Abstract
Purpose
Gunshot wounds (GSWs) to the upper extremities can be devastating and often require surgical treatment. Ballistic injuries to the distal radius in particular present a complex challenge for hand surgeons because of concerns of bony comminution, neurovascular injury, and injury to surrounding structures. This study compares the demographics, management, and complications of nonballistic versus ballistic distal radius fractures (DRFs).
Methods
In this retrospective study, patients over the age of 16 years with radiographically confirmed DRFs were reviewed from 2018 to 2023. Demographic data, surgical details, and postoperative complication data were collected. X-ray imaging was evaluated for fracture healing. In addition to comparison of all patients, 1:1 matched cohort comparison was conducted, controlling for age, smoking, and fracture classification.
Results
Of the 265 patients, 21 had DRFs due to GSWs, and 244 sustained DRFs from other mechanisms. GSW patients were significantly younger and predominantly male. Arbeitsgemeinschaft für Osteosynthesefragen classification demonstrated higher intra- and extra-articular comminution in GSW patients, and GSW patients had higher rates of distal radioulnar joint instability and carpal fractures. Additional injuries outside the upper extremity and neurovascular symptoms were also more common in GSW patients. GSW patients were more likely to undergo surgery and had longer times to surgery. Despite the delayed surgical intervention, no differences were observed in fixation methods, time to full weight bearing, or complications between groups. After 1:1 matching, there remained a significantly higher proportion of men in the GSW cohort, a higher rate of carpal fractures, a higher rate of nonhand injuries, and a greater time to surgery in the GSW cohort. There remained no significant difference in complications.
Conclusions
Because of their complexity, GSWs to the upper extremities present considerable management issues. The present study compares ballistic to nonballistic injuries to the distal radius. Although there were differences in presentation and surgical management, there were no significant differences in complications.
Type of study/level of evidence
Prognostic IV.
Key words: Ballistic, Distal radius fracture, Hand fracture, Trauma
Firearms injuries account for a significant proportion of morbidity and mortality in the United States civilian population.1 These injuries can cause polytrauma, with visceral as well as extremity injuries and often require coordination between several medical teams.2 However, many civilian firearms trauma injuries are isolated and can be managed without acute intervention. Gunshot wounds (GSWs) to the upper extremity are one of the most frequently seen injuries, often affecting a younger population and requiring surgical intervention.3 Gunshot injuries present an especially complex problem because of a severe degree of bony comminution as well as high incidence of concomitant injuries to other adjacent structures.4,5 A review of the National Trauma Databank reported high rates of associated extremity fracture after firearm injuries with concomitant vascular and nerve injuries as well as compartment syndrome.6 Furthermore, gunshot injured patients often present with polytrauma, some of which can be immediately life threatening, which can complicate their management.7
Distal radius fractures (DRFs) have been well studied because of their high incidence of injury as well as functional implications in range of motion and weightbearing of the hand and wrist.8, 9, 10 However, DRFs secondary to firearm injuries pose a unique set of challenges because of fracture comminution involving the radiocarpal joint, potential for bone loss, and possible damage to adjacent neurovascular structures. This differs significantly from injury patterns seen in DRFs secondary to blunt mechanism; however, a comparison between the two mechanisms of injury has never been performed. In this study, we aimed to compare the presentation, management, and complications of patients who presented with ballistic DRFs versus patients with DRFs from other mechanisms to examine differences in demographics, surgical treatment, complications, and healing.
Materials and Methods
An institutional review board-approved retrospective study was conducted examining the medical records of patients who presented to our institution’s level 1 trauma center between May 2018 and December 2023. Inclusion criteria were patients over the age of 16 years, presenting with GSWs to the upper extremity, and had a radiographically confirmed diagnosis of a DRF. Ballistic DRF patients were compared to patients presenting in a similar time frame but with DRFs secondary to other, nonballistic mechanisms. Patients under the age of 16 years or those with injuries that did not include a DRF were excluded. All included patients were initially evaluated in the emergency department (ED) and subsequently splinted, with or without bony reduction as deemed clinically appropriate. All patients received tetanus prophylaxis as appropriate. Ballistic wounds were irrigated with removal of gross debris and dressed at bedside as standard management in the ED. Institutional protocol for GSW injuries includes a single intravenous dose of first generation cephalosporin or equivalent. All patients were included for an analysis of presenting injury, associated injuries, initial management, and complications during the initial admission. For analysis of complications, only patients with follow-up of at least 4 weeks were included.
