnam, Iraq, and Afghanistan conflicts.
This illustrates an IED (“booby trap”) made from a grenade that is inserted into a can. When the wire is tripped, the grenade explodes. This drawing is taken from a World War II British Commando manual. IEDs are the most common type of land mine or booby trap seen in the Vietnam, Iraq, and Afghanistan conflicts.
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Figure 11-13
Improvised explosive device (IED).
This illustrates an IED (“booby trap”) made from a grenade that is inserted into a can. When the wire is tripped, the grenade explodes. This drawing is taken from a World War II British Commando manual. IEDs are the most common type of land mine or booby trap seen in the Vietnam, Iraq, and Afghanistan conflicts.
This illustrates an IED (“booby trap”) made from a grenade that is inserted into a can. When the wire is tripped, the grenade explodes. This drawing is taken from a World War II British Commando manual. IEDs are the most common type of land mine or booby trap seen in the Vietnam, Iraq, and Afghanistan conflicts.
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The majority of explosive devices used in Afghanistan and Iraq conflicts are IEDs. One of the larger antipersonnel mines used against civilians is the suicide bomber. This is a term given to an individual who carries a large explosive charge and detonates it in location of a crowd or building to achieve maximum casualties. One of the more common constructs for such a bomb is in the form of a vest containing explosive along with material for fragments. The fragments increase the wounding potential of the device and consist of items such as ball bearings or nails. Large antivehicle land mines have made transportation and troop movements difficult.1,8,34,126,127 Bombs are explosive devices that are dropped from aircraft. They may consist of one large explosive device or may carry submunitions that are distributed more uniformly over a target area. Cluster bombs are an example of the latter device.9,12,118 

Armored Vehicle Crew Casualties

Most of the world’s armies have tanks, infantry fighting vehicles, and armored reconnaissance vehicles within their inventory. Injuries to crewmembers occur both in and around vehicles. Those injured outside of the vehicle have injuries similar to infantrymen. Two types of weapons are used to perforate the armored vehicle’s envelope to cause injury to the crewmen (antitank land mines may be considered a third type). 
First, there is the kinetic energy round (Fig. 11-14). This consists of a hard piece of metal, such as tungsten or depleted uranium, which is fired out of a cannon at a high velocity. The projectiles used today are long and narrow and cause a high concentration of pressure over a very small cross-sectional area to defeat the armor plate. If the round penetrates to the crew compartment, injuries may be caused by the penetrating round itself, debris knocked off from the inside of the vehicle itself, or armor debris. Because the penetrating rounds are large, injuries to individuals tend to be catastrophic.33 
Figure 11-14
Kinetic energy armor piercing round.
 
This illustration shows the dense metal penetrator, shaped like an arrow and the “petals” of the sabot surrounding the penetrator falling away.
This illustration shows the dense metal penetrator, shaped like an arrow and the “petals” of the sabot surrounding the penetrator falling away.
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Figure 11-14
Kinetic energy armor piercing round.
This illustration shows the dense metal penetrator, shaped like an arrow and the “petals” of the sabot surrounding the penetrator falling away.
This illustration shows the dense metal penetrator, shaped like an arrow and the “petals” of the sabot surrounding the penetrator falling away.
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Shaped charges are the other type of weapon seen on the battlefield (Fig. 11-15). They consist of an explosive-filled war head that is packed around a reverse cone-shaped piece of metal (copper or aluminum). When detonated, the liner collapses and a jet is produced, which travels at up to 10,000 feet per second. The jet produces an area of high temperature and pressure over a very small cross-sectional area. When the jet penetrates the armor, it produces two areas of under armor debris. First, there is the jet of the shaped charge. The jet produces catastrophic wounds when it directly hits one of the crewmen. Second, there is an area of under armor debris called spall, which is material knocked off from the inside face of the armored plate itself. Many of today’s armored vehicles have liners that do not allow spall debris to form.33,110 
Figure 11-15
Shaped charge or high-explosive anti-tank (HEAT) round.
 
Explosive is packed around a reverse cone-shaped metal liner called a melt sheet. When detonated, it generates a jet of high temperature and pressure that defeats armor through plastic or elastic deformation.
Explosive is packed around a reverse cone-shaped metal liner called a melt sheet. When detonated, it generates a jet of high temperature and pressure that defeats armor through plastic or elastic deformation.
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Figure 11-15
Shaped charge or high-explosive anti-tank (HEAT) round.
Explosive is packed around a reverse cone-shaped metal liner called a melt sheet. When detonated, it generates a jet of high temperature and pressure that defeats armor through plastic or elastic deformation.
Explosive is packed around a reverse cone-shaped metal liner called a melt sheet. When detonated, it generates a jet of high temperature and pressure that defeats armor through plastic or elastic deformation.
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A variation on the shaped charge is the “explosively formed projectile (EFP)” (Fig. 11-16). This device has a shallow concavity for the liner and forms a “slug” rather than a fully developed jet to penetrate vehicles. The “slug” is less affected by intermediate targets, such as dirt and debris, than the jet of the shaped charge. Although it is considered to be a new innovation, this technology has been present since at least the 1930s.2 
Figure 11-16
Explosively formed projectile (EFP).
 
A modification of the shaped charge, the liner has a shallow concavity that propels a “slug” at high velocity. The slug is less likely to be disturbed by intermediate targets or debris compared with the jet of the shaped charge.
A modification of the shaped charge, the liner has a shallow concavity that propels a “slug” at high velocity. The slug is less likely to be disturbed by intermediate targets or debris compared with the jet of the shaped charge.
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Figure 11-16
Explosively formed projectile (EFP).
A modification of the shaped charge, the liner has a shallow concavity that propels a “slug” at high velocity. The slug is less likely to be disturbed by intermediate targets or debris compared with the jet of the shaped charge.
A modification of the shaped charge, the liner has a shallow concavity that propels a “slug” at high velocity. The slug is less likely to be disturbed by intermediate targets or debris compared with the jet of the shaped charge.
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Epidemiology

Nonmilitary Gunshot Wounds

Gotsch et al.55 reported estimates of gunshot injuries in the United States for 1993 through 1998. The authors estimated that during this period, there were approximately 180,533 fatal gunshot wounds and about 411,000 nonfatal gunshot wounds for the 6-year period. Over the course of the study there was a decline in the annual nonfatal rate by 40% (from 40.5 to 24 per 100,000 population) and in the fatal rate by 21.1% (from 15.4 to 12.1 per 100,000 population). This decline corresponded with the overall decrease in violent crime of 21%. During the study period, the average annual number of self-inflicted fatalities exceeded those from assault (18,227 vs. 15,371 per year).55 
From 1998 through 2006, there has been a further decline in violent crime from 566.4 to 473.5 per 100,000 population (16.5%) and in murder from 6.3 to 5.7 per 100,000 population (9.5%).77 Deaths caused by firearms in the United States also decreased from 35,957 (13.5 per 100,000) to 29,569 (10.5 per 100,000).125 
Gotsch et al.55 also found that males were seven times more likely to receive a firearm injury than females. Black men aged 20 to 24 years had the highest annual firearm-related injury rate for both fatal and nonfatal groups (166.7 and 690 per 100,000 population, respectively). This compared unfavorably to the firearm injury rate of 13.4 per 100,000 (fatal) and 30.1 per 100,000 (nonfatal) for the entire population. These demographics also explain why the concentration of patients with gunshot wounds is higher in trauma centers for cities with a higher black population such as Detroit, Los Angeles, Philadelphia, Chicago, and New Orleans.55,60,77 
There is an economic, as well as a human, cost in caring for patients with gunshot wounds.23,60,154 Hakanson et al.60 reported that the average cost of treating a gunshot orthopedic injury is $13,108 per patient. Brown et al.23 reported on orthopedic patients treated for gunshot wounds in New Orleans at an inner-city Level I trauma center. They found that patients with gunshot wounds represented 24% of all admissions and 26% of all orthopedic trauma surgical cases. The most common locations for nonfatal gunshot wounds are in the extremities (Table 11-2). Gotsch et al.55 reported that extremity wounds represented 46% of nonfatal wounds caused by assault and 71.8% of unintentional wounds. A series from Cordoba, Argentina, found that 63% of gunshot victims had injuries to the upper or lower extremities.14 A review of records at Henry Ford Hospital in Detroit, MI, from 2001 through 2006 found that 42.4% of all patients admitted with a diagnosis of gunshot wounds had extremity wounds. This figure increases to 50.2% if pelvic and spine injuries are included. 
 
Table 11-2
Anatomic Distribution of Gunshot Wounds
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Table 11-2
Anatomic Distribution of Gunshot Wounds
Henry Ford Hospital Detroit, MI (%) (n = 1,505) Cordoba, Argentina (n = 1,326)
Head, ears, eyes, nose, throat 11.7 12%
Chest 16 12%
Abdomen/pelvis 24 13%
Upper extremity 16.2 18%
Lower extremity 26.2 45%
Spine 5 Not reported
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Many patients with gunshot wounds are also treated in emergency departments without admission.21,55,116 Estimates for the number of patients with gunshot wounds who are treated on an outpatient basis range from 45% to 60%.13,116,122,125 

Overview of Battle Casualties

Two prospective epidemiologic studies concerning battle casualties have been done (one during World War II and the second during the Vietnam War), collecting data on the tactical nature surrounding casualty wounding, the type of weapon, the anatomic locations of wounds, and mortality.9,118 The first was conducted during the Bougainville campaign in the Solomon Islands during World War II to assess patient injuries based on the weapon and tactical circumstances.118 There were 1,569 casualties who were followed through their initial surgical care to look at outcome. A second study was performed during the Vietnam Conflict to assess 7,964 casualties during an 18-month period during the conflict. The patients in this study (Wound Data and Munitions Effectiveness Team [WDMET]) were evaluated in terms of the tactical situation, the weapons used, the injuries produced, and the patient outcome.9 A retrospective review of service members wounded in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF)119 from 2001 to 2005 showed 54% percent of injuries were extremity injuries with 82% of those being open fractures. 
The anatomic distribution of wounds among the war injured is relatively constant, probably because wounds produced on the battlefield tend to be a random event (Table 11-3). Between 60% and 70% of wounded patients admitted to a medical treatment facility have wounds to the extremities, and about 21% of those admitted have fractures. The use of body armor to protect soldiers and airmen was studied in World War II and the Korean Conflict and was found to reduce thoracic and abdominal wounds.13,37,72,99,119,122,127 
Table 11-3
Percentage Anatomic Distribution of Wounds (Living Wounded US Soldiers)
Anatomic Area US Civil War World War I World War II Bougainville Campaign OIF/OEF
Head, Face, Neck 9.1% 11.4% 16.1% 20.7% 30%
Chest 11.7% 3.6% 9.8% 12.4% 6%
Abdomen 6.0% 3.4% 5.6% 5.7% 11%
Upper Extremity 36.6% 36.2% 28.3% 27.4% 54% upper and lower
Lower Extremity 36.6% 45.4% 40.3% 33.8%
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The proportion of casualties caused by various weapons from World War I, the Bougainville campaign in World War II, the Vietnam Conflict, and the Global War on Terrorism is shown in Table 11-1.9,99,118,119 The proportion of injuries caused by bullets has been relatively constant from conflict to conflict. Recently, fragment producing explosive munitions have accounted for an increasing proportion of casualties seen from the battlefield. This trend is expected to continue. 
The lethality of a weapon is defined as the probability of death following a hit from that weapon (Table 11-4). The Bougainville and WDMET data showed the lethality of a bullet wound was approximately 0.33. Fragments from grenades, mortars, and artillery ranged from 0.05 to 0.10. Death from tripping a land mine has been shown to be approximately 33%.7,9,97,98,118,148 
 
Table 11-4
Lethality by Weapon
View Large
Table 11-4
Lethality by Weapon
Weapon Bougainville Campaign Vietnam Conflict WDMET
Bullet 0.32 0.39
Mortar 0.12 0.13
Grenade 0.05 0.13
Artillery 0.11 0.25
Land mine 0.38 0.31
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Medical Evacuation

Wounded soldiers from the battlefield must be simultaneously treated and moved through the evacuation chain (Fig. 11-17). All major armies throughout the world have made some provisions to care for wounded soldiers. The first treatment of a wounded soldier on the battlefield consists of self-care or buddy care. The first step may be to take cover from hostile fire. Treatment for extremity wounds consists of stopping the bleeding, applying a dressing, and splinting. The next step is care provided by a medic, who evaluates the patient and adjusts the dressings and splint. The medic also has the capability of providing pain relief, administering antibiotics, and arranging for further evacuation. A battalion aid station may be the first physician contact for a wounded soldier. Here, the patient is further evaluated, splints and dressings are adjusted, and the patient is triaged. If the casualty load is light, patients are treated as they arrive. If the casualty load is heavy, patients must be triaged to allocate the resources of evacuation and surgical care. Ideally, the triage takes place along the entire evacuation chain. If a patient’s condition worsens, his or her priority may increase.97,98 
Figure 11-17
Military medical evacuation.
 
