Abstract
Purpose
As gun violence continues to grow, hand surgeons are increasingly called upon to manage complex ballistic hand fractures. However, there is a relative scarcity of literature on civilian gunshot-related metacarpal fractures. In this study, we examine the management strategies and outcomes for ballistic metacarpal fractures at a high-volume, level-1 urban trauma center.
Methods
Through the use of an institutional database of all patients with firearm-related fractures who presented to our level 1 trauma center, we identified all patients with ballistic hand fractures over a 4-year period (2019–2023). Charts were reviewed for metacarpal fractures and associated injuries, and physical examination characteristics at initial presentation. We evaluated the surgical treatments, postoperative complications, and outcomes following the treatment of these injuries.
Results
Over a 4-year period, 98 patients sustained a total of 139 firearm-related metacarpal fractures. Of these, 28 patients with 39 fractures were lost to follow-up. Among the remaining, a total of 100 metacarpal fractures were treated with a mean follow-up of 5.5 months (range, 2–24 months). Of these, 79 (79%) required surgical intervention. Soft tissue injuries associated with these fractures were observed in 36% of cases. Among the 79 surgically treated fractures, complications included a 13% nonunion rate, an 18% malunion rate, and a 4% incidence of deep infections. Overall, the most common complication was stiffness, reported in 62% of operative metacarpals. The average active range of motion at the metacarpophalangeal joint was 58.
Conclusions
This large retrospective series of gunshot-related metacarpal injuries treated at a high-volume trauma center presents findings and outcomes for a challenging injury. The findings showed a moderate risk of nonunion and high rates of stiffness following these injuries, emphasizing the critical need for further research to develop optimal management strategies aimed at reducing complications in the treatment of firearm-related metacarpal fractures.
Type of study/level of evidence
Prognostic IV
Key words: Ballistic, Firearm, Fracture, Gunshot, Metacarpal
Gun violence is a serious public health concern both globally and within the United States. The incidence of civilian firearm-related injuries is on the rise, particularly within urban centers.1, 2, 3 Gunshot injuries now stand as the primary cause of mortality among children and adolescents, while continuing to be a leading cause of injuries sustained by adults in the United States.4 Despite the frequency of this issue, the existing body of research on ballistic injuries is scarce, predominantly originating from military gunshot wounds, which differ dramatically from the low-velocity firearm injuries commonly found in urban settings.
With the growing prevalence of civilian firearm-related injuries, understanding management strategies and expected outcomes for gunshot-related trauma is critical.4 This is particularly relevant to hand and upper-extremity surgeons, as previous studies have shown that approximately 70% of unintentional gunshot wounds and 45% of assault-related gunshot wounds affect the extremities, with the upper-extremity predominating.5,6 Metacarpal-related gunshot injuries are commonplace, with recent epidemiological studies demonstrating that such injuries comprised 37% of all firearm-related hand or wrist fractures.7,8
Although the general treatment of metacarpal fractures spans a spectrum from nonsurgical to operative interventions such as casting, Kirschner wire fixation, open reduction and internal fixation (ORIF), intramedullary screws, or external fixation, the management of ballistic fractures can be more complex. Atypical fracture patterns, bone loss, pronounced instability, and concurrent soft tissue injuries can complicate conventional fixation strategies.9, 10, 11 Currently, there are minimal data regarding the treatment modalities, characteristics, and outcomes associated with firearm-related metacarpal fractures. We present a large single-institution series of civilian low-energy metacarpal injuries describing the epidemiology, injury patterns, potential treatment options, and outcomes.
Materials and Methods
Our center’s Institutional Review Board approved this retrospective cohort study of patients presenting with gunshot-related traumatic injury to the upper extremities at a single level-1 urban trauma center. Between 2019 and 2024, all patients who presented to the trauma center and were treated for a firearm-related hand fracture were extracted from a prospectively collected database of hand service consultations and reviewed. Medical records of all patients with any ballistic fracture were reviewed manually to identify metacarpal fractures. The primary outcome measured was the nonunion rate, whereas secondary outcomes included postsurgical complication rates and range of motion at the metacarpophalangeal joint (MCPJ). Additionally, the study aimed to describe the treatment methods, fracture locations, and associated soft tissue injuries.
