Gunshot and Wartime Injuries

Ovid: Rockwood And Green’s Fractures In Adults

Editors: Bucholz, Robert W.; Heckman, James D.; Court-Brown, Charles M.; Tornetta, Paul
Title: Rockwood And Green’s Fractures In Adults, 7th Edition
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One – General Principles: Basics > Principles of Treatment > 11 –
Gunshot and Wartime Injuries

Gunshot and Wartime Injuries
Paul J. Dougherty
Soheil Najibi
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 help those who evaluate gunshot wounds as a major part of
their practice but also orthopaedic surgeons who occasionally see
patients with such injuries.
Weapons that are used in nonmilitary and military
settings differ. Firearms seen in nonmilitary settings include
handguns, rifles, and shotguns.7,35,83,84,141 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, and land mines. 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


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.7,35,83

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.
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.83,141
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.
Rifles are shoulder-fired weapons that are intended to
strike a target farther away from the shooter than can a handgun or
shotgun (Fig. 11-3). In general, the barrel is
longer and has rifling to impart a spin on the bullet, lending
gyroscopic stability in air. Rifling consists of spiral grooves that
line the barrel, engaging the bullet and causing it to spin on the
longitudinal axis. 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.130
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 twentieth
century.141 For example, the
standard Soviet infantry rifle for World Wars I and II was the Mosin
Nagant M 91/30, which fired a 7.62-mm, 150-grain bullet at
approximately 2800 feet per second (fps). After World War II, the
replacement rifle (AK-47) fired a 7.62-mm, 120-grain bullet at 2340
fps. The AK-47 also has the ability to be fired in the fully automatic
and semiautomatic modes.
Shotguns are shoulder-fired weapons that have a smooth barrel (Fig. 11-4). 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 from the barrel.84
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.

FIGURE 11-3 M-16 series military rifles (from top to bottom): M16A1, M-16A2, M-4A1, and M-16A4.
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.
Explosive Munitions
Explosive munitions include artillery, grenades, mortars, land mines, and bombs.8,9,34,100,120
They are the most common agents for wounding soldiers on a battlefield,
starting during the World War I (1914-1918), when artillery became more
common on the battlefield, and continuing to be the most common injury
mechanism through today. Table 11-1 describes
the relative proportion of different types of weapons that generated
casualties on the battlefield from various wars during the 20th century.
Explosive munitions wound via one or more of three mechanisms: ballistic, blast, or thermal (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 overpressure caused by the exploding munitions. Thermal injuries
are caused by a transient increase in local temperature as a result of
the explosion. Blast and thermal injuries occur relatively close to the
exploding munitions, whereas ballistic injuries also can occur farther
from the device.12,34,120
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.

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.
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])









Booby trap/land mine




Hand grenade












* Vietnam Conflict only.

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

Artillery includes cannons that fire large projectiles
in a range of up to several miles. The projectiles may be antivehicle,
contain white phosphorus, or be explosive filled. The diameter of U.S.
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.8,12,34,120
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 or
destroy tanks or to injure soldiers. As with artillery shells, the type
of fragments 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.8,12,34,120
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
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 U.S. 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


world because of vast land-mined tracts that remain in Asia, Africa,
and the Balkans. Estimates vary, but between about 70 to 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).1,7,8,12,34,112,120

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
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. They are the most common type of land
mine seen throughout the world. They contain a small amount of
explosive (100-200 g) and produce a characteristic pattern of injury112 (Fig. 11-10).
Russian surgeons obtained considerable experience with land mines
during their war in Afghanistan (1979-1988), 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. The area extends from below the knee to the level of
“avulsion” injury of the foot or lower leg. Third, more proximally,
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.1,112
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.

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.
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.
Bounding mines are land
mines that, when tripped, propel a small grenadelike 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.112
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
U.S. Army’s 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).112
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, 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 11-10
This photograph is of a foot injured by a small planted land mine. The
mine was under the forefoot and the patient had footwear.
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.
FIGURE 11-12
Claymore mine injury. This photograph illustrates multiple small
fragment wounds of a thigh from a patient injured by a Claymore mine.
The majority of explosive devices used in the
Afghanistan and Iraq conflicts are improvised explosive devices. 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
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.9,12,120
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).