This shows the present scheme of evacuation for wounded soldiers used by the modern armed forces. Surgical care by orthopedic surgeons takes place at the forward surgical team (FST), combat support hospital (CSH), or communication zone hospitals (COMMZ).
This shows the present scheme of evacuation for wounded soldiers used by the modern armed forces. Surgical care by orthopedic surgeons takes place at the forward surgical team (FST), combat support hospital (CSH), or communication zone hospitals (COMMZ).
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Figure 11-17
Military medical evacuation.
This shows the present scheme of evacuation for wounded soldiers used by the modern armed forces. Surgical care by orthopedic surgeons takes place at the forward surgical team (FST), combat support hospital (CSH), or communication zone hospitals (COMMZ).
This shows the present scheme of evacuation for wounded soldiers used by the modern armed forces. Surgical care by orthopedic surgeons takes place at the forward surgical team (FST), combat support hospital (CSH), or communication zone hospitals (COMMZ).
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A more established medical setting is typically the next echelon of care in the evacuation scheme. This facility has the capability of providing blood transfusions and has limited radiographic capability. This unit is the first level of care with any bed holding capability. Adjacent to the medical company may be the forward surgical team (FST) that provides the first possible surgical support near the battlefield. The purpose of this unit is to provide surgical care of those patients whose outcome would be compromised by being evacuated farther for surgical care. Examples of patients who should have surgery at the FST are those with penetrating abdominal wounds who are in shock and those with major traumatic amputations. Because of the mission to treat emergent patients, the FST is staffed with one orthopedic surgeon and two general surgeons. Having an orthopedic surgeon is important to make decisions concerning amputations as well as caring for those with multiple injuries. Often those with multiple injuries have major extremity wounds. Because the FST has no bed holding capability, it must be collocated with a medical company to complete its mission. Goals of surgery are to stabilize the patients and prepare them for evacuation. The next echelon of care on the battlefield is a permanent structure with inpatient beds and includes intensive care unit capability, operating rooms, laboratory capability, and it is staffed by orthopedic surgeons in addition to general surgeons, internists, and emergency physicians. This type of facility is the first surgical echelon for the majority of battlefield patients, including those with orthopedic injuries. Goals of care at this hospital (which is ideally located near the battlefield) are to stabilize the patients and to prepare them for evacuation out of the combat zone. Examples of care for patients arriving at this point include the treatment of soft tissues, fracture stabilization via casting or external fixator application, and treatment of a partial or complete amputation. Patients may be moved to one of these surgical facilities directly from the battlefield depending on the severity of the injury and if the tactical situation permits. In more stationary situations, such as during the Vietnam Conflict, this occurs more frequently.117,146 During the Vietnam Conflict, the US military controlled the airspace and had little geographic movement of hospitals or troops, such as occurred during World War II. Because of this, overflight of facilities in the evacuation chain occurred to bring patients promptly to a permanent facility that could provide more care. 

Wound Ballistics

Wound ballistics is the science that studies the effects of penetrating projectiles on the body.27,35,36,38,40,41,43,45,46,56,57,6568,77,88,102,105,131 Three observable phenomena occur when a bullet strikes tissue. First, tissue is crushed by the projectile as it passes through, leading to a localized area of cell necrosis that is proportional to the size of the projectile. This area of the projectile’s path is called the permanent track or permanent cavity (Fig. 11-18). 
Figure 11-18
Projectile tissue interaction.
 
Three areas can be measured in the projectile tissue interaction: The sonic wave, the temporary cavity, and the permanent track. The temporary cavity is caused by a transient lateral displacement of tissue (stretch), whereas the permanent track is made by passage of the projectile, crushing tissue. The sonic wave, although measurable, has not been shown to cause tissue injury.
Three areas can be measured in the projectile tissue interaction: The sonic wave, the temporary cavity, and the permanent track. The temporary cavity is caused by a transient lateral displacement of tissue (stretch), whereas the permanent track is made by passage of the projectile, crushing tissue. The sonic wave, although measurable, has not been shown to cause tissue injury.
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Figure 11-18
Projectile tissue interaction.
Three areas can be measured in the projectile tissue interaction: The sonic wave, the temporary cavity, and the permanent track. The temporary cavity is caused by a transient lateral displacement of tissue (stretch), whereas the permanent track is made by passage of the projectile, crushing tissue. The sonic wave, although measurable, has not been shown to cause tissue injury.
Three areas can be measured in the projectile tissue interaction: The sonic wave, the temporary cavity, and the permanent track. The temporary cavity is caused by a transient lateral displacement of tissue (stretch), whereas the permanent track is made by passage of the projectile, crushing tissue. The sonic wave, although measurable, has not been shown to cause tissue injury.
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There is a second area in which elastic tissue is stretched, causing a temporary cavity.35,36,45,75,78,88,102 The stretch results from a lateral displacement of tissue that occurs after the passage of the projectile. There is a transient increase in pressure of 4 to 6 atmospheres (atm) for a few milliseconds’ duration. This transient lateral displacement of elastic tissue, such as skeletal muscle, vessels, and nerves, appears as blunt trauma, whereas inelastic tissue, such as bone, may fracture. 
A third component, known as the shock wave, is a pressure wave that travels at the speed of sound preceding the bullet in tissue. This pressure wave is only a few microseconds, but may generate pressures up to 100 atm in magnitude.45,65,66 The shock wave has not been shown to cause tissue injury. 
The two mechanisms of injury (crush and stretch) have differing effects on skin just as with other tissues.35,36,66,68,77,88,102 When a projectile strikes skin and creates a permanent cavity, it produces a small amount of necrosis that is proportional to the size of the projectile. The temporary cavity splits the skin, which produces a larger opening of tissue. Grundfest et al.56 used cadaver skin stretched over a frame to test threshold velocities for penetration. The authors used steel ball bearings from 1/16 to 1/4 inch in size as well as 11/64-inch lead spheres fired from an air rifle. They found that increasing the size of the projectile also required increasing the velocity needed to perforate the skin. 
Fackler et al.41 studied healing of soft tissue using a large porcine animal model. These investigators used a solid nondeforming 5.56-mm bullet and fired it into the thighs of the animals. The authors found larger exit wounds compared with the entrance wounds as a result of splits in the skin caused by the larger temporary cavity produced as the bullet yawed in tissue. The larger wound allowed for better exposure of the wound path and freer drainage of wounds. Also, the authors found skin vasospasm, which produces blanching, soon after wounding. This area did not revascularize for several hours. If the loss of blood supply is a criterion for excision, the transitory nature of the blanching shows that viable tissue would be sacrificed in this area if evaluated soon after wounding. 
In another study, Fackler et al.39 found that projectile shape was important in determining the appearance of a skin wound. The authors fired a solid nondeforming bullet point first and then base first, noting the different appearance of the skin wound in each case. The bullets were fired at over 5,000 fps. For the projectile going base first, large skin splits were produced by an early temporary cavity. No such effect was seen with the bullets going point first through the skin. 
Injury to skeletal muscle has been studied using animal models by Harvey et al.,66 Dziemian et al.,36,102 Mendelson and Glover,102 Fackler et al.,45 Brien et al.,20 and Fackler.45,48 Muscle that is touched by the projectile in the permanent tract has a microscopic rim of tissue that is actually necrotic. This tissue, if the blood supply to the muscle remains intact, can heal over time without surgical intervention. The area of cell death sloughs and, as long as the wound can drain, will heal spontaneously. 
Surrounding the path is an area damaged by the stretch causing the temporary cavity, which may split along fascial planes. This area appears grossly as bruised or contused tissue. Microscopically, there are disrupted skeletal muscle fibers and capillaries. After a period, there is leukocyte infiltration followed by inflammation and healing.35,44,48,65,102 
When a bullet fragments, many permanent paths are formed; thus, the region stretched by the temporary cavity is perforated in multiple places. Tissue weakened by these tiny perforations is often split by the temporary cavity stretch, and pieces between perforations become detached. This often greatly increases the size of the permanent cavity.45 
If the muzzle of a firearm is in contact with a living body when it is fired, the high-pressure gas that pushes the projectile out of the barrel will pass into the tissues through the hole formed by the projectile—often causing greatly increased tissue displacement and disruption. 
Bone injury is common with gunshot wounds to the extremities.27,57,75,76,105,131 Fractures may occur via two mechanisms, directly when the projectile strikes bone (Fig. 11-19) or, rarely, indirectly by the temporary cavity. Due to the density and relative inelastic behavior of bone, fracture line propagation may occur well beyond the area crushed by the projectile itself, leading to bone comminution and the production of secondary missiles from the bone itself. Because the secondary missiles of bone disrupt tissue before it is stretched by the temporary cavity, this has the effect of increasing comminution around the bullet path, and can cause increased soft tissue disruption, reminiscent of the previously mentioned synergism between bullet fragmentation and temporary cavity stretch. 
Figure 11-19
Direct fracture.
 
Cortical bone is very dense, so when a projectile strikes, fracture lines propagate away from the bullet’s path, causing comminution. The temporary cavity may cause further displacement.
Cortical bone is very dense, so when a projectile strikes, fracture lines propagate away from the bullet’s path, causing comminution. The temporary cavity may cause further displacement.
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Figure 11-19
Direct fracture.
Cortical bone is very dense, so when a projectile strikes, fracture lines propagate away from the bullet’s path, causing comminution. The temporary cavity may cause further displacement.
Cortical bone is very dense, so when a projectile strikes, fracture lines propagate away from the bullet’s path, causing comminution. The temporary cavity may cause further displacement.
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Indirect fractures (Fig. 11-20) may occur when a projectile passes close to the bone in soft tissue and a strain occurs to such a degree as to cause a fracture. Indirect fractures are almost always simple in pattern (Fig. 11-20). Clinically, indirect fractures to bone are rare compared with those formed when bone is struck directly by the projectile.3,47,70,74,99 Figure 11-20 illustrates the shot path 8 mm from the edge of the diaphyseal bone in ordnance gelatin, showing how indirect fractures appear. The bullet path is perpendicular to the page, going away from the reader. 
Figure 11-20
Indirect fracture.
 
A fracture may occur without the bullet striking the bone. This illustrates a bullet path (arrow) 8 mm away from the edge of the bone. The path of the bullet is perpendicular to the plane of the page, with the bullet path going away from the reader. A simple fracture occurred from the effects of the temporary cavity.
A fracture may occur without the bullet striking the bone. This illustrates a bullet path (arrow) 8 mm away from the edge of the bone. The path of the bullet is perpendicular to the plane of the page, with the bullet path going away from the reader. A simple fracture occurred from the effects of the temporary cavity.
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Figure 11-20
Indirect fracture.
A fracture may occur without the bullet striking the bone. This illustrates a bullet path (arrow) 8 mm away from the edge of the bone. The path of the bullet is perpendicular to the plane of the page, with the bullet path going away from the reader. A simple fracture occurred from the effects of the temporary cavity.
A fracture may occur without the bullet striking the bone. This illustrates a bullet path (arrow) 8 mm away from the edge of the bone. The path of the bullet is perpendicular to the plane of the page, with the bullet path going away from the reader. A simple fracture occurred from the effects of the temporary cavity.
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Clasper et al.27 used sheep femora and hind limbs to study contamination of both direct and indirect fractures. The authors fired through fluorescein-soaked gauze placed on the surface of the skin to determine the amount of fracture site contamination that occurred with each shot. The authors found massive fluorescein contamination with the direct fractures; however, only 3 of 14 bones with indirect fractures had medullary fluorescein contamination. Periosteal contamination was less with indirect fractures compared with the direct fractures. 
Rose et al.131 proposed a classification of incomplete fractures because of gunshot wounds, describing “drill hole” and “divot” fractures. The “drill hole” fractures are seen with bullet perforation of both cortices yet minimal comminution surrounding the bullet tract. They occur in metaphyseal bone. The “divot” fracture was described as an eccentric perforation of a diaphyseal long bone usually producing a unicortical defect. More extensive injury may be present than apparent on plain radiographs, and the “divot” injury may be an occult complete fracture of diaphyseal bone. Such fractures should be treated as complete fractures unless other radiographic measures, such as a CT scan, show an incomplete fracture. 
There are common misconceptions about wound ballistics.48 First, some authors have exaggerated the effects of velocity to include it as being the sole criterion for increased injury or as a means to classify gunshot wounds. Velocity is one of several factors involved with the production of the wound. The introduction of the M16 rifle during the Vietnam Conflict was heralded as producing equivalent wounds or causing equivalent “incapacitation” because of the weapon’s higher muzzle velocity of an advertised 3,200 fps. Later testing in the laboratory found that the increased severity of wounds sometimes seen with the M16A1 was the result of bullet fragmentation, not the modest 10% increase in velocity. In fact, the greatest increase in muzzle velocity for military rifles occurred in the late 19th century when the armed services of several nations, changed to a full metal-jacketed bullet from a solid lead one: This doubled muzzle velocity. This resulted in an increase of muzzle velocity from about 1,000 to 2,000 fps.48 The change in firearms; however, resulted in decreased wound severity because bullet deformation was limited by the jacketing. 
A second common misconception48 is the idea that “kinetic energy” or “energy deposit” is directly proportional to wound severity. Kinetic energy is the amount of potential energy available for work. “Energy deposit” is a description of how much energy is lost or “deposited” in tissue. While one can measure the projectile’s velocity and weight as it enters and exits a body or tissue medium, it does not describe how this potential energy is used. The potential energy may be used for the crush or stretch, but it may also be consumed in mechanics that may not cause any tissue injury. Examples where energy may be consumed, but not cause tissue damage, include the shock wave, bullet heating, and bullet deformation. 

