High-yield overview

Energy transfer | Neurovascular status | Joint involvement | Debridement strategy

LowEnergy Changes Strategy

JointRemove Intra-Articular Fragments

VesselHard Signs Change Sequence

SerialCompartment Checks

Working Categories

Low-energy extra-articular

PatternUsually a handgun-type civilian injury with limited soft tissue destruction and no joint violation.

TreatmentTreat the fracture by standard principles; local wound care and selective antibiotics.

Intra-articular

PatternProjectile or fragments enter the joint or synovial space.

TreatmentRemove intra-articular fragments; wash out contaminated joints; protect cartilage.

High-energy / gross contamination

PatternLarge temporary cavity, fragmentation, devitalised tissue, blast effect, shotgun or delayed contaminated wound.

TreatmentFormal debridement, staged fixation and planned second look.

Vascular or compartment risk

PatternHard vascular signs, abnormal perfusion, expanding haematoma, reperfusion injury or tight compartments.

TreatmentRestore perfusion, stabilise bone, low fasciotomy threshold and serial checks.

Critical Must-Knows

Do not judge severity by skin wound size. A small entry wound can hide fracture comminution, vascular injury or compartment syndrome.
Energy transfer is the key concept. Velocity, yaw, fragmentation, tissue resistance and bone strike determine tissue damage.
Low-energy extra-articular fractures are not automatically massive open-fracture operations. They are often managed like the equivalent closed fracture with appropriate wound care.
Intra-articular bullets should be removed. Synovial fluid exposes lead and cartilage to ongoing chemical and mechanical injury.
Hard vascular signs change the sequence. Perfusion and haemorrhage control take priority over definitive fracture fixation.
High-energy or contaminated wounds need formal debridement and staged reconstruction. Do not close them primarily when tissue viability is uncertain.

Clinical Pearls

"
The safe first sentence is: assess the patient, limb perfusion, neurological status, wound energy, contamination, joint involvement and fracture stability.
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The orthopaedic decision is not 'bullet equals open fracture protocol for everything'; it is energy, contamination, joint violation and stability.
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Routine removal of deep asymptomatic extra-articular fragments can cause more damage than observation.
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A fracture with vascular repair has a low threshold for prophylactic fasciotomy, especially after ischaemia or reperfusion.

Immediate Safety Rule

Do not be reassured by palpable pulses alone. Document motor, sensory, capillary refill, Doppler signals and ankle-brachial index when appropriate; obtain vascular imaging or direct vascular surgery input when hard signs or abnormal perfusion are present.

At a Glance: First Orthopaedic Decisions

Question	Finding That Matters	Action
Is the patient unstable?	Major haemorrhage, shock, airway or chest/abdominal injury.	Primary survey, haemorrhage control and trauma resuscitation before fracture detail.
Is the limb perfused?	Absent pulses, expanding haematoma, bruit, thrill, active bleeding or ischaemic limb.	Vascular surgery, CTA when appropriate, temporary shunt or repair with bone stabilisation.
Is the joint violated?	Trajectory through a joint, intra-articular gas or fragments, haemarthrosis or synovial wound.	Remove intra-articular fragments and wash out contaminated joints.
Is it low-energy and extra-articular?	Small wound, limited contamination, stable patient, fracture behaves like standard pattern.	Treat fracture by standard principles; do not chase deep asymptomatic bullet fragments.
Is it high-energy or contaminated?	Large tissue defect, fragmentation, devitalised muscle, delayed presentation, bowel/farm/water contamination.	Formal debridement, staged fixation, second look and soft tissue planning.

Rapid Recall

SHOTInitial Assessment	BALLWhat Changes Treatment	FIREOperative Priorities
S Survey Primary survey and haemorrhage control first.	B Bone stability Fix the fracture by standard mechanical principles.	F Fixation Temporary or definitive, depending physiology and soft tissues.
H Haemorrhage Control bleeding and identify vascular hard signs.	A Artery Perfusion sequence overrides definitive fixation.	I Irrigation Formal washout when joint, contamination or high-energy injury exists.
O Open joint Joint violation changes washout and fragment removal.	L Lead in joint Intra-articular fragments should be removed.	R Remove dead tissue Debride devitalised muscle, bone and foreign material that matters.
T Tissues Energy and devitalisation decide debridement.	L Local contamination Bowel, farm, water or delayed contamination escalates debridement.	E Expect swelling Low threshold for fasciotomy when vascular or crush risk exists.
Do not start by chasing the bullet.	The projectile matters less than what it did.	Match the operation to the wound.

Overview

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.

Core Principle

Treat the patient and limb first, then the projectile. The operation is decided by physiology, perfusion, tissue viability, contamination, joint involvement and fracture stability.

Why this topic matters

Common but variable

Civilian gunshot wounds range from low-energy soft tissue wounds to comminuted open fractures with vascular injury.

Decision traps

Over-treatment causes unnecessary tissue damage; under-treatment misses joints, vessels, compartments and contamination.

Long-term risk

Missed infection, nonunion, nerve injury, vascular compromise and intra-articular lead can produce major disability.

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.