We included skeletally mature patients—confirmed by a fused distal radius growth plate—with metacarpal fractures resulting from low-energy gunshot injuries. Eligible patients had either a minimum of 4 months of clinical follow-up, achieved study end points of radiographic or clinical union, or underwent a secondary bony procedure for nonunion or malunion. Patients who did not meet these criteria, who were treated by surgeons not fellowship-trained in hand surgery, or who lacked imaging for review were excluded from the outcome analysis but were included in the epidemiological analysis. Additionally, we excluded fractures that were likely caused by high-energy firearms, as surgeons believed that the energy imparted was beyond what is typically seen and more indicative of high-energy trauma such as large flap requirements, limb loss, mangled extremity, or when the firearm was known to be high energy.
Data extraction from the chart review focused on injury location and characteristics of the metacarpal fracture, physical examination at initial presentation, and associated hand and wrist fractures. Metacarpal fractures were stratified based on location: head/neck, shaft, and base. Surgical treatments for the metacarpal fractures were compiled, and further clinical chart review was performed to assess postoperative complications and outcomes. All surgical and treatment decision making was at the discretion of the treating physician.
Clinical parameters were recorded including soft tissue injury as well as vascular and nerve status. Soft tissue injuries included observed tendon injuries, nerve injuries, vascular injuries, ligamentous injuries, and skin injuries that required any intervention other than primary closure when treated operatively or secondary healing when treated nonsurgically. Nerve assessment was reported according to the modified American Spinal Injury Association scale for sensation with touch graded into those that report full sensation (2/2) and those that reported subjectively diminished (1/2) or absent sensation (0/2).12 Range of motion was compiled when goniometer measurements were documented and reports of subjective or objective “stiffness” were also compiled regardless of range noted as a patient-reported outcome.
Fractures were radiographically classified into three categories: (1) fractures with simple patterns, (2) fractures with comminution and without obvious bony gapping, and (3) fractures with bony gapping. Radiographic outcomes were evaluated using all available imaging to determine radiographic union, nonunion, and malunion rates. There is no consensus on the definition of nonunion, with definitions varying widely including both clinical and radiographic evaluation13, 14, 15; therefore, we defined nonunion clinically as gross movement or pain at the fracture site and, radiographically, as lack of bridging callus on radiographs at 4 months of follow-up, similar to prior studies.15 Malunion was defined as healed fractures that resulted in clinically documented malrotation, angulation, or shortening. Shortening was defined as more than 5 mm as compared with contralateral hand radiographs when available, or greater than 5 mm of shortening on serial radiographs. Additional complications included deep infection, meaning operative irrigation and debridement were necessary.
The Shapiro-Wilk test was used to assess the normality of the epidemiological data. Descriptive statistics were used to summarize the data. Demographic characteristics were compared between the study group and those lost to follow-up using the Mann-Whitney U test.
Results
Epidemiology
Over the 4-year study period, a total of 223 patients with firearm-related distal upper-extremity fractures were abstracted from our institutional database. Of the total 223 patients, 98 patients (43.9%) with 139 gunshot-related metacarpal fractures were identified and met study inclusion criteria and were included in the epidemiological descriptive data (Fig. 1). After exclusions for loss to follow-up, 100 metacarpal fractures in 70 patients, including 61 men and 9 women, with a median age of 27.5 years (17–71 years) were included in the outcome data. There were no statistically significant differences in patient demographics or injury patterns between the study group and those lost to follow-up (full demographic information is available in Table 1). Average follow-up length was 5.2 months (range, 1.5–24 months; SD, 4.5 months; median, 4 months).
Figure 1.
Flowchart of patients included in the study.
Table 1.