Soft Tissue Wound Management

Patient Evaluation

Initial evaluation of a patient with any gunshot wound should include a thorough history and physical examination. The extremity should be inspected for both entrance and exit wounds after all clothing has been removed. The limb should also be inspected for swelling, deformity or shortening, and ecchymosis. The limb should be palpated for crepitus. Examination for distal pulses should be done to assess vascular status. In an awake patient, assessment should also be done to assess the patient’s motor and sensory status distal to the injury. If the patient is not able to comply, this fact should be documented with a note to recheck if the patient’s condition improves: The routine practice of writing “neurovascular intact” for a patient who cannot be properly examined is to be discouraged. 
Biplanar radiographs should be taken of the injured limb covering the path of the bullet. Standard long bone radiographs, including both the joint above and below, should be done if included in the bullet’s path. If a joint wound is suspected, standard views should be taken of the joint. 
The most common injuries by gunshot wound are to the soft tissues of skin, subcutaneous fat, and the skeletal muscle. 

Skin Injuries

Gunshot skin wounds have three general patterns. First, there is a punctate wound the size of the penetrating bullet (Fig. 11-21). Second, there is a wound that contains splits in the skin but has negligible skin loss and can eventually be closed without resorting to more extensive skin grafting or flap coverage (Fig. 11-22). Third, there is a wound in which there is skin loss, which requires the use of partial-thickness skin grafting or flap coverage (Fig. 11-23). 
Figure 11-21
Simple perforating wound.
 
This shows a simple wound caused by perforation of the bullet.
This shows a simple wound caused by perforation of the bullet.
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Figure 11-21
Simple perforating wound.
This shows a simple wound caused by perforation of the bullet.
This shows a simple wound caused by perforation of the bullet.
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Figure 11-22
Skin splits.
 
Splits in the skin may be caused by bone fragments, debris, or the stretch of the temporary cavity.
Splits in the skin may be caused by bone fragments, debris, or the stretch of the temporary cavity.
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Figure 11-22
Skin splits.
Splits in the skin may be caused by bone fragments, debris, or the stretch of the temporary cavity.
Splits in the skin may be caused by bone fragments, debris, or the stretch of the temporary cavity.
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Figure 11-23
Skin defect.
 
A skin defect may occur from secondary missiles created by bone fragments or by multiple fragments or projectiles. This case illustrates a shotgun wound from close range.
A skin defect may occur from secondary missiles created by bone fragments or by multiple fragments or projectiles. This case illustrates a shotgun wound from close range.
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Figure 11-23
Skin defect.
A skin defect may occur from secondary missiles created by bone fragments or by multiple fragments or projectiles. This case illustrates a shotgun wound from close range.
A skin defect may occur from secondary missiles created by bone fragments or by multiple fragments or projectiles. This case illustrates a shotgun wound from close range.
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Perforating nonarticular wounds without a fracture or vascular injury may be candidates for outpatient treatment.25,118 Under controlled circumstances, simple perforating wounds have been shown to heal uneventfully with simple dressing changes.49,67,102 Successful treatment with local wound care has been reported by several authors.25,31,62,100,108 Likewise, successful treatment of simple fractures associated with minimal soft tissue disruption have also been treated with local wound care and fracture stabilization in a cast or splint.85,92,100,158 
Simple splits in the skin are produced from dilation resulting from the temporary cavity, from a projectile that is traveling sideways and presenting the long axis of the bullet to the skin, or from bone becoming a secondary missile, causing a more extensive wound. The splits produce an exit wound that will allow for free drainage of the wound, preventing the formation of an abscess or a hematoma. 
More extensive wounds with skin loss may be produced from shotgun pellets, bullets, or bone fragmentation. Initial treatment of the more extensive wounds should be done in the operating room. Longitudinal incisions of the skin and underlying fascia to relieve pressure, remove hematoma and debris, and expose the underlying muscle should be done. Surgical removal of skin is rarely indicated for the initial surgery, other than trimming irregular edges. As described earlier, blanching may give a false impression of nonviable skin if seen soon after injury and lead the surgeon to excise viable skin. 
In contrast, fragment wounds are the most common types seen in wartime. Injuries range from single fragment wounds to multiple fragment wounds with extensive soft tissue loss (Fig. 11-24). Often, a person has multiple fragment wounds of the extremity skin, subcutaneous fat, and skeletal muscle, yet without significant injury to bone, vascular, or nerve structures.9,118,148 In certain controlled circumstances, small fragment wounds may be treated nonoperatively.17,77 
Figure 11-24
Multiple fragment wounds.
 
This illustrates multiple small skin wounds that occur with many exploding munitions. They are often of the skin, subcutaneous fat, and skeletal muscle only.
This illustrates multiple small skin wounds that occur with many exploding munitions. They are often of the skin, subcutaneous fat, and skeletal muscle only.
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Figure 11-24
Multiple fragment wounds.
This illustrates multiple small skin wounds that occur with many exploding munitions. They are often of the skin, subcutaneous fat, and skeletal muscle only.
This illustrates multiple small skin wounds that occur with many exploding munitions. They are often of the skin, subcutaneous fat, and skeletal muscle only.
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The use of negative pressure wound therapy (NPWT) for the initial management of more extensive wounds has been suggested to reduce the size of defect needing coverage, promote local growth factors, and remove debris and nonviable tissue from the wound. A randomized study comparing NPWT to standard dressing changes in “high-risk” fracture patients demonstrated a decreased incidence of wound dehiscence and total infections in the NPWT group.91,117,143 
Large soft tissue injury deficits that cannot be closed primarily can be treated with split-thickness skin grafting if there is adequate muscle to support the graft. Areas where tendon or bone are exposed generally require tissue transfers; however, some success has been achieved with the use of dermal substitutes followed by skin grafting.70 An early consultation should be made with a plastic surgeon or a hand surgeon who is skilled in extremity soft tissue coverage. Before soft tissue coverage, the wound should be stable. 

Skeletal Muscle Injuries

One of the most controversial aspects in caring for gunshot wounds is the treatment of skeletal muscle. Mendelson and Glover,102 Brien et al.,20 Dziemian and Herget,35 Fackler,46 Harvey et al.,66 and Helgeson et al.70 all demonstrated that a relatively minimal margin of necrosis occurs in skeletal muscle if the blood supply remains intact. Excision of tissue has been recommended for dead skeletal muscle but identification of tissue that needs to be excised remains imprecise. Artz et al.3 and Heitmann et al.69 evaluated 60 biopsy samples taken from the initial wound excision of 12 war wounds during the Korean Conflict. The surgery took place between 3 and 8 hours from the time of injury. The samples were graded by the surgeon as to the presence of the four “C’s”: Color, consistency, contractility, and circulation (bleeding). The samples were then evaluated by a pathologist who graded the degree of muscle fiber damage. The authors found correlation of microscopic damage to consistency, contractility, and bleeding. Color was not found to correlate to the degree of soft tissue damage. Also, time was not found to be a factor in determining tissue viability. 
For wounds in which there is a simple perforation of the limb, there is a small rim of cell death that will heal uneventfully if the wounds are allowed to drain.41,67,102 For wounds in which there is more extensive skeletal muscle injury, a more formal exploration of the wound is warranted. The wound may be enlarged through the use of longitudinal skin incisions as described earlier. Macroscopic evaluation of skeletal muscle helps determine what tissue needs to be removed. A simple analogy for surgeons is, “muscle that looks like hamburger should be excised, muscle that looks like steak should stay.” 
The term debridement is derived from the French verb débrider, which means “to unbridle or release.”29,47,52,65,74,94 As noted by Harvey et al.65 and Fackler,47 the original translation of works from the Napoleonic Wars by Larrey and Desault showed that incision, to allow for free drainage of the wound and to relieve swelling (compartment pressure), was the technique used by these surgeons for extremity wounds. 
Hampton had a similar description: “Debridement of any wound is designed to relieve the area of excessive tension, rid it of dead tissue and massive hematoma and provide excellent drainage. Perhaps relief of tension is the most important contribution of wound debridement.62 
Compartment syndrome occurs when there is swelling inside a relatively closed space, such as the anterior compartment of the leg, which is surrounded by fascia and bone. The swelling occurs because of direct trauma, hemorrhage, hematoma, or ischemia, and the diagnosis of compartment syndrome remains primarily clinical. 
Compartment syndrome associated with gunshot wounds has been reported in the forearm,37,107 leg,151 and thigh.11,52 Forearm compartment syndrome has been well documented and is present in up to 10% of patients with GSW’s to the forearm.107 Longitudinal incisions to release pressure within a compartment and to expose tissue has been recommended by military surgeons since the time of the Napoleonic Wars.47 
The amount of swelling present in a compartment after a gunshot wound may range from minimal to that involving the entire compartment. Involvement of the entire compartment is rare, but it does occur when patients have extensive soft tissue injury or vascular injury causing ischemia. With the initial evaluation, patients with a large hematoma, vascular injury, or excess swelling are candidates for formal operative release of the fascia. 

Wound Infection

Infection has been documented in 1.5% to 5% for those who sustain gunshot injury. Bullet wounds are contaminated wounds. Bullets themselves, when fired, do not become “sterile” because of the heating and friction encountered in the barrel. LaGarde89 created contaminated wounds by firing bullets contaminated with anthrax into an animal model. The animals developed an anthrax infection. Dziemian and Herget35 placed barium sulfate dye on the surface of an ordnance gelatin block. After shooting through the surface into the gelatin, the dye coated the entire path of the projectile’s path, showing that surface material is brought into the wound. 
Simchen et al.138 and Simchen and Sacks139 evaluated 420 wounded Israeli soldiers following the 1973 October War. They found an overall infection rate of 22% for all wounded. Wounds from explosive munitions have a higher rate of infection than those from gunshot wounds alone. Eight of 20 (40%) soldiers with femur fractures developed infection. In addition to femur fractures, the authors found burns of greater than 25% body surface area and penetrating abdominal wounds of the colon were risk factors. 
Simchen et al.138 further evaluated risk factors in war wounds after the 1982 War in Lebanon. The authors compared 1 month of hospital admissions for wounded Israeli soldiers during the 1973 and 1982 wars. They found the overall infection rates were similar between the two groups (31.5% and 30.4%, respectively). Risk factors for fracture site infections were found to be the presence of open drains, amputations, multisystem injury, and a fractured femur. 
The discovery of penicillin in 1929 by Sir Alexander Fleming led to its use in caring for the wounded during World War II. Fisher et al.51 compared 3,471 wounded soldiers with 436 soldiers who had wounds “at risk” for the development of gas gangrene (open fractures, more extensive soft tissue injury, long delay to care, wounds to the buttock or thigh). Those with wounds at risk were treated with penicillin, whereas those without at-risk wounds were not. Infection developed in 28 of 3,471 (5 with gas gangrene) untreated wounds and in 2 of 436 (0 with gas gangrene) penicillin-treated wounds. 
In a recent series of military long bone fractures treated with intramedullary fixation an infection rate of 40% was found, with osteomyelitis in 17%. Blast injuries were found to have a significantly higher number of infections. In a recent series of open tibia fractures treated with circular ring external fixation the infection rate was 8%.82 
Patzakis et al.121 divided 310 patients with open fractures (78 due to gunshot wounds) into one of three treatment groups: No antibiotics, penicillin and streptomycin, and cephalothin. Four of 78 wounds (5%) became infected, one with osteomyelitis. The authors attributed the infection to severity of injury in three of the patients who had shotgun wounds with extensive soft tissue damage. A fourth infection occurred in the no-antibiotic group. 
Hansraj et al.63 compared the use of a one dose of 1-g intravenous ceftriaxone to a 1-g intravenous dose of cefazolin given three times a day for 3 days for gunshot fractures with minimal soft tissue disruption (<1-cm wound) that were treated nonoperatively. There were 50 patients in each group with a follow-up of 59%. The authors reported no infections based on the cultures taken in the emergency department and concluded that the single 1-g dose of ceftriaxone regimen was more cost effective than the 3-day cefazolin regimen. 
Knapp et al.85 reported a prospective study at their institution of 186 patients with 218 gunshot fractures. All fractures were treated nonoperatively and were considered to be “low velocity” based on the appearance of the wound and history. Wounds larger than 1 cm associated with fractures were excluded. The authors compared the use of oral antibiotics (ciprofloxacin 750 mg twice a day) to the use of intravenous antibiotics (cephapirin sodium 2 g every 4 hours and gentamicin 80 mg every 8 hours). There were two infections reported in each group. All infections were associated with fractures of the distal tibia. 
The prevalence of infected gunshot wounds in the nonmilitary setting is low. These studies showed no difference in infection rates with any particular antibiotic regimen; rather, it was the use of antibiotics that helped reduce infection. Infection rates from war wounds remain higher than those associated with nonmilitary gunshot wounds alone due to multiple factors including higher velocity gunshot wounds, explosive munitions, and delayed care because of medical evacuation.53,59,161 

Authors’ Preferred Method of Treatment

 
 
Antibiotic Recommendations for Nonmilitary Gunshot Wounds
 

The authors’ current antibiotic recommendations (Table 11-5) for nonmilitary gunshot wounds are dependent on injury severity. Isolated perforating wounds of the soft tissue only without vascular injury, or those patients with isolated simple fractures, may be treated initially with a first-generation cephalosporin. This applies to those who are treated as either inpatients or outpatients. Those with more extensive injuries with soft tissue loss may benefit from the addition of an aminoglycoside. For patients who are allergic to penicillin, clindamycin or vancomycin is used.