Anatomy and Biomechanics

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

Energy Pattern and Clinical Meaning

Feature	Low-Energy Civilian Pattern	High-Energy / Military / Blast Pattern
Typical projectile	Handgun-type, lower velocity, often limited cavitation.	Rifle, fragmentation, blast, shotgun at close range or high-energy transfer.
Soft tissue zone	Often narrow wound track with limited devitalisation.	Wide zone of devitalised and contaminated tissue.
Fracture behaviour	May be treated like the equivalent non-gunshot fracture if extra-articular and clean.	Often needs formal debridement, staged fixation and soft tissue reconstruction.
Debridement	Selective; no routine deep bullet chase.	Formal; remove non-viable tissue and plan second look.
Closure	Depends on wound and contamination.	Avoid primary closure when viability is uncertain.

Energy Transfer Sentence

Velocity is important because kinetic energy rises with the square of velocity, but tissue damage is determined by the energy actually transferred into the limb. Yaw, fragmentation, bone strike and tissue resistance all matter.

Classification

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

Energy-Based Classification

Pattern	Features	Treatment Meaning
Low-energy	Limited soft tissue injury, small wound track, often handgun-type civilian injury.	May be managed like equivalent fracture if extra-articular and clean.
High-energy	Large temporary cavity, devitalised tissue, bone fragmentation, blast or rifle-type transfer.	Formal debridement, staged care and soft tissue planning.
Shotgun	Variable; close-range injuries can be devastating with pellets, wad and broad contamination.	Treat by tissue destruction and contamination, not by the word shotgun alone.
Blast combined injury	Penetrating fragments plus crush, burns, contamination and systemic trauma.	Damage-control principles and repeated debridement are common.

Clinical Assessment

Extremity gunshot injury first decisions flowchart — Initial management is a branching pathway. Perfusion, joint violation, contamination, energy and fracture stability determine the next step.Credit: Original OrthoVellum illustration

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

Examination Checklist

Step	What to Document	Why It Matters
Look	Entry and exit wounds, soft tissue loss, contamination, swelling, deformity, expanding haematoma.	Defines wound energy and urgent vascular concern.
Feel	Compartments, bony tenderness, crepitus, temperature and capillary refill.	Tense compartments and cool limb change urgency.
Move	Active motor function before reduction or anaesthesia.	Baseline nerve function may be lost later if not recorded.
Nerves	Named motor and sensory testing relevant to the region.	Ballistic nerve injuries can be neuropraxia, partial laceration or complete transection.
Vessels	Pulses, Doppler signals, ABI/API, capillary refill and hard signs.	Determines CTA, exploration, shunt or repair.
Joints	Trajectory across joint, haemarthrosis, intra-articular air or fragment.	Changes removal and washout decisions.

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.

Common Error

Normal pulses do not exclude compartment syndrome, and a normal pulse can coexist with a major venous injury, intimal arterial injury or evolving swelling.

Differential diagnosis of the painful, swollen gunshot limb

A small skin wound can hide several time-critical diagnoses. The differential is really a question of which limb-threatening process is driving the pain and swelling.

Distinguishing the Limb-Threatening Diagnoses

Diagnosis	Discriminating Features	Key Test	First Action
Arterial injury / ischaemia	Hard signs: pulsatile bleeding, expanding haematoma, bruit, thrill, absent distal pulses, cool pale ischaemic limb.	Examination plus ABI; CTA if signs equivocal.	Vascular surgery, haemorrhage control, shunt or repair with bone stabilisation.
Acute compartment syndrome	Pain out of proportion, pain on passive stretch, tense compartments, escalating analgesia; pulses often present.	Serial examination; compartment pressures if obtunded.	Urgent fasciotomy; do not wait for pulselessness.
Septic / contaminated joint	Trajectory across a joint, effusion, intra-articular gas or fragment, especially after a bowel-traversing path.	Imaging for joint violation; treat as septic arthritis if missile crossed large bowel.	Washout, fragment removal and joint-appropriate antibiotics.
Evolving deep infection	Delayed presentation, fever, spreading erythema, purulent or malodorous drainage.	Deep operative cultures (superficial swabs are inferior).	Debridement and targeted antibiotics.
Uncomplicated soft-tissue wound	Low-energy, extra-articular, normal perfusion, soft compartments, no contamination.	Clinical assessment and orthogonal radiographs.	Local wound care, tetanus and selective antibiotics; observe deep asymptomatic fragments.

Imaging and Investigations

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.

Management Algorithm

Debridement and fixation strategy matrix for extremity gunshot wounds — The operation is selected by wound energy, contamination, joint involvement, vascular risk and fracture stability.Credit: Original OrthoVellum illustration

Immediate measures

Initial measures should be done in parallel with trauma resuscitation:

Control external haemorrhage with direct pressure, haemostatic dressing or tourniquet when needed.
Photograph wounds before theatre when practical, then cover with sterile dressing.
Splint the limb in a position that protects soft tissue and neurovascular structures.
Give analgesia.
Give tetanus prophylaxis according to immunisation status and wound risk.
Give antibiotics according to wound severity, contamination, joint involvement and local protocol.
Do not probe the wound blindly in the emergency department.

