Gunshot Wounds – Principles and Orthopaedic Management

Gunshot wounds (GSWs) are complex traumatic injuries in which damage results not only from direct penetration by a projectile but also from the transfer of kinetic energy to surrounding tissues. Orthopaedic involvement is common because bullets may injure bone, joints, muscles, tendons, peripheral nerves and major blood vessels.

The severity of a gunshot injury cannot be determined simply by the size of the entry wound. Management depends on the energy transferred to the tissues, anatomical structures injured, degree of contamination, soft-tissue viability, fracture pattern and associated neurovascular or visceral injury.

Treat the injury produced by the projectile – not simply the presence of a bullet wound.

Ballistics refers to the study of projectile motion and its effects. From the orthopaedic perspective, the most important concept is the amount of energy transferred from the projectile to the tissue.

The kinetic energy of a projectile is represented conceptually by:

Kinetic Energy = ½ × mass × velocity²

Because velocity is squared, an increase in projectile velocity can markedly increase kinetic energy. However, the amount of tissue damage depends on how much of this energy is actually transferred to the body.

Traditional descriptions often divide gunshot wounds according to projectile velocity. Clinically, however, the resulting tissue injury is more important than the nominal muzzle velocity.

The “personality of the wound” is more clinically useful than velocity alone.

1. Permanent Cavity

Tissue directly crushed and destroyed by the projectile forms the permanent wound track.

2. Temporary Cavitation

Rapid energy transfer may cause surrounding tissues to be temporarily displaced outward, producing a transient cavity larger than the projectile itself.

The clinical importance of temporary cavitation depends greatly on tissue elasticity.

3. Fragmentation

The projectile, bone or both may fragment. Secondary bone fragments can behave like additional missiles and increase local tissue injury.

Entry wounds are often smaller than exit wounds, but this is not sufficiently reliable to determine projectile direction or severity of tissue damage.

The skin wound may dramatically underestimate deep tissue injury.

A patient may have:

• Entry and exit wounds.
• An entry wound with retained projectile.
• Multiple wounds produced by one or multiple projectiles.
• Fragment wounds caused by projectile or bone fragmentation.

Do not assume that two skin wounds necessarily represent one simple straight projectile path.

A gunshot wound should initially be approached as a trauma patient rather than as an isolated orthopaedic fracture.

In major trauma, management follows standard trauma resuscitation principles:

1. Airway with cervical-spine considerations where appropriate.
2. Breathing and ventilation.
3. Circulation and haemorrhage control.
4. Neurological assessment.
5. Complete exposure while preventing hypothermia.

Life-threatening haemorrhage, thoracic, abdominal, pelvic and vascular injuries take priority over definitive fracture treatment.

After stabilisation, the injured extremity should be systematically assessed.

Document

• Location and number of wounds.
• Active bleeding.
• Soft-tissue loss.
• Gross contamination.
• Exposed bone or tendon.
• Deformity.
• Swelling and compartment tension.
• Motor function.
• Sensory function.
• Distal pulses.
• Capillary refill and limb temperature.

A complete pre- and post-intervention neurovascular examination should be documented.

Important features suggesting a more severe wound include:

• Large soft-tissue defect.
• Extensive contamination.
• Devitalised skin or muscle.
• Exposed bone.
• Bone loss.
• Major vascular injury.
• Compartment syndrome.
• Gross joint contamination.
• Associated hollow-viscus injury.

Plain Radiographs

Obtain appropriate AP and lateral radiographs of the involved region and include the joints above and below when fracture pattern or projectile path warrants it.

Radiographs may demonstrate:

• Fracture configuration.
• Comminution.
• Bone loss.
• Projectile fragments.
• Possible intra-articular fragments.

CT

CT is useful for complex periarticular fractures, pelvis and acetabulum injuries, spinal injuries and localisation of projectiles relative to joints or vital structures.

CT Angiography

CT angiography is appropriate when vascular injury is suspected in a haemodynamically stable patient and immediate operative exploration is not already indicated.

Gunshot wounds near major vessels require careful vascular assessment.

Hard Signs of Vascular Injury

• Pulsatile or uncontrolled haemorrhage.
• Expanding haematoma.
• Absent distal pulse with evidence of limb ischaemia.
• Palpable thrill.
• Audible bruit.

Hard signs generally warrant urgent vascular surgical assessment and intervention rather than delaying definitive treatment for unnecessary imaging.

Possible Subtle Findings

• History of significant bleeding.
• Diminished pulse.
• Small stable haematoma.
• Wound close to a major vessel.
• Associated neurological deficit.