 
Table 11-5
Recommended Antibiotic Regimen
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Table 11-5
Recommended Antibiotic Regimen
Location Antibiotic Dosing
Soft tissue First-generation cephalosporin 1 g IV in ED, then followed by PO if outpatient
Soft tissue (shotgun) with defect First-generation cephalosporin; consider aminoglycoside for similar time Check renal function
Joint First-generation cephalosporin 1 g IV q8h for 48 h
Joint with soft tissue defect First-generation cephalosporin; consider aminoglycoside for similar time Check renal function
Long bone fracture; minimally displaced with minimal soft tissue injury, outpatient First-generation cephalosporin or oral fluoroquinolones 1 g IV kefzol followed by cephalexin 500 mg PO TID or ciprofloxacin 750 mg BID
Long bone fracture with internal fixation First-generation cephalosporin 1 g IV q8h for 48 h
Long bone plus extensive soft tissue injury First-generation cephalosporin; consider aminoglycoside Check renal function
 

If cephalosporin or penicillin allergy, consider clindamycin (600 mg IV BID) or vancomycin (dosing per individual patient).

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Joint Injury

Gunshot injuries of the joint are associated with a high morbidity compared with other gunshot wounds. Intra-articular injuries may result in arthritis secondary to trauma as well as through the degenerative effects of lead itself if there is a retained intra-articular bullet fragment. While elevated serum lead levels may be present with extra-articular gunshot wounds, the most common reports are with intra-articular retained bullet fragments.95,136 

Pathophysiology of Lead Toxicity

Lead is soluble in synovial fluid and has been shown to induce lead synovitis and degenerative arthritis.15,64,93,95,136 Retained intra-articular bullets not only cause lead synovitis and arthritis but also can cause systemic lead poisoning. Animal studies have demonstrated significant articular degeneration with implantation of lead into rabbit knees compared with controls.15 Early changes (1 to 2 weeks) include synovial hyperplasia, mild inflammation, and articular surface slit formation. Late changes (3 to 6 weeks) include giant cells and foreign particles (lead and bone fragments) in the synovium, focal chondrocyte proliferation, duplication of the tidemark, and chondrocyte columnar disorganization.15,164 Implantation of lead pellets into rabbit knees induces significantly greater degeneration in the femoral and tibial articular surfaces; medial and lateral menisci; and synovium at 4, 6, 10, and 14 weeks.15,64,93,95,136 
The normal blood lead level for adults is 0 to 19 μg/dL. Nearly 95% of the lead storage in the body occurs in bone. The half-life of lead in the blood stream is less than 2 months compared with 20 to 30 years in the bone.95 

Principles of Management

Lead is still the major component of both rifle and handgun bullets, and it may be a potential source of lead poisoning. Steel shot has replaced lead in many areas of the world in an attempt to reduce the lead burden on wildlife. Bismuth shot is also being used as a lead replacement in Canada. Modern shotguns may therefore be firing steel rather than lead shot. Regardless of whether the projectile is known to be lead, trauma from a bullet, pellet, or fragment will still have adverse consequences for the joint and most intra-articular projectiles should be removed. Through irrigation and debridement of the joint cavity is necessary to remove all the foreign material, including fragments of skin and clothing. 
A perforating wound through a joint cavity, even with the absence of fracture, should undergo surgery. Clothing and other debris from the outside may be left entrapped in the joint. Cartilage damage is common despite the normal radiographic appearance of the joint.149 
Arthroscopy has been described as a technique for treating patients with intra-articular bullet injures of the shoulder, elbow, hip, and knee. Advantages of this technique include better visualization of the joint surface and the ability to more easily repair osteochondral fragments, ligament tears, or meniscal damage. Disadvantages include increased146 operative and setup time as well as potential compartment syndrome from extravasation of lavage fluid, particularly if a pressure pump is used. Care must be taken with using this technique to ensure the equipment is available and the surgeon is familiar with its use. 

Shoulder Injuries

Gunshot injury to the entire shoulder region is relatively common, with one series reporting an incidence of 9%.117 Injuries involving the shoulder joint itself, however, range from 1% to 2% of an overall series.24,29,109,116,117,146 Associated injuries are common with penetrating injuries of the shoulder region, including arterial, venous, and nerve injuries. Vascular injury is present in 15% of these cases. The risk of vascular injury in the shoulder is four times higher in patients with a major fracture than in those without a major fracture.158,161 Nerve injuries are the most important determinant of long-term function of the limb. The literature supports the use of either arthroscopy or open surgical techniques for removal of the bullet or its fragments from the shoulder joint and the subacromial space.24,29,116,117,146 In cases where the joint capsule is violated by the bullet and the bullet has traversed the joint, clothing fragments, skin, and other debris may be driven into the joint. Even in the absence of intra-articular bullet fragments, irrigation and debridement of the joint is warranted. 
Fractures that are nondisplaced or easily reducible may be stabilized with arthroscopic techniques. Small and nonviable fragments should be removed.26 Unstable fractures and those involving the articular surface require open reduction and internal fixation. Large osteochondral fragments can be stabilized with bioabsorbable pins, headless screws, or a combination of these devices (Fig. 11-25). In the presence of intra-articular fracture displacement, comminution, and metaphyseal–diaphyseal dissociation, an open technique with a deltopectoral approach is used to reconstruct the joint surface. Fractures of the surgical neck and shaft can be addressed with internal fixation using a locked plate and screws. Hemiarthroplasty is an option in nonreconstructable fractures. 
Figure 11-25
Preoperative anteroposterior (A) and lateral (B) radiographs and computed tomography scan (C) of the shoulder showing intra-articular injury from gunshot.
 
D: Postoperative radiograph showing reduction with plate and screws and removal of intra-articular bullet fragments. Headless screws were used for the articular fragments.
D: Postoperative radiograph showing reduction with plate and screws and removal of intra-articular bullet fragments. Headless screws were used for the articular fragments.
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Figure 11-25
Preoperative anteroposterior (A) and lateral (B) radiographs and computed tomography scan (C) of the shoulder showing intra-articular injury from gunshot.
D: Postoperative radiograph showing reduction with plate and screws and removal of intra-articular bullet fragments. Headless screws were used for the articular fragments.
D: Postoperative radiograph showing reduction with plate and screws and removal of intra-articular bullet fragments. Headless screws were used for the articular fragments.
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Brachial plexus and nerve injuries can occur with gunshot wounds to the shoulder region.144 In a series of 58 patients with penetrating injury to the brachial plexus, there were 6 ulnar nerve injuries, 12 median nerve injuries, 2 radial nerve injuries, 5 musculocutaneous nerve injuries, 1 axillary nerve injury, and 3 suprascapular nerve injuries. In the same cohort, there were 13 fifth cervical, 10 sixth cervical, 10 seventh cervical, 5 eighth cervical, and 10 first thoracic root injuries. There were 8 lateral cord, 6 medial cord, and 10 posterior cord injuries. The trunk injuries included seven upper trunk, three middle trunk, and three lower trunk injuries. In this series, 24% of the patients had associated vascular injuries. One or more elements of the plexus were repaired in 36 of the 58 patients in this series. There were 3 good (8%), 23 useful (64%), and 8 (22%) poor results.144 The main complications include stiffness, infection, and pain. 

Elbow Injuries

The incidence of gunshot wounds to the elbow may be underestimated in the literature.18,24,30,78,101,141 Associated injuries include periarticular fractures, nerve injuries, and arterial and venous injuries.24,115 In rare cases of an isolated bullet or pellet retained in the elbow joint, irrigation and debridement and bullet removal can be achieved with the use of the arthroscope.78 

Authors’ Preferred Method of Treatment

 
 
Recommended Treatment for a Suspected Elbow Joint Injury
 

Recommended treatment for patients with a suspected elbow joint injury from a gunshot wound is open irrigation and debridement of the joint, and removal of foreign material, bullet fragments, or small loose bone fragments, if present. Initial stabilization of the elbow following a fracture of the distal humerus, the proximal radius, or proximal ulna can be done with a splint. With more comminuted fractures, use of external fixation spanning the elbow can be utilized temporarily. After stabilization, CT will aid in assessment of the fracture and the elbow joint for definitive fracture fixation (Fig. 11-26A–D). In unstable fracture-dislocations, urgent internal fixation of the fractures may be necessary, alone or in addition to spanning external fixation of the joint.18

 
Figure 11-26
Anteroposterior (A) and lateral (B) preoperative views of a distal humerus fracture with intra-articular extension.
 
C, D: Computed tomography scan shows the lateral femoral condyle fracture at that both CT scans shown are of the distal femur at multiple levels. E,F: An external fixator was applied, followed by bicolumnar plate fixation after the swelling of the limb subsided. The external fixator pins should be placed outside the (1) zone of injury and (2) the anticipated operative field.
C, D: Computed tomography scan shows the lateral femoral condyle fracture at that both CT scans shown are of the distal femur at multiple levels. E,F: An external fixator was applied, followed by bicolumnar plate fixation after the swelling of the limb subsided. The external fixator pins should be placed outside the (1) zone of injury and (2) the anticipated operative field.
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C, D: Computed tomography scan shows the lateral femoral condyle fracture at that both CT scans shown are of the distal femur at multiple levels. E,F: An external fixator was applied, followed by bicolumnar plate fixation after the swelling of the limb subsided. The external fixator pins should be placed outside the (1) zone of injury and (2) the anticipated operative field.
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Figure 11-26
Anteroposterior (A) and lateral (B) preoperative views of a distal humerus fracture with intra-articular extension.
C, D: Computed tomography scan shows the lateral femoral condyle fracture at that both CT scans shown are of the distal femur at multiple levels. E,F: An external fixator was applied, followed by bicolumnar plate fixation after the swelling of the limb subsided. The external fixator pins should be placed outside the (1) zone of injury and (2) the anticipated operative field.
C, D: Computed tomography scan shows the lateral femoral condyle fracture at that both CT scans shown are of the distal femur at multiple levels. E,F: An external fixator was applied, followed by bicolumnar plate fixation after the swelling of the limb subsided. The external fixator pins should be placed outside the (1) zone of injury and (2) the anticipated operative field.
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C, D: Computed tomography scan shows the lateral femoral condyle fracture at that both CT scans shown are of the distal femur at multiple levels. E,F: An external fixator was applied, followed by bicolumnar plate fixation after the swelling of the limb subsided. The external fixator pins should be placed outside the (1) zone of injury and (2) the anticipated operative field.
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Definitive treatment may involve a combination of various techniques, including internal fixation and/or hinged external fixation (Fig. 11-26E–F). Salvage of a severely injured joint may be achieved with compression plate arthrodesis of the elbow101 or, in elderly low demand patients arthroplasty could be used.30 Young and active patients are not good candidates for elbow arthroplasty. In one study, intermediate-range follow-up of 8 to 12 years postarthroplasty showed a five of seven (71%) failure rate. Arthrodesis may be indicated for a nonsalvagable elbow joint in which there is good distal limb function. This is particularly true if the patient is young, has reasonable bone stock, poor soft tissue coverage, and is free of infection.101 Complications of elbow gunshot wounds include stiffness, malunion, nonunion, infection, and nerve injury.115 In a cohort of 44 patients at the author’s institution, 4 died of other injuries and 6 were lost to follow-up. Of the remaining 34 patients, 19 (56%) patients had nerve injuries. The nerve injuries included 8 ulnar, 11 radial, and 2 median nerve injuries. Two patients had combined injuries. Two nerves (one radial and one ulnar) were repaired with partial return of function. Two complete radial nerve injuries were treated with tendon transfers. Four patients (12%) had brachial artery injury that required repair. Four patients (12%) developed deep infections requiring irrigation and debridement in the operating room. Three patients required secondary bone grafting to achieve bony union of the fracture.

Hip Injuries

In our series (Table 11-2), the prevalence of gunshot wounds to the hip joint was 2% of all extremity gunshot wounds and 4% of lower extremity gunshot wounds. The prevalence of gunshot wounds to the hip region (femoral neck, peritrochanteric region), was 9% of all extremity gunshot wounds and 17% of lower extremity gunshot wounds. 
The diagnosis of hip joint violation is an important step in management of these injuries. The trajectory of the bullet or its fragments can traverse the abdomen, bowel, and/or bladder before violating the hip joint. The projectile may enter the hip capsule without causing a fracture of the acetabulum or the proximal femur, or enter through the acetabulum. In the absence of a fracture, the diagnosis of hip joint violation can be difficult. 
The diagnosis is based on radiographic and CT scan findings. In the absence of fractures, or when radiographs are inconclusive, a fluoroscopically assisted arthrogram is the most sensitive test to detect joint violation.20,96 Documentation is important to determine the need for surgery to lavage the joint. A negative arthrogram eliminates the need for surgery due to joint contamination. 
Transabdominal gunshot wounds to the hip joint carry a high risk of infection and should be treated with emergent arthrotomy, irrigation, and debridement. Bowel and bladder injuries should be managed by general surgeons and urologists with either direct repair or diverting colostomy and diversion procedures for the urinary tract respectively.6,20,32 
Bullet removal can be achieved via arthrotomy or arthroscopy.28,54,96,103,104,106,140,147,163 Hip arthroscopy requires special equipment and experience with the technique. The use of a fracture table and fluoroscopy aids in arthroscopy of the hip. Hip arthroscopy carries the risk of intra-abdominal fluid extravasation and abdominal compartment syndrome.6 In the presence of acetabular fractures, extreme care must be taken to measure the arthroscopy fluid inflow and outflow. If the inflow and outflow are mismatched, fluid is likely extravasating into the pelvis and abdomen and can cause cardiopulmonary arrest.96 
Recommended treatment of associated fractures is by open reduction and internal fixation. For acute fractures of the femoral neck, use of standard techniques such as a compression screw and side plate may be used for fractures with minimal comminution (Fig. 11-27). Comminuted fractures of the femoral neck may be treated by using fixed-angle devices such as a locking plate or blade plate. 
Femoral neck fractures caused by gunshots tend to be comminuted.
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Figure 11-27
Anteroposterior preoperative (A) and postoperative (B) radiographs of a femoral neck fracture caused by a gunshot.
Femoral neck fractures caused by gunshots tend to be comminuted.
Femoral neck fractures caused by gunshots tend to be comminuted.
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Patients with more extensive injury to the articular surface of the femoral head or acetabulum represent difficult clinical problems. Hip arthroplasty or arthrodesis in the acute setting is not recommended.109,112 These procedures are reserved as elective salvage procedures. In the presence of severe comminution when inadequate bone is available for internal fixation, resection arthroplasty may be performed in the acute setting. Complications of gunshot wounds to the hip include arthrosis, infection, fistula formation,115,132 nonunion, malunion, and osteonecrosis. 