Surgical Technique

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

Formal debridement

Confirm patient identity, limb, imaging, antibiotics, tetanus status and vascular plan.
Position to allow access to entry wound, exit wound, fracture and potential vascular repair.
Prep widely; include adjacent joints if the trajectory may involve them.
Extend wounds only as needed for safe exposure and debridement.
Identify the projectile track, but do not tunnel blindly through healthy tissue.
Excise non-viable skin and subcutaneous tissue.
Assess muscle using colour, consistency, contractility and capacity to bleed.
Remove loose dead bone, gross debris, clothing fragments and heavily contaminated foreign material.
Preserve bone and soft tissue required for reconstruction when viable.
Irrigate with low-pressure fluid; avoid tissue-destructive high-pressure lavage.
Obtain deep cultures if infection is suspected or delayed presentation is infected.
Stabilise the fracture in a way that protects soft tissue access.
Leave wounds open or use temporary coverage when viability is uncertain.
Plan second look and reconstruction early.

Retained Bullet Fragments

Retained bullet decision diagram showing extra-articular observation and intra-articular removal indications — Retained fragments are managed by location and symptoms. Intra-articular fragments are different from deep extra-articular fragments.Credit: Original OrthoVellum illustration

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.

Region-Specific Traps

High-Yield Regional Problems

Region	Do Not Miss	Practical Point
Shoulder and elbow	Intra-articular fragments, nerve injury, vascular proximity.	CT helps locate fragments; arthroscopy may remove selected joint fragments.
Forearm	Compartment syndrome, nerve injury, unstable both-bone mechanics.	Assess median, ulnar, radial and AIN/PIN function before anaesthesia.
Hand	Tendon, nerve, vessel, joint and contamination in a small volume.	Low-calibre does not mean low-risk in the hand.
Pelvis and acetabulum	Bowel, rectal, bladder, urethral, vascular and intra-articular contamination.	Trajectory and visceral injury decide antibiotics and debridement.
Femur and tibia	Vascular injury, compartment syndrome, comminution, nonunion.	Treat fracture mechanically, but respect soft tissues and perfusion.
Foot and ankle	Contamination from shoe, small compartments, joint violation, retained fragments in sole.	Do not underestimate infection and compartment risk.

Complications and Follow-Up

Early

Haemorrhage, vascular thrombosis, compartment syndrome, missed nerve injury, wound contamination and acute infection.

Intermediate

Deep infection, fixation failure, delayed union, nonunion, stiffness, neuropathic pain and soft tissue breakdown.

Late

Lead arthropathy, systemic lead toxicity, chronic osteomyelitis, post-traumatic arthritis, malunion and complex regional pain.

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

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

Postoperative Priorities

Priority	What to Do	Why
Neurovascular status	Document pulses, Doppler signals, capillary refill, motor and sensory function after surgery.	Detects vascular thrombosis, nerve deterioration and compartment syndrome.
Compartment surveillance	Repeat examinations and measure pressures when examination is unreliable.	Gunshot fractures with vascular injury or reperfusion remain high risk.
Wound plan	Schedule dressing review, second look, delayed closure, graft or flap timing.	Soft tissue failure is a major driver of infection and nonunion.
Antibiotics	Stop prophylaxis when appropriate; continue targeted therapy only for established infection or high-risk contamination.	Prevents unnecessary prolonged antibiotics while treating real infection.
Rehabilitation	Begin joint motion when fixation and soft tissues allow.	Stiffness is common after periarticular and upper-limb gunshot injuries.

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.

Outcomes and Prognosis

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

Better prognosis

Low-energy, extra-articular, clean wound, stable fracture, normal neurovascular status and reliable follow-up.

Worse prognosis

High-energy transfer, vascular injury, compartment syndrome, bone loss, joint injury, infection, smoking and poor soft tissue cover.

Recovery limits

Nerve injury, stiffness, chronic infection, nonunion and post-traumatic arthritis may dominate function even after fracture union.

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.

Evidence Base

Management of Civilian Low-Velocity Gunshot Injuries to an Extremity

Jabara, Gannon, Vallier, Nguyen • J Bone Joint Surg Am (2021)

Key Findings:

Most low-velocity gunshot-induced extremity fractures can be managed similarly to equivalent non-gunshot fractures, with goals of restoring function and minimising complications.
Intra-articular retained bullets should be removed; routine prophylactic irrigation and debridement of a transarticular bullet track is not warranted purely for infection prevention.
Evidence supporting prophylactic antibiotics in non-operatively treated wounds is limited; most literature is Level III or IV.

Finding: Review

Clinical Implication: Do not over-operate every low-energy extra-articular gunshot fracture, but do remove intra-articular fragments and escalate when tissue, contamination or perfusion demands it.

Verify on PubMed (PMID 33755646)

Gunshot Injuries to the Lower Extremities: Issues, Controversies and Algorithm of Management

Maqungo, Kauta, Held, et al. • Injury (2020)

Key Findings:

Proposes conservative management of soft-tissue-only wounds and of incomplete (non-displaced) tibial or femoral shaft fractures, with fixation of all complete fractures and prophylactic fixation of incomplete peritrochanteric fractures.
All intra-articular projectiles should be removed.
A joint should be treated as septic arthritis only when the missile traverses large bowel (not small bowel) before entering the joint capsule.
Evidence remains scarce and limited by high loss to follow-up in this population.

Finding: Current concepts review

Clinical Implication: Use a structured pathway rather than a single rule for every gunshot wound; bowel-traversing trajectories that enter a joint warrant septic-arthritis-level treatment.

