Ballistic Injuries Research Articles

Country-Made Firearm (Desi-Katta)-Related Cranial Injuries: An Institutional Experience.

Approximately, 80% of civilian cranial gunshot injuries in India are mainly due to unlicensed mostly country-made guns, called the "Desi-Kattas," manufactured by the traditional gunsmiths. These injuries constitute a unique subgroup, with respect to the make and design along with the unique wound ballistics compared to the factory-made firearms. This study is aimed at defining the prognostic factors in predicting the outcomes related to cranial gunshot injuries due to these desi-kattas. Ten patients with kata-related cranial gunshot injury underwent surgical intervention at our institution, between 2014 and 2018. Their clinical status, imaging features, and outcomes were retrospectively analyzed. Ten patients with kata-related gunshot injuries to the head were identified. Homicidal injuries were documented in six cases. Five had a GCS of 13-15 at presentation. Exit wounds were noted in 50% of the suicidal cases. Multilobar involvement was seen in 70% of cases, with the bullet crossing the midline in only 40% cases. Decompressive craniectomy was required in five cases. Eight patients had a Glasgow Outcome Score of four or more at 6 months of follow-up. There was one death during the follow-up period, while the other patient remains to be in vegetative state. The Katta-related cranial injuries constitute low-muzzle velocity injuries with the majority of the patients sustaining nonfatal injuries, especially homicidal. The presence of positive CT findings and the crossing of the bullet across the midline on CT brain predicts dismal prognosis. Optimal neurosurgical approach should consist of minimal local debridement and attain water seal dural closure.

200 Online Trauma Care Learning Helped Young Myanmar Doctors Managing War-Wounded

Abstract Aim Myanmar military's brutal crackdowns on pro-democracy protestors after Feb-2021 coup resulted in a staggering number of death and wounded. An on-line trauma care series was launched in March 2021 for general practitioners and young medical graduates with limited trauma care experience. Method A pilot study was conducted to assess the effectiveness of online learning and address the demands of the medical personnel in the frontline areas. Pre- and post-assessments were sent out via anonymised Google forms and analysed. Results Among 106 participants, 65% graduated between 2011 and 2020. 46% worked in a hospital setting before the coup while 19.2% were GPs. Trauma first aid (70.8%), wound ballistics (68.8%) and ATLS updates (62.5%) were the most demanded topics. Average confidences grew in managing all 4 components (24.3% to 85.4% in Trauma First Aid, 23.5% to 72.9% in Trauma Wound Management, 12.5% to 81.3% in Wound Ballistics and 27.2% to 85.5% in Red Cross Wound scoring). Conclusions This pilot study highlighted an urgent demand for training and education in trauma care among young Myanmar doctors. With ongoing public hospital closures due to civil disobedience movement, care of war-wounded would still be largely dependent on makeshift casualty care chain in community setting.

Head injuries by firearms and sharp weapons in the Battle of San Martino (1859, Italy)

AbstractThe research was focused on the study of weapon‐related traumas in the skeletal remains of the soldiers who died in the Battle of San Martino (Italy, 1859). These remains are housed in the monumental ossuary of San Martino. The examination of 817 skulls revealed traces of injuries in 90 skulls, selected and submitted to anthropological studies. The aim of this work was to study the head injuries attributable to firearms and blade weapons in relation to the armaments and the military tactics used in that period.The shape, size, and features of the wounds were macroscopically examined to characterize the lesions. As regards the ballistic traumas, the caliber, the trajectory of the projectiles, and the kind of artillery were based on the diameter and localization of the entry and of the exit holes in the skulls. The sharp force traumas were identified as linear‐edge cuts or pointed lesions. The results evidenced different types of perimortem injuries, principally caused by firearms (79%) with projectiles of different calibers, mostly ranging between 14 and 18 mm. Sharp force injuries probably caused by bayonets and sabers had affected 17.8% of the skulls. The remnant 2.2% of the examined skulls presented only antemortem lesions. Moreover, seven other skulls showed healed lesions, in some cases surgically treated, testifying a rather intense war period, and the capacity of the soldiers to survive even severe injuries. The higher prevalence of gunshot wounds with respect to sharp force traumas is consistent with the military tactics and with the weapons used in that period: hand‐to‐hand combat was restricted and bayonet assault was unsuccessful compared to the use of efficient ranged weapons. This research presents important information on war‐related traumas, ballistic wounds and sharp force injuries of the armaments, and the military tactics of the mid‐19th century.