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.
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.
First, there is the kinetic energy round (Fig. 11-14).
This consists of a hard piece of metal, such as tungsten or depleted
uranium, that 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.35
FIGURE 11-15
Shaped charge or high-explosive, antitank (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.
Shaped charges are the other type of weapon seen on the battlefield (Fig. 11-15).
They consist of an explosive-filled warhead 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.35,112
A variation on the shaped charge is the “explosively formed projectile” (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
Nonmilitary Gunshot Wounds
Gotsch et al.56
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. There was a decline in the annual


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%. The
stated cause for injury was assault in 57%, self-inflicted in 20%,
unintentional for 13%, and unknown for 10%. During the study period,
the average number of self-inflicted fatalities exceeded those from
assault (18,227 versus 15,371 per year).56

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.
Antivehicle land mines based on this principal are being used against
U.S. and Allied Forces in the Iraqi Conflict.
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%).48 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).26
Gotsch et al.56 also
found that males were seven times more likely to receive a firearm
injury than were 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.26,48,61
There is an economic, as well as a human, cost in caring for patients with gunshot wounds.23,61,153 Hakanson et al.61 reported that the average cost of treating a gunshot orthopaedic injury is $13,108 per patient. Brown et al.23
reported on orthopaedic 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 orthopaedic trauma surgical cases. The most common locations for
nonfatal gunshot wounds are in the extremities (Table 11-2). Gotsch et al.56
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.
Many patients with gunshot wounds are also treated in emergency departments without admission.21,56,118 Estimates for the number of patients with gunshot wounds who are treated on an outpatient basis range from 45% to 60%.26,118 Gotsch et al.56
reported a ratio of 1:1.2:1 for deaths:hospital admissions and
transfers:emergency department treatment and discharge, respectively.
Overview of Battle Casualties
The two best epidemiologic studies concerning battle casualties consist of data from World War II and the Vietnam Conflict.9,120
A prospective study on battle casualties 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.120
The patients were then followed through their initial surgical care to
look at outcome. A second study was performed during the Vietnam
Conflict to assess 7964 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 patient outcome.9
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. 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.13,73

TABLE 11-2 Anatomic Distribution of Gunshot Wounds

Henry Ford Hospital,
Detroit, MI
(N = 1505)

(N = 1326)

Head, ears, eyes, nose, throat









Upper extremity



Lower extremity





Not reported

TABLE 11-3 Percentage Anatomic Distribution of Wounds (Living Wounded U.S. Soldiers)

Anatomic Area

U.S. Civil War

World War I

World War II

Bougainville Campaign

Head, face, neck















Upper extremity





Lower extremity





The proportion of casualties caused by various weapons
from World War I, the Bougainville campaign in World War II, and the
Vietnam Conflict is shown in Table 11-1.9,92,111
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
The lethality of a weapon is defined as the probability of death from a hit from that weapon (Table 11-4).
From both the Bougainville and WDMET data, the lethality of a bullet
wound is about 0.33. Fragments from grenades, mortars, and artillery
range from 0.05 to 0.10. Death from tripping a land mine is also about
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 U.S. military (Army, Navy, and Air Force)
have similar echelons of care to treat wounded solders.97,98
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.
TABLE 11-4 Lethality by Weapon