Verify on PubMed (PMID 32471684)

Common Pitfalls

Pitfalls That Change Outcome

Overtreatment

Chasing a deep asymptomatic extra-articular bullet can injure nerves, vessels and soft tissue without benefit.

Undertreatment

Missing joint violation, bowel contamination, vascular injury or compartment syndrome can be limb-threatening.

Wrong antibiotic logic

Low-energy evidence does not justify ignoring contamination, operative fixation, delayed infection or high-energy tissue loss.

Wrong closure

Closing high-energy or contaminated wounds before tissue viability is clear increases infection risk.

Applied Scenarios

Use these scenarios to practise clinical reasoning and management decisions

CLINICAL SCENARIOStandard

Low-Energy Extra-Articular Tibial Fracture

CLINICAL PROMPT

"A stable adult has a small entry and exit wound, normal neurovascular examination and an extra-articular tibial shaft fracture after a handgun injury."

PRACTICAL APPROACH

I would assess the patient using trauma principles, then focus on limb perfusion, neurological status, compartments, wound contamination and fracture pattern. If this is a low-energy extra-articular wound with no gross contamination, no vascular injury and no compartment syndrome, I would not automatically perform extensive bullet-track debridement. I would give tetanus prophylaxis and antibiotics according to local protocol, dress the wound, splint the limb and treat the tibial fracture by standard principles. If the fracture pattern needs fixation, intramedullary nailing may be appropriate once the wound and soft tissues are safe. I would document serial compartment checks and follow closely for infection and union.

KEY CLINICAL POINTS

Low-energy extra-articular injuries can be treated like equivalent fractures.

Neurovascular and compartment documentation is essential.

No routine deep asymptomatic bullet chase.

Fixation is based on fracture mechanics and soft tissue safety.

COMMON PITFALLS

Assuming every gunshot fracture requires wide debridement.

Ignoring compartment syndrome risk because pulses are present.

Forgetting tetanus, antibiotics and wound follow-up.

FURTHER QUESTIONS

"What findings would make you escalate to formal debridement?"

CLINICAL SCENARIOChallenging

Intra-Articular Knee Fragment

CLINICAL PROMPT

"A patient has a gunshot wound crossing the knee with a retained metallic fragment visible inside the joint."

PRACTICAL APPROACH

This is an intra-articular retained fragment. I would assess the limb, exclude vascular injury and define the fracture and fragment location with X-ray and CT if needed. Intra-articular fragments should be removed because they can damage cartilage and cause synovitis, lead arthropathy and loose-body symptoms. Depending on the fragment position and associated fracture, I would plan arthroscopic or open removal, joint irrigation if contaminated and fixation of any unstable fracture. I would document cartilage injury, remove accessible intra-articular debris, give antibiotics according to joint and wound contamination and arrange follow-up for infection, stiffness and lead-related symptoms.

KEY CLINICAL POINTS

Intra-articular is different from extra-articular.

Remove retained intra-articular fragments.

Choose arthroscopic or open approach based on location and fracture.

Assess vascular status and cartilage injury.

COMMON PITFALLS

Observing a true intra-articular bullet.

Removing only the visible large fragment and ignoring smaller intra-articular debris.

Missing associated vascular injury around the knee.

FURTHER QUESTIONS

"When would you check blood lead levels?"

CLINICAL SCENARIOCritical

High-Energy Contaminated Wound

CLINICAL PROMPT

"A patient has a comminuted femoral fracture with a large soft tissue defect, devitalised muscle and gross contamination after a high-energy projectile injury."

PRACTICAL APPROACH

This is a high-energy contaminated open fracture pattern. I would manage the patient with trauma resuscitation, antibiotics, tetanus prophylaxis, neurovascular documentation and early theatre. Operative priorities are formal debridement of devitalised tissue, removal of gross contamination, fracture stabilisation that respects soft tissue access and a planned second look. If the patient is unstable or the soft tissue envelope is poor, temporary external fixation is appropriate. Definitive fixation and coverage are planned with the reconstructive team once the wound is clean and viability is clear. I would avoid primary closure if tissue viability is uncertain.

KEY CLINICAL POINTS

High-energy tissue destruction requires formal debridement.

Temporary fixation is appropriate when soft tissues or physiology are not ready.

Second look is planned, not accidental.

Avoid unsafe primary closure.

COMMON PITFALLS

Treating it like a small low-energy wound.

Definitive fixation that blocks wound access.

Closing devitalised contaminated tissue.

FURTHER QUESTIONS

"How do you decide muscle viability at debridement?"

CLINICAL SCENARIOCritical

Vascular Injury With Fracture

CLINICAL PROMPT

"A patient with a gunshot fracture around the distal femur has an ischaemic foot and expanding popliteal fossa haematoma."

PRACTICAL APPROACH

This is a limb-threatening vascular injury. I would activate vascular surgery immediately, control haemorrhage, document neurological status and avoid delaying reperfusion for prolonged fracture planning. The sequence is agreed with vascular surgery. If the fracture is unstable and threatens the repair, rapid temporary external fixation may be performed first. If orthopaedic stabilisation would delay reperfusion, a temporary vascular shunt may be needed. After reperfusion, I would have a low threshold for fasciotomy because ischaemia, reperfusion and fracture bleeding increase compartment syndrome risk. Definitive fixation follows once perfusion, soft tissues and physiology allow.

