Location of civilian ballistic femoral fracture indicates likelihood of arterial injury

Ballistic impact of hollow-point ammunition on porcine bone

Identifying failure mechanisms in skeletal tissue allows a deeper understanding of the effects of specific projectile impacts on bone. While ballistic trauma in flat bones is largely researched, knowledge of how long bones react to gunshot impacts is limited in the literature. The impacts of deforming ammunition appear to produce higher levels of fragmentation; however, these have not been studied in depth. This study compares the damage to femora bone by HP 0.357 and 9 mm projectiles constructed with both full and semi-metal jackets. Impact experiments were undertaken on a single-stage light gas gun involving the use of a high-speed video camera and full reconstruction of the bones to ascertain fracture patterns occurring in the femora. Higher degrees of fragmentation are likened to the presence of semi-jacketed HP projectiles than jacketed HP projectiles. The observations of external facing beveled edges are believed to be associated with the increased separation of the jacket and lead core of projectiles. Additionally, experimentation has shown that the amount of kinetic energy lost postimpact is likely related to the presence or the absence of a metal jacket on an HP projectile. The observed data, therefore, suggest that the composition, rather than the configuration, of a projectile affects the type and extent of the damage.

Isolated ballistic femoral condyle fractures: a case series of eighteen patients

PURPOSE

Ballistic fractures of the femoral condyles are rare injuries with limited literature to help guide treatment. The purpose of this study is to report on the presentation, management, and outcomes for patients with isolated ballistic condylar fractures.

METHODS

Eighteen patients between ages 16 and 65 with low-energy ballistic injuries isolated to the femoral condyles (OTA 33B) were included, 15 with CT imaging. Clinical records and imaging were reviewed, as well as treatment strategy. Fractures were classified by AO/OTA classification. Outcome and follow-up data were gathered at outpatient appointments and telephone calls.

RESULTS

Of the 18 patients, 78% were treated operatively (61% with open reduction and internal fixation, 17% with removal of foreign body alone). There were two instances of traumatic vascular injury and no neurologic injuries. Furthermore, there were no identified infections. Only 58% of the patients had follow-up for more than 6 weeks with average KOOS Jr. Score of 50, and average VAS pain score of 5.2.

CONCLUSIONS

Ballistic femoral condyle fractures are rare Orthopaedic injuries seen in relatively high frequency at our institution. Most (78%) were treated operatively and with few complications. These fractures are not easily classified according to common classification schemes and may benefit from more rigorous study to guide treatment and anticipate outcomes.

Rare popliteal mass following retrograde nailing of ballistic femur fracture: a case report

Introduction:

Civilian ballistic injuries are commonly associated with fracture, vascular injury, and soft tissue trauma. Posttraumatic pseudoaneurysms represent an extremely rare subset of vascular injuries following ballistic fractures.

Case:

We present the rare case of a posttraumatic pseudoaneurysm that occurred after retrograde femoral nailing of a ballistic distal femur fracture. The patient presented in clinic postoperatively with a pulsatile popliteal mass. Distal pulses were intact but subsequent ultrasound and angiography revealed a pseudoaneurysm of the distal superficial femoral artery. The pseudoaneurysm was subsequently treated with a covered stent and the patient's recovery was uncomplicated.

Conclusion:

Due to the potential life and limb-threating complications from pseudoaneurysm rupture, this case report emphasizes the early recognition and expeditious management of vascular complications following ballistic fractures in the civilian population.

Orthopedic injuries in patients with multiple injuries: Results of the 11th trauma update international consensus conference Milan, December 11, 2017

BACKGROUND

In blunt trauma, orthopedic injuries are often associated with cerebral and torso injuries. The optimal timing for definitive care is a concern. The aim of the study was to develop evidence-based guidelines for damage-control orthopedic (DCO) and early total care (ETC) of pelvic and long-bone fractures, closed or open, and mangled extremities in adult trauma patients with and without associated injuries.

METHODS

The literature since 2000 to 2016 was systematically screened according to Preferred Reporting Items for Systematic Reviews and meta-analyses protocol. One hundred twenty-four articles were reviewed by a panel of experts to assign grade of recommendation and level of evidence using the Grading of recommendations Assessment, Development, and Evaluation system, and an International Consensus Conference, endorsed by several scientific societies was held.

RESULTS

The choice between DCO and ETC depends on the patient's physiology, as well as associated injuries. In hemodynamically unstable pelvic fracture patient, extraperitoneal pelvic packing, angioembolization, external fixation, C-clamp, and resuscitative endovascular balloon occlusion of the aorta are not mutually exclusive. Definitive reconstruction should be deferred until recovery of physiological stability. In long bone fractures, DCO is performed by external fixation, while ETC should be preferred in fully resuscitated patients because of better outcomes. In open fractures early debridement within 24 hours should be recommended and early closure of most grade I, II, IIIa performed. In mangled extremities, limb salvage should be considered for non-life-threatening injuries, mostly of upper limb.

CONCLUSION

Orthopedic priorities may be: to save a life: control hemorrhage by stabilizing the pelvis and femur fractures; to save a limb: treat soft tissue and vascular injuries associated with fractures, stabilize fractures, recognize, and prevent compartmental syndrome; to save functionality: treat dislocations, articular fractures, distal fractures. While DCO is the best initial treatment to reduce surgical load, ETC should be applied in stable or stabilized patients to accelerate the recovery of normal functions.

LEVEL OF EVIDENCE

Systematic review of predominantly level II studies, level II.

Rates of neurovascular injury, compartment syndrome, and early infection in operatively treated civilian ballistic forearm fractures

PURPOSE

The purpose of this study is to evaluate the incidence of neurovascular injuries, compartment syndrome, early postoperative infection as well as the injury factors predictive of neurovascular injury following ballistic fractures of the radius and ulna.

METHODS

A retrospective review was performed to identify all ballistic fractures of the radius and ulna in skeletally mature patients over a 5-year period at a single level-1 trauma center. Chart and radiographic review was performed to identify patient and injury demographics, associated neurologic or vascular injuries, and fracture characteristics. Fracture location was measured on computerized imaging software and fractures were grouped into bone(s) segments involved. Proximal, mid-diaphyseal, and distal locations were used for statistical analysis.

RESULTS

Fifty-six extremities in fifty-five patients were identified (mean age 32 years; male to female ratio 9:1). Overall incidence of neurologic injury was 50%, arterial injury 32%, and compartment syndrome 7.1%. Presence of a proximal third forearm fracture was associated with an increased risk for neurologic injury (p < 0.01), with an odds ratio of 5.7 (95% confidence interval, 1.7-18.4). Furthermore, all high velocity/energy ballistic injuries had associated neurologic injuries (p = 0.02).

CONCLUSION

Ballistic forearm fractures result in high rates of neurovascular injury. Fractures caused by high velocity/energy firearms have extremely high rates of neurologic injury when compared with low velocity ballistic injuries. Ballistic fractures involving the proximal third of the radius or ulna are five times more likely to be associated with neurologic injury after a ballistic injury and should be assessed carefully on initial evaluation.