Pediatric and adolescent ballistic femur fractures: treatment, outcomes, and costs from a level-one trauma center

Abstract

Purpose

Pediatric ballistic femur fractures are severe injuries that require extensive follow-up and have high rates of complication and cost. Treatment strategies are largely derived from adult trauma principles; this study aims to characterize the management, outcomes, and costs of pediatric and adolescent ballistic femur fracture patients presenting to an academic level I trauma center.

Methods

This retrospective case series gathered data from a single academic level I trauma center. Patients aged 0–21 years who sustained a ballistic femur fracture and presented between 2017 and 2022 were included. Pediatric patients were defined as ≤ 18 years, and adolescents as 19–21 years. Patient demographics, injury characteristics, management details, in-hospital costs, and outcomes were recorded. Subgroup analysis compared pediatric and adolescent cohorts.

Results

A total of 34 patients were identified, including 19 pediatric and 15 adolescent patients. Comorbidities were uncommon and non-contributory in both groups. No significant differences were noted between groups with respect to demographics, treatment strategies, outcomes, or complications. Inpatient management was significantly more costly than outpatient management.

Conclusions

This series includes a mixture of non-operative, intramedullary nailing, and open reduction internal fixation patients to broadly represent the pediatric ballistic femur fracture population. High union rates, similar time to union, and low complication rates were observed in both pediatric and adolescent cohorts. Subgroup analysis demonstrated no significant differences in outcomes or complications, supporting extrapolation of adult trauma literature to this population. A considerable loss to follow-up was noted, with male sex, lack of insurance, substance use, and non-operative management identified as common risk factors.

Introduction

Over the past decade, pediatric firearm-related injuries have become increasingly common, placing a considerable burden on the healthcare system and affecting patients, families, and public resources [1–5]. Among these injuries, ballistic fractures often require complex and prolonged treatment, especially in skeletally immature patients with open or injured physes [6, 7]. Of particular concern are ballistic femur fractures, which represent some of the most severe and disabling musculoskeletal injuries resulting from pediatric firearm violence [8]. These fractures often require extensive monetary resources and demanding follow-up which may be unfamiliar and difficult for many families to navigate, resulting in high rates of loss to follow up (LTFU) and complication [9, 10].

Despite the rising incidence of pediatric ballistic fractures, there remains a notable lack of evidence guiding the management or discussing the outcomes of femoral gunshot injuries in children. Current treatment strategies are largely extrapolated from adult trauma literature, single patient case reports, or non-high energy mechanisms, which may not account for the unique anatomical and physiological considerations of the pediatric population [11, 12].

This study aims to characterize the management and outcomes of pediatric and adolescent patients with ballistic femur fractures using retrospective data from an academic level I trauma center. Given the limited pediatric-specific literature and the reliance on adult trauma guidelines, this study seeks to provide a detailed description of injury patterns, treatment strategies, complication rates, functional outcomes, and costs in this population. An analysis will also be made comparing outcomes of the pediatric versus adolescent population. This study will build upon the foundational understanding and treatment of pediatric ballistic injuries.

Methods

This retrospective case series utilized data collected from a single academic level I trauma center institutional database. All relevant information was obtained from the institution’s trauma registry and electronic medical records (EMR). The study included all patients aged 0 to 21 years who sustained a ballistic femur fracture and presented between January 1, 2017, and December 31, 2022. All patients underwent orthopaedic surgical evaluation and treatment. Data collected encompassed patient demographics, injury characteristics, orthopaedic management, and follow-up outcomes. Two groups were generated by sub-stratifying based on patient age, with a pediatric population, defined as ≤ 18 years old, and an adolescent group, defined as between the ages of 19–21 years old. These age ranges were defined based on the definitions provided by the American Academy of Pediatrics, the American Board of Pediatrics, and the Centers for Disease Control and Prevention Injury tracking system [13, 14].

