Ballistic femoral neck fractures: Current concepts in evaluation and management

Ballistic femoral neck fractures are complex, high-energy injuries that require a management approach distinct from conventional blunt trauma. These current concepts review examines the evolving landscape of evaluation and treatment for these rare injuries based on contemporary literature. Initial management emphasizes the Advanced Trauma Life Support (ATLS) protocol, with a critical focus on identifying associated neurovascular and skeletal injuries, which are present in approximately one-third of cases. Diagnostic evaluation relies on plain radiography and thin-slice CT to delineate fracture morphology and bullet trajectory, with CT angiography recommended if vascular compromise is suspected. Surgical decision-making balances the goals of head preservation through open reduction and internal fixation (ORIF) against the definitive stability provided by total hip arthroplasty (THA). While ORIF remains the standard for young, active patients, clinicians must account for the historically high incidence of nonunion and infection associated with ballistic mechanisms. In cases of failed osteosynthesis or catastrophic articular comminution, conversion to THA offers a reliable salvage option with favorable functional outcomes. This review highlights the need for individualized treatment plans and meticulous clinical follow-up to manage the inherent risks of this challenging injury pattern.