Management Principles of Civilian Ballistic Orthopaedic Trauma

Gun-related violence is becoming increasingly more common in the United States, and ballistic injuries pose a challenge to the orthopaedic surgeon on trauma call. The guiding principles of trauma care are almost exclusively based on blunt trauma, and the management principles do not always translate. Ballistic long bone fractures, particularly of the lower extremity, can often be managed with similar principles, although the injury pattern can make restoration of anatomic alignment a challenge. Some data suggest that patients with ballistic arthrotomies can be safely treated with medical management and antibiotic therapy alone; however, gross contamination can be encountered, and this decision is at the surgeon's discretion. Retained ballistic fragments may result in intra-articular changes and elevated lead levels over time, warranting consideration for surgical excision. Ballistic injuries to the hand and wrist are often present with concomitant soft-tissue injury, including nerve and tendon injuries. Providing stable bony fixation while also facilitating early motion for rehabilitation is a difficult balance to reach. In addition, the management of ballistic nerve injuries is controversial, as many injuries are not simply neurapraxic, and either early exploration or evaluation with ultrasonographic imaging may help detect injuries for which repair or grafting can be considered. Last, ballistic trauma can have mental health implications for patients and families and even contribute to the burnout epidemic demonstrated in health care professionals.