Management of the facial nerve following temporal bone ballistic injury.

ObjectiveTo understand the patterns of temporal bone fracture and facial nerve injury from ballistic trauma.Study DesignRetrospective case series.MethodsRetrospective review of 42 patients evaluated following temporal bone ballistic injury at a single institution, university‐based level‐one trauma center between 2012 and 2021. Demographics, facial nerve status, CT images, interventions, complications, and outcomes were reviewed.ResultsMean age 30.3 years (range 5–58 years); 79% male. Racial demographics reflected the surrounding community. Seven mortalities occurred. Nineteen patients (54%) demonstrated facial nerve injury. Of those, 13/19 displayed immediate paralysis, 1 delayed, 5 unknown (due to altered mental status). On consultation, House‐Brackmann grade 6 paralysis was common (13/19). Fracture was otic capsule‐sparing in 17/19 (90%), universally comminuted, with significant disruption along the mastoid tip (16/19), external auditory canal (EAC) (15/19), and periauricular soft tissues (13/19). Nine patients underwent surgical intervention: Transmastoid facial nerve decompression to remove compressive bony spicules (n = 5); eye protection surgery (n = 3); and peripheral facial nerve exploration (n = 1), noting transection at the pes. One required middle cranial fossa and transmastoid repair of cerebrospinal fistulae in setting of severe meningitis. House‐Brackmann scores improved in 80% following transmastoid nerve decompression despite CT evidence of likely additional injury in its extratemporal course.ConclusionsCommon patterns of temporal bone fracture seen in blunt trauma (longitudinal/transverse, otic capsule‐sparing/disrupting) were not found in patients with ballistic facial nerve injury. Rather, injury was commonly apparent in the EAC, mastoid tip, and periauricular soft tissues. Clinicians should have high suspicion for extratemporal facial nerve injury following ballistic trauma.

Comprehensive Treatment and Reconstructive Algorithm for Functional Restoration after Ballistic Facial Injury.

Background:Ballistic facial injuries are rare, with most trauma centers reporting 1–20 cases annually. These patients present significant management challenges to reconstructive surgeons, not only due to their rarity but also due to the complex decision-making process that is involved. The aim of this study was to review our experience with the application of craniofacial microsurgery in management of facial gunshot wounds.Methods:A retrospective review of a single-surgeon experience at a level I trauma center from 2011 to 2020 for patients sustaining self-inflicted gunshot wounds to the face requiring microsurgical reconstruction was performed. Outcomes included reconstructive techniques, free flap type and indication, airway evolution, feeding modality, respective timing of interventions, and complications.Results:Between 2012 and 2021, 13 patients presented for microsurgical reconstruction at our institution for gunshot wounds to the face. The majority (90%) of patients were men, and the average age at time of injury was 26. The median from the time of injury to first free flap was 93 days. Thirteen patients represented 23 free flaps. On average, patients underwent a total of two free flaps. The most common microsurgical flap was the fibula flap (14) followed by the radial forearm flap (6).Conclusions:Based on our findings, we describe a novel algorithm for function restoration and aesthetic revisions based on injury location. Underlying principles include avoiding early use of reconstruction plates, establishing occlusion early, and aligning bony segments using external fixation. An algorithmic approach to these injuries can improve outcomes.