Primary outcomes included initial management strategy (operative vs nonoperative), length of inpatient hospital stay, disposition (home, rehabilitation, etc.), and rates of medical and surgical complications. Medical complications included but were not limited to embolic events, cardiac events, acute kidney injury, and infection. Surgical complications assessed included intra-operative complication, loss of reduction, hardware-related complications, presence of nonunion or malunion, and unplanned return to operating room. The occurrence of nerve or arterial injury requiring surgical intervention was also recorded. Functional outcomes included time to full weight bearing and time to radiographic union, defined as bridging callus across three of four cortices in the independent opinion of at least one practicing orthopedic provider. LTFU was defined as follow-up less than six-weeks and complete LTFU was defined as follow-up of 0 days post-discharge. A subgroup analysis comparing outcomes of the pediatric and adolescent groups was performed.

A cost analysis was performed to evaluate direct patient care costs associated with femoral procedures and in-hospital non-operative in pediatric and adolescent patients. Each cohort was further stratified by care setting, including inpatient and outpatient disposition. Cost data were obtained from the institutional hospital cost accounting system. Patient encounters prior to 2020 were excluded from the cost analysis due to institutional accounting system changes resulting in incomplete or unobtainable data. Only direct patient costs were included in the analysis, and indirect costs such as hospital administration costs, marketing, billing, infrastructure, and other non-tangible hospital expenses were excluded. Direct costs were defined as expenses directly attributable to an individual patient encounter. These include but are not limited to implants, supplies, medications, imaging and lab testing, clinical labor, and hospital room charges. Costs were summarized using medians and interquartile ranges, and comparisons between groups were performed using simple t-test or a Wilcoxon rank-sum test for non-normal distributed data, as appropriate.

Statistical analysis

Descriptive statistics for categorical variables were reported as frequencies and percentages, while continuous variables were summarized using medians and standard deviations.

Comparisons between pediatric and adolescent outcomes were performed using independent sample t-tests for continuous variables and the chi-square test (or Fisher’s exact test when appropriate) for categorical variables. A p-value of < 0.05 was considered statistically significant. Statistical analyses were conducted using Microsoft Excel.

Results

Combined cohort (N = 34)

The study included 34 patients. All patients were male but two (32, 94%). Mean age was 16.9 ± 4 years. Mean age for the pediatric cohort was 14.7 ± 4.2, while the adolescent cohort was 19.7 ± 0.8. Mean body mass index was 22.9 ± 4.9 kg/m2. Racial identity was primarily White (79%) with majority Hispanic ethnicity (74%). Comorbidities were extremely limited and non-contributory in both groups. Most patients were insured (22, 65%). Injury mechanism was predominately assault (25, 74%) with a low-velocity or unknown velocity firearm (33, 97%). All patients were transported via ground ambulance with trauma activation. Substance use screening was positive in 67% of patients, with THC (19, 56%), opiates (14, 41%), and amphetamines (5, 15%) being the most prevalent. Full demographic information can be found in Table 1.

Table 1.