Knee Injuries

Gunshot wounds to the knee region, including the distal femur and proximal tibia, are relatively frequent in reported series of gunshot wounds.9,24,120,122124,149 Perry et al.122 and Guo and Chiou-Tan58 described on gunshot-related 67 fractures to the knee: 37 sustained intra-articular fractures and 27 sustained extra-articular fractures. There were 29 femoral, 29 tibial, and 9 patellar fractures. Twenty-three patients had arteriograms for suspected vascular injury; six were positive. Five limbs required vascular repair: One each of the common popliteal artery, a branch of the common femoral artery, both the peroneal and posterior tibial arteries, and the superficial femoral artery. Two patients had a common peroneal nerve injury. There were also two reported infections: One superficial and one deep. 
The diagnosis of an open knee joint injury in the absence of radiographic evidence of intra-articular debris, air, or presence of fractures can be difficult. A saline arthrogram or dye arthrogram can aid in diagnosis if the test is positive although large volumes of saline (75 to 100 mL) may be required. However, these tests traditionally have a low sensitivity of around 40% and a negative arthrogram does not rule out an open joint injury.128,148 More recent studies have revealed higher sensitivities with increased volumes of saline injected.87 
Goals of initial surgical treatment are to prevent infection and stabilize the limb. In the presence of severely comminuted and unstable fractures, spanning external fixation of the joint is recommended. Delayed reconstruction of the joint may be undertaken once the limb is stable. For larger fractures, an arthrotomy should be used in treating major fractures with open reduction and internal fixation (Fig. 11-28). 
Figure 11-28
Preoperative anteroposterior (A) and lateral (B) radiographs of a knee.
 
C and D: Computed tomography scan shows the lateral femoral condyle fracture and proximal tibia fractures. E and F: This patient was treated with open reduction and internal fixation of both fractures and irrigation/debridement of the joint.
C and D: Computed tomography scan shows the lateral femoral condyle fracture and proximal tibia fractures. E and F: This patient was treated with open reduction and internal fixation of both fractures and irrigation/debridement of the joint.
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C and D: Computed tomography scan shows the lateral femoral condyle fracture and proximal tibia fractures. E and F: This patient was treated with open reduction and internal fixation of both fractures and irrigation/debridement of the joint.
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Figure 11-28
Preoperative anteroposterior (A) and lateral (B) radiographs of a knee.
C and D: Computed tomography scan shows the lateral femoral condyle fracture and proximal tibia fractures. E and F: This patient was treated with open reduction and internal fixation of both fractures and irrigation/debridement of the joint.
C and D: Computed tomography scan shows the lateral femoral condyle fracture and proximal tibia fractures. E and F: This patient was treated with open reduction and internal fixation of both fractures and irrigation/debridement of the joint.
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C and D: Computed tomography scan shows the lateral femoral condyle fracture and proximal tibia fractures. E and F: This patient was treated with open reduction and internal fixation of both fractures and irrigation/debridement of the joint.
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In the presence of unstable fractures, or other associated injuries, acute reconstruction of ligaments is not recommended. In these cases, a delayed reconstruction after fracture healing and rehabilitation may be undertaken. Meniscal tears, ligament tears with bony avulsions, and large osteochondral fragments may be fixed acutely. 
The role of arthroscopy in managing gunshot wounds of the knee has been studied by Tornetta and Hui149 and Nowotarski and Brumback.114 In a review of 33 gunshot wounds to the knee without radiographic evidence of injury, arthroscopy showed 5 chondral injuries, 14 meniscal injuries, and 5 cases with intra-articular debris not seen on radiographs. Based on these findings, diagnostic arthroscopy and arthroscopic-assisted bullet removal and irrigation and debridement are recommended for gunshot wounds through the knee. 

Ankle Injuries

In our series, the prevalence of gunshot wounds to the ankle is 0.5% of those to the lower extremity. Associated injuries include fractures and nerve, vascular, and tendon injuries.16,160 Treatment is based on the personality of the fracture, ranging from spanning external fixation and/or internal fixation for a low-velocity injury. For patients with more severe soft tissue or bone injury, arthrodesis or even amputation should be considered. Arthroscopy is of limited use because of the confined ankle space, good access through conventional incisions, and the prevalence of fracture necessitating open debridement or repair. 

Long Bone Fractures

Long bone fractures caused by gunshot wounds still pose a significant clinical problem for orthopedic surgeons in war or peace. On the battlefield, caring for patients involves both transportation and treatment. The evacuation of patients may involve long distances, aircraft flight, and delayed definitive care. Initial treatment of gunshot fractures in this setting involves temporary stabilization with subsequent evacuation, followed by definitive fixation once the patient arrives in a stable hospital environment. Temporary stabilization involves the use of an external fixator to span the fracture segment. 
In the nonmilitary setting, patients are usually seen and cared for at the same institution, in a stable medical environment without the complexity of patient transportation through multiple echelons of care. Immediate definitive stabilization for patients with isolated long bone gunshot fractures is the standard of care in most civilian settings. 

Humerus Fractures

Upper extremity long bone fractures are less prevalent than lower extremity long bone fractures, with gunshot diaphyseal humerus fractures generally being the third most common shaft fracture. Complication such as nerve injuries58,115,137 are relatively common with patients who sustain gunshot wounds of the humerus. There is an increased prevalence of nerve injury associated with the distal humerus compared with more proximal injuries.4,5,61,79,80,84,86,132,133,155,162 
Treatment of humeral fractures in either war or peace is controversial. Reported methods of care include fracture brace, external fixation, and internal fixation. There are no prospective studies comparing the various methods of treatment for patients with gunshot wounds.5,80,84,132,133,155,162 
The fracture brace or coaptation splint is appropriate when there is minimal soft tissue injury and the fracture can be held in alignment by this means. Proximal or very distal fractures are often not amenable to this method of care.5,132,133 
External fixation has been reported for use in patients with more extensive soft tissue injuries, such as with military wounds. Zinman et al.162 reported on 26 Israeli war casualties who had external fixation applied for treatment of open humerus fractures. They applied monolateral external fixators to obtain union in 15 patients (57.7%). Conversion to compression plates (five patients) or a cast (six patients) was used for the other patients. Five delayed unions were identified, four of which were treated with plating and bone grafting. Fifteen patients had a total of 20 nerve injuries. One of the nerve injuries was caused by a distal, lateral pin placement that injured the radial nerve. There were four brachial and two radial artery repairs. Of 23 patients with 6.5 years of follow-up there were excellent results in 14 patients, good results in 4, fair results in 3, and poor results in 2. All fractures did eventually heal. The authors felt that external fixation was the best means for stabilizing fracture and allowing access to wounds for wound care. For the distal humerus, the authors recommended open pin placement if lateral pins are to be used or placing the pins from a posterior direction. 
In 1995, the Red Cross evaluated the treatment of refugees who sustained gunshot fractures of the humerus. Keller84 studied 37 patients who were treated at a Red Cross Hospital on the Sudanese border. Patients were seen an average of 9.5 days after injury, at which time 89% of the wounds were found to be infected. Nerve palsy secondary to injury was present in eight patients in this series. Twenty-three patients received a functional brace with plaster of Paris and splint, and seven patients received external fixation skeletal traction. Those treated with the splint had an average time of immobilization of 35.8 days, and 90% obtained adequate alignment. The authors also reported eight reoperations on four patients. The seven patients treated with external fixation had the frame applied for an average of 46.3 days, and 60% obtained adequate angulation. The authors also reported a 71.5% nonunion rate and 11 reoperations in five of the patients. Traction was used in seven patients as well, with an average immobilization of 27.7 days, with five patients obtaining union, and six reoperations on three of the patients. Although the best results were obtained in patients who were treated with splinting, the authors reported that those who had external fixation and traction had the more severe injuries. 
Keller et al.84 reported on 37 patients who sustained gunshot humerus fractures and were treated at a Red Cross Hospital on the Sudanese border. The patients were seen late (average 9.5 days after injury) and nearly 90% were infected. There were three treatment methods: (1) functional brace (n = 23, average 35 days treatment), (2) external fixation (n = 7, average 46.3 days treatment), and (3) skeletal traction (n = 7, average treatment 28 days). The authors reported the best results were obtained with functional bracing, but noted the more severely injured were treated with external fixation and traction. 
Hall and Pankovich61 treated 89 humerus fractures with Ender nails, of which 22 were caused by gunshot wounds (4 shotgun wounds). The authors reported good results with these patients using this technique. We know of no reports using Ender nails since this 1987 report. This technique has been superseded by other methods. 
For simple fractures with minimal soft tissue disruption, use of a functional brace following a coaptation splint seems to yield acceptable results for both initial and definitive care.5,132,133 For patients with more extensive injuries, such as a shotgun blast at close range, we recommend the use of a spanning external fixator to provide initial stabilization for the patient.80,86,155,162 Use of the spanning external fixator is more common with distal fractures. When both the limb and the patient are stable, planning for fracture stabilization and soft tissue coverage can be done. 
Definitive treatment of severe bone or soft tissue defects may be challenging. Dressing changes, as well as maintaining fracture alignment, are difficult with bracing/splinting. With extensive comminution and soft tissue injury, use of a small pin fixator has been reported with good success.4,141 For skeletal defects, use of a cage with allograft4 or a fibular osteoseptocutaneous flap69 has been described. 

Forearm Fractures

There are relatively few reports describing treatment and results of gunshot wounds to the forearm.37,42,53,59,71,129,130,159 There is a high reported rate of nerve injury associated with gunshot wounds to this region, and a 10% rate of compartment syndrome.37,59,107 The goals of fracture care are to restore the length, alignment, and radial bow of the forearm. Care for diaphyseal forearm fractures depends on the severity of both the soft tissue and bone injury, just as with open forearm fractures not associated with firearms.37,42,53,59,71,107,129,130,144,159 Patients with isolated relatively stable fractures of the ulna from a gunshot wound and associated minimal soft tissue trauma may be treated by application of a cast after appropriate wound treatment. Displaced fractures should be treated with open reduction and plate fixation when soft tissues permit. 
For patients with bone loss, initial stabilization with external fixation should be done when both forearm bones are involved.53,59 If just the radius or ulna is involved, only splinting may be required. Use of a soft tissue antibiotic-impregnated spacer may be used for initial care of the void.53 A second, staged procedure to reconstruct bone defects should then be done once the limb is stable. Use of autologous bone graft has been described to fill defects. Use of allograft and bioactive substances, such as bone morphogenetic protein (BMP) or demineralized bone matrix, has yet to be described. 