Gunshot Wound to the Hip Resulting in a Femoral Head and Acetabulum Fracture Treated With Open Reduction and Internal Fixation and Bipolar Hemiarthroplasty

Combined fractures of the femoral head and acetabulum due to ballistic injuries are rare injuries, especially in the elderly. We present a case of a 70-year-old female who sustained a gunshot wound to the left hip, resulting in a comminuted femoral head fracture and posterior wall acetabular fracture. She was treated with open reduction and internal fixation of the acetabulum, as well as bipolar hemiarthroplasty for treatment of her femoral head fracture. At her 18-month follow-up visit, the patient was doing well and had no complaints.

Effectiveness of reactive hepatitis therapy in injured with ballistic wounds

Reactive hepatitis complicates the treatment of ballistic wounds. The aim of our studywas to study the clinical and pharmacoeconomic effectiveness of the treatment of reactive hepatitis
 in the wounded. A prospective study of 112 wounded servicemen with increased transaminase ac-tivity was randomized into three groups: group I received arginine glutamate intravenously for 10
 days, group II received phosphatidylcholine intravenously for 10 days, and group III received stan-dard treatment. In the presence of hypoalbuminemia, the wounded received intravenous infusions
 of albumin to normalize its level in serum. The initial level of alanine aminotransferases was 62.5in group I patients [50.5; 80.0] IU / l, in the second group - 64.0 [48.5; 83.0] IU / l and 62.0 [47.0;85.5] IU / l, respectively, in group III (p> 0.05 according to the Mann-Whitney test). In the periodup to 14 days after injury, alanine aminotransferase levels decreased significantly in all groups(p <0.05 according to Wilcoxon’s test) and amounted to 38.5 in group I [34,0; 63.5] IU / l, in thesecond group 46.0 [32.0; 62.5] IU / l, in group III 50.0 [40.0; 78.0] IU / l (p = 0.014 accordingto the Mann-Whitney test compared to group I). In 14 and more days after injury in all groups the
 average concentration of alanine aminotransferases was significantly lower compared to the pre-vious study period (p <0.05 according to Wilcoxon’s test): in group I the concentration of alanine
 aminotransferases was 33.0 [29,8; 40.0] IU / l (p = 0.048, p <0.001 according to the Mann-Whit-ney test in comparison with group II and III, respectively), in group II - up to 38.0 [31.0; 62.0] and
 in group III to 48.0 [39.5; 69.0] (p = 0.014 according to the Mann-Whitney test compared to groupII). Also, there was a tendency to reduce the frequency of complications from internal organs: in13% (8 of 63) patients of groups I and II, compared with 27% (13 of 49) of group III (p = 0.063).Significantly decreased both the duration of treatment in the intensive care unit: in group I (4.2 ±1.8) days, compared with group III (7.4 ± 6.0) days, p = 0.012, and the duration of total hospitalstay (20.4 ± 11.1) days for group I, compared with (29.7 ± 3.5) days for group III, p = 0.022. Inthe cost-effectiveness analysis of arginine glutamate and phosphatidylcholine regimens, a 2-foldbetter cost-effectiveness ratio was found in the group of reactive hepatitis wounded who receivedarginine glutamate.

Persistent coagulopathy after gunshot traumatic brain injury: the importance of INR and the SPIN score.