Manual electronic medical record chart review collected sociodemographic and fracture related factors. Age (years), gender, dominant handedness, comorbidities, fracture mechanism, Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification, and presence of other hand and nonhand related injuries were included in review. Surgical factors including operative or nonsurgical management, time from injury to surgery, and method of fixation were also chart extracted. Nonhand injuries, including injuries to the ipsilateral extremity proximal to the elbow, injury to other extremities, or injury to the trunk, abdomen, or head, were also collected. Complications included malunion, delayed and nonunion, need for revision surgery, wound healing complications, and infection (deep and superficial). Malunion was defined as healing of the fracture with >5 mm of shortening or articular step off, whereas nonunion was defined as lack of progression of healing 6 months following injury. Delayed union was defined as a lack of anticipated healing at 3 months after injury. Although all patients were included for analysis of demographics, injury patterns, and operative management, postoperative complications were only compared between patients who presented for required follow-up (16/21 in the GSW cohort, 189/244 in the non-GSW cohort).
In addition to comparison of all patients, 1:1 matched cohort comparison was conducted with all patients who had completed required follow-up, controlling for age, smoking, and fracture classification. Bivariate independent t test and chi-square analysis was conducted for continuous and categorical variables, respectively, using SPSS version 29. Significance was determined by two-tailed P value of less than 0.05.
Results
A total of 265 patients met inclusion criteria, including 21 patients with DRFs secondary to GSWs and 244 patients with DRFs secondary to other mechanisms (non-GSW), as listed in Table 1. Demographic comparison between the two groups demonstrated GSW patients to be significantly younger (28.62 years ± 11.02 vs 50.48 years ± 20.20, P < .001) with a significantly higher proportion of men (20/21, 95.2% vs 88/244, 36.1%, P < .001) (Table 1). Comparison of AO classification of fractures between the two groups demonstrated a significantly higher concentration of both intra- and extra-articular comminution in GSW patients compared to the fractures in the non-GSW group which were more uniformly distributed among the AO classes.11 A representative X-ray from the GSW cohort is shown in Figure 1. The overall occurrence of concomitant wrist and hand injuries were not statistically different between injury mechanisms; however, the specific occurrence of distal radioulnar joint instability as determined by clinical examination (2/21, 9.5% vs 1/244, 0.4%, P < .001) and carpal fractures (4/21, 19.0% vs 12/244, 4.9%, P = .009) was higher in GSW patients. This cohort also had a significantly higher incidence of injury outside of the upper extremity (12/21, 57.1% vs 70/244, 28.7%, P = .007) (Table 2). There were no significant differences in method of fixation or time to full weightbearing between the groups (Table 2).
Table 1.
Demographics
| GSW (n = 21) | Non-GSW (n = 244) | P Value | |
|---|---|---|---|
| Age (y) | 28.62 ± 11.02 | 50.48 ± 20.20 | <.001 |
| Men, n (%) | 20 (95.2) | 88 (36.1) | <.001 |
| Injury to dominant hand | 9 (42.9) | 130 (53.3) | .359 |
| PMH, n (%) | |||
| HTN | 0 (0) | 64 (26.2) | .007 |
| Asthma/COPD | 0 (0) | 15 (6.1) | .242 |
| CVA | 0 (0) | 4 (1.6) | .554 |
| DM | 0 (0) | 25 (10.2) | .123 |
| CAD | 0 (0) | 10 (4.1) | .344 |
| Anticoagulation | 0 (0) | 8 (3.3) | .399 |
| Smoking | 4 (19.0) | 48 (19.7) | .945 |
| Mean follow-up (d) | 87.53 ± 35.24 | 80.23 ± 38.45 | .510 |
| Mechanism, n (%) | |||
| MVC | 70 (28.7) | ||
| Fall | 145 (59.4) | ||
| Pedestrian versus auto | 14 (5.7) | ||
| Motorcycle | 3 (1.2) | ||
| Assault | 4 (1.6) | ||
| Accidental other injury | 8 (3.3) | ||
| AO classification, n (%) | <.001 | ||
| A2 | 3 (14.3) | 70 (28.7) | |
| A3 | 11 (52.4) | 28 (11.5) | |
| B1 | 1 (4.8) | 23 (9.4) | |
| B2 | 0 (0) | 16 (6.6) | |
| B3 | 4 (19.0) | 17 (7.0) | |
| C1 | 0 (0) | 46 (18.9) | |
| C2 | 1 (4.8) | 30 (12.2) | |
| C3 | 1 (4.8) | 14 (5.7) |
Statistically significant P values in bold.
CAD, coronary artery disease. COPD, chronic obstructive pulmonary disease; CVA, cerebrovascular accident; DM, diabetes mellitus type II; HTN, hypertension. MVC, motor vehicle collision. PMH, past medical history.