Femur Fractures

Diaphyseal femur fractures are the most common long bone fractures associated with gunshot wounds.10,19,26,73,111,112,114,128,134,150,152,156 Within the past 50 years, balanced skeletal traction has been the mainstay of care for femur fractures in war or peace.150,152 Temporary stabilization with balanced skeletal traction may still be used today as a means of stabilization until more definitive care can be provided, particularly for patients who are not able to withstand more extensive, definitive procedures in the operating room.135,156 
External fixation has been used for open fractures on the battlefield. Reis et al.128 reported on 19 femur fractures that were intended to be treated with external fixation to union. Six were converted to cast brace because of pin track infection and a further five femurs underwent open reduction internal fixation (one for refracture). Fourteen of the femurs were treated with bone grafting. The authors noted that further procedures were not done until the limb was free of obvious infection. Average time to union was 19 weeks. 
Recently, external fixation been used for patients who are physiologically unable to undergo a more extensive surgery.114,134,135 The concept of using temporary external fixation as a bridge from injury to definitive fracture stabilization has become the standard to initially stabilize a patient’s fracture. Recently, Scannell et al.135 reviewed 79 patients who sustained femur fractures due to blunt trauma with an Injury Severity Score ≥17. Nineteen of the patients were treated with external fixation while 60 were initially treated with skeletal traction as a temporizing measure prior to intramedullary rodding of the femur. The authors concluded that unless the patient was going to the operating room for other reasons, balanced skeletal traction offered a safe means to temporize the patient.135 
The use of intramedullary nailing for complex femur fractures or malunion, nonunion, and infection associated with gunshot wounds became widespread after World War II, influenced by the pioneering work of Küntscher.26,101 
Hollman and Horowitz73 reviewed 26 patients who sustained fractures because of “low-velocity” gunshot wounds that were treated with intramedullary nailing an average of 9 days after injury. Nineteen of the patients were followed to union, which occurred an average of 4.5 months after injury. Two patients had open nailing and the remaining 17 had closed nailing. 
Bergman et al.10 reviewed a series of 65 patients with gunshot femur fractures at Kings County Hospital Center in Brooklyn, New York. The patients were treated with reamed intramedullary nailing an average of 2 days (range, 0 to 14 days) after injury and were followed an average of 2 years after injury (range, 9.5 months to 6 years). The authors found all fractures healed at an average of 18 weeks (range, 13 to 31 weeks). Two patients had persistent drainage, which resolved with a course of oral antibiotics at 2 and 3 weeks. 
Tornetta and Tiburzi150 reviewed 38 of 55 patients with gunshot femur fractures treated with intramedullary nailing who were followed an average of 2 years (range, 14 to 36 months). Average time to union was 8.6 weeks (range, 5 to 22 weeks). Nicholas and McCoy111 reviewed 12 patients with 14 femur fractures treated with immediate (within 8 hours) intramedullary nailing. Three patients had vascular repairs and two patients had sciatic nerve injuries. Average time to union was 5.5 months (range, 3 to 8 months). None of the patients developed an infection. Wiss et al.156 performed a retrospective review of 77 patients who sustained gunshot femur fractures, of which 56 had adequate records for follow-up. The patients were initially treated with skeletal traction for 10 to 14 days, with intramedullary nailing done when the wound tracks healed. No deep wound infections were reported. Average time to union was 23 weeks (range, 14 to 40 weeks), and average follow-up was 16 months (range, 12 to 29 months). Five patients had limb length discrepancy of greater than 1 cm, and one patient had angulation of 15 degrees. 
This review shows that antegrade reamed, locked intramedullary nails may be safely used for gunshot-induced diaphyseal femur fractures. This procedure may be done immediately or on a delayed basis, depending on the patient’s condition and the degree of soft tissue injury. More proximal fractures, such as subtrochanteric fractures, may do best with using reconstruction nails to obtain more proximal fracture stabilization (Fig. 11-29). 
Figure 11-29
Anteroposterior preoperative (A) and postoperative (B–D) views of a subtrochanteric fracture.
 
The patient was treated with a reconstruction nail and had good callus formation in the zone of injury at 6 months. The periosteal sleeve and soft tissue envelope, if left relatively undisturbed, will allow for rapid bone formation despite the lack of anatomic reduction of the same fragments.
The patient was treated with a reconstruction nail and had good callus formation in the zone of injury at 6 months. The periosteal sleeve and soft tissue envelope, if left relatively undisturbed, will allow for rapid bone formation despite the lack of anatomic reduction of the same fragments.
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Figure 11-29
Anteroposterior preoperative (A) and postoperative (B–D) views of a subtrochanteric fracture.
The patient was treated with a reconstruction nail and had good callus formation in the zone of injury at 6 months. The periosteal sleeve and soft tissue envelope, if left relatively undisturbed, will allow for rapid bone formation despite the lack of anatomic reduction of the same fragments.
The patient was treated with a reconstruction nail and had good callus formation in the zone of injury at 6 months. The periosteal sleeve and soft tissue envelope, if left relatively undisturbed, will allow for rapid bone formation despite the lack of anatomic reduction of the same fragments.
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Retrograde nailing has become a popular technique in caring for diaphyseal femur fractures, particularly those near the knee. Initially, it was believed that an open fracture would be too great of a risk for knee sepsis to permit using retrograde nails. Our group recently reported on our series of 196 gunshot femur fractures, of which 56 were treated with retrograde nailing (Fig. 11-30). There was no increased infection rate associated with this method of treatment, at either the fracture site or the knee joint. Therefore, use of retrograde nailing for diaphyseal gunshot femur fractures does not appear to result in an increased infection rate compared to antegrade nailing. 
Figure 11-30
Preoperative (A and B) and postoperative (C and D) radiographs of a distal femur fracture that resulted from a “low-velocity” gunshot.
 
The patient was treated with an immediate retrograde intramedullary nail, with excellent restoration of length, angulation, and rotation.
The patient was treated with an immediate retrograde intramedullary nail, with excellent restoration of length, angulation, and rotation.
View Original | Slide (.ppt)
Figure 11-30
Preoperative (A and B) and postoperative (C and D) radiographs of a distal femur fracture that resulted from a “low-velocity” gunshot.
The patient was treated with an immediate retrograde intramedullary nail, with excellent restoration of length, angulation, and rotation.
The patient was treated with an immediate retrograde intramedullary nail, with excellent restoration of length, angulation, and rotation.
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Complications

Wiss et al.156 reported 5 of 56 patients requiring vascular repair in addition to the treatment of the femur fracture. He also reported three associated sciatic nerve injuries, one with full recovery, one with partial recovery, and one with no recovery. Two patients had peroneal nerve palsies, one of which recovered. Infection of patients is infrequent in the civilian setting following gunshot femur fractures. Wiss et al.156 reported no deep infections with 56 patients at follow-up. Hollman and Horowitz73 reported no patients with infection after intramedullary nailing. Bergman et al.10 reported two patients with persistent drainage, and Nicholas and McCoy111 reported that none of their 14 patients with immediate nailing were infected. 
Compartment syndrome is an infrequent complication of femoral shaft fractures. We found the 3 of 102 patients treated for diaphyseal gunshot wounds from 2001 through 2006 at Henry Ford Hospital had the diagnosis of thigh compartment syndrome. The patients were treated with compartment release of the anterior and lateral thigh compartments via one incision at the time of their initial surgery. 
Malunion is infrequent with the use of intramedullary nailing. Wiss et al.156 reported angulation deformity of 15 degrees for one of 56 patients, rotational deformity reported in one patient, and five patients with a leg length discrepancy of greater than 1 cm. 
Immediate intramedullary nailing is now routine in many hospitals that treat nonmilitary gunshot wound femoral fractures on a routine basis. Intramedullary nailing allows for better alignment, less limb length discrepancy, and earlier return to ambulation without an increased rate of infection. The use of temporary external fixation to initially care for patients with more extensive soft tissue wounds, severe systemic injuries, or fractures sustained in austere environments, allows for the patient to be stabilized before undergoing more extensive surgery. Skeletal traction is an option for the short-term stabilization of a fracture before more definitive care. 
Treatment of femur fractures during the recent Iraq and Afghanistan conflicts has been with the staged management of care. For Coalition soldiers, the fracture is stabilized with an external fixator and the patient transported to a site of definitive care, where fixation by intramedullary nailing is performed secondarily. 

Tibia Fractures

The tibia is the second most frequent long bone fractured by gunshot, following the femur.21,22,50,90,157 A variety of treatment methods have been reported for fracture care, including the use of cast or fracture brace, external fixation, and intramedullary nailing. 
Witschi and Omer157 reported on the ambulatory treatment in a cast and then fracture brace of 84 patients who sustained tibia fractures secondary to missile injuries. All of the fractures in this series had some comminution. Despite this, the authors reported less than 1 cm of shortening in 48 of 58 patients with isolated injury and an additional three patients with 1 cm of shortening. Seven patients were reported to have osteomyelitis, which prolonged the time to union. Brown and Urban22 reported on 63 fractures in 60 patients who were also injured by war wounds and were treated in a similar manner. The fractures in this series healed at an average of 19 weeks. Shortening averaged 9 mm, ranging from 2 to 38 mm, compared with the contralateral limb. Twenty-seven of the fractures had no shortening. Four of the 63 patients had persistent drainage. Sarmiento reported on 32 tibia fractures caused by gunshot wounds treated with a fracture brace. The average time to union was 17.5 weeks, with one nonunion, and little residual deformity. 
Leffers and Chandler90 conducted a retrospective review of 40 patients with 41 tibia fractures caused by gunshot wounds. Thirty-five fractures were treated by casting followed by fracture brace. An additional five fractures were treated with external fixation because of injury severity, followed by a functional brace within the first 2 months. One patient had pins and plaster. Those treated by casting healed at an average of 12 weeks, whereas those treated by external fixation healed at an average of 21 weeks. Eight patients had persistent wound drainage, with two undergoing a surgical procedure to care for the wound. This study was limited in that it reported follow-up of only 27% of the total number of patients seen with this diagnosis at the institution. 
Ferraro and Zinar50 reported a retrospective review of 90 of 133 patients with tibia fractures caused by gunshot wounds treated at Harbor/UCLA Medical Center. Fracture stabilization was a long leg cast for 58, external fixation for 17, and unreamed intramedullary nailing for 15 patients. The authors found that fractures classified as Winquist 0, 1, or 2 healed within 12 to 14 weeks and those with Winquist 3, 4, or 5 and treated with intramedullary nailing healed at an average of 18 weeks; those treated with external fixation averaged 27 weeks to union. 
Present treatment of gunshot fractures of the tibial shaft depends on the amount of bone comminution and degree of soft tissue injury. Patients with tibia shaft fractures having minimal comminution, soft tissue injury, displacement, and angulation may be successfully treated with local wound care in the emergency department and application of a cast, followed by a functional brace. More comminuted fractures are better cared for with intramedullary nailing. If there is major soft tissue injury requiring a soft tissue transfer, consideration should be given to external fixation until the soft tissues are reconstructed and stable, at which point the fixator may be removed and an intramedullary nail is inserted. Because of concerns about pin site sepsis, external fixation should be used for a limited period of time, generally less than 2 weeks if definitive fixation with an intramedullary rod is anticipated. 

Foot Injuries

Injuries to the foot are infrequent with nonmilitary gunshot wounds. Foot and ankle injuries accounted for only 39 of 2,277 (1.7%) injuries in 1,505 patients with gunshot wounds seen at Henry Ford Hospital between 2001 and 2006. Gunshot toe and metatarsal injuries vary in the degree of both soft tissue and bone injury. Minimally displaced fractures, particularly when isolated, may be treated without surgical stabilization. After treatment of the soft tissues, a period of using a hard-soled postoperative shoe with dressing changes allows for a good result. 
Patients with multiple metatarsal fractures or those with bone loss are candidates for surgical stabilization. Kirschner wires or external fixation may be used for initial surgical stabilization in these patients.16,153 Midfoot injuries tend to be more comminuted than metatarsal injuries and as a consequence require surgical stabilization. For acute injuries with bone loss, external fixation is used to span the fracture defect, followed by reconstruction of the bone with plates when the limb is stable. Talus and calcaneus fractures are less likely to require surgical stabilization unless bone loss is present. Treatment for isolated fractures should be dependent on the degree of bone and soft tissue injury. With minimal soft tissue and bone disruption, treatment of the soft tissues followed by casting gives the best results. Infection is more common with foot injuries than other anatomic regions. Boucree et al.16 reported that 12 of 101 patients with gunshot foot wounds had an infection; this is a higher incidence than reported with other anatomic regions. 
Foot injuries in wartime are common injuries, most often resulting from mine explosions. Nikolic et al.113 reported that 250 of 1,860 war casualties (13.4%) treated at the authors’ facility in the former Republic of Yugoslavia had foot injuries. Amputations were performed in 76 (26.5%) of the feet. 
Severe closed fractures are reported in patients inside vehicles struck by a large mine. This “behind armor blunt trauma” is similar to injuries seen with severe motor vehicle accidents and may be treated with the same definitive care.110 

Conclusions

Gunshot injuries remain a major clinical problem in both war and peace. Caring for patients in war-torn regions of the world remains challenging. Patients are often initially managed under austere circumstances before and during transport for definitive care. Gunshot injuries are a significant part of the health care problem for inner-city hospitals around the world. The orthopedic surgeon should be knowledgeable about the clinical course and outcome of patients with gunshot wounds to provide the complete, thorough, and efficient care within the context of his or her medical system. 

