Epidemiology and Management of Femoral Gunshot Fractures. Our Experienceñol
Article Sidebar
Published:
Jun 17, 2023
Keywords:
Firearm, femur fracture, epidemiology, classification
Main Article Content
Abstract
Introduction: Gunshot injuries affect the civilian population with increasing frequency. 57% of the patients present bone compromise, with femur fractures being the most common. The lack of a standardized protocol for its treatment prompted the development of this study.
Materials and Methods: A retrospective, descriptive study was conducted. Patients with femur fractures caused by firearms between 2019 and 2021 were included. The anatomical region, classification, treatment, and complications were analyzed.
Results: Of a total of 35 patients, 25 (71.43%) had complete fractures and 10 (28.57%) had incomplete fractures. The distal femur was the most affected area (48.57%), according to the location. Reduction and osteosynthesis were used to treat 26 patients, with 9 being treated noninvasively.
Conclusions: We used a simple classification system to categorize fractures as complete or incomplete. All complete ones were deemed unstable regardless of location, and all incomplete ones were deemed stable,with the exception of those in the proximal third, for which prophylactic fixation is advised. Incomplete shaft fractures can be treated noninvasively, but complete shaft fractures require reduction and osteosynthesis. For zone I and II fractures, the intramedullary nail is the preferred treatment. In zone III, an individualized analysis is required for each pattern. We believe that the initial management and the correct selection of the implant according to the affected area are decisive factors in achieving satisfactory outcomes.
Materials and Methods: A retrospective, descriptive study was conducted. Patients with femur fractures caused by firearms between 2019 and 2021 were included. The anatomical region, classification, treatment, and complications were analyzed.
Results: Of a total of 35 patients, 25 (71.43%) had complete fractures and 10 (28.57%) had incomplete fractures. The distal femur was the most affected area (48.57%), according to the location. Reduction and osteosynthesis were used to treat 26 patients, with 9 being treated noninvasively.
Conclusions: We used a simple classification system to categorize fractures as complete or incomplete. All complete ones were deemed unstable regardless of location, and all incomplete ones were deemed stable,with the exception of those in the proximal third, for which prophylactic fixation is advised. Incomplete shaft fractures can be treated noninvasively, but complete shaft fractures require reduction and osteosynthesis. For zone I and II fractures, the intramedullary nail is the preferred treatment. In zone III, an individualized analysis is required for each pattern. We believe that the initial management and the correct selection of the implant according to the affected area are decisive factors in achieving satisfactory outcomes.
Downloads
Download data is not yet available.
Metrics
Metrics Loading ...
Article Details
How to Cite
Taboadela, F. J., Mantella Gorosito, D., Borre, F., & Narváez, F. (2023). Epidemiology and Management of Femoral Gunshot Fractures. Our Experienceñol. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 88(3), 275-285. https://doi.org/10.15417/issn.1852-7434.2023.88.3.1691
Issue
Section
Clinical Research
Copyright (c) 2023 Revista de la Asociación Argentina de Ortopedia y Traumatología
Manuscript acceptance by the Journal implies the simultaneous non-submission to any other journal or publishing house. The RAAOT is under the Licencia Creative Commnos Atribución-NoComercial-Compartir Obras Derivadas Igual 4.0 Internacional (CC-BY-NC.SA 4.0) (http://creativecommons.org/licences/by-nc-sa/4.0/deed.es). Articles can be shared, copied, distributed, modified, altered, transformed into a derivative work, executed and publicly communicated, provided a) the authors and the original publication (Journal, Publisher and URL) are mentioned, b) they are not used for commercial purposes, c) the same terms of the license are maintained.
In the event that the manuscript is approved for its next publication, the authors retain the copyright and will assign to the journal the rights of publication, edition, reproduction, distribution, exhibition and communication at a national and international level in the different databases. data, repositories and portals.
It is hereby stated that the mentioned manuscript has not been published and that it is not being printed in any other national or foreign journal.
The authors hereby accept the necessary modifications, suggested by the reviewers, in order to adapt the manuscript to the style and publication rules of this Journal.