Bougainville Campaign

Vietnam Conflict













Land mine



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
The U.S. Army Medical Company is 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 on the battlefield.
The purpose of this unit is to provide surgical care of
nontransportable patients, who are 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 orthopaedic surgeon and three
general surgeons. Having an orthopaedic 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 colocated with a medical company to complete its mission. Goals
of surgery are to stabilize the patients and prepare them for
evacuation. Similar units for the U.S. Navy are the Surgical Company to
support the U.S. Marines and the MFST for the U.S. Air Force. While all
three are not exactly the same because of the need to meet
service-specific requirements, they all function at the same level of
The U.S. Army’s Combat Support Hospital (CSH) is the
next echelon of care on the battlefield. The entire unit when assembled
has 296 beds and includes intensive care unit capability, six operating
rooms, and laboratory capability, and it is staffed by three
orthopaedic surgeons in addition to general surgeons, internists, and
emergency physicians. This hospital is presently deployed as a modular
unit in a 40-bed slice with two operating rooms. There are three
general surgeons and one orthopaedic surgeon assigned to the hospital
in this configuration. This facility is the first surgical echelon for
the majority of battlefield patients, including those with orthopaedic
injuries. Goals of care at this hospital are to stabilize the patients
and to prepare them for evacuation out of the combat zone. Examples of
care for patients arriving at the CSH include the treatment of soft


fracture stabilization via casting or external fixator application, and
treatment of a partial or complete amputation. The CSH is ideally
located near an airfield. The equivalent U.S. Navy hospital is the
Fleet Hospital, and for the U.S. Air Force, the Expeditionary Medical
Support (EMEDS) Hospital, which is a modular system.97,98

FIGURE 11-17
U.S. military medical evacuation. This shows the present scheme of
evacuation for wounded soldiers used by the U.S. Army. Surgical care by
orthopaedic surgeons takes place at the forward surgical team (FST),
combat support hospital (CSH), or communication zone hospitals.
Patients may be moved to one of the surgical facilities
(FST or CSH) 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
During the Vietnam Conflict, the U.S. military controlled the airspace
and did not have much 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 facility that could provide more care.
Wound ballistics is the science that studies the effects of penetrating projectiles on the body.*
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).
There is a second area in which elastic tissue is stretched, causing a temporary cavity.36,37,47,77,78,79,88,103
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 tissue, such as skeletal muscle,
vessels, and nerves, macroscopically appears as blunt trauma. Inelastic
tissue, such as bone, may fracture in this area.
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 of very short duration, a few
microseconds, but it may generate pressures up to 100 atm in magnitude.43,67,68 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.36,37,48,67,68,69,70,88,103
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.57
used cadaver skin to test threshold velocities for penetration. The
skin was stretched over a frame during testing, thus altering the
behavior seen in vivo. The authors used steel ball bearings from 1/16
inch 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.46 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.

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.
In another study, Fackler et al.45
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 5000 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.,63 Dziemian and Herget,36 Mendelson and Glover,103 and Fackler.43,48
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 up spontaneously.
Surrounding the path is an area damaged by the stretch
causing the temporary cavity. The stretched area of temporary cavity
may split along fascial planes. This area appears grossly as bruised or
contused tissue. Bruised skeletal muscle ordinarily heals uneventfully.
Microscopically, there are disrupted skeletal muscle fibers and
capillaries. After a period, there is leukocyte infiltration followed
by inflammation and healing.36,42,48,69,103
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 are detached. This often greatly increases the
size of the permanent cavity.48
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
Bone injury is common with gunshot wounds to the extremities.28,58,77,78,79,106,129
Fractures may occur via two mechanisms, either when the projectile
strikes bone or, rarely, indirectly by the temporary cavity. Direct
fractures (Fig. 11-19) occur when a projectile
strikes the bone. Because of 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 might even cause increased soft tissue disruption,
reminiscent of the previously mentioned synergism between bullet
fragmentation and temporary cavity stretch.
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. Clinically, indirect fractures to
bone are rare compared with those formed when bone is struck directly
by the projectile.28,67,68,69,70 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 11-19
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.
Clasper et al.28 used sheep femora and hindlimbs 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.