KEY CLINICAL POINTS

Hard vascular signs require urgent vascular management.

Bone stabilisation protects vascular repair when it can be done rapidly.

Temporary shunt is an option when reperfusion cannot wait.

Fasciotomy threshold is low after ischaemia and reperfusion.

COMMON PITFALLS

Sending an ischaemic limb for routine CT without a vascular plan.

Performing prolonged definitive fixation before reperfusion.

Forgetting prophylactic fasciotomy.

FURTHER QUESTIONS

"What are the indications for prophylactic fasciotomy?"

MCQ Practice Points

MCQ Trap 1

Q: Does every low-energy extra-articular gunshot fracture need wide operative debridement? A: No. Many can be treated like the equivalent fracture with local wound care and appropriate antibiotic/tetanus decisions.

MCQ Trap 2

Q: Which retained bullet fragments should be removed? A: Intra-articular, intra-bursal, infected, symptomatic, neurovascularly threatening or accessible fragments during planned surgery.

MCQ Trap 3

Q: What is the key determinant of tissue destruction? A: Energy transferred into the tissue, influenced by velocity, yaw, fragmentation, bone strike and tissue resistance.

MCQ Trap 4

Q: Why is fasciotomy considered after vascular repair? A: Ischaemia and reperfusion increase compartment syndrome risk, especially with fracture, swelling and prolonged ischaemia.

Guidelines, Registries & Global Practice

Global epidemiology and practice variation

The burden of ballistic limb trauma is extremely unevenly distributed. Civilian gunshot violence is concentrated in specific high-incidence regions — parts of the Americas and southern Africa carry a disproportionate share of orthopaedic ballistic workload, and centres such as the OrthoBallistics group in Cape Town manage volumes rarely seen elsewhere. By contrast, in the United Kingdom, much of Europe and Australasia, civilian gunshot injury is comparatively uncommon, so the largest published high-energy experience is military and is reported through defence trauma systems. This drives a real practice gap: a low-energy handgun fracture is the everyday lesion in high-incidence civilian settings, whereas blast and high-velocity rifle wounds dominate the military literature and shape much of the published surgical doctrine.

A recurring methodological problem, emphasised by the Cape Town group (according to PubMed, Maqungo et al., Injury 2020, DOI), is that the field is scientifically under-represented: high loss to follow-up and poor compliance in affected populations make high-quality prospective evidence scarce, so most guidance rests on Level III to V data and expert consensus.

Side-by-side guideline and doctrine comparison

There is no single international gunshot-fracture guideline; instead, principles are drawn from open-fracture and trauma-system standards applied to the ballistic wound.

How Major Bodies Frame Ballistic Limb Injury

Body / Source	Position Relevant to Gunshot Wounds	Evidence Basis
BOA / BAPRAS (BOAST – Open Fractures, UK)	High-energy or contaminated ballistic wounds follow open-fracture standards: early antibiotics, senior orthoplastic assessment, debridement of devitalised tissue and combined skeletal-soft-tissue reconstruction; avoid premature closure.	National standard / consensus.
AAOS / OTA (USA)	Stratify by energy: low-velocity extra-articular fractures may be treated like equivalent closed fractures; remove intra-articular bullets; reserve extensive debridement for high-energy or contaminated wounds.	Review-level, mostly Level III-IV.
AO Foundation / AO Trauma	Apply standard fracture-fixation mechanics once contamination and soft tissues are controlled; favour temporary external fixation and staged care for severe contamination or poor soft-tissue envelope.	Educational consensus.
Defence / military trauma doctrine (e.g. UK RCDM, US Joint Trauma System)	High-velocity and blast wounds: haemorrhage control first, never close primarily, repeated debridement and planned reconstruction; liberal damage-control and shunting.	Combat-casualty series.
WHO / ICRC (resource-limited and conflict settings)	Wound excision, delayed primary closure and tetanus prophylaxis form the backbone where staged reconstruction and imaging may be limited.	Field experience / guidance.

Registry and surveillance evidence

There is no dedicated international gunshot-fracture implant registry. Relevant population-level data instead come from national trauma registries and injury surveillance systems — for example the Australian and New Zealand trauma registries, the UK Trauma Audit and Research Network (TARN), and the US National Trauma Data Bank — which capture mechanism, injury severity and outcome but not bullet-specific decisions. Vascular-imaging practice has been validated in this registry-style way: an Australian major trauma centre series confirmed that CTA is the accurate first-line vascular study yet rarely changes management when no clinical signs are present (according to PubMed, Joseph et al., Injury 2021, DOI).

Applying this locally (Australia)

Use a major trauma pathway for unstable patients and high-energy wounds, with early multidisciplinary involvement (orthopaedics, vascular surgery, plastic surgery, emergency medicine, intensive care, infectious diseases and rehabilitation).
Antibiotic choice should follow eTG antimicrobial guidance and the 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, multiple or symptomatic fragments, or any lead-toxicity concern, coordinate blood lead surveillance with physicians, toxicology or infectious diseases according to local service availability.

Clinical Context

Clinical management should be based on injury severity, patient physiology, local trauma pathways and available specialist services, recognising that civilian and military ballistic patterns differ markedly between regions.

