Most bullets made of lead alloy


Fracture lines usually propagate beyond what can be seen on traditional radiographs



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Fracture lines usually propagate beyond what can be seen on traditional radiographs

  • Out of plane of radiograph
  • Non displaced cracks
  • Be prepard to extending fixation beyond what traditionally would be done for fracture

    • i.e.. Subtrochanteric fracture with lesser trochanter intact, use nail with neck fixation as opposed to standard nail.




    23 y.o. male

    • 23 y.o. male

    • Single low-energy GSW to leg

    • ABI > 1.0

    • Neurologically intact

    • XR: Fracture of distal femur

      • Moderate comminution noted
      • Lateral condyle comminuted through articular surface
      • Not fully appreciated on plain film




    27 y.o. male

    • 27 y.o. male

    • GSW to right leg

    • ABI = .7

    • On table angiogram

      • Laceration of popliteal artery
    • Temporizing external fixator placed to stabilize length of limb

    • Arterial repair performed

    • Note comminution of fractured femur





    19 y.o. male

    • 19 y.o. male

    • GSW to leg

    • ABI = .95

    • Neuro intacy

    • Radiographs

      • Comminuted fracture femoral shaft


    2 months post op

    • 2 months post op

    • Early healing with callus forming

    • Weight Bearing as tolerated, No pain



    28 y.o. male

    • 28 y.o. male

    • Shotgun load with large pellets

    • Neuro intact

    • Vascular intact

    • Large lateral wound from close range injury

    • Exploration

      • Wadding, packing and pellets, all removed
    • Repeat debridement at 72 hours



    Significant comminution not appreciated pre-op

    • Significant comminution not appreciated pre-op

      • Head split present
    • ORIF performed



    Significant bone loss and muscle damage from energy of Shotgun

    • Significant bone loss and muscle damage from energy of Shotgun

    • Treated as open fracture with multiple debridements



    Healed at three months

    • Healed at three months

    • Motion limited

      • No active Abduction due to injury to rotator cuff insertion


    Knee most common

    • Knee most common

    • Ankle second

    • Look for vascular injury especially around knee

    • Careful evaluation for fractures

    • May need CT scan especially about hip



    Large amount of articular and cartilage damage, especially in knee

    • Large amount of articular and cartilage damage, especially in knee

      • ? Significance
    • Indication for surgery

      • Retained bone fragments
        • Acts as three body wear
      • Metal fragments in joints
        • Plumbism (lead poisoning)
      • Fix unstable fractures


    Hip Injuries

    • Hip Injuries

      • Look for association with bowel injury
      • If visceral injury, joint needs to irrigated to prevent infection
    • Other operative indications same as other joints





    Tissue damage and contamination dependant upon missile energy

    • Tissue damage and contamination dependant upon missile energy

    • Careful vascular assessment mandatory

    • High velocity and shotgun blasts require surgical debridement. Joints if retained metal or bone

    • Recommend all victims treated with antibiotics

      • Route of delivery dependant on need for surgery
    • fracture extension, fragmentation common

      • Many require surgical stabilization d/t instability
      • Indirect reduction, internal fixation recommended for diaphyseal injuries


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