Demographics of Patients Including Those Who Were Lost to Follow-up. There was No Statistically Significant Difference in Demographics Between Those Lost to Follow-up and Those Included in the Study Group
| Patient and Fracture Characterisitcs | Total | Study Group∗ | Lost to Follow-up | |
|---|---|---|---|---|
| Age, y | P value = 0.3510 | |||
| Mean | 30.5 ± 11 | 31.3 ± 12 | 28.5 ± 10 | |
| Median | 27.5 | 27.5 | 27 | |
| Range | 17–71 | 17–71 | 17–54 | |
| Sex, N (%)† | P value = 0.316 | |||
| Men | 88 (90) | 61 (87) | 27 (96) | |
| Women | 10 (10) | 9 (13) | 1 (4) | |
| Race, N (%) | P value = 0.302 | |||
| Black | 88 (90) | 63 (90) | 25 (89) | |
| White | 7 (7) | 6 (9) | 1 (4) | |
| Hispanic | 1 (1) | 0 (0) | 1 (4) | |
| Unknown | 2 (2) | 1 (1) | 1 (4) | |
| Fracture location, N (%) | P value = 0.35 | |||
| MC shaft | 86 (62) | 62 (62) | 24 (62) | |
| MC head/neck | 26 (19) | 21 (21) | 5 (13) | |
| MC base | 27 (19) | 17 (17) | 10 (26) |
MC, metacarpal.
Patients who met the inclusion criteria and were followed up.
Biological sex.
Among all patients, metacarpal fracture locations included 86 shaft fractures, 26 head/neck fractures, and 27 base fractures. Concomitant fractures included 30 associated phalangeal and 26 carpal fractures. Concomitant soft tissue injuries were confirmed on exploration in 36% (50/139) of cases, with some metacarpals sustaining multiple soft tissue injuries. These included 28 (20%) extensor tendon lacerations, 8 (6%) flexor tendon lacerations, 4 (3%) sagittal band injuries, 3 (2%) collateral ligament injuries, 2 (1%) median nerve lacerations, 4 (3%) digital nerve lacerations, 5 (4%) digital artery laceration, 2 (1%) ulnar nerve laceration, 2 (1%) injuries requiring local skin flaps, and 2 (1%) ulnar artery laceration (Table 2).
Table 2.
Associated Soft Tissue Injuries Among All Metacarpal Fractures
| Soft Tissue Injury | N (%) |
|---|---|
| Extensor tendon injury | 28 (20%) |
| Flexor tendon injuries | 8 (6%) |
| Nerve injuries | 8 (6%) |
| Vascular injuries | 7 (5%) |
Outcomes
Among the 100 metacarpal fractures, 79 fractures (79%) were treated with surgical intervention, and 21 fractures (21%) were managed nonoperatively (Fig. 1). The most common method of surgical fixation was percutaneous pinning in 42 cases (53%). Other surgical techniques included internal plate fixation, external fixation, intramedullary screws, temporary joint-spanning bridge plating, and acute MCPJ fusion. A summary of these interventions can be found in Table 3. Radiographically, 32 of these fractures were not comminuted, 44 were comminuted without bone loss or gapping, and 24 had significant comminution with obvious gapping (Table 4).
Table 3.
Treatment Methods of Metacarpal Fractures
| Fracture Type | No. of Fractures | Operatively Treated | Percutaneous Pinning | ORIF | External Fixation | Intramedullary Screw | Joint-spanning Bridge Plate | Acute Joint Fusion | Amputation |
|---|---|---|---|---|---|---|---|---|---|
| MC shaft | 62 | 52 (84%) | 29 (56%) | 4 (8%) | 2 (4%) | 16 (31%) | 1 (2%) | 0% | 0% |
| MC head/neck | 21 | 17 (81%) | 8 (47%) | 1 (6%) | 4 (24%) | 0% | 2 (12%) | 1 (6%) | 1 (6%) |
| MC base | 17 | 10 (59%) | 5 (50%) | 5 (50%) | 0% | 0% | 0% | 0% | 0% |
| Total | 100 | 79 (79%) | 42 (53%) | 10 (13%) | 6 (8%) | 16 (20%) | 3 (4%) | 1 (1%) | 1 (1%) |
MC, metacarpal.
Table 4.
Fractures Were Radiographically Classified Into Three Categories: (1) Fractures Without Comminution, (2) Fractures With Comminution and Without Obvious Bony Gapping, and (3) Fractures With Obvious Bony Gapping
| Fracture Type | Simple Fractures (1) | Comminuted Without Gap (2) | Comminuted With Gap (3) | |
|---|---|---|---|---|
| MC shaft | 16 | 27 | 19 | P value = 0.15 |
| MC head/neck | 7 | 11 | 3 | |
| MC base | 9 | 6 | 2 | |
| Total | 32 | 44 | 24 |
MC, metacarpal.