FIGURE 11-20 Indirect fracture. A fracture may occur without the bullet striking the bone. This illustrates a bullet path (arrow) adjacent to the bone. A simple fracture occurred from the effects of the temporary cavity.
Rose et al.129
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. 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
computed tomography scan, show an incomplete fracture.
There are common misconceptions about wound ballistics.43
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 M-16 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 3200 fps. The M-193 bullet fired from
the M-16A1 rifle was 5.56 mm in diameter and weighed 3.6 g. This
compared with the 7.62-mm bullet fired at a velocity of 2700 fps
weighing 8 g. Later testing in the laboratory found that the increased
severity of wounds sometimes seen with the M-16A1 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 nineteenth century when the armed services of several
nations, including the United States, changed to a full metal jacketed
bullet from a solid lead one. This resulted in an increase of muzzle
velocity from about 1000 fps to 2000 fps.39 The change in firearms, however, resulted in decreased wound severity because bullet deformation was limited by the jacketing.
A second common misconception43
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.
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. If the patient
is not able to comply, this fact should be documented with a note to
recheck if the patient’s condition improves.
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 skeletal muscle.
Skin Injuries
Gunshot skin wounds have three general patterns. First, there is a punctate wound about 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).
Perforating nonarticular wounds without a fracture or vascular injury may be candidates for outpatient treatment.24,120 Under controlled circumstances, simple perforating wounds have been shown to heal uneventfully with simple dressing changes.49,67,103 Successful treatment with local wound care has been reported by several authors.24,32,64,101,109,114
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.54,72,86,92,101,157
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
FIGURE 11-21 Simple perforating wound. This shows a simple wound caused by perforation of the bullet.

FIGURE 11-22 Skin splits. Splits in the skin may be caused by bone fragments, debris, or the stretch of the temporary cavity.
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.9,120 In certain controlled circumstances, small fragment wounds may be treated nonoperatively.17
The use of negative pressure dressings (vacuum-assisted
closure [VAC] dressings) 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 this method to
standard dressing changes is not available in the literature.91
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.
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.
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,103 Dziemian et al.,37 and Harvey67
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 skeletal muscle that would not survive, thus
acting as a bacteria medium. Recognition of how to identify tissue that
needs to be excised is imprecise, at best. Scully et al.135
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.46,67,103
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 will 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 débridement is derived from the French verb débrider, which means “to unbridle or release.”44,76,93 As noted by Fackler,44 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 [authors’ emphasis].”64
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, or ischemia. A hematoma inside of
a compartment may lead to pressure and ischemia of muscle. The
diagnosis of compartment syndrome is primarily clinical.
Compartment syndrome associated with gunshot wounds has been reported in the forearm,38,108 leg,150 and thigh.11,52 Forearm compartment syndrome has been well documented and is present in up to 10% of patients.108
Longitudinal incisions to release pressure within a compartment and to
expose tissue has been recommended by military surgeons at least since
the time of the Napoleonic Wars.44
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
more formal operative treatment of the soft tissues.
Infection has been documented in between 1.5% and 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 Herget36 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 and Sachs138
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.137
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 Fleming led to its use in caring for the wounded during World War II. Fisher et al.51
compared 3471 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 3471 (5 with gas gangrene) untreated wounds and in 2 of 436 (0
with gas gangrene) penicillin-treated wounds.
Patzakis et al.122
divided 310 patients with open fractures (78 because of 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.65
compared the use of ceftriaxone and cefazolin for gunshot fractures
with minimal soft tissue disruption (<1-cm wound) that were treated
nonoperatively, with 50 patients in each group. Follow-up was 59%, and
the authors reported no infections based on the cultures taken in the
emergency department. They concluded that the 1-day ceftriaxone regimen
is more cost effective than the 3-day cefazolin regimen.
Knapp et al.86
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
(ciprofloxicillin 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. None of these studies show the superiority
of any particular antibiotic regimen; rather, it is the presence of
antibiotics versus no antibiotics that helps reduce infection.
Infections from war wounds remain higher than those associated with
nonmilitary gunshot wounds alone.95,137,138
Patients with war wounds are usually injured by explosive munitions,
which are more debris and dirt ridden, as well as historically having
delayed care because of medical evacuation.