Cohort demographics

Characteristic	Overall Cohort (n = 34)	Pediatric Cohort (n = 19)	Adolescent Cohort (n = 15)
Female, n (%)	2 (5.9%)	2 (10.5%)	0 (0.0%)
Age, years (median, SD)	17.5, 4.0	16.0, 4.2	20.0, 0.8
BMI, kg/m2 (median, SD)	22.0, 4.9	22.4, 4.6	21.5, 5.2
Race, n (%)
White	27 (79.4%)	16 (84.2%)	11 (73.3%)
Black or African American	4 (11.8%)	2 (10.5%)	2 (13.3%)
American Indian	1 (2.9%)	0 (0.0%)	1 (6.7%)
Other/Unknown	2 (5.9%)	1 (5.3%)	1 (6.7%)
Ethnicity, n (%)
Hispanic or Latino	25 (73.5%)	13 (68.4%)	12 (80.0%)
Not Hispanic or Latino	8 (23.5%)	6 (31.6%)	2 (13.3%)
Unknown	1 (2.9%)	1 (5.3%)	1 (6.7%)
Insurance status, n (%)
Self-pay	13 (38.2%)	2 (10.5%)	11 (73.3%)
Medicaid	18 (52.9%)	16 (84.2%)	2 (13.3%)
Private	2 (5.9%)	0 (0.0%)	2 (13.3%)
Other	1 (2.9%)	1 (5.3%)	0 (0.0%)
Mechanism of injury, n (%)
Accidental	7 (20.6%)	4 (21.1%)	3 (20.0%)
Assault	25 (73.5%)	15 (78.9%)	10 (66.7%)
Unknown	2 (5.9%)	0 (0.0%)	2 (13.3%)
Bullet velocity, n (%)
High	1 (2.9%)	1 (5.3%)	0 (0.0%)
Low	28 (82.4%)	15 (78.9%)	13 (86.7%)
Unknown	5 (14.7%)	3 (15.8%)	2 (13.3%)
Smoking history	6 (17.6%)	2 (10.5%)	4 (26.7%)
Substance use*, n (%)	23 (67.6%)	11 (58.0%)	12 (80.0%)
Recreational drug use	22 (64.7%)	11 (57.9%)	11 (73.3%)
Alcohol use	2 (5.9%)	0 (0.0%)	2 (13.3%)

*Substance Use is a binary variable that includes individuals who use either recreational drugs or alcohol

Twenty-one patients (62%) had comminuted femur fractures. The majority of fractures were located in the diaphysis (50%). A full breakdown of fracture characteristics is identified in Table 2.

Table 2.

Fracture characteristics by cohort

Characteristic	Overall cohort (n = 34)	Pediatric cohort (n = 19)	Adolescent cohort (n = 15)
Location, n (%)
Proximal epiphysis	0 (0.0%)	0 (0.0%)	0 (0.0%)
Proximal Metaphysis	4 (11.8%)	3 (15.8%)	1 (6.7%)
Diaphysis	17 (50.0%)	7 (36.8%)	10 (66.7%)
Distal metaphysis	11 (32.4%)	7 (36.8%)	4 (26.7%)
Distal epiphysis	2 (5.9%)	2 (10.5%)	0 (0.0%)
Fracture pattern, n (%)
Comminuted	21 (61.8%)	11 (57.9%)	10 (66.7%)
Wedge	2 (5.9%)	2 (10.5%)	0 (0.0%)
Avulsion	2 (5.9%)	1 (5.3%)	1 (6.7%)
Oblique	8 (23.5%)	4 (21.1%)	4 (26.7%)
Unicortical	1 (2.9%)	1 (5.3%)	0 (0.0%)
Intra-articular Involvement, n (%)	15 (44.1%)	9 (47.4%)	6 (40.0%)

Three patients had concomitant non-orthopedic related injuries (9%). 25 patients (74%) required operative management (17 intramedullary fixation, 6 open reduction internal fixation (ORIF), 1 external fixation, 1 irrigation and debridement/suture fixation/casting). Average operative time was 104 min ± 44 min, with average blood loss of 152.8 mL ± 107 mL. Median time from injury to surgery was 0.9 days ± 0.7. Median length of stay was 4.6 days, with 26 patients requiring admission (76%). All but two patients were discharged home (32, 94%).

Median follow‐up was 211 days, with 13 patients (38%) being LTFU (< 6 weeks), and 6 patients (18%) having complete LTFU. Of the individuals LTFU, all were male, 12/13 were of Hispanic ethnicity, 100% had either governmental or no insurance, 9/13 (70%) had current substance use, and, perhaps most notable, 70% of these individuals were managed non-operatively. Only 3 patients went on to a documented non-union (9%), all of which had extensive comminution and soft tissue injury or infection. Average time to union was 89.7 days. Average time to full weight-bearing was 64.7 days with all delayed cases being attributed to excessive fracture comminution or intra-articular involvement. There were two cases of deep infection (7%), which required hardware removal. No loss of reduction or hardware complications were recorded. A single patient developed a limb length discrepancy. This patient had a non-reconstructable proximal femur fracture that required femoral head and proximal femur resection. Despite the resulting discrepancy, the patient is doing well clinically, with controlled pain and the ability to ambulate without significant functional limitation. No other growth disturbance was noted for any skeletally immature patient during the follow-up period. Three patients (9%) required reoperation, 2 for arthrofibrosis, and 1 for deep implant infection and nonunion. Management strategy, outcomes, and complications in the collective patient cohort can be found in Tables 3 and 4.