Penetrating ballistic brain injury (gunshot traumatic brain injury or GTBI) is associated with a high mortality. Admission Glascow Coma Scale (GCS), injury severity score and neurological findings, cardiopulmonary instability, coagulopathy and radiological finding such as bullet trajectory and mass effect are shown to predict survival after GTBI. We aimed to examine the dynamics of the observed coagulopathy and its association with outcome. In this single-centered retrospective cohort study, we examined 88 patients with GTBI between 2015 and 2021. Variables analyzed include patient age; temperature, hemodynamic and respiratory variables, admission Glasgow Coma Scale (GCS); injury severity score (ISS); head abbreviated injury scale (AIS); Marshall, Rotterdam, SPIN and Baylor scores, and laboratory data including PTT, INR and platelet count. Receiver operating characteristic analysis was conducted to evaluate the performance of the predictive models. The average age of our sample was 28.5years and a majority were male subjects (92%). Fifty-four (62%) of the patients survived to discharge. The GCS score, as well as the motor, verbal, and eye-opening sub-scores were higher in survivors (P < 0.001). As was expected, radiologic findings including the Marshall and Rotterdam Scores were also associated with survival (P < 0.001). Although the ISS and Head AIS scores were higher (P < 0.001), extracranial injuries were not more prevalent in non-survivors (P= 0.567). Non-survivors had lower platelet counts and elevated PTT and INR (P < 0.001) on admission. PTT normalized within 24h but INR continued to increase in non-survivors. SPIN score, which includes INR, was a better predictor for mortality than Rotterdam, Marshall, and Baylor etc. CONCLUSION: Progressively increasing INR after GTBI is associated with poor outcome and may indicate consumption coagulopathy from activation of the extrinsic pathway of coagulation and metabolic derangements that are triggered and sustained by the brain injury. The SPIN score, which incorporates INR as a major survival score component, outperforms other available prediction models for predicting outcome after GTBI.

Outcomes in Ballistic Injuries to the Hand: Fractures and Nerve/Tendon Damage as Predictors of Poor Outcomes.

Gunshot injuries can be devasting, regardless of their location. However, ballistic injuries involving the upper extremity have not been thoroughly investigated. The goal of this study is to evaluate the injury patterns and outcomes of patients who sustained gunshot injuries to the hand. A retrospective chart review of patients with gunshot injuries to the upper extremity at a single, level 1 trauma center between January 2016 and December 2017 was performed. Patient demographics and mechanisms of injuries were reviewed. The injury patterns, location, tendon/nerve involvement, and bony involvement were analyzed. Surgical interventions and long-term outcomes were reviewed. Outcomes were compared using the presence of fractures and nerve/tendon injuries as independent variables. In all, 32 patients met our inclusion criteria. Of these, 15 patients had gunshots to the hand, 10 patients to the fingers, and 7 patients involving both the finger and hand. In patients with isolated hand injuries, 60% had fractures and 53% had nerve/tendon injuries. The presence of fractures was associated with a 7.9-fold increase in tendon and nerve injuries (P = .032). Patients who sustained tendon/nerve injuries had significantly higher rates of permanent disability (P = .01). The presence of a fracture leads to a higher likelihood of long-term complications, although not statistically significant (P = .13). Ballistic injuries to the hand are frequently associated with fractures and neurovascular and tendon injuries. The presence of fractures is associated with a higher incidence of nerve and tendon injuries. Involvement of these structures is linked to an increased risk of long-term disability.

Dental Management of Maxillofacial Ballistic Trauma.

Maxillofacial ballistic trauma represents a devastating functional and aesthetic trauma. The extensive damage to soft and hard tissue is unpredictable, and because of the diversity and the complexity of these traumas, a systematic algorithm is essential. This study attempts to define the best management of maxillofacial ballistic injuries and to describe a standardized, surgical and prosthetic rehabilitation protocol from the first emergency stage up until the complete aesthetic and functional rehabilitation. In low-velocity ballistic injuries (bullet speed <600 m/s), the wound is usually less severe and not-fatal, and the management should be based on early and definitive surgery associated with reconstruction, followed by oral rehabilitation. High-velocity ballistic injuries (bullet speed >600 m/s) are associated with an extensive hard and soft tissue disruption, and the management should be based on a three-stage reconstructive algorithm: debridement and fixation, reconstruction, and final revision. Rehabilitating a patient with ballistic trauma is a multi-step challenging treatment procedure that requires a long time and a multidisciplinary team to ensure successful results. The prosthodontic treatment outcome is one of the most important parameters by which a patient measures the restoration of aesthetic, functional, and psychological deficits. This study is a retrospective review: twenty-two patients diagnosed with outcomes of ballistic traumas were identified from the department database, and eleven patients met the inclusion criteria and were enrolled.