Authors’ Preferred Method of Treatment (Military-Related Injuries)

 
 

Blast injuries and combat-related gunshot wounds are generally more contaminated than similar injuries seem in the civilian sector and an increased focus on adequate debridement is necessary. Blast injuries in particular are much more highly contaminated as significant quantities of foreign material is driven deep into the soft tissues. The Emergency War Surgery Handbook specifically recommends early aggressive debridement and advises against early closure of wounds. The nature of the blast injury frequently makes tissue friable and wounds tend to progress for many days after the initial injury. Frequent debridements every other day until wounds are stable and clean are the mainstay of treatment. Long bone fixation in an austere setting is also avoided and external fixation should be used not only for damage control but rather as a stabilizing frame to aid in transfer of rewounded soldier to a stable medical environment. Definitive stabilization varies little from civilian standards; however, higher grade tibia fractures are less likely to become infected when utilizing circular external fixation.82 Soft tissue management is also frequently a challenge requiring large soft tissue transfers. Not infrequently the extremity injury is so great that patients choose elective amputation. As prosthesis improves and the care of the amputee has improved, small improvements in outcomes have been seen with amputation compared to limb salvage.145

References

Aboutanos MB, Baker SP. Wartime civilian injuries: Epidemiology and intervention strategies. J Trauma. 1997;43(4):719–726.
Anonymous. Improvised Explosive Device/Booby Trap. 2008.
Artz CP, Sako Y, Scully RE. An evaluation of the surgeon’s criteria for determining the viability of muscle during debridement. AMA Arch Surg. 1956;73(6):1031–1035.
Attias N, Lehman RE, Bodell LS, et al. Surgical management of a long segmental defect of the humerus using a cylindrical titanium mesh cage and plates: A case report. J Orthop Trauma. 2005;19(3):211–216.
Balfour GW, Marrero CE. Fracture brace for the treatment of humerus shaft fractures caused by gunshot wounds. Orthop Clin North Am. 1995;26(1):55–63.
Bartlett CS, DiFelice GS, Buly RL, et al. Cardiac arrest as a result of intra-abdominal extravasation of fluid during arthroscopic removal of a loose body from the hip joint of a patient with an acetabular fracture. J Orthop Trauma. 1998;12(4):294–299.
Bellamy RF, Zajtchuk R, eds. Assessing the effectiveness of conventional weapons. Conventional Warfare: Ballistic Blast and Burn Injuries. Washington, DC: Borden Institute, Office of the Surgeon General; 1991:53–82.
Bellamy RF, Zajtchuk R. The weapons of conventional land warfare. In: Conventional Warfare: Ballistic Blast and Burn Injuries. Washington, DC: Borden Institute, Office of the Surgeon General; 1991:1–52.
Bellamy RF. Combat trauma overview. In: Zajtchuck R, ed. Anesthesia and Perioperative Care of the Combat Casualty. Washington, DC: Borden Institute, Office of the Surgeon General; 1995.
Bergman M, Tornetta P, Kerina M, et al. Femur fractures caused by gunshots: Treatment by immediate reamed intramedullary nailing. J Trauma. 1993;34(6):783–785.
Best IM, Bumpers HL. Thigh compartment syndrome after acute ischemia. Am Surg. 2002;68(11):996–998.
Beyer JC, Arima JK, Johnson DW. Enemy ordnance material. In: Beyer JC, ed. Wound Ballistics. Washington, DC: Office of the Surgeon General; 1962: 1–90.
Beyer JC, Enos WF, Holmes RH. Personal protective armor. In: Beyer JC, ed. Wound Ballistics. Washington, DC: Office of the Surgeon General; 1962.
Biasutto SN, Moral AL, Bella JA. Firearm-related injuries: Clinical considerations on 1326 cases. Int Surg. 2006;91(1):39–43.
Bolanos AA, Vigorita VJ, Meyerson RI, et al. Intra-articular histopathologic changes secondary to local lead intoxication in rabbit knee joints. J Trauma. 1995;38(4):668–671.
Boucree JB Jr, Gabriel RA, Lezine-Hanna JT. Gunshot wounds to the foot. Orthop Clin North Am. 1995;26:191–197.
Bowyer GW, Cooper GJ, Rice P. Small fragment wounds: Biophysics and pathophysiology. J Trauma. 1996;40(3 suppl):S159–S164.
Brannon JK, Woods C, Chandran RE, et al. Gunshot wounds to the elbow. Orthop Clin North Am. 1995;26(1):75–84.
Brav EA. Further evaluation of the use of intramedullary nailing in the treatment of gunshot fractures of the extremities. J Bone Joint Surg Am. 1957;39-A(3):513–520.
Brien EW, Brien WW, Long WT, et al. Concomitant injuries of the hip joint and abdomen resulting from gunshot wounds. Orthopedics. 1992;15(11):1317–1319; discussion 1319–1320.
Brien WW, Kuschner SH, Brien EW, et al. The management of gunshot wounds to the femur. Orthop Clin North Am. 1995;26(1):133–138.
Brown PW, Urban JG. Early weight-bearing treatment of open fractures of the tibia. An end-result study of sixty-three cases. J Bone Joint Surg Am. 1969;51(1):59–75.
Brown TD, Michas P, Williams RE, et al. The impact of gunshot wounds on an orthopaedic surgical service in an urban trauma center. J Orthop Trauma. 1997;11(3):149–153.
Burkhalter A, Ballard WE, eds. Orthopedic surgery in Vietnam. In: Medical Department, United States Army, Surgery in Vietnam. Washington, DC: Office of the Surgeon General and Center for Military History; 1994.
Byrne A, Curran P. Necessity breeds invention: A study of outpatient management of low velocity gunshot wounds. Emerg Med J. 2006;23(5):376–378.
Carr CR, Turnipseed D. Experiences with intramedullary fixation of compound femoral fractures in war wounds. J Bone Joint Surg Am. 1953;35-A(1):153–171.
Clasper JC, Hill PF, Watkins PE. Contamination of ballistic fractures: An in vitro model. Injury. 2002;33(2):157–160.
Cory JW, Ruch DS. Arthroscopic removal of a .44 caliber bullet from the hip. Arthroscopy. 1998;14(6):624–626.
Davis GL. Management of open wounds of joints during the Vietnam war. A preliminary study. Clin Orthop Relat Res. 1970;68:3–9.
Demiralp B, Komurcu M, Ozturk C, et al. Total elbow arthroplasty in patients who have elbow fractures caused by gunshot injuries: 8- to 12-year follow-up study. Arch Orthop Trauma Surg. 2008;128(1):17–24.
Depage A. The peace lessons of war surgery. Br Med J. 1919;2(3077):820–821.
DiGiacomo JC, Schwab CW, Rotondo MF, et al. Gluteal gunshot wounds: Who warrants exploration? J Trauma. 1994;37(4):622–628.
Dougherty P. Armored vehicle crew casualties. Mil Med. 1990;155:417–420.
Dougherty PJ, Hetz SP, Fackler ML. Weapons and weapons effects. In: Lounsbury DE, ed. Emergency War Surgery Handbook. 4th ed. Washington, DC: Office of the Surgeon General; 2004.
Dziemian AJ, Herget CM. Physical aspects of primary contamination of bullet wounds. Mil Surg. 1950;106:294–299.
Dziemian AJ, Mendelson JA, Lindsey D. Comparison of the wounding characteristics of some commonly encountered bullets. J Trauma. 1961;1:341–353.
Elstrom JA, Pankovich AM, Egwele R. Extra-articular low-velocity gunshot fractures of the radius and ulna. J Bone Joint Surg Am. 1978;60(3):335–341.
Fackler M. Missile-caused wounds. In: Bowen TF, Bellamy RF, eds. Emergency War Surgery. 2nd Am. Rev. Washington, DC: Office of the Surgeon General; 1988:13–34.
Fackler ML, Bellamy RF, Malinowski JA. A reconsideration of the wounding mechanism of very high velocity projectiles–importance of projectile shape. J Trauma. 1988;28(1 suppl):S63–S67.
Fackler ML, Bellamy RF, Malinowski JA. The wound profile: Illustration of the missile-tissue interaction. J Trauma. 1988;28(1 suppl):S21–S29.
Fackler ML, Breteau JP, Courbil LJ, et al. Open wound drainage versus wound excision in treating the modern assault rifle wound. Surgery. 1989;105(5):576–584.
Fackler ML, Burkhalter WE. Hand and forearm injuries from penetrating projectiles. J Hand Surg Am. 1992;17(5):971–975.
Fackler ML, Dougherty PJ. Theodor Kocher and the scientific foundation of wound ballistics. Surg Gynecol Obstet. 1991;172(2):153–160.
Fackler ML, Malinowski JA. Internal deformation of the AK-74; a possible cause for its erratic path in tissue. J Trauma. 1988;28(1 suppl):S72–S75.
Fackler ML, Surinchak JS, Malinowski JA, et al. Bullet fragmentation: A major cause of tissue disruption. J Trauma. 1984;24(1):35–39.
Fackler ML, Surinchak JS, Malinowski JA, et al. Wounding potential of the Russian AK-74 assault rifle. J Trauma. 1984;24(3):263–266.
Fackler ML. Misinterpretations concerning Larrey’s methods of wound treatment. Surg Gynecol Obstet. 1989;168(3):280–282.
Fackler ML. Wound ballistics. A review of common misconceptions. JAMA. 1988;259(18):2730–2736.
Ferguson LK, Brown RB, Nicholson JT, et al. Observations on the treatment of battle wounds aboard a hospital ship. US Nav Med Bull. 1943;41:299–305.
Ferraro SP Jr, Zinar DM, Management of gunshot fractures of the tibia. Orthop Clin North Am. 1995;26(1):181–189.
Fisher GH, Florey ME, Adelaide. M. B, et al. Penicillin in clostridial infections. Lancet. 1945;245(6344):395–399.
Foster RD, Albright JA. Acute compartment syndrome of the thigh: Case report. J Trauma. 1990;30(1):108–110.
Georgiadis GM, DeSilva SP. Reconstruction of skeletal defects in the forearm after trauma: Treatment with cement spacer and delayed cancellous bone grafting. J Trauma. 1995;38(6):910–914.
Goldman A, Minkoff J, Price A, et al. A posterior arthroscopic approach to bullet extraction from the hip. J Trauma. 1987;27(11):1294–1300.
Gotsch KE, Annest JL, Mercy JA, et al. Surveillance for fatal and nonfatal firearm-related injuries: United States, 1993–1998. MMWR Morb Mortal Wkly Rep. 2001;50:1–31.
Grundfest H, Korr IM, McMillen JH, et al. Ballistics of the Penetration of Human Skin by Small Spheres. Washington, DC: Office of Scientific Research and Development; 1945.
Grundfest H. Penetration of Steel Spheres into Bone. Washington, DC: Office of Scientific Research and Development; 1945.
Guo Y, Chiou-Tan FY. Radial nerve injuries from gunshot wounds and other trauma: Comparison of electrodiagnostic findings. Am J Phys Med Rehabil. 2002;81(3):207–211.
Hahn M, Strauss E, Yang EC. Gunshot wounds to the forearm. Orthop Clin North Am. 1995;26(1):85–93.
Hakanson R, Nussman D, Gorman RA, et al. Gunshot fractures: A medical, social, and economic analysis. Orthopedics. 1994;17(6)519–523.
Hall RF Jr, Pankovich AM. Ender nailing of acute fractures of the humerus. A study of closed fixation by intramedullary nails without reaming. J Bone Joint Surg Am. 1987;69(4):558–567.
Hampton OP Jr. The indications for debridement of gunshot (bullet) wounds of the extremities in civilian practice. J Trauma. 1961;1:368–372.
Hansraj KK, Weaver LD, Todd AO, et al. Efficacy of ceftriaxone versus cefazolin in the prophylactic management of extra-articular cortical violation of bone due to low-velocity gunshot wounds. Orthop Clin North Am. 1995;26:9–17.
Harding NR, Lipton JF, Vigorita VJ, et al. Experimental lead arthropathy: An animal model. J Trauma. 1999;47(5):951–955.
Harvey EN, Korr IM, Oster G, et al. Secondary damage in wounding due to pressure changes accompanying the passage of high velocity missiles. Surgery. 1947;21(2):218–239.
Harvey EN, Mcmillan JH, Butler EG. Mechanism of wounding. In: Beyer JC, ed. Wound Ballistics. Washington, DC: Office of the Surgeon General; 1962:143–235.
Harvey EN. Studies on wound ballistics. In: Andrus EC, Keefer CS, et al. eds. Advances in Military Medicine. Boston, MA: Little, Brown, and Co; 1948:191–205.
Harvey EN. The mechanism of wounding by high velocity missiles. Proc Am Philos Soc. 1948;92(4):294–304.
Heitmann C, Erdmann D, Levin LS. Treatment of segmental defects of the humerus with an osteoseptocutaneous fibular transplant. J Bone Joint Surg Am. 2002;84-A(12):2216–2223.
Helgeson MD, Potter BK, Evans KN, et al. Bioartificial dermal substitute: A preliminary report on its use for the management of complex combat-related soft tissue wounds. J Orthop Trauma. 2007;21(6):394–399.
Hennessy MJ, Banks HH, Leach RB, et al. Extremity gunshot wound and gunshot fracture in civilian practice. Clin Orthop Relat Res. 1976(114):296–303.
Herget CM, Coe GB, Beyer JC. Wound ballistics and body armor in Korea. In: Beyer JC, ed. Wound Ballistics. Washington, DC: Office of the Surgeon General; 1962:691–767.
Hollmann MW, Horowitz M. Femoral fractures secondary to low velocity missiles: Treatment with delayed intramedullary fixation. J Orthop Trauma. 1990;4(1):64–69.
Hoover NW, Ivins JC. Wound debridement. Arch Surg. 1959;79:701–710.