Table 3.

Treatment Outcomes and Complications by Cohort

Characteristic	Overall cohort (n = 34)	Pediatric cohort (n = 19)	Adolescent cohort (n = 15)	P
Operative Fixation, n (%)	25 (73.5%)	12 (63.2%)	13 (86.7%)	0.277
Fixation type, n (%)
IMN	17 (50.0%)	7 (36.8%)	10 (66.7%)	0.106
External fixation	1 (2.9%)	1 (5.3%)	0 (0.0%)	0.367
ORIF	6 (17.6%)	3 (15.8%)	3 (20.0%)	0.873
Length of stay, days (median, SD)	2.7, 7.0	3.5, 9.1	2.3, 1.6	0.110
Time to Union*, days (median, SD)	64.0, 73.0	72.0, 84.9	51.5, 42.0	0.409
Time to Full Weight-Bearing*, days (median, SD)	54.0, 74.7	54.0, 93.8	51.5, 43.8	0.962
iLTFU, n (%)	6 (17.6%)	5 (26.3%)	1 (6.7%)	0.142
Follow-up Length†, days (median, SD)	88.0, 299.6	119.5, 382.1	52.0, 178.2	0.962
Discharge disposition, n (%)
Home	32 (94.1%)	17 (89.5%)	15 (100.0%)	0.266
Inpatient rehab	2 (5.9%)	2 (10.5%)	0 (0.0%)	0.298
Complications, n (%)
Non-union	4 (11.8%)	2 (10.5%)	2 (13.3%)	0.882
Deep infection	2 (5.9%)	2 (10.5%)	0 (0.0%)	0.298
Loss of reduction	0 (0.0%)	0 (0.0%)	0 (0.0%)	1.000
Growth disturbance	0 (0.0%)	0 (0.0%)	0 (0.0%)	1.000
Reoperation, n (%)
Hardware removal	1 (2.9%)	1 (5.3%)	0 (0.0%)	0.367
Arthrofibrosis requiring reoperation	1 (2.9%)	1 (5.3%)	0 (0.0%)	0.367
Manipulation under Anesthesia	1 (2.9%)	0 (0.0%)	1 (6.7%)	0.296

^*Calculated excluding those lost to follow up at time of assessment

^†Calculated excluding those immediately lost to follow up

iLTFU = immediate loss to follow up

P-values calculated by student’s t-tests (two tails; assuming unequal variance) and Chi-square tests between pediatric and adolescent cohorts

Table 4.