In selected extremity trauma patients without obvious hard signs, an ankle-brachial or arterial pressure index can support vascular assessment.

An abnormal result, concerning examination or proximity to a major vessel may prompt CT angiography or formal vascular assessment.

Clinical judgement remains essential, particularly where shock, pre-existing arterial disease or complex limb trauma makes pressure measurements less reliable.

Gunshot injuries can cause compartment syndrome because of fracture bleeding, vascular injury, swelling or reperfusion after vascular repair.

Clinical features include:

• Pain out of proportion to the apparent injury.
• Pain with passive stretch.
• Tense swollen compartments.
• Progressive sensory deficit.
• Motor dysfunction as a later feature.

Distal pulses may remain present despite severe compartment syndrome.

Suspected acute compartment syndrome requires urgent fasciotomy; do not wait for loss of pulse.

Ballistic nerve injury can result from:

• Direct nerve transection.
• Contusion.
• Stretch injury.
• Temporary cavitation.
• Compression from haematoma or fracture fragments.

The traditional assumption that most ballistic nerve deficits are simple neurapraxias is unsafe. Some injuries represent partial or complete structural nerve disruption.

A meticulous motor and sensory examination should be documented before and after reduction, surgery or vascular intervention.

Management should be individualised according to the nerve, clinical deficit and associated injuries.

Exploration may be particularly considered when:

• The nerve is visibly transected in an open wound.
• The nerve is encountered during necessary fracture or vascular surgery.
• There is progressive neurological deterioration.
• Compression by a projectile or fracture fragment is suspected.
• Serial evaluation suggests failure of expected recovery from a severe nerve injury.

Ultrasound, electrodiagnostic studies and specialist peripheral nerve assessment may help characterise injuries when immediate exploration is not indicated.

A projectile passing through bone may produce anything from a small cortical defect to extensive segmental comminution and bone loss.

Important determinants of treatment are:

• Mechanical stability of the fracture.
• Energy transferred to the tissues.
• Degree of soft-tissue injury.
• Contamination.
• Bone loss.
• Joint involvement.
• Neurovascular injury.

Low-energy fractures with minimal soft-tissue damage can frequently be treated according to the usual mechanical principles applied to comparable fractures.

A stable fracture associated with a small uncomplicated civilian gunshot wound may sometimes be managed non-operatively.

Treatment may include:

• Local wound care.
• Appropriate antibiotic prophylaxis according to injury pattern and institutional protocol.
• Tetanus prophylaxis.
• Splint or cast immobilisation when required.
• Serial neurovascular examinations.
• Follow-up for infection, displacement and union.

Routine extensive surgical debridement is not required for every uncomplicated low-energy extremity gunshot fracture.

High-energy injuries behave more like severe open fractures.

They may be characterised by:

• Large zones of muscle devitalisation.
• Gross contamination.
• Highly comminuted fractures.
• Bone loss.
• Vascular injury.
• Compartment syndrome.
• Major skin and soft-tissue defects.

Management generally follows open-fracture principles with prompt antibiotic therapy, formal irrigation and debridement, fracture stabilisation and appropriate soft-tissue reconstruction.

The purpose of debridement is to remove clearly devitalised tissue and gross contamination while preserving viable tissue.

Formal operative debridement is particularly indicated when there is:

• Extensive soft-tissue devitalisation.
• Gross contamination.
• Large open wound.
• Open fracture requiring operative management.
• Intra-articular contamination requiring surgery.
• Vascular injury requiring exploration.
• Compartment syndrome.
• Necrotic tissue.
• Associated infection.

During debridement, muscle viability has traditionally been assessed using the Four Cs:

These features are guides rather than infallible tests and must be interpreted together.

In severe ballistic injuries, the full extent of tissue devitalisation may not be immediately apparent.

Planned repeat examination and debridement may therefore be necessary before definitive wound closure or complex reconstruction.

Early coverage should be pursued once contamination has been controlled and the wound contains viable tissue suitable for reconstruction.

There is no special universal implant for gunshot fractures. The fixation strategy should be chosen according to standard fracture principles while considering the biological damage to the limb.

Options include:

• Splint or cast immobilisation.
• External fixation.
• Intramedullary nailing.
• Plate fixation.
• Temporary damage-control fixation followed by staged reconstruction.

External fixation is particularly valuable when there is:

• Severe soft-tissue injury.
• Gross contamination.
• Vascular injury requiring access and repair.
• Haemodynamic instability requiring damage-control orthopaedics.
• Bone loss.
• Need for repeated wound access.