References
1. Pérez Ruiz SA, Matus Jiménez J. Factores de riesgo asociados a infección de fracturas expuestas por proyectil de arma de fuego. Acta Ortop Mex 2019;33(1):28-35. Disponible en: https://www.medigraphic.com/pdfs/ortope/or-2019/or191g.pdf
2. Nguyen MP, Savakus JC, O’Donnell JA, Prayson NF, Reich MS, Golob Jr JF, et al. Infection rates and treatment of
low velocity extremity gunshot injuries. J Orthop Trauma 2017;31(6):326-9. https://doi.org/10.1097/BOT.0000000000000827
3. Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg 1990;72(2):299-304. PMID: 2406275
4. Moye Elizalde GA, Ruiz Martínez F, Suarez Santamaría JJ, Ruiz Ramírez M, Reyes Gallardo A, Díaz Apodaca BA.
Epidemiology of gunshot wounds at Ciudad Juárez, Chihuahua General Hospital. Acta Ortop Mex 2013;27(4):221-
35. Disponible en: https://www.medigraphic.com/pdfs/ortope/or-2013/or134b.pdf
5. Brenes Méndez M. Open fractures management. Revista Médica Sinergia 2020;5(4):e440.
https://doi.org/10.31434/rms.v5i4.440
6. Marecek GS, Earhart JS, Gardner MJ, Davis J, Merk BR. Surgeon preferences regarding antibiotic prophylaxis for
ballistic fractures. Arch Orthop Trauma Surg 2016;136(6):751-4. https://doi.org/10.1007/s00402-016-2450-8
7. Patel NM, Yoon RS, Cantlon MB, Koerner JD, Donegan DJ, Liporace FA. Intramedullary nailing of diaphyseal
femur fractures secondary to gunshot wounds. J Orthop Trauma 2014;28(12):711-4. https://doi.org/10.1097/BOT.0000000000000124
8. Assari S, Kaufmann A, Darvish K, Park J, Hawb J, Safadi F, et al. Biomechanical comparison of locked plating and
spiral blade retrograde nailing of supracondylar femur fractures. Injury 2013;44(10):1340-5.
https://doi.org/10.1016/j.injury.2013.04.016
9. Georgiadis G M, Andrews KA, Redfern RE. Gunshot fracture of the femoral neck: Internal fixation and immediate proximal femoral valgus osteotomy: A case report. JBJS Case Connector 2021;11(3):e20.
https://doi.org/10.2106/JBJS.CC.20.01009
10. Held M, Engelmann E, Dunn R, Ahmad SS, Laubscher M, Keel MJB, et al. Gunshot induced injuries in
orthopaedic trauma research. A bibliometric analysis of the most influential literature. Orthop Traumatol Surg Res 2017;103(5):801-7. https://doi.org/10.1016/j.otsr.2017.05.002
11. Congiusta D, Oettinger JP, Merchant AM, Vosbikian M, Ahmed IH. Epidemiology of orthopaedic fractures due to firearms. J Clin Orthop Trauma 2020;12(1):45-9. https://doi.org/10.1016/j.jcot.2020.10.047
12. Gugala Z, Lindsey RW. Classification of gunshot injuries in civilians. Clin Orthop Relat Res 2003;(408):65-81.
https://doi.org/10.1097/00003086-200303000-00007
13. Smith HW, Wheatley KK Jr. Biomechanics of femur fractures secondary to gunshot wounds. J Trauma
1984;24(11):970-7. https://doi.org/10.1097/00005373-198411000-00008
14. Long WT, Chang W. Grading system for gunshot injuries to the femoral diaphysis in civilians. Clin Orthop Relat Res 2003;408:92-100. https://doi.org/10.1097/00003086-200303000-00010
15. Nguyen MP, Prayson N, Vallier HA. Low-velocity gunshot injuries to the femur: What is the utility of stabilizing
incomplete fractures? J Am Acad Orthop Surg 2019;27(18):685-9. https://doi.org/10.5435/JAAOS-D-17-00849
16. Sathiyakumar V, Thakore RV, Stinner DJ, Obremskey WT, Ficke JR, Sethi MK. Gunshot-induced fractures of the
extremities: a review of antibiotic and debridement practices. Curr Rev Musculoskelet Med 2015;8(3):276-89.
https://doi.org/10.1007/s12178-015-9284-9
17. Scharfenberger AV, Alabassi K, Smith S, Weber D, Dulai SK, Bergman JW, et al. Primary wound closure after open fracture: a prospective cohort study examining nonunion and deep infection. J Orthop Trauma 2017;31(3):121-6. https://doi.org/10.1097/BOT.0000000000000751
18. Maqungo S, Kauta N, Held M, Mazibuko T, Keel MJB, Laubscher M, et al. Gunshot injuries to the lower
extremities: Issues, controversies and algorithm of management. Injury 2020;51(7):1426-31.