After excluding 2 patients with confounding injuries, including an acute finger amputation and a ballistic cervical spine injury, documented nerve transection was seen in 8% (8/98) of cases. When excluding patients with documented nerve transections, 30% (27/90) of patients reported altered (1/2 sensory score) or absent (0/2 sensory score) sensation in the injured digit at initial evaluation. Of these patients, 66% (18/27) had return of normal subjective sensation (2/2) at final follow-up without intervention. Conversely, 33% (9/27) of these patients, or 9% (9/98) of all patients, continued to endorse decreased sensation without any documented nerve transection.
Regarding complications following surgery, 10/78 fractures (13%) developed a nonunion, and 14/78 (19%) developed a malunion after excluding 1 patient who underwent an acute amputation (Table 5). All fractures that went to nonunion were comminuted. Of these, 8 out of 10 demonstrated comminution with bony gapping, whereas the remaining 2 exhibited comminution without appreciable gapping (Fig. 2). Infection necessitating operative irrigation and debridement occurred in 3/78 (4%). Globally, the most frequent sequela was stiffness, with patients reporting subjective stiffness in 62% (48/78) of operatively metacarpal fractures. The patients. Overall, 47 patients had documented range of motion, with an average active range of motion of 58° at the MCPJ. Given the nature of the treatment, patients with amputations and joint fusions were not included in the range of motion measurements. In general, patients who had a concomitant tendon or neurovascular injury had worse range of motion as documented in Table 6.
Table 5.
Postoperative Complications of Metacarpal Fractures
| Fracture Type | Nonunion | Malunion | Infection |
|---|---|---|---|
| MC shaft | 8/52 (15%) | 9/52 (17%) | 2/52 (4%) |
| MC head/neck | 2/17 (13%) | 5/17 (31%) | 1/17 (6%) |
| MC base | 0% | 0% | 0% |
| Total | 10/79 (13%) | 14/79 (18%) | 3/79 (4%) |
MC, metacarpal.
Figure 2.
Radiograph of firearm-related metacarpal shaft fracture with bone gapping.
Table 6.
Active Range of Motion With and Without Soft Tissue Structural to Tendon or Neurovascular Structures
| Fractures and Injuries | N | Range of Motion | |
|---|---|---|---|
| All MC fractures | 47 | 58 ± 27 | |
| MC shaft fractures | 33 | 61 ± 27 | P value = 0.041 |
| with injury | 10 | 46 ± 20 | |
| without injury | 23 | 67 ± 27 | |
| MC head/neck fractures | 9 | 44 ± 8 | |
| with injury | 4 | 38 ± 7 | |
| without injury | 5 | 48 ± 7 | |
| MC base | 5 | 75 ± 0 |
Operatively treated metacarpal shaft fractures
A total of 62 metacarpal shaft fractures were treated during the study time frame, of which 52 (84%) were managed operatively (Fig. 2). Of the patients treated operatively, 8/52 (15%) went on to nonunion, 9/52 (17%) were noted to have a malunion because of shortening, and 2/52 (4%) were noted to have a deep infection. All nonunions were atrophic with no callus seen on radiographs. The index surgery for six the eight nonunions was percutaneous pinning. Among these eight patients with nonunion, four were transferred to in-network hand surgeons for further treatment, two patients underwent revision ORIF, one patient declined additional procedures, and one patient was lost to follow-up prior to planned surgery. The two patients who underwent revision surgery at our institution both received a revision ORIF with a tricortical iliac crest bone autograft. One achieved an uneventful union, and the other was lost to follow-up shortly after surgery. No patients with malunion elected to proceed with corrective surgery. A total of 34 patients had detailed and specific range of motion data documented at final follow-up with the average active range of motion at the MCPJ being 61° at final follow-up.