External fixation can be temporary or definitive depending on the injury and reconstructive plan.

Intramedullary nailing is commonly useful for appropriate ballistic fractures of long bones, particularly the femur and tibia, when the wound and soft-tissue environment permit internal fixation.

Benefits include:

• Load-sharing fixation.
• Preservation of periosteal biology.
• Relatively limited additional soft-tissue dissection.
• Good control of length and alignment with appropriate interlocking.

Antibiotic management of gunshot fractures remains an area in which practice varies because the quality of evidence is limited and injuries are heterogeneous.

Antibiotics are particularly important when the injury includes:

• Open fracture with substantial tissue injury.
• Gross contamination.
• High-energy injury.
• Operative fracture fixation.
• Joint penetration.
• Associated bowel contamination.
• Major soft-tissue injury.

For uncomplicated low-energy extremity gunshot fractures managed non-operatively, prolonged broad-spectrum antibiotic courses have not been shown to be uniformly necessary. Local trauma and antimicrobial protocols should be followed.

Antibiotic strategy should reflect contamination and tissue injury rather than the mere presence of a bullet.

Tetanus immunisation status should be assessed in all penetrating injuries.

Tetanus-containing vaccination and, when indicated according to immunisation history and wound characteristics, tetanus immune globulin should be administered according to standard wound prophylaxis guidelines.

No. Routine removal of every retained bullet or metallic fragment is unnecessary and may cause more tissue damage than leaving an asymptomatic fragment in situ.

Deep fragments embedded in soft tissue or bone without symptoms, contamination concerns or risk to important structures can often be left in place.

The indication for bullet removal is determined by location and clinical consequences – not simply by its radiographic visibility.

Removal should be strongly considered when a projectile is:

• Intra-articular.
• Within a bursa in selected symptomatic cases.
• Causing mechanical irritation.
• Compressing a nerve or producing neurological symptoms.
• Within or immediately threatening a vessel.
• Associated with infection.
• Migrating to a clinically dangerous location.
• Associated with symptomatic lead toxicity.
• Easily accessible during another required operation where removal adds little morbidity.

Joint penetration requires special consideration because the projectile may introduce contamination, damage articular cartilage and leave metallic or osteochondral debris within the joint.

Retained intra-articular bullets are usually removed because of:

• Mechanical cartilage damage.
• Synovitis.
• Potential lead dissolution in synovial fluid.
• Potential lead arthropathy.
• Loose-body symptoms.
• Contamination.

Arthroscopic or open irrigation, debridement and projectile removal may be selected depending on the joint, associated fracture and degree of contamination.

Most retained bullet fragments in inert soft tissue do not cause clinically important lead poisoning.

Risk is greater when fragments are located in environments where lead can dissolve more readily, particularly within a synovial joint.

Patients with retained fragments and unexplained systemic symptoms or high-risk fragment locations may require blood lead assessment.

A projectile that traverses the gastrointestinal tract before reaching bone creates a different contamination problem from an isolated extremity gunshot wound.

Particular concern exists with:

• Pelvic fractures.
• Acetabular fractures.
• Hip-joint penetration.
• Colonic injury.

These injuries require multidisciplinary management with trauma/general surgery and appropriate antimicrobial coverage directed at the degree and source of contamination.

Pelvic gunshot wounds require careful evaluation because life-threatening injuries may involve:

• Major blood vessels.
• Small or large bowel.
• Bladder.
• Urethra.
• Rectum.
• Nerves.
• Hip joint and acetabulum.

Most mechanically stable pelvic ring fractures do not require fixation simply because they were caused by a bullet. Skeletal stability, associated injuries and contamination determine treatment.

Hip-joint penetration deserves particular attention because of the deep location of the joint and potential contamination.

Indications for operative treatment commonly include:

• Retained intra-articular projectile.
• Significant intra-articular debris.
• Fracture requiring fixation.
• Gross contamination.
• Associated bowel contamination involving the joint.

The hand contains many critical structures within a small volume, meaning a relatively small wound may disrupt multiple bones, tendons, nerves and vessels.

Important goals are:

• Preserve viable tissue.
• Restore skeletal stability.
• Repair critical tendons when appropriate.
• Address nerve and vascular injury.
• Obtain soft-tissue coverage.
• Begin controlled mobilisation as early as safely possible.

Excessive immobilisation can lead to severe stiffness even after successful fracture union.