Figure 1.
A Preoperative X-ray showing ballistic distal radius fracture before surgery. B X-ray of the same patient 2 weeks following surgical fixation.
Table 2.
Injury and Operative Characteristics
| GSW (n = 21) | Non-GSW (n = 244) | P Value | |
|---|---|---|---|
| Underwent surgery | 14 (66.7) | 99 (40.6) | .020 |
| Time to surgery (d) | 10.42 ± 15.51 | 5.52 ± 6.04 | .002 |
| Other hand injuries | 10 (47.6) | 83 (34.0) | .210 |
| Distal ulna fracture | 3 (14.3) | 58 (23.8) | .322 |
| Distal radioulnar joint | 2 (9.5) | 1 (0.4) | <.001 |
| Carpal fracture | 4 (19.0) | 12 (4.9) | .009 |
| Phalanx/metacarpal fracture | 2 (9.5) | 13 (5.3) | .425 |
| Midshaft ulna | 0 (0) | 5 (2.0) | .508 |
| Elbow | 0 (0) | 6 (2.5) | .467 |
| Humerus | 0 (0) | 12 (4.9) | .298 |
| Other injuries (nonhand) | 12 (57.1) | 70 (28.7) | .007 |
| Symptoms of nerve injury | 8 (38.1) | 30 (12.3) | <.001 |
| Nerve decompression | 2 (9.5) | 11 (4.5) | .307 |
| Carpal tunnel release | 2 (9.5) | 10 (4.1) | .251 |
| Guyon canal release | 1 (4.8) | 1 (0.4) | .027 |
| Time to full weight bearing (wk) | 12.12 ± 3.74 | 9.53 ± 4.74 | .097 |
| RUST score | |||
| 0–6 wk | 9.97 ± 1.69 | 9.50 ± 2.07 | .427 |
| 6–12 wk | 12.40 ± 1.56 | 11.17 ± 0.94 | .012 |
| 12–18 wk | 13.18 ± 0.75 | 12.02 ± 0.24 | .021 |
| >18 wk | 14.40 ± 1.07 | 10.64 ± 6.76 | .579 |
| Mode of fixation | GSW (n = 12) | Non-GSW (n = 99) | .953 |
| Volar plate | 11 (84.6) | 73 (73.7) | |
| Dorsal bridging plate | 2 (15.4) | 12 (12.1) | |
| Volar plate and distal radioulnar joint Pin |
0 (0) | 4 (4.0) | |
| Volar plate and radial Column plate |
0 (0) | 3 (3.0) | |
| Radial column plate and Dorsal bridging plate | 0 (0) | 2 (2.0) | |
| Dorsal bridging plate and carpal pin | 0 (0) | 2 (2.0) | |
| Volar plate and dorsal Bridging plate |
0 (0) | 2 (2.0) | |
| Kirschner wires | 0 (0) | 1 (1.0) |
Statistically significant P values in bold.
RUST, radiographic union score for tibia.
When assessing neurovascular injury, a significantly higher proportion of GSW patients reported symptoms of nerve palsy (numbness, paresthesia) and/or had increased two-point discrimination compared to the uninjured hand (8/21, 38.1% vs 30/244, 12.3%, P < .001). This did not result in a significantly increased incidence of overall nerve exploration in the former group, although we did note a higher rate of Guyon canal release in the GSW cohort. In terms of management, our data showed a significantly higher proportion of GSW patients were treated operatively (14/21, 66.7% vs 99/244, 40.6%, P = .020) and had a significantly longer time to operative management compared to non-GSW patients (10.42 ± 15.51 days vs 5.52 ± 6.04 days, P = .002) (Table 2).
Complications were compared between 16 out of 21 patients in the GSW cohort and 189 out of 244 in the non-GSW cohort who presented for required follow-up. In terms of complications, the overall rate of complications across the cohort was 12 out of265 (4.5%). Of these complications, there was one reported case of malunion in the GSW cohort. In the non-GSW cohort, there were two cases of delayed union, three cases of malunion, three cases of wound dehiscence, one patient with complex regional pain syndrome, and two patients with infected hardware (Table 3). No differences were seen in the rate of complication between the groups.
Table 3.
Complications
| Presence of Complications | GSW (n = 21) | Non-GSW (n = 244) | P Value |
|---|---|---|---|
| .989 | |||
| Yes | 1 (4.8) | 11 (4.5) | |
| -Malunion (n = 1) | -Delayed union (n = 2) -Malunion (n = 3) -Wound dehiscence (n = 3) -CRPS (n = 1) -Infected hardware (n = 2) |
||
| No | 15 (71.4) | 178 (73.0) | |
| Lost to follow-up | 5 (23.8) | 55 (22.5) |
CRPS, complex regional pain syndrome.
