Orthopaedic Gunshot Wounds and Ballistics

Gunshot wounds produce orthopaedic problems through penetrating soft tissue injury, fracture, contamination, vascular injury, nerve injury, compartment syndrome and retained foreign material. The visible wound is only the entry point. The injury that matters is the tissue damage along the projectile path and the zone of energy transfer around it.

Why this topic matters

Practical language

Avoid describing a wound simply as "a gunshot fracture." Use a more useful description:

• Low-energy or high-energy mechanism.
• Extra-articular or intra-articular path.
• Clean, contaminated or delayed presentation.
• Stable or unstable fracture.
• Normal or abnormal neurovascular status.
• Isolated limb injury or polytrauma.
• Retained fragment location and whether it matters.

View larger

Permanent cavity

The permanent cavity is the direct tissue track made by the projectile and fragments. It is produced by crushing, cutting and shearing. It determines the true contaminated track and the structures that may be disrupted.

Temporary cavitation

Temporary cavitation is radial tissue stretch around the projectile path. It is more important in high-energy wounds, fragmenting projectiles and tissues that do not tolerate stretch well. Muscle may recover if viable; vessels, nerves and inelastic compartments may not.

Bone strike

When a projectile hits bone:

• Energy transfer rises abruptly.
• Bone becomes secondary missiles.
• Comminution and segmental defects may occur.
• The wound may behave more like a high-energy open fracture even if the skin wounds look small.
• Compartment syndrome and vascular injury risk increase.

Low-energy versus high-energy

Classify the injury in a way that changes treatment. Weapon labels alone are less helpful than tissue behaviour.

View larger

History

The history should clarify:

• Time of injury and time to antibiotics.
• Weapon type if known, distance, number of shots and whether shotgun or blast was involved.
• Environment: street, farm, water, soil, clothing, shoe or bowel contamination.
• Immediate bleeding, tourniquet use, transient limb ischaemia or prehospital reduction.
• Numbness, weakness, severe pain, progressive swelling or increasing analgesia requirement.
• Tetanus status, allergies, anticoagulation, diabetes, smoking and immunosuppression.

Do not rely on the patient's description of calibre or velocity to decide treatment. Use the clinical wound, imaging and tissue findings.

Examination

Hard vascular signs

Hard signs include pulsatile bleeding, expanding haematoma, bruit or thrill, absent distal perfusion, ischaemic limb and rapidly progressive neurological deficit from ischaemia. These findings require immediate vascular decision-making rather than delayed outpatient fracture review.

Compartment syndrome risk

Gunshot wounds can cause compartment syndrome through fracture bleeding, vascular injury, reperfusion, swelling, crush, tight dressings or delayed presentation. Pain with passive stretch, tense compartments and increasing analgesic requirement remain important, but obtunded or intubated patients need pressure measurement and proactive monitoring.

Plain radiographs

Order orthogonal X-rays of:

• The injured bone or region.
• The joint above and below when a long bone is involved.
• Adjacent joints when the trajectory is near a joint.
• The pelvis or abdomen when the bullet path may be transpelvic.

On X-ray, assess:

• Fracture pattern, comminution, segmental bone loss and cortical violation.
• Retained fragment location: intra-articular, intra-bursal, extra-articular soft tissue, within bone or near a neurovascular bundle.
• Intra-articular gas or haemarthrosis clues.
• Bullet fragmentation, which suggests higher energy transfer.
• Foreign material and clothing debris when visible.

CT

CT is useful for:

• Intra-articular fracture extension.
• Pelvis, acetabulum, foot, ankle, hand or complex periarticular injuries.
• Retained fragment localisation when removal is planned.
• Bone loss and fixation planning.
• Transpelvic trajectory and associated visceral concern.

CTA and vascular studies

CTA is indicated when perfusion is abnormal, ABI/API is abnormal, hard or soft vascular signs exist, or the projectile path is close to a major vessel with concerning findings. Do not delay direct vascular surgery for a clearly ischaemic limb when the diagnosis is clinically obvious.

Laboratory tests

Blood tests depend on severity. Consider:

• Full blood count and group/crossmatch in major trauma.
• Creatine kinase, renal function and urine myoglobin if crush, ischaemia or compartment risk.
• Inflammatory markers are not useful for the acute decision but may help delayed infection follow-up.
• Baseline blood lead level when a retained fragment is intra-articular, intra-bursal, multiple, symptomatic or long-standing.

This section describes operative principles rather than one universal operation. The correct operation depends on the limb region, wound, fracture and associated injuries.