Spinal gunshot injuries should be managed according to neurological status, mechanical stability, projectile location and associated visceral or vascular injury.

Routine surgical removal of every projectile within or near the spinal canal is not indicated.

Possible indications for surgery include selected cases of:

• Progressive neurological deterioration with surgically addressable compression.
• Mechanical instability.
• CSF leak.
• Infection.
• Projectile migration.
• Symptomatic lead toxicity.

These cases usually require multidisciplinary spinal and trauma expertise.

The severity of a shotgun injury is highly dependent on firing distance.

At close range, the shot remains concentrated and can produce:

• Extensive tissue destruction.
• Severe contamination.
• Large soft-tissue defects.
• Highly comminuted fractures.
• Vascular injury.

Such injuries should be treated as severe high-energy open trauma.

Severe gunshot injuries may require coordinated orthopaedic and plastic reconstructive management.

Reconstruction may involve:

• Primary closure in selected clean wounds.
• Delayed primary closure.
• Negative-pressure wound therapy as a temporary adjunct.
• Skin grafting.
• Local flap coverage.
• Free-tissue transfer.

Definitive coverage should be coordinated with fracture stability and eradication of devitalised tissue.

Severe ballistic injury may result in substantial segmental bone loss.

Reconstructive options depend on defect size, location, infection status and soft-tissue envelope and may include:

• Autologous bone grafting.
• Induced membrane technique.
• Bone transport.
• Vascularised bone graft.
• Structural grafts in selected cases.
• Custom reconstruction in exceptional situations.

Severe gunshot trauma may produce combined bone, vascular, nerve and soft-tissue destruction.

Decisions regarding limb salvage should consider:

• Patient physiology.
• Duration and severity of ischaemia.
• Extent of muscle destruction.
• Vascular reconstructability.
• Nerve injury.
• Bone loss.
• Contamination.
• Expected long-term function.
• Patient goals and rehabilitation potential.

Limb-salvage scores may aid communication but should not be used as the sole determinant of amputation.

Infection risk is influenced by:

• Energy of injury.
• Quantity of devitalised tissue.
• Gross contamination.
• Bowel contamination.
• Delayed treatment.
• Bone loss.
• Soft-tissue coverage.
• Host factors such as diabetes or smoking.

Infection following a complicated ballistic fracture may progress to fracture-related infection and chronic osteomyelitis and should be managed using established principles of debridement, microbiological sampling, stability and targeted antimicrobial therapy.

A commonly repeated misconception is that the heat generated during firing sterilises a projectile and therefore makes the wound sterile.

Gunshot wounds should be regarded as contaminated injuries. The projectile can carry material from clothing, skin and the external environment into deeper tissues, and contamination may also result from bowel or other hollow-viscus injury.

Gunshot wounds are not sterile wounds.

Blind aggressive probing of a gunshot track is generally unnecessary and can cause additional tissue damage or disrupt haemostasis.

Anatomical examination and appropriate imaging are preferable for determining the probable course of the projectile and identifying associated injuries.

• Fracture requiring operative stabilisation.
• Major soft-tissue devitalisation.
• Gross contamination.
• Vascular injury.
• Compartment syndrome.
• Intra-articular projectile or debris.
• Significant tendon injury.
• Selected nerve injuries requiring exploration.
• Large bone defect.
• Infection.
• Retained projectile causing mechanical or neurological problems.

Potential complications include:

• Haemorrhage.
• Limb ischaemia.
• Compartment syndrome.
• Infection.
• Chronic osteomyelitis.
• Delayed union.
• Nonunion.
• Malunion.
• Joint stiffness.
• Post-traumatic arthritis.
• Nerve palsy.
• Chronic neuropathic pain.
• Vascular thrombosis.
• Pseudoaneurysm.
• Arteriovenous fistula.
• Lead arthropathy.
• Lead toxicity.
• Complex regional pain syndrome.

Rehabilitation depends on the fracture, soft-tissue reconstruction and neurovascular status.

Important goals are:

• Maintain joint range of motion.
• Prevent contracture.
• Restore muscle strength.
• Protect tendon and nerve repairs.
• Progress weight bearing according to fracture stability.
• Manage neuropathic pain.
• Restore hand or limb function.
• Address psychological consequences of traumatic injury.