Matched comparison
Given the demographic and fracture morphology differences between GSW and non-GSW injuries, we performed an additional matching analysis to control for established covariates among patients who completed required follow-up. Patients with DRFs from non-GSW mechanisms were matched 1:1 controlling for age, smoking, and fracture classification. Following this matching, there remained a significantly higher proportion of males in the GSW cohort (15/16, 93.8% vs 10/16, 62.5%, P = .033). After matching, there remained a higher rate of carpal fractures (4/16, 25% vs 0, P = .033), a higher rate of nonhand injuries (10/16, 62.5% vs 4/16, 25%, P = .049) and a greater time to surgery (10.42 days ± 5.51 vs 5.56 days ± 6.23, P = .048) in the GSW cohort. Radiographic Union Score for Tibia (RUST) scores were no longer higher in the GSW cohort at 6–12 weeks but remained higher between 12 and 18 weeks. There remained no significant difference in complications (Table 4).
Table 4.
Matched Cohort Comparison
| GSW (n = 16) | Non-GSW (n = 16) | P Value | |
|---|---|---|---|
| Age (y) | 30.63 ± 10.81 | 29.19 ± 10.89 | .711 |
| Men, n (%) | 15 (93.8) | 10 (62.5) | .033 |
| Injury to dominant hand, n (%) | 7 (43.8) | 7 (43.8) | 1.000 |
| PMH, n (%) | |||
| HTN | 0 (0) | 0 (0) | NA |
| Asthma/COPD | 0 (0) | 0 (0) | NA |
| CVA | 0 (0) | 0 (0) | NA |
| DM | 0 (0) | 0 (0) | NA |
| CAD | 0 (0) | 1 (6.3) | .311 |
| Anticoagulation | 0 (0) | 0 (0) | NA |
| Smoking | 4 (25.0) | 3 (18.8) | .669 |
| AO classification, n (%) | .668 | ||
| A2 | 2 (12.5) | 4 (25.0) | |
| A3 | 8 (50.0) | 7 (43.8) | |
| B1 | 1 (6.3) | 2 (12.5) | |
| B2 | 0 (0) | 1 (6.3) | |
| B3 | 3 (18.8) | 1 (6.3) | |
| C1 | 0 (0) | 0 (0) | |
| C2 | 1 (6.3) | 1 (6.3) | |
| C3 | 1 (6.3) | 0 (0) | |
| Other hand injuries, n (%) | 8 (50.0) | 9 (56.3) | .723 |
| Distal ulna fracture | 1 (6.3) | 5 (31.3) | .070 |
| Distal radioulnar joint | 2 (12.5) | 0 (0) | .144 |
| Carpal fracture | 4 (25.0) | 0 (0) | .033 |
| Phalanx/Metacarpal fracture | 2 (12.5) | 4 (25.0) | .365 |
| Midshaft ulna | 0 (0) | 2 (12.5) | .144 |
| Elbow | 0 (0) | 0 (0) | NA |
| Humerus | 0 (0) | 3 (18.8) | .069 |
| Other injuries (nonhand), n (%) | 10 (62.5) | 4 (25.0) | .033 |
| Underwent surgery, n (%) | 13 (81.3) | 9 (56.3) | .049 |
| Time to surgery (days) | 10.42 ± 5.51 | 5.56 ± 6.23 | .048 |
| Complications, n (%) | 1 (6.3) | 0 (0) | .310 |
| Time to full weight bearing (wk) | 12.12 ± 3.74 | 11.70 ± 5.98 | .850 |
| RUST score | |||
| 0–6 wk | 9.43 ± 0.98 | 9.43 ± 1.13 | 1.000 |
| 6–12 wk | 11.09 ± 0.70 | 11.90 ± 1.66 | .156 |
| 12–18 wk | 14.67 ± 1.53 | 12.25 ± 0.50 | .029 |
| >18 wk | 14.00 ± 1.00 | 13.33 ± 0.58 | .374 |
Statistically significant P values in bold.
CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; CVA, cerebrovascular accident; DM, diabetes mellitus type II; HTN, hypertension; MVC, motor vehicle collision; NA, not applicable; PMH, past medical history; RUST, Radiographic Union Score for Tibia.
