Editorial Comment

Abstract

During the past 140 years, the United States has experienced an increased productivity and demand for firearms. The emergence of the American gun culture seems to coincide with the production of mass produced firearms resulting from the technological breakthroughs realized as a result of the Civil War. Despite the congressional efforts to provide restrictions on federal firearms licenses with the passage of the 1994 crime bill, there still are 140,000 authorized sellers of firearms in the United States. 1 “Most of the world associates the United States with firearms, if not as the world’s leading maker of guns, then for such global cultural icons as the cowboy, the gangster, the street thug, and the heroic cop.”1 In 1962, the number of firearm-related deaths was 16,720 increasing to 38,505 deaths in 1994. 3 In 1998, firearm-related injuries were the second leading cause of death after motor vehicle-related deaths. 2 Although the firearm-related injury rates decreased between 1993 and 1998, the estimated average number of firearm-related injuries was 115,000 with 30% resulting in death. Of these injuries, more than 70% of unintentional injuries and more than 45% of intentional nonfatal injuries were gunshot wounds to the extremities. 1,2 Given the enormity of this public health problem, we are forced to examine the etiology, to identify the available economic resources, to form an effective political response, to provide public access to education, and to reevaluate the medical science of our trauma protocols. Ostensibly, this symposium will not be able to address the myriad issues associated with this emerging healthcare problem. Alternatively, we hope to provide an overview of the relevant ethical issues and to address the thinking and science of the current medical treatment of firearm-related musculoskeletal injuries. In this symposium, Cornwell urges an emphasis on the evidence-based improvement of trauma systems nationwide with special attention directed toward the appropriate principles of triage, emergent transport, and the critical first-hour of intervention. A balanced discussion of the ethical issues relevant to gun control in the United States is provided by Boylan’s essay highlighting the contrasting and passionately contested world views of the gun control debate through thought-provoking appraisal of both sides of the discussion. Shepard et al evaluate the reliability of the Association Osteosynthesis/Orthopaedic Trauma Association classification system for the evaluation of the femur fractures caused by gunshots. Their retrospective radiographic review of femur fractures tests the limits of interobserver and intraobserver reliability of this classification system. Additionally, Long et al propose a new classification system of gunshot femur fractures based on a retrospective study of more than 100 femur fractures. Gugala and Lindsey introduce a new classification of gunshot injuries in civilians based on specific parameters including missile energy, vital structures involved, wound characteristics, fracture patterns, and the extent of wound contamination. The studies by Johnson and Strauss, Wilson, Holmes, Zura and Bosse, Kitchel, Waters and Sie, Smith et al, and Simpson and Grant are underscored by the definitive review of the history and evolution of ballistics developed by Bartlett during the past several years. Bartlett’s contribution to increasing our understanding of ballistics allows his review of the literature to serve as a primary source and future reference for our evolving treatment protocols for patients with gunshot injuries. We hope that this symposium will serve as an overview of the emerging public healthcare crisis resulting from firearm-related musculoskeletal injuries. Although new technologies and evidence-based clinical outcomes have changed our approach to the treatment of patients with gunshot-induced injuries, the trauma community still is faced with the consequences of advancing firearm technologies and the indirect marketing influences of popular culture. Finally, the guest editors are appreciative of the guidance and assistance of the outgoing Editor-in-Chief of Clinical Orthopaedics and Related Research, Dr. Carl T. Brighton, for encouraging the development and completion of this project for the benefit of the orthopaedic community and the numerous subspecialties that support our trauma efforts.