Post Traumatic Stress Disorder (PTSD) Following Craniomaxillofacial Trauma - A Five Year Retrospective Study

Introduction: The psychological and psychiatric derangements as well as psychosocial impact that craniomaxillofacial trauma can have upon patients, often goes undetected, ignored and unaddressed. This can adversely affect the mental and physical well-being of the patient, leading to a lifetime of severe debility and incapacitation. Methods: This retrospective study examined the incidence, severity, predictors and likely predisposing factors for development of PTSD among 378 patients treated for craniomaxillofacial trauma at a tertiary care centre, over a five-year period. It correlated the likelihood of development of PTSD with the mode of injury sustained and analysed the management protocols employed and outcomes achieved. Results: 31% of the patients demonstrated a positive diagnosis for PTSD and were managed for the same. Self-inflicted maxillofacial trauma patients exhibited the highest risk for developing PTSD, followed by victims of natural disasters, combat associated trauma victims (blast and ballistic injuries), followed thereafter by physical assault and RTA victims. Depending upon the severity of PTSD exhibited by the different patients, counselling, psychotherapy, and/or pharmacotherapy were employed. Discussion: Careful screening of craniomaxillofacial trauma victims for features of PTSD cannot be overemphasized. Timely and effective management of the same can go a long way towards successful rehabilitation of these vulnerable group of patients. Surgical management of orofacial injuries should integrate case management that addresses psychosocial sequelae as it is not only necessary to restore the integrity of the anatomy and function, but also to provide psychiatric support and therapy for patients experiencing symptoms of PTSD caused by traumatic events.

A review of the first wave of lower limb amputees from the Great March of Return in Gaza: Taking stock and preparing for the task ahead

AimBallistic injuries during the Great March of Return (GMR) protests in Gaza have resulted in young, civilian amputees. This article defines this unique population, their injuries and clinical variables that impacted on amputation. MethodA multidisciplinary team (MDT) assessed 103 lower limb amputees (104 stumps). Individualized prescriptions of care were formulated and applied for both stump and prosthesis management.The cohort's health state was assessed at screening by applying the EQ-5D-L5 questionnaire. The EQ-5D-L5 will be repeated on completion of the prescription of care. ResultsThe population is predominantly young, male, suffering unilateral amputation with an equal ratio of above knee (AKA) to below knee (BKA) amputations. 18% were amputated immediately and 82% with delay. Most amputations occur within 15 days of gunshot wound (GSW).All tissue elements were affected by the severe, ballistic injury. Division, gapping and tissue loss consolidated the decision for amputation rather than limb salvage. Knee zone injury was common, influencing the high numbers AKAs.Primary injury ramified beyond the amputated leg: 38% have contralateral leg injuries. 20% had physiological challenges requiring Intensive care unit (ICU) admissions. Infection was reported in 49% of amputees with 12% reporting acute sepsis. Psychologically, 49% reported severe, or extreme, anxiety and depression.AKAs were associated with greater morbidity: amputees are significantly younger, have more proximal vascular injuries, receive delayed amputations and experience longer time intervals to stump healing. ICU care and contralateral leg injuries were more frequent.One third of amputees used their prostheses’, one third did not and one third do not have a prosthesis yet. The limiting factor for repair was supply of materials. 11% of amputees needed no adjustment to stump or prosthesis. Surgical stump revision was recommended in 26% of stumps and prosthetic management in 41%. A further 22%, subject to the success or failure of prescribed prosthetic adjustment, could require stump revision. ConclusionYouth, proximal injury, high numbers of AKA, psychosocial issues and the need for stump and prosthetic support define this group of amputees. Unifying expertise within a National MDT will promote continuity of care necessary for decades to come.The ultimate aim is an evidence-based amputee care system in Gaza, with lower limb specialists promoting best outcomes, judicious allocation of funds and maximising amputee quality of life.