1. Resuscitate first. Identify and treat immediately life-threatening haemorrhage and associated torso injuries.
2. Perform a complete neurovascular examination. Document pulses, perfusion, motor and sensory function.
3. Look for vascular injury and compartment syndrome. These may require emergency intervention.
4. Define the projectile path and associated injuries. Use appropriate radiographs, CT or vascular imaging.
5. Assess the wound personality. Determine soft-tissue destruction, contamination and energy transfer.
6. Assess the fracture. Determine stability, comminution, bone loss and joint involvement.
7. Give appropriate antimicrobial and tetanus prophylaxis. Tailor antibiotics to wound severity and contamination.
8. Debride when indicated. Extensive devitalisation, contamination and complex open injury require operative debridement.
9. Stabilise the skeleton. Choose cast, nail, plate or external fixation according to mechanical and biological considerations.
10. Do not routinely chase the bullet. Remove it only when its location or clinical effect provides a valid indication.
11. Restore the soft-tissue envelope. Coordinate coverage early in severe injuries.
12. Begin rehabilitation. Functional recovery is the ultimate goal, not merely fracture union.

• Judging injury severity only by the entry wound.
• Assuming every gunshot fracture requires extensive debridement.
• Assuming every retained bullet must be removed.
• Failing to document a detailed neurovascular examination.
• Missing vascular injury because a distal pulse is still palpable.
• Missing compartment syndrome because pulses remain present.
• Treating a high-energy ballistic injury like a simple puncture wound.
• Ignoring the possibility of bowel contamination in pelvic injuries.
• Using prolonged antibiotics as a substitute for adequate surgical debridement.
• Focusing on the fracture while overlooking soft-tissue viability.
• Assuming a nerve palsy is automatically neurapraxic.

• Projectile kinetic energy is proportional to mass × velocity².
• Tissue damage depends more on energy transfer and wound characteristics than velocity classification alone.
• Permanent cavity represents directly destroyed tissue; temporary cavitation represents transient tissue displacement.
• Bone fragments can behave as secondary missiles.
• A small entry wound does not exclude major deep tissue injury.
• Gunshot trauma is managed according to standard trauma resuscitation priorities before definitive orthopaedic treatment.
• Always document the neurovascular status before and after intervention.
• A palpable distal pulse does not exclude important arterial injury or compartment syndrome.
• Hard signs of vascular injury require urgent vascular assessment and usually operative management.
• Uncomplicated low-energy gunshot fractures do not automatically require formal extensive surgical debridement.
• High-energy ballistic fractures should generally be approached using severe open-fracture principles.
• The Four Cs of muscle viability are colour, consistency, contractility and capacity to bleed.
• Antibiotic requirements depend on tissue damage and contamination and remain incompletely standardised for uncomplicated low-energy fractures.
• Tetanus status should be reviewed in all gunshot wounds.
• Retained bullets do not require routine removal.
• Intra-articular retained bullets are an important indication for removal.
• Retained intra-articular lead can cause synovitis, lead arthropathy and systemic absorption.
• A projectile crossing bowel before reaching bone markedly changes the contamination profile.
• Low-energy fractures can often be stabilised according to ordinary fracture mechanics.
• External fixation is useful when severe soft-tissue injury, vascular repair, contamination or damage-control surgery is present.
• Ballistic nerve injuries range from neurapraxia to complete nerve transection.
• Gunshot wounds are contaminated wounds; a fired bullet should not be assumed to be sterile.

1. Save life before limb: perform trauma resuscitation and control haemorrhage before definitive fracture management.
2. Assess the wound rather than the weapon: the degree of energy transfer and tissue destruction determines treatment.
3. Never miss vascular injury or compartment syndrome: these are time-critical limb-threatening complications.
4. Document nerve function carefully: ballistic nerve deficits range from temporary conduction block to complete transection.
5. Do not over-treat uncomplicated low-energy wounds: every bullet fracture does not require extensive operative debridement.
6. Do not under-treat high-energy wounds: devitalised and contaminated injuries require formal open-fracture principles.
7. Treat the fracture mechanically: stabilise according to alignment, stability, bone loss and soft-tissue condition.
8. Use antibiotics intelligently: contamination, bowel injury, operative fixation and soft-tissue damage determine the antimicrobial strategy.
9. Do not chase every bullet: remove projectiles when their location or clinical consequences justify the additional surgery.
10. Remember the joint: retained intra-articular projectiles usually require removal and management of associated contamination and cartilage injury.
11. Think beyond fracture union: soft-tissue coverage, nerve recovery, joint movement, rehabilitation and functional restoration determine the final outcome.

The central principle of orthopaedic gunshot management is to treat the biological and mechanical consequences of the injury rather than treating the bullet itself.