Pediatric cohort fracture patterns and treatment/fixation strategy

Pediatric cohort fracture and fixation
Patient ID	Age	Weight (kg)	Ped AO femur classification	Pattern	Intraarticular	Treatment	Fixation/Surgery
1	3	24.5	31-M	Comminuted	Yes	Operative	I&D, Femoral Head Resection
2	4	18	32-D	Comminuted	No	Operative	ORIF (Bridge Plate)
3	13	49.9	33-M	Unicortical	No	Nonoperative	Hinged Knee Brace
4	13	50	31-M	Oblique	No	Nonoperative	No Brace or Fixation
5	15	68.9	33-E	Comminuted	Yes	Nonoperative	Hinged Knee Brace
6	15	69	32-D	Comminuted	No	Operative	Rigid IMN Anterograde
7	15	77.1	33-E	Oblique	Yes	Nonoperative	Hinged Knee Brace
8	16	68	33B2.2	Comminuted	Yes	Operative	External Fixation
9	16	115	33B1	Wedge	Yes	Operative	ORIF (Percutaneus Screws)
10	16	62.8	33C1.2	Wedge	Yes	Nonoperative	Hinged Knee Brace
11	16	64.4	32-D	Comminuted	No	Operative	Rigid IMN Anterograde
12	16	56.7	32-D	Oblique	No	Operative	Rigid IMN Anterograde
13	17	70	33A-1	Avulsion	Yes	Nonoperative	Hinged Knee Brace
14	17	60.6	33A-3	Comminuted	Yes	Operative	Rigid IMN Retrograde
15	17	72.5	32C-3	Comminuted	No	Operative	Rigid IMN Retrograde
16	17	51.2	32C-3	Comminuted	No	Operative	Rigid IMN Anterograde
17	17	72.6	33-M	Comminuted	Yes	Operative	Rigid IMN Anterograde
18	18	55	31-M	Comminuted	No	Nonoperative	No Brace or Fixation
19	18	90.7	32	Oblique	No	Operative	Rigid IMN Retrograde

Cost outcomes

16 pediatric patients were included in the cost analysis. Inpatient encounters (n = 9) had an average total direct cost of $30,763 (range $10,031–$76,933), with supply costs averaging $5,320 (range $1,440–$11,299) and implant costs averaging $2,408 (range $910–$4,406). Outpatient pediatric encounters (n = 7) were substantially lower in cost, with an average total direct cost of $1,017 (range $553–$1,517), supply costs averaging $231 (range $162–$785), and implant costs averaging $0.

In the 11 adolescent femur procedures, inpatient encounters (n = 10) had an average total direct cost of $14,519 (range $8,601–$18,713), supply costs averaging $2,382 (range $1,377–$3,256), and implant costs averaging $3,446 (range $1,216–$5,580). Outpatient adolescent encounters (n = 1) had a total direct cost of $12,026, supply costs of $1,363, and implant costs of $0. The single outpatient adolescent femur patient underwent delayed tibia ORIF. Implant costs were deducted from this data, but supply and direct costs were biased by this (Fig. 1).

Fig. 1.

Cost analysis for each direct cost measure across all pediatric and adolescent inpatient and outpatient cohorts. Pediatric Cohort (N = 19) vs Adolescent Cohort (N = 15)

No significant difference was found when comparing pediatric and adolescent demographics, treatments, outcomes, or complications. There was a trend towards significance in several categories. The pediatric group was more insured (90% vs 67%; p = 0.10), had shorter time to the operating room (0.7 vs 1.1 days; p = 0.07), had longer length of stay (6.3 vs 2.6 days; p = 0.13), and had less substance use (58% vs 80%; p = 0.10). The adolescent group had less associated arterial or nervous injury (0% vs 11%; p = 0.103) and were treated operatively more frequently (80% vs 63%; p = 0.123). Management strategy, outcomes, and complications in each age-grouped cohort can also be found in Tables 3 and 4.

Comparing all pediatric versus adolescent procedures, total direct cost was $3,303 higher in pediatric cases (p = 0.03), and supply costs were $453 higher in pediatric cases (p = 0.02), both likely reflecting the longer length of stay for the pediatric population. In contrast, implant costs were $1,506 higher in adolescent cases (p = 0.01). Overall, pediatric and adolescent inpatient care accounted for the majority of total direct costs, whereas outpatient care incurred minimal costs.