Discussion
Gunshot injuries continue to be a major public health issue, especially in the United States. Though often studied in the context of mortality, ballistic injury causes significant morbidity, with the upper extremity being one of the most commonly injured areas.12 An extensive epidemiologic study conducted by Hooper et al13 showed over 48,000 firearm-related upper extremities over a ten-year period, most often occurring in males between the ages of 20 and 39 years. When specifically examining ballistic injuries to the hand, Hutchinson et al14 found similar demographic trends, with the most frequent cause stemming from cleaning of loaded firearms, whereas Tarkunde et al15 reported on patients most frequently affected by intentional violence. This correlates well with our data, which demonstrate that patients with gunshot injury are typically younger and more often men when compared to nonballistic patients. This also correlated with fewer comorbidities in patients who experienced ballistic trauma, although this did not reach statistical significance.
Though DRFs are one of the most common upper-extremity fractures seen in US and international populations, the management of DRFs associated with ballistic trauma, or ballistic injuries to the upper extremity overall, has not been well studied.16,17 Engelmann et al18 reported their 90-patient experience of upper-extremity ballistic trauma at a single center, the majority of which were treated with nonsurgical splinting, antibiotics, and therapy. Of note, the authors reported a 43.1% incidence of neurovascular injuries in patients with upper-extremity ballistic trauma. Similarly, Mehta et al19 conducted a retrospective study of 55 patients with gunshot-related forearm injuries and noted a 45% incidence of nerve injury and 29% incidence of arterial injury in low-velocity injuries, which increased to 100% and 66%, respectively, with high-velocity injuries. A previous study at our institution examined 148 patients with ballistic lower-extremity injuries and found a 14% incidence of associated nerve injury, most often affecting the peroneal and sciatic nerves, with 11/15 (73%) of these patients going on to complete nerve recovery.20 A similar study conducted in 117 patients with upper-extremity ballistic injuries found a 30% incidence of nerve deficit upon initial evaluation with 68% of patients experiencing spontaneous improvement, further highlighting the most often neuropraxic nature of these injuries.12 This supports our data, which found a notably higher incidence of neurologic symptoms and physical examination findings in the GSW cohort. Interestingly, this did not lead to a higher incidence of overall surgical nerve exploration because of signs of nerve recovery on follow-up examinations, suggesting a substantial number of symptoms were secondary to neurapraxic injury.
We also noted a higher rate of surgical intervention in patients with ballistic injury versus those with blunt injury. Despite this, there was a significantly longer time from injury to surgery in the former cohort. This may be attributed to the high rate of associated, nonhand injuries seen in the GSW cohort, which often require more urgent treatment, thus delaying fixation of the DRF. This finding emphasizes the importance of multidisciplinary care coordination in the treatment of these patients.
The treatment of ballistic injuries as open or closed fractures remains controversial, varies greatly by institution, and may be predicated on the velocity of injury, contamination, and energy imparted.21, 22, 23 Though there are advocates for surgical debridement and antibiotic prophylaxis for all low-velocity gunshot wounds, other studies have demonstrated this may not be necessary.24, 25, 26 A prospective study performed in 1989 by Dickey et al27 randomized patients with ballistic injuries which could be treated by closed reduction and immobilization into a prophylactic antibiotic or nonantibiotic group and found no difference in infection between the two. Even with antibiotic treatment, the duration, method of delivery, and choice of antibiotic also vary greatly.28, 29, 30 In a systematic review assessing antibiotic use in these patients, Papasoulis et al31 found no difference between infection in nonsurgical ballistic fractures treated with or without antibiotics, as well as no benefit to adding gram-negative antibiotic coverage. Our patient cohort was uniformly treated with updated tetanus prophylaxis and bedside irrigation without surgical debridement or use of antibiotic prophylaxis. Despite this, there were no reported infections within the GSW cohort, even with 7 out of 21 total GSW treated without surgical fixation.
This study is limited by its retrospective nature and likely incomplete capture of every distal radius fracture treated in our institution. We further excluded those without postoperative follow-up, leaving a small population of GSW-related distal radius fracture patients. This reflects an unfortunate circumstance of many of our patients who are often lost to follow-up thereby preventing assessment of long-term outcomes. The small size of the cohort further limits the generalizability of our findings; however, we believe there are valuable lessons to learn from this comparative study.
This study presents novel findings on gunshot-related DRFs, which have been less frequently studied than those via other mechanisms. Future studies with large numbers would be useful to further delineate the nuances of management and functional outcomes in these complex injuries.
Conflicts of Interest
Jason A. Strelzow, MD, FRCSC, is on the editorial boards of The Journal of Hand Surgery, Journal of Orthopaedic Trauma, and The Journal of Bone & Joint Surgery; has consultancy and educational involvement with Acumed, Stryker, and Bonesupport; and serves on OTA and ASSH committees. No benefits in any form have been received or will be received by the other authors related directly to this article.
References
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