Huelke DF, Harger JH, Buege LJ, et al. An experimental study in bio-ballistics femoral fractures produced by projectiles. J Biomech. 1968;1(2):97–105.
Huelke DF, Harger JH, Buege LJ, et al. An experimental study in bio-ballistics: Femoral fractures produced by projectiles–II. Shaft impacts. J Biomech. 1968;1(4):313–321.
Investigation, F.B.o. Uniformed crime reports. 2012.
Jamdar S, Helm AT, Redfern DR. Arthroscopic removal of a shotgun pellet from the elbow joint. Arthroscopy. 2001;17(7):E30.
Johnson EC, Strauss E. Recent advances in the treatment of gunshot fractures of the humeral shaft. Clin Orthop Relat Res. 2003;408:126–132.
Joshi A, Labbe M, Lindsey RW. Humeral fracture secondary to civilian gunshot injury. Injury. 1998;29(suppl 1):SA13–SA17.
Josserand MH, Stevenson J. Pistols, Revolvers, and Ammunition. New York, NY: Bonanza Books; 1972.
Keeling JJ, Gwinn DE, Tintle SM, et al. Short-term outcomes of severe open wartime tibial fractures treated with ring external fixation. J Bone Joint Surg Am. 2008;90(12):2643–2651.
Keith E. Shotguns. Harrisburg, PA: Stackpole Books; 1950.
Keller A. The management of gunshot fractures of the humerus. Injury. 1995;26(2):93–96.
Knapp TP, Patzakis MJ, Lee J, et al. Comparison of intravenous and oral antibiotic therapy in the treatment of fractures caused by low-velocity gunshots. A prospective, randomized study of infection rates. J Bone Joint Surg Am. 1996;78(8):1167–1171.
Kömürcü M, Yanmis¸ I, Ates¸alp AS, et al. Treatment results for open comminuted distal humerus intra-articular fractures with Ilizarov circular external fixator. Mil Med. 2003;168(9):694–697.
Konda SR, Howard D, Davidovitch RI, et al. The saline load test of the knee redefined: A test to detect traumatic arthrotomies and rule-out periarticular wounds not requiring surgical intervention. J Orthop Trauma. 2013;27(9):491–497. [Epub ahead of print].
Krause M. Studies in wound ballistics: Temporary cavity effects in soft tissues. Mil Med. 1957;121:221–231.
LaGarde L. Poisoned wounds by the implements of warfare. JAMA. 1903;40:984–1067.
Leffers D, Chandler RW. Tibial fractures associated with civilian gunshot injuries. J Trauma. 1985;25(11):1059–1064.
Leininger BE, Rasmussen TE, Smith DL, et al. Experience with wound VAC and delayed primary closure of contaminated soft tissue injuries in Iraq. J Trauma. 2006;61(5):1207–1211.
Lenihan MR, Brien WW, Gellman H, et al. Fractures of the forearm resulting from low-velocity gunshot wounds. J Orthop Trauma. 1992;6(1):32–35.
Leonard MH. The solution of lead by synovial fluid. Clin Orthop Relat Res. 1969;64:255–261.
Lewis DD. Debridement. JAMA. 1919;73:377–383.
Linden M, Manton W, Stewart R, et al. Lead poisoning from retained bullets. Pathogenesis, diagnosis, and management. Ann Surg. 1982;195(3):305–313.
Long WT, Brien EW, Boucree JB, et al. Management of civilian gunshot injuries to the hip. Orthop Clin North Am. 1995;26:123–131.
Lounsbury DE. Levels of medical care. In: Lounsbury DE, ed. Emergency War Surgery. 4th ed. Washington, DC: Borden Institute, Office of the Surgeon General; 2004:1–11.
Lounsbury DE. Triage. In: Lounsbury DE, ed. Emergency War Surgery. 4th ed. Washington D C: Borden Institute, Office of the Surgeon General; 2004:1–17.
Love AG. Statistics. The Medical Department of the United States in the World War. Vol 15. Washington, DC: Office of the Surgeon General; 1925.
Marcus NA, Blair WF, Shuck JM, et al. Low-velocity gunshot wounds to extremities. J Trauma. 1980;20(12):1061–1064.
McAuliffe JA, Burkhalter WE, Ouellette EA, et al. Compression plate arthrodesis of the elbow. J Bone Joint Surg Br. 1992;74(2):300–304.
Mendelson JA, Glover JL. Sphere and shell fragment wounds of soft tissues: Experimental study. J Trauma. 1967;7(6):889–914.
Meyer NJ, Thiel B, Ninomiya JT. Retrieval of an intact, intra-articular bullet by hip arthroscopy using the lateral approach. J Orthop Trauma. 2002;16(1):51–53.
Mineo RC, Gittins ME. Arthroscopic removal of a bullet embedded in the acetabulum. Arthroscopy. 2003;19(9):E121–E124.
Ming L, Yu-Yuan M, Rong-Xiang F, et al. The characteristics of the pressure waves generated in the soft target by impact and its contribution to indirect bone fractures. J Trauma. 1988;28:s104–s109.
Miric DM, Bumbasirevic MZ, Senohradski KK, et al. Pelvifemoral external fixation for the treatment of open fractures of the proximal femur caused by firearms. Acta Orthop Belg. 2002;68(1):37–41.
Moed BR, Fakhouri AJ. Compartment syndrome after low-velocity gunshot wounds to the forearm. J Orthop Trauma. 1991;5(2):134–137.
Morgan MM, Spencer AD, Hershey FB. Debridement of civilian gunshot wounds of soft tissue. J Trauma. 1961;1:354–360.
Najibi S, Dougherty PJ, Morandi M. Management of gunshot wounds to the joints. Techniques in Orthopaedics. 2006;21(3):200–204.
Nechaev EA, Gritsanov AI, Fomin, NF, et al. Mine blast trauma. Experience from the war in Afghanistan. Stockholm: Falths Tryckeri; 1995.
Nicholas RM, McCoy GF. Immediate intramedullary nailing of femoral shaft fractures due to gunshots. Injury. 1995;26(4):257–259.
Nikoli´c D, Jovanovi´c Z, Turkovi´c G, et al. Subtrochanteric missile fractures of the femur. Injury. 1998;29(10):743–749.
Nikolic D, Jovanovic Z, Vulovic R, et al. Primary surgical treatment of war injuries of the foot. Injury. 2000;31(3):193–197.
Nowotarski P, Brumback RJ. Immediate interlocking nailing of fractures of the femur caused by low- to mid-velocity gunshots. J Orthop Trauma. 1994;8(2):134–141.
Omer GE Jr. Injuries to nerves of the upper extremity. J Bone Joint Surg Am. 1974;56(8):1615–1624.
Ordog GJ, Wasserberger J, Balasubramanium S, et al. Civilian gunshot wounds–outpatient management. J Trauma. 1994;36(1):106–111.
Otero F, Cuartas E. Arthroscopic removal of bullet fragments from the subacromial space of the shoulder. Arthroscopy. 2004;20(7):754–756.
Oughterson AW, Hull HC, Sutherland FA, et al. Study on wound ballistics: Bougainville campaign. In: Beyer JC, ed. Wound Ballistics. Washington, DC: Office of the Surgeon General; 1962: 281–436.
Owens BD, Kragh JF Jr, Macaitis J, et al. Characterization of extremity wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Orthop Trauma. 2007;21(4):254–257.
Parisien JS, Esformes I. The role of arthroscopy in the management of low-velocity gunshot wounds of the knee joint. Clin Orthop Relat Res. 1984(185):207–213.
Patzakis MJ, Harvey JP Jr, Ivler D. The role of antibiotics in the management of open fractures. J Bone Joint Surg Am. 1974;56(3):532–541.
Perry DJ, Sanders DP, Nyirenda CD, et al. Gunshot wounds to the knee. Orthop Clin North Am. 1995;26(1):155–163.
Petersen W, Beske C, Stein V, et al. Arthroscopical removal of a projectile from the intra-articular cavity of the knee joint. Arch Orthop Trauma Surg. 2002;122(4):235–236.
Pool EH, Lee BJ, Dineen PA. Surgery of the soft parts, bones, and joints, at a front hospital. Surg Gynecol Obstet. 1919:289–311.
Prevention, C.C.f.D.C.a. WISQARS fatal injuries: Mortality reports. 2012; http://webappa.cdc.gov/sasweb/ncipc/mortrate.html.
Ramasamy A, et al. Blast mines: Physics, injury mechanisms and vehicle protection. J R Army Med Corps. 2009;155(4):258–264.
Ramasamy A, Hill AM, Clasper JC. Improvised explosive devices: Pathophysiology, injury profiles and current medical management. J R Army Med Corps. 2009;155(4):265–272.
Reis ND, Zinman C, Besser MI, et al. A philosophy of limb salvage in war: Use of the fixateur externe. Mil Med. 1991;156(10):505–520.
Robert RH. Gunshots to the hand and upper extremity. Clin Orthop Relat Res. 2003;408:133–144.
Rodrigues RL, Sammer DM, Chung KC. Treatment of complex below-the-elbow gunshot wounds. Ann Plast Surg. 2006;56(2):122–127.
Rose SC, Fujisaki CK, Moore EE. Incomplete fractures associated with penetrating trauma: Etiology, appearance, and natural history. J Trauma. 1988;28(1):106–109.
Sarmiento A, Latta L. The evolution of functional bracing of fractures. J Bone Joint Surg Br. 2006;88(2):141–148.
Sarmiento A, Zagorski JB, Zych GA, et al. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am. 2000;82(4):478–486.
Scalea TM, Boswell SA, Scott JD, et al. External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: Damage control orthopedics. J Trauma. 2000;48(4):613–621.
Scannell BP, Waldrop NE, Sasser HC, et al. Skeletal traction versus external fixation in the initial temporization of femoral shaft fractures in severely injured patients. J Trauma. 2010;68(3):633–640.
Sclafani SJ, Vuletin JC, Twersky J. Lead arthropathy: Arthritis caused by retained intra-articular bullets. Radiology. 1985;156(2):299–302.
Shao YC, Harwood P, Grotz MR, et al. Radial nerve palsy associated with fractures of the shaft of the humerus: A systematic review. J Bone Joint Surg Br. 2005;87(12):1647–1652.
Simchen E, Raz R, Stein H, et al. Risk factors for infection in fracture war wounds (1973 and 1982 wars, Israel). Mil Med. 1991;156(10):520–527.
Simchen E, Sacks T. Infection in war wounds: Experience during the 1973 October War in Israel. Ann Surg. 1975;182(6):754–761.
Singleton SB, Joshi A, Schwartz MA, et al. Arthroscopic bullet removal from the acetabulum. Arthroscopy. 2005;21(3):360–364.
Skaggs DL, Hale JM, Buggay S, et al. Use of a hybrid external fixator for a severely comminuted juxta-articular fracture of the distal humerus. J Orthop Trauma. 1998;12(6):439–442.
Smith WHB. Small Arms of the World. Harrisburg, PA: Stackpole Books; 1983.
Stannard JP, Volgas DA, McGwin G 3rd, et al. Incisional negative pressure wound therapy after high-risk lower extremity fractures. J Orthop Trauma. 2012;26(1):37–42.
Stewart MP, Birch R. Penetrating missile injuries of the brachial plexus. J Bone Joint Surg Br. 2001;83(4):517–524.
Stinner DJ, Burns TC, Kirk KL, et al. Prevalence of late amputations during the current conflicts in Afghanistan and Iraq. Mil Med. 2010;175(12):1027–1029.
Tarkin IS, Hatzidakis A, Hoxie SC, et al. Arthroscopic treatment of gunshot wounds to the shoulder. Arthroscopy. 2003;19(1):85–89.
Teloken MA, Schmietd I, Tomlinson DP. Hip arthroscopy: A unique inferomedial approach to bullet removal. Arthroscopy. 2002;18(4):E21.
Tornetta P 3rd, Boes MT, Schepsis AA, et al. How effective is a saline arthrogram for wounds around the knee? Clin Orthop Relat Res. 2008;466(2):432–435.
Tornetta P 3rd, Hui RC. Intra-articular findings after gunshot wounds through the knee. J Orthop Trauma. 1997;11(6):422–424.
Tornetta P 3rd, Tiburzi D. Anterograde interlocked nailing of distal femoral fractures after gunshot wounds. J Orthop Trauma. 1994;8(3):220–227.
Turen CH, Burgess AR, Vanco B. Skeletal stabilization for tibial fractures associated with acute compartment syndrome. Clin Orthop Relat Res. 1995(315):163–168.
Urist MR, Quigley TB. Use of skeletal traction for mass treatment of compound fractures; a summary of experiences with 4,290 cases during World War II. AMA Arch Surg. 1951;63(6):834–844.
Verheyden CN, McLaughlin B, Law C, et al. Through-and-through gunshot wounds to the foot: The “Fearless Fosdick” injury. Ann Plast Surg. 2005;55(5):474–478.
Weaver LD, Hansraj KK, Idusuyi OB, et al. Gunshot wound injuries. Frequency and cost analyses in south central Los Angeles. Orthop Clin North Am. 1995;26(1):1–7.
Wisniewski TF, Radziejowski MJ. Gunshot fractures of the humeral shaft treated with external fixation. J Orthop Trauma. 1996;10(4):273–278.
Wiss DA, Brien WW, Becker V Jr. Interlocking nailing for the treatment of femoral fractures due to gunshot wounds. J Bone Joint Surg Am. 1991;73(4):598–606.
Witschi TH, Omer GE Jr. The treatment of open tibial shaft fractures from Vietnam War. J Trauma. 1970;10(2):105–111.
Woloszyn JT, Uitvlugt GM, Castle ME. Management of civilian gunshot fractures of the extremities. Clin Orthop Relat Res. 1988(226):247–251.
Wu CD. Low-velocity gunshot fractures of the radius and ulna: Case report and review of the literature. J Trauma. 1995;39(5):1003–1005.
Yildiz C, Ates¸alp AS, Demiralp B, et al. High-velocity gunshot wounds of the tibial plafond managed with Ilizarov external fixation: A report of 13 cases. J Orthop Trauma. 2003;17(6):421–429.
Zellweger R, Hess F, Nicol A, et al. An analysis of 124 surgically managed brachial artery injuries. Am J Surg. 2004;188(3):240–245.
Zinman C, Norman D, Hamoud K, et al. External fixation for severe open fractures of the humerus caused by missiles. J Orthop Trauma. 1997;11(7):536–539.
Zura RD, Bosse MJ. Current treatment of gunshot wounds to the hip and pelvis. Clin Orthop Relat Res. 2003(408):110–114.