Isolated ballistic femoral condyle fractures: a case series of eighteen patients.

Ballistic fractures of the femoral condyles are rare injuries with limited literature to help guide treatment. The purpose of this study is to report on the presentation, management, and outcomes for patients with isolated ballistic condylar fractures. Eighteen patients between ages 16 and 65 with low-energy ballistic injuries isolated to the femoral condyles (OTA 33B) were included, 15 with CT imaging. Clinical records and imaging were reviewed, as well as treatment strategy. Fractures were classified by AO/OTA classification. Outcome and follow-up data were gathered at outpatient appointments and telephone calls. Of the 18 patients, 78% were treated operatively (61% with open reduction and internal fixation, 17% with removal of foreign body alone). There were two instances of traumatic vascular injury and no neurologic injuries. Furthermore, there were no identified infections. Only 58% of the patients had follow-up for more than 6weeks with average KOOS Jr. Score of 50, and average VAS pain score of 5.2. Ballistic femoral condyle fractures are rare Orthopaedic injuries seen in relatively high frequency at our institution. Most (78%) were treated operatively and with few complications. These fractures are not easily classified according to common classification schemes and may benefit from more rigorous study to guide treatment and anticipate outcomes.

Pain, medicine and the monitoring of war violence: the case of rifle bullets (1868–1918)

AbstractThe St Petersburg declaration, signed in 1868, is a milestone in the history of warfare and humanitarian law, as it prohibits the use of explosive bullets, which are considered to cause unnecessary suffering. As this article shows, the framing of this declaration that put suffering at its centre, as well as the development of the humanitarian movement, favoured the birth of a new field of expertise: wound ballistics. The wars that broke out after the declaration was signed are the subject of intense scrutiny, while the advances in weaponry, and notably, the creation by the British of a new expansive bullet, provided physicians with new fields of investigation. Numerous experiments have attempted to reproduce the effects of bullets on different materials, including corpses. Based on numerous medical reports and publications, as well as military archives from France and the United Kingdom, this investigation critically examines the notion of pain, its assessment and its use in the monitoring of war violence. It argues that, paradoxically, the greater attention paid to suffering has resulted in a need to objectify pain. This rationalisation and the quest for the quantification of suffering have not been without bias and have shifted attention away from care and treatment.

Ballistic peripheral nerve injuries: basic concepts, controversies, and proposal for a management strategy.

Ballistic injuries to peripheral nerves are devastating injuries frequently encountered in modern conflicts and civilian trauma centers. Such injuries often produce lifelong morbidity, mainly in the form of function loss and chronic pain. However, their surgical management still poses significant challenges concerning indication, timing, and type of repair, particularly when they are part of high-energy multi-tissue injuries. To help trauma surgeons, this article first presents basic ballistic concepts explaining different types of missile nerve lesions, described using the Sunderland classification, as well as their usual associated injuries. Current controversies regarding their surgical management are then described, including nerve exploration timing and neurolysis's relevance as a treatment option. Finally, based on anecdotal evidence and a literature review, a standardized management strategy for ballistic nerve injuries is proposed. This article emphasizes the importance of early nerve exploration and provides a detailed method for making a diagnosis in both acute and sub-acute periods. Direct suturing with joint flexion is strongly recommended for sciatic nerve defects and any nerve defect of limited size. Conversely, large defects require conventional nerve grafting, and proximal injuries may require nerve transfers, especially at the brachial plexus level. Additionally, combined or early secondary tendon transfers are helpful in certain injuries. Finally, ideal timing for nerve repair is proposed, based on the defect length, associated injuries, and risk of infection, which correlate intimately to the projectile velocity.