Reference Links

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
deSouza IS, Benabbas R, McKee S, et al. Accuracy of physical examination, ankle-brachial index and ultrasonography in the diagnosis of arterial injury in penetrating extremity trauma: a systematic review and meta-analysis. PubMed
Joseph TI, Ratnakanthan PJ, Paul E, Clements W. Utility of computed tomography angiography in traumatic lower limb injury: review of clinical impact in a level 1 trauma centre. PubMed
Nickel WN, Steelman TJ, Sabath ZR, Potter BK. Extra-articular retained missiles: is surveillance of lead levels needed? PubMed

Gunshot Wounds and Ballistics: Decision Sheet

Clinical summary

Start with

•Primary survey and haemorrhage control.
•Neurovascular status before anaesthesia.
•Entry, exit, contamination, joint path and fracture stability.

Image

•Orthogonal X-rays of limb and adjacent joints.
•CT for joint, pelvis, complex fracture or fragment localisation.
•CTA for hard or soft vascular signs, abnormal ABI/API or concerning trajectory.

Operate for

•High-energy devitalised tissue.
•Gross contamination, delayed infected wounds or bowel contamination.
•Joint violation with retained intra-articular fragments.
•Unstable fractures needing standard fixation.
•Vascular injury or compartment syndrome.

Do not

•Judge severity by skin wound size alone.
•Chase deep asymptomatic extra-articular fragments.
•Close high-energy contaminated wounds primarily.
•Ignore compartment syndrome because pulses are present.

Question

Finding That Matters

Action

Is the patient unstable?

Major haemorrhage, shock, airway or chest/abdominal injury.

Primary survey, haemorrhage control and trauma resuscitation before fracture detail.

Is the limb perfused?

Absent pulses, expanding haematoma, bruit, thrill, active bleeding or ischaemic limb.

Vascular surgery, CTA when appropriate, temporary shunt or repair with bone stabilisation.

Is the joint violated?

Trajectory through a joint, intra-articular gas or fragments, haemarthrosis or synovial wound.

Remove intra-articular fragments and wash out contaminated joints.

Is it low-energy and extra-articular?

Small wound, limited contamination, stable patient, fracture behaves like standard pattern.

Treat fracture by standard principles; do not chase deep asymptomatic bullet fragments.

Is it high-energy or contaminated?

Large tissue defect, fragmentation, devitalised muscle, delayed presentation, bowel/farm/water contamination.

Formal debridement, staged fixation, second look and soft tissue planning.

SHOTInitial Assessment

BALLWhat Changes Treatment

FIREOperative Priorities

Survey

Primary survey and haemorrhage control first.

Bone stability

Fix the fracture by standard mechanical principles.

Fixation

Temporary or definitive, depending physiology and soft tissues.

Haemorrhage

Control bleeding and identify vascular hard signs.

Artery

Perfusion sequence overrides definitive fixation.

Irrigation

Formal washout when joint, contamination or high-energy injury exists.

Open joint

Joint violation changes washout and fragment removal.

Lead in joint

Intra-articular fragments should be removed.

Remove dead tissue

Debride devitalised muscle, bone and foreign material that matters.

Tissues

Energy and devitalisation decide debridement.

Local contamination

Bowel, farm, water or delayed contamination escalates debridement.

Expect swelling

Low threshold for fasciotomy when vascular or crush risk exists.

Do not start by chasing the bullet.

The projectile matters less than what it did.

Match the operation to the wound.

Feature

Low-Energy Civilian Pattern

High-Energy / Military / Blast Pattern

Typical projectile

Handgun-type, lower velocity, often limited cavitation.

Rifle, fragmentation, blast, shotgun at close range or high-energy transfer.

Soft tissue zone

Often narrow wound track with limited devitalisation.

Wide zone of devitalised and contaminated tissue.

Fracture behaviour

May be treated like the equivalent non-gunshot fracture if extra-articular and clean.

Often needs formal debridement, staged fixation and soft tissue reconstruction.

Debridement

Selective; no routine deep bullet chase.

Formal; remove non-viable tissue and plan second look.

Closure

Depends on wound and contamination.

Avoid primary closure when viability is uncertain.

Pattern

Features

Treatment Meaning

Low-energy

Limited soft tissue injury, small wound track, often handgun-type civilian injury.

May be managed like equivalent fracture if extra-articular and clean.

High-energy

Large temporary cavity, devitalised tissue, bone fragmentation, blast or rifle-type transfer.

Formal debridement, staged care and soft tissue planning.

Shotgun

Variable; close-range injuries can be devastating with pellets, wad and broad contamination.

Treat by tissue destruction and contamination, not by the word shotgun alone.

Blast combined injury

Penetrating fragments plus crush, burns, contamination and systemic trauma.

Damage-control principles and repeated debridement are common.

Step

What to Document

Why It Matters

Look

Entry and exit wounds, soft tissue loss, contamination, swelling, deformity, expanding haematoma.

Defines wound energy and urgent vascular concern.

Feel

Compartments, bony tenderness, crepitus, temperature and capillary refill.

Tense compartments and cool limb change urgency.

Move

Active motor function before reduction or anaesthesia.

Baseline nerve function may be lost later if not recorded.