Discussion

The current literature and guidelines pertaining to pediatric ballistic femur fractures is limited by extrapolation from adult data, extremely small case series, and even case reports [5, 7, 15]. Much of the literature pertaining to pediatric ballistic injuries is cross-sectional in nature, focusing on demographics and identifying at-risk populations. When referencing past literature, femur fractures have been underrepresented, treatment with external fixation was common, and there was no long-term follow-up of these patients⁵. The most recent review article specifically mentions that the literature used to guide femoral ballistic fracture operative intervention, “have been conducted in adults, and their applicability to pediatric patients is unknown” [11]. This study provides insight and long-term outcomes on both a true pediatric, as well as an adolescent population with femoral ballistic fractures. We achieved over 200 days of follow-up and almost a 90% union rate when controlling for LTFU. This study had a good mixture of non-operative, IMN, and ORIF patients, allowing broad application to other patient populations. Perhaps most importantly, the subgroup analysis comparing the pediatric and adolescent populations showed no statistically significant differences in outcomes or complications. If one considers the adolescent population to be similar to, or equivalent, to adults given their age and skeletal maturity, then this may allow more confidence in extrapolating adult literature to the pediatric population in the future.

Extensive literature and well-established clinical practice guidelines (CPGs) exist for the treatment of pediatric diaphyseal femur fractures [16]. However, much of this data is primarily based on blunt trauma mechanisms, and these studies largely exclude high-energy ballistic injuries, which are often associated with significant soft tissue damage and periosteal stripping. Despite this distinction, our findings align with existing literature on pediatric and adolescent femoral fractures, demonstrating high union rates, similar time to union, and low complication rates [17, 18]. These results suggest that current evidence and CPGs for blunt pediatric femur fractures may be applicable to ballistic fracture cases, as well. This can provide useful framework to guide orthopedic management in these complex injuries.

LTFU is a common problem in both the trauma and ballistic injury patient populations and has been shown to negatively impact patient reported outcomes, range of motion, and pain [19, 20]. Some studies cite a LTFU rate approaching 50% [9, 10]. Many key factors have been identified that contribute to this LTFU, including male sex, non-operative management, uninsured status, and substance use. Within our population, LTFU rate was 38% (13/34), with almost half of those patients having complete LTFU. Of these individuals, all exhibited risk factors for LTFU including 100% male sex, no insurance or under-insured status, current substance use, and non-operative management. These risk factors should be noted and identified in future pediatric ballistic fracture patients to decrease LTFU incidence.

Pediatric gun violence imposes a substantial economic burden on the United States healthcare system. Hospitalization and surgical treatment costs for firearm-related injuries in children and adolescents are considerable, with studies reporting median surgical costs of $18,576 per patient and annual initial hospitalization costs reaching approximately $109 million nationwide [21, 22]. Regional analyses, such as in Colorado, estimate direct costs of pediatric gunshot injuries at $26 million [23]. Beyond these immediate medical expenses, the broader economic impact includes ongoing care, rehabilitation, and long-term treatment or disability, which are compounded by psychological consequences. In our cohort, the average direct cost per inpatient encounter was $22,214, reflecting these significant resource demands. Based on prior epidemiologic estimates indicating that approximately 5.4% of pediatric ballistic injuries, roughly 38 patients annually, result in a femur fracture, this injury pattern alone accounts for nearly $650,000 in direct healthcare costs each year, with indirect costs to patients, families, and society likely far exceeding this figure [24].

Complications and case series

Patient 1

A 17-year-old male with current tobacco and marijuana use sustained a gunshot wound resulting in a comminuted, segmental fracture of the right femoral diaphysis. At the time of injury, he was treated with rigid antegrade cephalomedullary nailing. His postoperative course was complicated by infection requiring irrigation and debridement of the right thigh, followed by hardware removal, placement of an antibiotic nail, and stage I Masquelet. He subsequently was treated with stage II bone grafting using the Masquelet technique. At 7 months following hardware exchange and bone grafting, the patient achieved fracture union and was doing well clinically and radiographically (Fig. 2).

Fig. 2.