Operatively treated metacarpal head/neck fracture
A total of 21 metacarpal head/neck fractures occurred in the study population, of which 17 (80%) were treated operatively (Fig. 3). Of the 21 metacarpal head/neck fractures, 17 had intra-articular involvement while 4 were extra-articular. One patient experienced a devascularized digit and elected for acute amputation and was excluded from analysis. After surgery, 2/16 (13%) went on to nonunion. Of the patients who sustained a nonunion, 1 patient was offered revision surgery but failed to present for surgery and was lost to follow-up. The other opted for continued observation and was also subsequently lost to follow-up. Malunion was diagnosed in 31% (5/16) of patients with 1 finger noted to have a coronal deformity, 1 with a rotational deformity, and 3 metacarpals with significant shortening. One additional patient was noted to have a deep infection necessitating hardware removal and antibiotic spacer placement. Excluding one patient who underwent an immediate MCP fusion at the time of injury and the patient who opted for amputation, nine patients had final follow-up range of motion data documented with the average active range of motion at the MCPJ of 44°.
Figure 3.
Radiograph of firearm-related metacarpal neck fracture with marked comminution.
Operatively treated metacarpal base fractures
There were 17 metacarpal base fractures (Figs. 4 and 5), of which 10 underwent operative fixation. This included five treated with percutaneous pinning and five managed with ORIF. A patient with multiple metacarpal base fractures was managed operatively and had concomitant ulnar artery and nerve injury. One patient sustained a concomitant ballistic scaphoid fracture that required concomitant fixation. Two patients sustained two comminuted metacarpal base fractures, and two patients sustained a fracture at the base of the thumb metacarpal. All metacarpal base fractures eventually went on to union. Six patients had final follow-up range of motion data documented with the average active range of motion at the MCPJ being 78°.
Figure 4.
Radiograph showing comminuted firearm-related fractures of the 4th and 5th metacarpal bases, along with an associated metacarpal shaft fracture of the 3rd digit.
Figure 5.
Radiograph showing healed ballistic metacarpal fractures following surgical treatment.
Nonoperatively treated metacarpal fractures
A total of 21 patients with ballistic metacarpal fractures were treated nonoperatively. These included seven metacarpal base fractures, with five being incomplete fractures having at least one cortex intact on radiographs, and one nondisplaced fracture. There were nine metacarpal shaft fractures, seven of which were complete but nondisplaced, and two were incomplete with at least one cortex intact. Finally, there were four metacarpal head fractures; three were partial fractures, and one was complete but nondisplaced. All patients eventually achieved radiographic union, evidenced by callus formation and/or resolution of fracture lines. Of the 15 patients who had documented range of motion examinations, 14 demonstrated full range of motion at the MCPJ (0°–90°). One patient, who sustained a metacarpal head fracture, had a range of motion of 20°–60° at the MCPJ.
Discussion
Firearm injuries to the hand present distinct challenges when compared with blunt injuries. Gunshot-related fractures often exhibit severe comminution, bone loss, and instability, which can be accompanied by significant soft tissue damage, affecting neurovascular and tendinous structures. This combination of bony and soft tissue damage creates a complex environment for fracture healing and optimal outcomes. We evaluated a series of metacarpal fractures secondary to gunshot wounds, demonstrating high rates of concomitant injuries and complications including nonunion and stiffness. This series represents a unique pragmatic cohort evaluating a high-volume urban trauma center’s experience with gun injuries to the hand.
Indications for surgical management of metacarpal fractures remain a subject of debate. However, operative intervention is generally supported when there are clinical signs of scissoring, malalignment leading to overlapping digits, and displaced intra-articular fractures.16, 17, 18 Additionally, fractures involving multiple digits and fractures with bone loss or significant soft tissue injury are also often considered for surgical intervention. Numerous studies have shown high union rates for conventional metacarpal shaft fractures treated with plate and screw fixation, Kirschner wire fixation, and, more recently, headless intramedullary screw fixation.19, 20, 21, 22, 23
In contrast, the literature is limited with regard to union rates of gunshot-related fracture metacarpal fractures. In our surgical cohort, we observed a nonunion rate of 13%, with 10 out of 78 surgically treated metacarpal fractures resulting in nonunion. This contrasts with a study by Ghareeb et al,24 which reported a 5.2% nonunion rate in their analysis of 77 patients with ballistic hand fractures, including both phalanges and metacarpals.24 However, the lower reported nonunion rate in their study was accompanied by a significant loss to follow-up and an additional 10% of patients requiring subsequent bone grafting procedures, suggesting a higher nonunion rate. Although Ghareeb et al’s24 study included all hand fractures, including phalangeal fractures, the literature specifically focusing on ballistic metacarpal union rates is sparse. One small case series of 10 patients that concentrated on ballistic metacarpal shaft fractures reported a 10% nonunion rate when treated with intramedullary nailing and bone grafting, which aligns more closely with our results.25 Although this study used intramedullary nailing, by far the most common method of fixation used in our cohort was K-wire fixation, which was also the most common method of treatment for firearm-related hand fractures in the literature.8,24,26, 27, 28, 29 It should also be noted that the definition of metacarpal nonunion remains controversial, a 4-month period was chosen as the marker for nonunion. However, some may argue that a longer duration is necessary before definitively diagnosing nonunion. As such, our nonunion rate may be an overestimation.
