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Ballistic Forearm Fractures are Associated with Higher Neurovascular Injury, Nonunion, and Complications Compared to
Helena F Barber1, Daniel E Pereira1, Brian D Rust1
1Department of Orthopaedic Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri.
Objectives:
To characterize injury patterns, treatment differences, and clinical outcomes associated with ballistic and blunt forearm fractures.
Methods:
Design: Retrospective cohort study.
Setting:
Single Level 1 tertiary trauma center, 2018-2023.
Patient Selection Criteria:
The study included adults (≥18) who underwent operative fixation of diaphyseal radius and/or ulna fractures. Exclusion criteria were ipsilateral intra-articular or unstable elbow injuries, pathologic fractures or fractures involving pre-existing implants. Patients were stratified into two groups: ballistic and blunt injuries, which were further subclassified as blunt-closed or blunt-open.
Outcome Measures And Comparisons:
Primary outcomes included nerve deficit, complication rate, unplanned reoperation, nonunion, and postoperative infection.
Results:
The study included 395 patients with 398 forearm fractures: 81 ballistic fractures in 78 patients (32 years [18-69], 88.9% male), 213 blunt-closed fractures (41 years [18-82], 59.2% male), and 104 blunt-open fractures (46 years [19-92], 71.2% male). Ballistic fractures had significantly higher rates of nerve deficits (48.2% vs 6.3%, p < 0.001), complications (38.5% vs 21.1%, p = 0.020), and unplanned reoperation (30.8% vs 14.2%, p = 0.012) compared with blunt injuries. Infection rates were similar between ballistic and blunt groups (10.3% vs 5.8%, p = 0.294). Nonunion differed only between ballistic and blunt-closed fractures (18.0% vs 5.6%, p = 0.042), not blunt-open fractures (18.0% vs 9.2%, p=0.228). On multivariable analysis, injury group remained an independent predictor of nerve deficit (p<0.001), complication (p=0.008), and unplanned reoperation (p=0.015), with ballistic injuries demonstrating the highest rates.
Conclusions:
Ballistic forearm fractures posed unique challenges compared to blunt injuries. They were associated with significantly higher rates of nerve deficit, unplanned reoperations, and overall complications, with higher nonunion observed when compared with blunt-closed injuries. These injuries warrant a high index of suspicion for nerve injury and close long-term follow-up to optimize patient outcomes and address the needs of a disproportionately affected, high-risk population.
Level Of Evidence:
Level III.
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