Radiographic progression and staged management of a right femoral shaft gunshot injury. A Initial injury radiograph demonstrating a comminuted femoral shaft fracture. B Postoperative radiograph following operative fixation with right femur intramedullary nailing. C Radiograph obtained during the postoperative course demonstrating complications related to infection. D Image following irrigation and debridement with antibiotic nail exchange and stage I Masquelet technique after persistent infection. E Final follow-up radiograph demonstrating fracture union after stage II bone grafting using the Masquelet technique

Patient 2

An 18-year-old male with a past medical history of marijuana use sustained multiple gunshot wounds resulting in an incomplete spinal cord injury at the T8 level and a nondisplaced unicortical fracture of the left distal femoral shaft that was initially managed nonoperatively. His recovery course was complicated by infection of the left thigh GSW wound, displacement, and shortening of the previously nondisplaced distal femoral shaft fracture during physical therapy. He underwent open treatment of the left femoral shaft fracture with retrograde intramedullary nail fixation, placement of an antibiotic beads, reamer–irrigator–aspirator (RIA) for infection management, and extensive irrigation and debridement of open thigh wounds down to bone. At follow-up approximately seven months after surgery, the patient was doing well clinically and had a radiographic union (Fig. 3).

Fig. 3.

Radiographic progression of a left distal femoral shaft fracture following gunshot injury. A Initial radiograph demonstrating an incomplete, nondisplaced unicortical fracture of the distal femoral shaft after gunshot injury. B Subsequent radiograph demonstrating displacement and shortening of the fracture following physical therapy in the setting of ongoing soft-tissue infection. C Intraoperative fluoroscopic image demonstrating fixation with intramedullary nail. D Follow-up radiograph demonstrating fracture union and maintained alignment

Limitations

This study has several important limitations. The small sample size (N = 34) limits the statistical power to detect differences between pediatric and adolescent cohorts. These injuries are rare, and this paper reports the highest number of pediatric ballistic femur fractures within the literature, however. The population’s age range included primarily teenagers which limits the application of these outcomes to the traditional pediatric skeletally immature population. These injuries are especially rare in this population at baseline, however. As a retrospective case series from a single institution, the results may not be broadly applicable to other populations. The retrospective design also inherently carries risks of bias including dependence on the accuracy and completeness of electronic health records. The lack of a true comparison group limits the ability to draw causal inferences regarding treatment efficacy. The cost analysis is limited to in-hospital expenses only due to the inability to obtain accurate and complete 90-day global cost data. This does not account for post-operative care or rehabilitation, thereby underestimating the total costs associated with ballistic fracture care. Lastly, the loss to follow-up rate was considerable, but our follow-up was higher than the traditionally cited literature values. Future prospective, multicenter studies with larger sample sizes and standardized follow-up protocols are necessary to validate and extend these findings.

Conclusion

Pediatric ballistic femur fractures are rare but complex injuries with limited evidence to guide management. This study is the largest of its kind to date and demonstrates high union rates, low complication rates, and good long-term follow-up, aligning with outcomes from pediatric blunt trauma literature. No significant differences were found between pediatric and adolescent cohorts, suggesting that existing clinical guidelines and even select adult data may be cautiously extrapolated to younger patients. However, loss to follow-up remains a major challenge, particularly among uninsured patients, those with substance use, and those treated non-operatively. These findings provide a foundation for current treatment guidelines, as well as future prospective studies to further refine management of pediatric femoral ballistic injuries.

Author contributions

Z.J. was the lead investigator and primary author and was responsible for study conception and design, data collection, data analysis and interpretation, and drafting of the manuscript. V.M., C.G., A.N., and S.D. contributed substantially to data collection and original manuscript development. D.S. and C.H. were responsible for data management, cost analysis, and figure and visualization preparation. S.G. and T.L.H. served as faculty investigators and provided supervision, critical intellectual input, and manuscript review. All authors reviewed and approved the final manuscript and agree to be accountable for all aspects of the work.

Funding

No funding was received for this project.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request. Due to the retrospective nature of the study and the inclusion of protected health information, the data are not publicly available.

Declarations

Conflict of interest

The authors declare no competing interests.

Ethical approval

All procedures performed in this study were conducted in accordance with the ethical standards of the institutional and/or national research committee and with the current laws of the country in which the experiments were performed. This project received IRB exemption from the institution the research was performed at.