Management of Unique Complex Long Bone Fractures by Gunshot Injuries with Linear Rail System

The insurgence of banditry, kidnapping and farmer-herdsmen clashes has presented a unique etiological factor of complex long bone (fracture) and soft tissue gunshot injuries to orthopaedic Surgeons in North West Nigeria. These complex fractures and soft tissues injuries are of very challenging and with high risks of bone loss being open fracture, infected gap nonunion and soft tissue defects which are individually and/or collectively difficult situation to manage to salvage the affected limbs. The management include but not limited to resuscitation using Advanced Trauma Life Support Protocols, often staged management of the injury which entails: wound debridement with external fixation, soft tissue cover or grafting, bone grafting including vascularized bone grafting and bone transport.

The objective of this retrospective study is to share our experience of the outcome of Linear Rail System (LRS) in salvaging long bone complex fractures from gunshot injuries.

Twenty-seven patients who had limb salvage procedures with LRS on account of complex fractures from gunshot injuries between January 1, 2019 and December 30, 2022 and were recruited into this retrospective study. The clinical details of the patients were retrieved from the medical record department and analyzed.

The study involved 27 patients (male-female ratio of 5.75:1) aged 22-49 years with a mean age of 30.5 years. All patients suffered Gustilo type III injuries associated with varying bone loss resulting from debridement of devitalized bone or bone loss at the scene of the injury. There were 17 cases of tibia, 7 femurs, and 3 humerus. All patients presented at the accident and emergency room. The surgical treatment included debridement, docking, corticotomy at an appropriate level and distraction/compression by LRS respectively. All cases had antibiotics, achieved union and limb length equalization/bone transport. Primary docking was done in 59% with subsequent limb lengthening while 41% had bone transport from the osteotomy sites. The average bone gap regenerated was 8.92 cm (range 3.23-16.90 cm) over a period of 19 months (ranging between 7 and 19 months). At the end of fracture union, 78% of the patients had normal range of motion in nearby joints and with satisfactory limb function in 93% of the cases according to patients' report.

The uniqueness of complex long bone fractures by gunshot injuries with extensive soft tissue and fractures especially with cases of bone loss due to the injury or from the debridement required a faster, simpler and more acceptable device that will achieve the desired result. The use of LRS in this study was a good option to achieve soft tissue care, infection control, fracture union, restore limb length and rehabilitation to restore function with satisfactory outcome. However, appropriate patients counselling and education about the device and the likely outcome are imperative parts of the keys to the success.