Epidemiology of ballistic fractures in the United States: A 20-year analysis of the Firearm Injury Surveillance Study

Abstract

IntroductionBallistic (i.e., gunshot-induced) fractures present unique treatment challenges and can be associated with high rates of complications and considerable morbidity. Large-scale epidemiologic data on these types of fractures are scarce. There is concern that gun-related violence may be on the rise, potentially increasing the burden of ballistic orthopaedic trauma, but there are few contemporary studies on the topic. The aim of this study, therefore, was to investigate the incidence and demographics of patients with ballistic fractures in the United States (US) over the last 20 years. Materials and MethodsThis descriptive epidemiology study retrospectively analyzed the Firearm Injury Surveillance Study to identify cases of ballistic fractures in the US from 2000 to 2019. Overall and annual numbers of fractures and fracture incidence rates (IRs), patient demographics, incident characteristics, and temporal trends were analyzed. Patients of all ages were included. Ballistic fractures were grouped by anatomic location for comparisons (non-spine axial, spine, upper extremity, lower extremity). ResultsAn estimated N = 240,555 patients (n = 8,322 unweighted cases) sustained ballistic fractures over the 20-year study period for an overall IR of 39.2 per 1,000,000 person-years at-risk (PYR). Overall, lower extremity fractures accounted for the largest percentage of cases (45.9%; IR=18.8 PYR), followed by upper extremity fractures (32.8%; IR=13.4 PYR), non-spine axial fractures (16.1%; IR=6.6 PYR), and spine fractures (5.2%; IR=2.1 PYR). Diaphyseal femur fractures were the most common ballistic fractures overall. Nearly three-fourths (71.2%) of all cases occurred in males in the second through fourth decades. The most common injury intent was assault (71.8%) and a majority of patients (71.2%) required hospital admission. Accounting for population growth yielded a significantly increasing incidence of all ballistic fractures over the study period from 15.7 PYR in 2000 to 96.8 PYR in 2019 (average annual percent change=10.3, p < 0.00001). ConclusionThese data suggest that the nationwide burden of ballistic fractures in the US has increased significantly in the last two decades. Ballistic fractures are associated with significant morbidity and societal cost, and increasing injury rates highlight the need for future research aimed at better understanding the ideal treatment of these types of fractures and their outcomes.