Most bullets made of lead alloy

Fracture lines usually propagate beyond what can be seen on traditional radiographs

• Out of plane of radiograph
• Non displaced cracks

Be prepard to extending fixation beyond what traditionally would be done for fracture

• i.e.. Subtrochanteric fracture with lesser trochanter intact, use nail with neck fixation as opposed to standard nail.

23 y.o. male

• 23 y.o. male

• Single low-energy GSW to leg

• ABI > 1.0

• Neurologically intact

• XR: Fracture of distal femur

• Moderate comminution noted
• Lateral condyle comminuted through articular surface
• Not fully appreciated on plain film

27 y.o. male

• 27 y.o. male

• GSW to right leg

• ABI = .7

• On table angiogram

• Laceration of popliteal artery

• Temporizing external fixator placed to stabilize length of limb

• Arterial repair performed

• Note comminution of fractured femur

19 y.o. male

• 19 y.o. male

• GSW to leg

• ABI = .95

• Neuro intacy

• Radiographs

• Comminuted fracture femoral shaft

2 months post op

• 2 months post op

• Early healing with callus forming

• Weight Bearing as tolerated, No pain

28 y.o. male

• 28 y.o. male

• Shotgun load with large pellets

• Neuro intact

• Vascular intact

• Large lateral wound from close range injury

• Exploration

• Wadding, packing and pellets, all removed

• Repeat debridement at 72 hours

Significant comminution not appreciated pre-op

• Significant comminution not appreciated pre-op

• Head split present

• ORIF performed

Significant bone loss and muscle damage from energy of Shotgun

• Significant bone loss and muscle damage from energy of Shotgun

• Treated as open fracture with multiple debridements

Healed at three months

• Healed at three months

• Motion limited

• No active Abduction due to injury to rotator cuff insertion

Knee most common

• Knee most common

• Ankle second

• Look for vascular injury especially around knee

• Careful evaluation for fractures

• May need CT scan especially about hip

Large amount of articular and cartilage damage, especially in knee

• Large amount of articular and cartilage damage, especially in knee

• ? Significance

• Indication for surgery

• Retained bone fragments
• Acts as three body wear
• Metal fragments in joints
• Plumbism (lead poisoning)
• Fix unstable fractures

Hip Injuries

• Hip Injuries

• Look for association with bowel injury
• If visceral injury, joint needs to irrigated to prevent infection

• Other operative indications same as other joints

Tissue damage and contamination dependant upon missile energy

• Tissue damage and contamination dependant upon missile energy

• Careful vascular assessment mandatory

• High velocity and shotgun blasts require surgical debridement. Joints if retained metal or bone

• Recommend all victims treated with antibiotics

• Route of delivery dependant on need for surgery

• fracture extension, fragmentation common

• Many require surgical stabilization d/t instability
• Indirect reduction, internal fixation recommended for diaphyseal injuries