Description of oral and maxillofacial ballistic missile injuries based on tactics and terrain of conflict in Yemen civil war: account from a level 1 trauma center in Najran, Saudi Arabia

article: Description of oral and maxillofacial ballistic missile injuries based on tactics and terrain of conflict in Yemen civil war: account from a level 1 trauma center in Najran, Saudi Arabia - European Journal of Oral and Maxillofacial Surgery 2022 April;6(1):17-23 - Minerva Medica - Journals

Correlations of Autopsy and Postmortem CT in Fatal Ballistic Injuries

Purpose: To study the respective contributions and correlations of autopsy and PMCT in fatal ballistic injuries. Methods: A single-center retrospective descriptive study was carried out over a 10-years period (2008–2017) that included cases of fatal ballistic injuries that had undergone unenhanced PMCT followed by autopsy. In addition to demographics, the main data collected independently at autopsy and PMCT were the number of injuries, their trajectory, distances from the sole of the feet of the entry and exit wounds, projectile caliber and gunshot residue, detailed examination of the injuries, and detection of effusions. Results: Initially, 225 cases were included, of which 158 complete records were analyzed. The mean age of the victims was 41.5 years, and 93% were male. PMCT and autopsy findings were concordant concerning the number of injuries, their trajectory, and distance of the entry and exit wounds from the sole of the feet. Findings were not concordant regarding gunshot residues on the skin (autopsy more efficient) or detection of effusions (PMCT more efficient). The limitations of PMCT were the positioning of the limbs outside the field of acquisition and the impossibility of reliably determining the caliber of the projectiles. Some discrepancies were related to occasionally missing autopsy data, particularly the distance from the sole of the feet or measurements of the volume of effusion. Conclusions: This study provides more detailed knowledge of the accordance of autopsy and PMCT in analyzing fatal ballistic injuries.

Acute and Delayed Cerebrovascular Injury From Gunshot to the Head in a 12-Year-Old Child During the COVID-19 Pandemic

Acute and Delayed Cerebrovascular Injury From Gunshot to the Head in a 12-Year-Old Child During the COVID-19 Pandemic

A comparison of the incidence of concomitant ipsilateral femoral neck fractures in ballistic versus blunt femur fractures.

The purpose of this study is to evaluate the rate of ipsilateral femoral neck fractures in ballistic femur fractures and compare this to similar non-ballistic blunt fractures. A retrospective review of an institutional trauma database was completed at a single Level 1 trauma academic medical center. All patients treated for a ballistic or blunt femur fracture presenting to our institution between May 1, 2018, and February 29, 2020, were included. In all, 270 femur fractures were identified. We excluded 73, including 29 pediatric fractures and 44 geriatric peritrochanteric fractures. The final cohort included 197 femur fractures in 187 patients. Of the 197 femur fractures included, 68 were ballistic and 129 were blunt mechanism. Four ipsilateral femoral neck fractures were identified in the ballistic fracture cohort. There was no significant difference between ipsilateral femoral neck fractures associated with blunt femur fractures when compared with ballistic fractures, 7.7 versus 5.8%, respectively. We identified one occult femoral neck fracture that was associated with a ballistic 32-B3 femoral shaft fracture. The ipsilateral femoral neck fracture associated with the 32-B3 ballistic femoral shaft fracture was not identified on plain films (Fig.3A, B) and review of CTA during initial trauma workup. Identification of this fracture intra-operatively changed the treatment plan from standard proximal locking to recon proximal locking for this case. Patients included in the blunt fracture cohort were more likely to be poly-trauma patients with a higher rate of associated fractures. We detected no difference in rate of associated femoral neck fracture between blunt and ballistic femur fractures. These fractures can be missed on initial evaluation, which may lead to a delayed diagnosis and alter treatment plans. The authors conclude that treating surgeons must remain vigilant with a high index of suspicion for occult femoral neck fractures in patients who suffer ballistic femoral shaft fractures. Low-energy ballistic injuries should not rule out the possibility of an occult femoral neck fracture.

Non-Operative Management of Multiple Left Ventricular Ballistic Injuries from Shotgun Blast.

Non-Operative Management of Multiple Left Ventricular Ballistic Injuries from Shotgun Blast.