https://doi.org/10.1016/j.injury.2020.05.024
19. Dougherty PlJ, Gherebeh P. Retrograde versus antegrade intramedullary nailing of gunshot diaphyseal femur
fractures. Clin Orthop Relat Res 2013;471(12):3974-80. https://doi.org/10.1007/s11999-013-3058-8
20. Papadokostakis C, Dimitriou R, Giannoudis PV. The role and efficacy of retrograding nailing for the treatment of diaphyseal and distal femoral fractures: a systematic review of the literature. Injury 2005;36 (7):813-22.
https://doi.org/10.1016/j.injury.2004.11.029
21. Gill SPS, Mittal A, Raj M, Singh P, Singh, J, Kumar S. Extra articular supracondylar femur fractures managed with locked distal femoral plate or supracondylar nailing: a comparative outcome study. J Clin Diagn Res 2017;11(5):19-23. https://doi.org/10.7860/JCDR/2017/25062.9936
22. Riehl, JT, Connolly K. Fractures due to gunshot wounds: Do retained bullet fragments affect union? Iowa Orthop J 2015;35:55-61. PMID: 26361445
23. Ordog GJ, Balasubramanium S, Wasserberger J, Kram H, Bishop M, Shoemaker W. Extremity gunshot wounds:
Part one—Identification and treatment of patients at high risk of vascular injury. J Trauma 1994;36(3):358-68.
PMID: 8145317
24. Yusuf E, Cagri N, Koca K, Ersen O, Bek D. Is staged management with immediate conversion of external fixation to retrograde intramedullary nailing for combat-related Gustilo type III supracondylar femur fractures safe and reliable method? Injury 2019;50(3):764-9. https://doi.org/10.1016/j.injury.2019.01.019
25. Johnson D, Versteeg G, Middleton J, Cantrell C, Butler B. Epidemiology and risk factors for loss to follow-up
following operatively treated femur ballistic fractures. Injury 2021;52(8):2403-6.
https://doi.org/10.1016/j.injury.2021.06.012
2. Nguyen MP, Savakus JC, O’Donnell JA, Prayson NF, Reich MS, Golob Jr JF, et al. Infection rates and treatment of
low velocity extremity gunshot injuries. J Orthop Trauma 2017;31(6):326-9. https://doi.org/10.1097/BOT.0000000000000827
3. Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg 1990;72(2):299-304. PMID: 2406275
4. Moye Elizalde GA, Ruiz Martínez F, Suarez Santamaría JJ, Ruiz Ramírez M, Reyes Gallardo A, Díaz Apodaca BA.
Epidemiology of gunshot wounds at Ciudad Juárez, Chihuahua General Hospital. Acta Ortop Mex 2013;27(4):221-
35. Disponible en: https://www.medigraphic.com/pdfs/ortope/or-2013/or134b.pdf
5. Brenes Méndez M. Open fractures management. Revista Médica Sinergia 2020;5(4):e440.
https://doi.org/10.31434/rms.v5i4.440
6. Marecek GS, Earhart JS, Gardner MJ, Davis J, Merk BR. Surgeon preferences regarding antibiotic prophylaxis for
ballistic fractures. Arch Orthop Trauma Surg 2016;136(6):751-4. https://doi.org/10.1007/s00402-016-2450-8
7. Patel NM, Yoon RS, Cantlon MB, Koerner JD, Donegan DJ, Liporace FA. Intramedullary nailing of diaphyseal
femur fractures secondary to gunshot wounds. J Orthop Trauma 2014;28(12):711-4. https://doi.org/10.1097/BOT.0000000000000124
8. Assari S, Kaufmann A, Darvish K, Park J, Hawb J, Safadi F, et al. Biomechanical comparison of locked plating and
spiral blade retrograde nailing of supracondylar femur fractures. Injury 2013;44(10):1340-5.
https://doi.org/10.1016/j.injury.2013.04.016
9. Georgiadis G M, Andrews KA, Redfern RE. Gunshot fracture of the femoral neck: Internal fixation and immediate proximal femoral valgus osteotomy: A case report. JBJS Case Connector 2021;11(3):e20.