TABLE 11-5 Recommended Antibiotic Regimen




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


First-generation cephalosporin

1 g IV q8h for 48 hours

Joint with soft tissue defect

First-generation cephalosporin; consider aminoglycoside for similar time

Check renal function

Long fone 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 ciprofloxicillin 750 mg BID

Long bone fracture with internal fixation

First-generation cephalosporin

1 g IV q8h for 48 hours

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).

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. While elevated serum lead levels
may be present with extra-articular gunshot wounds, the most common
reports are with intra-articular wounds.94,134
Pathophysiology of Lead Toxicity
Lead is soluble in synovial fluid and has been shown to induce lead synovitis and degenerative arthritis.15,66,94,96,134
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 (1-2 weeks) include synovial hyperplasia, mild
inflammation, and articular surface slit formation. Late changes (3-6
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.15,66
Implantation of lead pellets into rabbit knees induces significantly
greater degeneration in the femoral and tibial articular surfaces,
medial and lateral meniscus, and synovium at 4, 6, 10, and 14 weeks.15,66,94,96,134
Normal blood lead levels 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.94
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 therefore may 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. Because of
this, all 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 aspirated into the joint. Also,
cartilage damage is common despite the normal radiographic appearance
of the joint.148
In most cases where articular and periarticular
fractures are present, the stabilization of the fractures is carried
out initially with spanning external fixation, followed by repeat
irrigation and debridement 48 to 72 hours later and definitive internal
fixation once adequate debridement has been achieved.
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, ligaments, or knee meniscus.
Disadvantages include increased operative and setup time as well as
potential compartment syndrome. 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%.118 Injuries involving the shoulder joint itself, however, range from 1% to 2% of an overall series.5,30,111,118,119,145
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.157,160 Nerve injuries are the most important determinant of long-term function of the limb.

Literature supports the use of either arthroscopy or
open surgical techniques for removal of the bullet and its fragments
from the shoulder joint and the subacromial space.5,30,111,119,145
In cases where the joint capsule is violated by the bullet and the
bullet has traversed the joint, clothing fragments, skin, and other
debris could be driven into the joint. In the absence of
intra-articular bullet fragments, irrigation and débridement 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.145
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 such as Herbert
screws, Acutrak 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. D. Postoperative radiograph showing reduction with plate and screws. Headless screws were used for the articular fragments.
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 C-5, 10 C-6, 10 C-7, 5 C-8, and 10 T-1 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 vascular injuries when brachial plexus injury was present.
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.5,18,31,80,102,140 Associated injuries include periarticular fractures, nerve injuries, and arterial and venous injuries.5,117
In rare cases of an isolated bullet or pellet in the elbow joint,
irrigation and débridement and bullet removal can be achieved with the
use of the arthroscope.80
Hip Injuries
In our series, the prevalence of gunshot wounds to the
hip joint is about 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), with or without joint
involvement, with or without fractures is 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 absence of a fracture, the diagnosis
of hip joint violation can be difficult.
Diagnosis is based on radiographic and computed
tomography 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.20,97
Documentation is important to determine the need for surgery to lavage
the joint. A negative arthrogram indicates no joint violation, possibly
allowing for nonoperative treatment.
Transabdominal gunshot wounds to the hip joint carry a
high risk of infection and should be treated with emergent arthrotomy,
irrigation, and débridement. 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
Bullet removal can be achieved via arthrotomy or arthroscopy.55,97,107,139,162 Hip arthroscopy is an available technique for removal of bullet and fragments from the hip joint.*
Hip arthroscopy requires special equipment and experience with the
technique. The use of a fracture table and fluoroscopy aid in
arthroscopy of the hip. Hip arthroscopy carries the risk of
intraabdominal fluid extravasation and abdominal compartment syndrome.6
In 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.
Recommended treatment of the 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.
Patients with more extensive injury to the articular
surface of the femoral head or acetabulum are more difficult clinical
problems. Hip arthroplasty or arthrodesis in the acute setting is not
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,102,131 nonunion, malunion, and osteonecrosis.
Knee Injuries
Gunshot wounds to the knee region, including the distal
femur and proximal tibia, are relatively frequent in all larger series
of gunshot wounds. Perry et al.123
reported on 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


vascular injury; of these, 6 arteriograms 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
common peroneal nerve injury. There were also two reported infections:
one superficial and one deep.