Nerves

Named motor and sensory testing relevant to the region.

Ballistic nerve injuries can be neuropraxia, partial laceration or complete transection.

Vessels

Pulses, Doppler signals, ABI/API, capillary refill and hard signs.

Determines CTA, exploration, shunt or repair.

Joints

Trajectory across joint, haemarthrosis, intra-articular air or fragment.

Changes removal and washout decisions.

Diagnosis

Discriminating Features

Key Test

First Action

Arterial injury / ischaemia

Hard signs: pulsatile bleeding, expanding haematoma, bruit, thrill, absent distal pulses, cool pale ischaemic limb.

Examination plus ABI; CTA if signs equivocal.

Vascular surgery, haemorrhage control, shunt or repair with bone stabilisation.

Acute compartment syndrome

Pain out of proportion, pain on passive stretch, tense compartments, escalating analgesia; pulses often present.

Serial examination; compartment pressures if obtunded.

Urgent fasciotomy; do not wait for pulselessness.

Septic / contaminated joint

Trajectory across a joint, effusion, intra-articular gas or fragment, especially after a bowel-traversing path.

Imaging for joint violation; treat as septic arthritis if missile crossed large bowel.

Washout, fragment removal and joint-appropriate antibiotics.

Evolving deep infection

Delayed presentation, fever, spreading erythema, purulent or malodorous drainage.

Deep operative cultures (superficial swabs are inferior).

Debridement and targeted antibiotics.

Uncomplicated soft-tissue wound

Low-energy, extra-articular, normal perfusion, soft compartments, no contamination.

Clinical assessment and orthogonal radiographs.

Local wound care, tetanus and selective antibiotics; observe deep asymptomatic fragments.

Region

Do Not Miss

Practical Point

Shoulder and elbow

Intra-articular fragments, nerve injury, vascular proximity.

CT helps locate fragments; arthroscopy may remove selected joint fragments.

Forearm

Compartment syndrome, nerve injury, unstable both-bone mechanics.

Assess median, ulnar, radial and AIN/PIN function before anaesthesia.

Hand

Tendon, nerve, vessel, joint and contamination in a small volume.

Low-calibre does not mean low-risk in the hand.

Pelvis and acetabulum

Bowel, rectal, bladder, urethral, vascular and intra-articular contamination.

Trajectory and visceral injury decide antibiotics and debridement.

Femur and tibia

Vascular injury, compartment syndrome, comminution, nonunion.

Treat fracture mechanically, but respect soft tissues and perfusion.

Foot and ankle

Contamination from shoe, small compartments, joint violation, retained fragments in sole.

Do not underestimate infection and compartment risk.

Priority

What to Do

Why

Neurovascular status

Document pulses, Doppler signals, capillary refill, motor and sensory function after surgery.

Detects vascular thrombosis, nerve deterioration and compartment syndrome.

Compartment surveillance

Repeat examinations and measure pressures when examination is unreliable.

Gunshot fractures with vascular injury or reperfusion remain high risk.

Wound plan

Schedule dressing review, second look, delayed closure, graft or flap timing.

Soft tissue failure is a major driver of infection and nonunion.

Antibiotics

Stop prophylaxis when appropriate; continue targeted therapy only for established infection or high-risk contamination.

Prevents unnecessary prolonged antibiotics while treating real infection.

Rehabilitation

Begin joint motion when fixation and soft tissues allow.

Stiffness is common after periarticular and upper-limb gunshot injuries.

Management of Civilian Low-Velocity Gunshot Injuries to an Extremity

Jabara, Gannon, Vallier, Nguyen • J Bone Joint Surg Am (2021)

Key Findings:

Most low-velocity gunshot-induced extremity fractures can be managed similarly to equivalent non-gunshot fractures, with goals of restoring function and minimising complications.
Intra-articular retained bullets should be removed; routine prophylactic irrigation and debridement of a transarticular bullet track is not warranted purely for infection prevention.
Evidence supporting prophylactic antibiotics in non-operatively treated wounds is limited; most literature is Level III or IV.

Finding: Review

Clinical Implication: Do not over-operate every low-energy extra-articular gunshot fracture, but do remove intra-articular fragments and escalate when tissue, contamination or perfusion demands it.

Verify on PubMed (PMID 33755646)

Gunshot Injuries to the Lower Extremities: Issues, Controversies and Algorithm of Management

Maqungo, Kauta, Held, et al. • Injury (2020)

Key Findings:

Proposes conservative management of soft-tissue-only wounds and of incomplete (non-displaced) tibial or femoral shaft fractures, with fixation of all complete fractures and prophylactic fixation of incomplete peritrochanteric fractures.
All intra-articular projectiles should be removed.
A joint should be treated as septic arthritis only when the missile traverses large bowel (not small bowel) before entering the joint capsule.
Evidence remains scarce and limited by high loss to follow-up in this population.

Finding: Current concepts review

Clinical Implication: Use a structured pathway rather than a single rule for every gunshot wound; bowel-traversing trajectories that enter a joint warrant septic-arthritis-level treatment.

Verify on PubMed (PMID 32471684)

Body / Source

Position Relevant to Gunshot Wounds

Evidence Basis

BOA / BAPRAS (BOAST – Open Fractures, UK)

High-energy or contaminated ballistic wounds follow open-fracture standards: early antibiotics, senior orthoplastic assessment, debridement of devitalised tissue and combined skeletal-soft-tissue reconstruction; avoid premature closure.

