Civilian Ballistic Proximal Femur Fractures and Blunt Proximal Femur Fractures: Comparing Outcomes and Complications

To assess ballistic proximal femur fracture outcomes in comparison with proximal femur fractures sustained by blunt mechanisms. We hypothesized that ballistic proximal femur fractures would have higher rates of infection, nonunion, and compartment syndrome than nonballistic fractures.

A retrospective cohort was collected from the electronic medical record of a single, Level I, trauma center over a 10-year period (2013 to 2022) using Current Procedural Terminology codes. All consecutive adult patients with ballistic proximal third femur fractures (femoral neck, intertrochanteric, subtrochanteric) managed with surgical fixation were identified. A comparison group of proximal femur fractures sustained by nonballistic mechanisms was collected from consecutive patients in a 3-year period (2020 to 2022), creating a 2:1 nonballistic-to-ballistic fracture ratio. Exclusion criteria consisted of younger than 18 years or older than 65 years, primary fixation of total/hemi hip arthroplasty, primary pathologic fractures, and fractures across existing prosthesis. The primary outcomes measured include concomitant genitourinary injury, computed tomographic angiography with abnormality, vascular injury requiring repair, soft-tissue reconstruction, thigh compartment syndrome, length of stay, fracture-related infection, revision surgery to promote bone healing, and implant failure.

A total of 411 patients were included with 137 (33%) sustaining ballistic proximal femur fractures. Most blunt fractures were closed (86.8%), whereas most ballistic fractures were Gustilo Anderson type 1 open fractures (81.7%). The individuals in the ballistic cohort were more likely to have vascular injury requiring surgical intervention (8.8% vs. 1.1%, P < 0.001), computed tomographic angiography with abnormality (10.9% vs. 1.1%, P < 0.001), compartment syndrome (7.3% vs. 0.7%, P < 0.001), concomitant GU injury (12.4% vs. 1.8%, P < 0.001), and deep vein thrombosis (5.1% vs. 1.5%, P = 0.048).

Ballistic proximal femur fractures are associated with a higher risk of developing complications associated with trauma to nearby vascular structures and concomitant genitourinary structures. The rates of infection, revision surgery to promote bone healing, and implant failure were similar between the ballistic and nonballistic proximal femur fractures.