FIGURE 11-26 Anteroposterior (A) and lateral (B) preoperative views of a distal humerus fracture that extends to the joint. C-F. An external fixator was applied and then converted to internal fixation after the swelling of the limb subsided. (continues)

FIGURE 11-26 (Continued) The external fixator pins should be used outside the zone of injury.
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. However, these
tests have a low sensitivity of around 40% and a negative arthrogram
does not rule out an open joint injury.149
FIGURE 11-27 Anteroposterior preoperative (A) and postoperative (B) radiographs of a femoral neck fracture sustained by an intra-articular bullet. Femoral neck fractures tend to be comminuted.
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,D. Computed tomography scan shows the lateral femoral condyle fracture and proximal tibia fractures.
In 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 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 Hue.148
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 knees with debris not seen on radiographs. Based on
these findings, diagnostic arthroscopy and arthroscopicassisted bullet
removal and irrigation and débridement are recommended for gunshot
wounds through the knee.
Ankle Injuries
In our series, the prevalence of gunshot wounds to the ankle is about 0.5% of those to the lower extremity. Associated injuries


include fractures and nerve, vascular, and tendon injuries.159
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 amputation should be considered. Arthroscopy is of
limited use because of the confined ankle space, good access through
incisions, and the prevalence of fracture necessitating open

FIGURE 11-28 (Continued) E,F. This patient was treated with open reduction and internal fixation of both fractures.
Long bone fractures caused by gunshot wounds still pose
a significant clinical problem for orthopaedic 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 initially seen
and cared for at the same institution without the complexity of patient
transportation through multiple echelons of care. Because of this,
immediate definitive stabilization for patients with isolated long bone
gunshot fractures has become a more common treatment method.
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 injuries59,117,136
are relatively common with patients who sustain gunshot wounds of the
humerus. There is an increased prevalence nerve injury associated with
the distal humerus compared with more proximal injuries.*
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.
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.4,130,131
External fixation has been reported for use in patients
with more extensive injuries, such as with military wounds. Zinman et
al.161 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


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. A
total of 23 patients had 6.5 years of follow-up after injury. The
authors reported excellent results in 14 patients, good results in 4,
fair results in 3, and poor results in 2. All fractures did eventually
heal. They believed 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. They recommended this as a treatment for patients with
severe open injuries secondary to war wounds.

In 1995, the Red Cross evaluated the treatment of refugees who sustained gunshot fractures of the humerus. Keller85
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. They were treated with external fixation, traction, and a
plaster of Paris splint. 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.
Hall and Pankovich62
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 overtaken
by conventional intramedullary nailing as for other trauma indications.
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.4,130,131
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.82,87,154,161
Use of the spanning external fixator is more common with distal
fractures. When both the limb and the patient have become stable,
planning for fracture stabilization and soft tissue coverage can be
Definitive treatment of large bone or soft tissue
defects may be challenging. With extensive comminution and soft tissue
injury, use of a small pin fixator has been reported with good success.3,140 For skeletal defects, use of a cage with allograft3 or a fibular osteoseptocutaneous flap71 has been described.
Forearm Fractures
There are relatively few reports describing care of gunshot wounds to the forearm.*
There is a high reported rate of nerve injury associated with gunshot
wounds to this region, and a 10% rate of compartment syndrome.38,60,108
The goals of fracture care are to restore the length, alignment and bow
of the forearm. Care for diaphyseal forearm fractures depends on the
severity of the both the soft tissue and bone injury, just as with open
forearm fractures not associated with firearms.* Patients
with relatively stable fractures of the ulna 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 internal fixation when soft tissues permit.
For patients with bone loss, initial stabilization with external fixation should be done when both forearm bones are involved.60
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. Within the past 50 years, balanced skeletal traction has been the mainstay of care for femur fractures in war or peace.151
Initial stabilization with this traction is commonly used today as a
temporary means of stabilization until more definitive care can be
External fixation has been used for open fractures on the battlefield. Reis et al.126
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.114,132
The concept of using temporary external fixation as a bridge from
injury to definitive fracture stabilization has become a popular means
to initially stabilize a patient’s fracture.
Use of intramedullary nailing for complex femur
fractures or malunion, nonunion, and infection associated with gunshot
wounds in the United States began after World War II.19,25
Holloman and Horowitz75
reviewed 26 patients who sustained fractures because of “low-velocity”
gunshot wounds and were treated with intramedullary nailing an average
of 9 days after injury. Nineteen of the patients were followed to
union, which occurred at an average of 4.5 months after injury. Two
patients had open nailing and the remaining 17 had closed nailing.