National standard / consensus.

AAOS / OTA (USA)

Stratify by energy: low-velocity extra-articular fractures may be treated like equivalent closed fractures; remove intra-articular bullets; reserve extensive debridement for high-energy or contaminated wounds.

Review-level, mostly Level III-IV.

AO Foundation / AO Trauma

Apply standard fracture-fixation mechanics once contamination and soft tissues are controlled; favour temporary external fixation and staged care for severe contamination or poor soft-tissue envelope.

Educational consensus.

Defence / military trauma doctrine (e.g. UK RCDM, US Joint Trauma System)

High-velocity and blast wounds: haemorrhage control first, never close primarily, repeated debridement and planned reconstruction; liberal damage-control and shunting.

Combat-casualty series.

WHO / ICRC (resource-limited and conflict settings)

Wound excision, delayed primary closure and tetanus prophylaxis form the backbone where staged reconstruction and imaging may be limited.

Field experience / guidance.

Path	Clinical Concern	Action
Extra-articular soft tissue	Pain, wound contamination and possible retained fragment.	Local wound care; observe deep asymptomatic fragments.
Extra-articular fracture	Fracture stability, cortical violation and contamination.	Treat fracture according to standard mechanical principles.
Intra-articular	Cartilage injury, synovitis, lead arthropathy, loose body and infection concern.	Remove intra-articular fragment; wash out contaminated joint.
Transpelvic / bowel trajectory	Polymicrobial contamination, pelvic fracture, rectal or genitourinary injury.	Multidisciplinary trauma, antibiotics, contamination control and selective debridement.
Neurovascular corridor	Artery, vein or nerve injury may be occult initially.	Serial examination, CTA when indicated and specialist input.

Scenario	Reasonable Approach	Important Caveat
Low-energy soft tissue only	Local wound care; antibiotics vary by local protocol and patient risk.	Evidence does not support prolonged broad coverage for every minor wound.
Low-energy extra-articular fracture	Short course of a first-generation cephalosporin is commonly used.	Systematic review evidence has not proven benefit strongly, so avoid unnecessary prolonged therapy.
Operative fixation	Perioperative prophylaxis as for fracture surgery, adjusted for wound contamination.	Do not confuse prophylaxis with treatment of established infection.
High-energy, gross contamination or delayed wound	Broad open-fracture-style coverage based on contamination source.	Farm, water, bowel and soil contamination need organism-specific thinking.
Infected delayed presentation	Cultures, debridement and targeted antibiotics.	Superficial swabs are inferior to deep operative cultures.

Situation	Fixation Choice	Why
Stable fracture pattern	Splint, cast, brace or functional treatment if alignment and patient factors allow.	A bullet does not automatically mandate fixation.
Diaphyseal long bone fracture with acceptable soft tissues	Intramedullary nail or plate according to the bone and fracture pattern.	Use standard mechanics once contamination and soft tissues are controlled.
Severe contamination or poor soft tissue envelope	Temporary external fixation or staged fixation.	Allows access for debridement and soft tissue reconstruction.
Periarticular fracture	Anatomic joint reconstruction when feasible, often after CT planning.	Joint congruity, cartilage injury and retained fragments matter.
Vascular injury	Temporary stabilisation before repair or definitive stabilisation if rapid and safe.	The sequence is chosen with vascular surgery to protect repair and minimise ischaemia.
Bone loss	Staged reconstruction, grafting, bone transport, Masquelet technique or amputation discussion depending severity.	The defect must be planned, not ignored after initial fixation.

Path	Clinical Concern	Action
Extra-articular soft tissue	Pain, wound contamination and possible retained fragment.	Local wound care; observe deep asymptomatic fragments.
Extra-articular fracture	Fracture stability, cortical violation and contamination.	Treat fracture according to standard mechanical principles.
Intra-articular	Cartilage injury, synovitis, lead arthropathy, loose body and infection concern.	Remove intra-articular fragment; wash out contaminated joint.
Transpelvic / bowel trajectory	Polymicrobial contamination, pelvic fracture, rectal or genitourinary injury.	Multidisciplinary trauma, antibiotics, contamination control and selective debridement.
Neurovascular corridor	Artery, vein or nerve injury may be occult initially.	Serial examination, CTA when indicated and specialist input.

Scenario	Reasonable Approach	Important Caveat
Low-energy soft tissue only	Local wound care; antibiotics vary by local protocol and patient risk.	Evidence does not support prolonged broad coverage for every minor wound.
Low-energy extra-articular fracture	Short course of a first-generation cephalosporin is commonly used.	Systematic review evidence has not proven benefit strongly, so avoid unnecessary prolonged therapy.
Operative fixation	Perioperative prophylaxis as for fracture surgery, adjusted for wound contamination.	Do not confuse prophylaxis with treatment of established infection.
High-energy, gross contamination or delayed wound	Broad open-fracture-style coverage based on contamination source.	Farm, water, bowel and soil contamination need organism-specific thinking.
Infected delayed presentation	Cultures, debridement and targeted antibiotics.	Superficial swabs are inferior to deep operative cultures.