Gunshot-related metacarpal fractures appear to confer a high risk of joint stiffness. Although data regarding the range of motion following ballistic injury remain limited, this finding was also supported by previous studies. Gonzalez et al30 reported a final range of motion of 65° at the MCPJ in 64 patients treated with iliac crest bone grafting and various forms of surgical fixation. Bach et al25 showed a mean range of motion at 81° in 10 patients who were treated with intramedullary nailing and bone grafting. Other studies that primarily used pinning as their fixation method for ballistic hand fractures noted full range of motion in only 24.7% of patients.24 Our findings were closer in line with these findings as our average range of motion at the MCPJ was 58°. Importantly, our analysis is limited to active range of motion data; because of inconsistent documentation, we did not include other metrics such as range of motion at additional joints or extensor lag. There are multiple possible factors that may precipitate stiffness in these cases including soft tissue adhesions, scarring, concomitant hand or wrist fractures, bony blocks to motion, and tendon injuries. Additionally, lack of therapy services may have played a role in decreased finger motion; many patients in our cohort had difficulty obtaining access to formal hand therapy. Future studies are needed to assess the effectiveness of hand therapy for these ballistic injuries.
Associated soft tissue injuries are common in ballistic hand fractures, with rates of tendon and/or neurovascular injuries requiring surgical repair ranging from 16% to 56%.24,31,32 Our study revealed a similarly high incidence of associated injuries, 36%, with tendon injuries being the most common soft tissue injury, occurring in nearly a quarter of all surgically treated fractures. These associated injuries likely contribute to the reported stiffness and decreased range of motion in many patients during follow-up. Other soft tissue structures were less commonly injured, including nerve, artery, and ligament injuries. Interestingly, when excluding known nerve transections, 30% (27/91), reported altered sensation in the injured digit. The majority, 70% (19/27), had a return of normal subjective sensation at final follow-up without intervention. Unfortunately, eight patients reported persistently altered sensation despite no documented nerve injury. It should also be noted that there was incomplete and inconsistent documentation of 2-point discrimination data, which limit these findings.
The current study has several limitations. As a retrospective analysis, it is inherently subject to observer bias, selection bias, reporting bias, and issues stemming from missing, incomplete, or varied data. Additionally, with a larger data set, a regression analysis would have been valuable for a more robust assessment. However, because of the limited sample size, we opted for a descriptive study, as the small number of nonunion events posed a risk of overfitting and would not have supported a reliable model. Furthermore, the heterogeneity of metacarpal fractures and limited samples of differing fracture categories necessitates cautious interpretation of our data. Inconsistent follow-up and loss to follow-up further limited our ability to assess longer-term outcomes, echoing difficulties encountered in previous research on ballistic hand injuries.24,29,31 These findings underscore the multifaceted obstacles, including psychological, social, economic, and legal factors, that may impede consistent and prolonged follow-up within the population affected by gunshot injuries. Finally, although this is the largest study of metacarpal ballistic injuries currently available, it remains underpowered, which may limit the conclusions that can be made from our data.
This study offers insight into a large level-1 urban trauma center’s experience and outcomes treating a high proportion of gunshot-related hand injuries. This has allowed characterization of treatment modalities and outcomes of gunshot-related metacarpal fractures. We report a large series of ballistic metacarpal fractures to add to the existing literature on gunshot-related hand fractures. Our data suggest that there is a high risk for nonunion, as well as associated soft tissue injuries in these fractures. Further research on the treatment of ballistic fractures is needed to help identify optimal management to reduce complications after these difficult injuries.
Conflicts of Interest
No benefits in any form have been received or will be received related directly to this article.
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