https://doi.org/10.2106/JBJS.CC.20.01009
10. Held M, Engelmann E, Dunn R, Ahmad SS, Laubscher M, Keel MJB, et al. Gunshot induced injuries in
orthopaedic trauma research. A bibliometric analysis of the most influential literature. Orthop Traumatol Surg Res 2017;103(5):801-7. https://doi.org/10.1016/j.otsr.2017.05.002
11. Congiusta D, Oettinger JP, Merchant AM, Vosbikian M, Ahmed IH. Epidemiology of orthopaedic fractures due to firearms. J Clin Orthop Trauma 2020;12(1):45-9. https://doi.org/10.1016/j.jcot.2020.10.047
12. Gugala Z, Lindsey RW. Classification of gunshot injuries in civilians. Clin Orthop Relat Res 2003;(408):65-81.
https://doi.org/10.1097/00003086-200303000-00007
13. Smith HW, Wheatley KK Jr. Biomechanics of femur fractures secondary to gunshot wounds. J Trauma
1984;24(11):970-7. https://doi.org/10.1097/00005373-198411000-00008
14. Long WT, Chang W. Grading system for gunshot injuries to the femoral diaphysis in civilians. Clin Orthop Relat Res 2003;408:92-100. https://doi.org/10.1097/00003086-200303000-00010
15. Nguyen MP, Prayson N, Vallier HA. Low-velocity gunshot injuries to the femur: What is the utility of stabilizing
incomplete fractures? J Am Acad Orthop Surg 2019;27(18):685-9. https://doi.org/10.5435/JAAOS-D-17-00849
16. Sathiyakumar V, Thakore RV, Stinner DJ, Obremskey WT, Ficke JR, Sethi MK. Gunshot-induced fractures of the
extremities: a review of antibiotic and debridement practices. Curr Rev Musculoskelet Med 2015;8(3):276-89.
https://doi.org/10.1007/s12178-015-9284-9
17. Scharfenberger AV, Alabassi K, Smith S, Weber D, Dulai SK, Bergman JW, et al. Primary wound closure after open fracture: a prospective cohort study examining nonunion and deep infection. J Orthop Trauma 2017;31(3):121-6. https://doi.org/10.1097/BOT.0000000000000751
18. Maqungo S, Kauta N, Held M, Mazibuko T, Keel MJB, Laubscher M, et al. Gunshot injuries to the lower
extremities: Issues, controversies and algorithm of management. Injury 2020;51(7):1426-31.
https://doi.org/10.1016/j.injury.2020.05.024
19. Dougherty PlJ, Gherebeh P. Retrograde versus antegrade intramedullary nailing of gunshot diaphyseal femur
fractures. Clin Orthop Relat Res 2013;471(12):3974-80. https://doi.org/10.1007/s11999-013-3058-8
20. Papadokostakis C, Dimitriou R, Giannoudis PV. The role and efficacy of retrograding nailing for the treatment of diaphyseal and distal femoral fractures: a systematic review of the literature. Injury 2005;36 (7):813-22.
https://doi.org/10.1016/j.injury.2004.11.029
21. Gill SPS, Mittal A, Raj M, Singh P, Singh, J, Kumar S. Extra articular supracondylar femur fractures managed with locked distal femoral plate or supracondylar nailing: a comparative outcome study. J Clin Diagn Res 2017;11(5):19-23. https://doi.org/10.7860/JCDR/2017/25062.9936
22. Riehl, JT, Connolly K. Fractures due to gunshot wounds: Do retained bullet fragments affect union? Iowa Orthop J 2015;35:55-61. PMID: 26361445
23. Ordog GJ, Balasubramanium S, Wasserberger J, Kram H, Bishop M, Shoemaker W. Extremity gunshot wounds:
Part one—Identification and treatment of patients at high risk of vascular injury. J Trauma 1994;36(3):358-68.
PMID: 8145317
24. Yusuf E, Cagri N, Koca K, Ersen O, Bek D. Is staged management with immediate conversion of external fixation to retrograde intramedullary nailing for combat-related Gustilo type III supracondylar femur fractures safe and reliable method? Injury 2019;50(3):764-9. https://doi.org/10.1016/j.injury.2019.01.019
25. Johnson D, Versteeg G, Middleton J, Cantrell C, Butler B. Epidemiology and risk factors for loss to follow-up
following operatively treated femur ballistic fractures. Injury 2021;52(8):2403-6.
https://doi.org/10.1016/j.injury.2021.06.012