View larger

Remove

Remove or strongly consider removal when the fragment is:

• Intra-articular.
• Intra-bursal or in a synovial sheath.
• Causing nerve compression.
• Threatening a vessel or repair.
• Infected or associated with abscess.
• Symptomatic and safely accessible.
• Encountered during planned exposure without added morbidity.
• In the palm, sole or other pressure-bearing region where it causes functional symptoms.

Observe

Observation is reasonable when:

• The fragment is deep, extra-articular and asymptomatic.
• Removal would require extensive dissection through healthy tissue.
• There is no infection, nerve compression, vascular risk or joint communication.
• The fragment is within soft tissue and not causing mechanical symptoms.

Lead arthropathy

Lead dissolves more readily in synovial fluid than in inert soft tissue. Retained intra-articular fragments can cause synovitis, cartilage damage, radiographic lead deposition, systemic lead toxicity and secondary arthritis. Symptoms may appear years later.

Follow-up considerations:

• Ask about pain, swelling, stiffness, fatigue, abdominal symptoms, neuropathy and cognitive symptoms when retained intra-articular fragments are known.
• Check blood lead level for intra-articular, intra-bursal, multiple or symptomatic retained fragments.
• Coordinate medical toxicology or physician input for elevated levels or systemic symptoms.

Follow-up priorities

• Recheck wound within the timeframe appropriate for contamination and surgery.
• Repeat neurovascular examination.
• Continue compartment vigilance while swelling evolves.
• Monitor fracture alignment and union.
• Review cultures and adjust antibiotics when infection is present.
• Start early motion when fixation and soft tissues permit.
• Counsel on smoking cessation, diabetes optimisation and return precautions.
• Monitor retained intra-articular or symptomatic fragments.

Red flags after discharge

Patients should return urgently for:

• Increasing pain out of proportion.
• Increasing swelling or tight compartments.
• Numbness, weakness or cold limb.
• Fever, spreading redness, pus or foul odour.
• New drainage after an initially dry wound.
• Worsening joint pain when a fragment may be intra-articular.

Postoperative care depends on the wound and fixation, but the same priorities recur.

Follow-up schedule

• Early wound review for high-risk, contaminated or surgically treated wounds.
• Radiographs to confirm alignment and progression to union.
• Review cultures and histology when debridement was performed.
• Lead monitoring for retained intra-articular, intra-bursal, multiple or symptomatic fragments.
• Hand therapy, splinting or physiotherapy when tendons, joints or nerves are involved.

Outcome depends more on tissue injury and associated structures than on the bullet itself.

Prognostic factors to state clearly

• Energy and tissue devitalisation.
• Time to antibiotics and debridement when contamination is significant.
• Vascular injury and ischaemia duration.
• Need for fasciotomy.
• Joint surface injury.
• Bone defect size and fixation stability.
• Patient factors: smoking, diabetes, immunosuppression, nutrition and adherence.

Management should follow local major trauma, open fracture, antimicrobial and tetanus protocols. In Australia, the practical principles are:

• Use a major trauma pathway for unstable patients and high-energy wounds.
• Involve orthopaedics, vascular surgery, plastic surgery, emergency medicine, intensive care, infectious diseases and rehabilitation early when required.
• Antibiotic choice should follow local antimicrobial guidance and hospital open-fracture policy rather than a fixed international recipe.
• Tetanus assessment is part of every penetrating wound plan.
• Document neurovascular status, wound appearance, antibiotics, tetanus decision, splinting, imaging and serial compartment checks clearly.
• For retained intra-articular fragments or lead toxicity concern, coordinate with physicians, toxicology or infectious diseases according to local service availability.

• Jabara JT, Gannon NP, Vallier HA, Nguyen MP. Management of civilian low-velocity gunshot injuries to an extremity. PubMed
• Maqungo S, Kauta N, Held M, et al. Gunshot injuries to the lower extremities: issues, controversies and algorithm of management. PubMed
• Sathiyakumar V, Thakore RV, Stinner DJ, et al. Gunshot-induced fractures of the extremities: a review of antibiotic and debridement practices. PubMed
• Papasoulis E, Patzakis MJ, Zalavras CG. Antibiotics in the treatment of low-velocity gunshot-induced fractures: a systematic literature review. PubMed
• Penn-Barwell JG, Brown KV, Fries CA. High velocity gunshot injuries to the extremities: management on and off the battlefield. PubMed
• Omid R, Stone MA, Zalavras CG, Marecek GS. Gunshot wounds to the upper extremity. PubMed
• Sclafani SJ, Vuletin JC, Twersky J. Lead arthropathy: arthritis caused by retained intra-articular bullets. PubMed