Berman 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, 0-14
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
an average of 18 weeks (range, 13-31 weeks). Two patients had
persistent drainage, which resolved with a course of oral antibiotics
at 2 and 3 weeks.
Tornetta and Tiburzi147
reviewed 38 of 55 patients with gunshot femur fractures treated with
intramedullary nailing who were followed an average of 2 years (range,
14-36 months). Average time to union was 8.6 weeks (range, 5-22 weeks).
Nicholas and McCoy113 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, 3-8 months). None of the patients had an infection.
Wiss et al.155
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, 14-40 weeks), and average follow-up was 16 months (range, 12-29
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 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).
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
appears to be safe.
Wiss et al.155
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 return, one with partial return, and
one with no return to function. Two patients had peroneal nerve
palsies, one with return to function. Infection of patients is
infrequent in the nonmilitary setting with gunshot femur fractures.
Wiss et al.155 reported no deep infections with 56 patients at follow-up. Holloman and Horowitz75 reported no patients with infection after intramedullary nailing. Bergman et al.10 reported two patients with persistent drainage, and Nicolas and McCoy113 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.
Malunion is infrequent with the use of intramedullary nailing. Wiss et al.155
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.
Use of intramedullary nailing is now routine in many
hospitals that treat nonmilitary gunshot wounds 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 wounds or other severe injuries 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 present Iraq and
Afghanistan conflicts has been with the staged management of care. For
U.S. or Allied soldiers, the fracture is stabilized with an external
fixator and the patient transported to a site of definitive care,
usually in the Continental United States. Once at a site of definitive
care, treatment of the bone by intramedullary nailing may be done if
the limb is free of infection and has good soft tissue coverage.
Tibia Fractures
The tibia is the second most frequent long bone fracture because of gunshot wounds, following the femur.21,22,50
A variety of treatment methods have been reported for fracture care,
including the use of cast or fracture brace, external fixation, and
intramedullary nailing.
Wischi and Omer156
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 on 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.
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
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.


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.

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, if left relatively undisturbed,
will allow for bone formation.

FIGURE 11-30 Preoperative (A,B) and postoperative (C,D) radiographs of a distal femur fracture. The patient was treated with an immediate retrograde intramedullary nail.

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, at which point the fixator may be removed
and an intramedullary nail is inserted.
Foot Injuries
Injuries to the foot are infrequent with nonmilitary
gunshot wounds. The anatomic location of foot and ankle was 39 of 2277
(1.7%) of all gunshot injuries in 1505 patients 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 an isolated injury, may be
treated without surgical stabilization. After treatment of the soft
tissues, a period of using a hardsoled 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 with these patients.16,152
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 to
span the area, followed by reconstruction of the bone with plates when
the limb is stable, is used. 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 reported that 12 of 101 patients with gunshot
foot wounds had an infection; this is a higher incidence than reported
with other anatomic regions.16
Foot injuries in wartime are common injuries, most often resulting from mine explosions. Nikolic et al.115
reported that 250 of 1860 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 of 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.112
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inner-city hospitals around the world. The orthopaedic surgeon should
be knowledgeable about the clinical course and outcome of patients with
gunshot wounds to provide the best care within the context of his or
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