Low-velocity Gunshot Injuries to the Femur: What Is the Utility of Stabilizing Incomplete Fractures?

INTRODUCTION: Extremity involvement is common among nonfatal gunshot injuries. Most of these injuries are low energy in nature and may be associated with fractures. Although displaced fractures of lower extremity long bones are often treated surgically, the purpose of this study was to review our experience in managing incomplete femur fractures caused by gunshot penetration and to develop treatment recommendations.

METHODS: We retrospectively reviewed clinical and radiographic data for 46 consecutive patients with incomplete femur fractures secondary to low-energy gunshot wounds. Fracture patterns included OTA/AO 31 (n = 7), 32 (n = 20), and 33 (n = 19). All fractures were nondisplaced and extra-articular. Type of treatment, clinical and radiographic healing, and related complications were recorded.

RESULTS: Thirty-two patients (70%) were managed nonsurgically with progressive weight bearing from toe touch to full weight bearing by 6 weeks of follow-up, whereas 14 patients (30%) underwent prophylactic fixation of the femur. No differences in treatment were seen based on age, body mass index, fracture pattern, or the presence of other fractures or systemic injuries. Two of the 32 patients (6.2%) treated nonsurgically for femoral shaft fractures fell subacutely after the original injury and displaced their fractures. Both underwent reduction and fixation. All other fractures maintained alignment until union. No infections or nonunions were seen. Among patients who underwent prophylactic fixation, two underwent removal of prominent implants after union.

DISCUSSION: Only 6% of incomplete femur fractures treated at our hospital required later surgery for fracture displacement. Although incomplete fractures occur infrequently, nonsurgical management with limited weight bearing seems to be successful and cost-effective for most patients. We propose initial nonsurgical management of nondisplaced femoral fractures secondary to cortical penetration from low-energy gunshot wounds.