Gunshot Fractures

Handgun wounds of the extremities yield characteristic fracture patterns. Frequently seen are divot fractures of cortical bone, drill-hole fractures, butterfly fractures, and double butterfly fractures.8 Nondisplaced fracture lines sometimes radiate from these defects. These usually heal well. The bullet hole itself can act as a stress riser. Spiral fractures extending proximally or distally from the bullet hole may result from the dissipation of stress forces at the bullet hole. Occasionally, remote spiral fractures at some distance proximal or distal to the bony gunshot wound also occur, probably because of the presence of stress risers, such as vascular channels in the bone, and the fact that the bone was under load and often torsional stress at the time of impact. 20

In gunshot fractures from rifles and large handguns, a greater extent of comminution may be seen. These fractures often have complications because of the soft tissue damage these bullets cause.8 The vascular compromise associated with these comminuted gunshot fractures increases the likelihood of delayed union or nonunion of the fracture. Wound infections are more common in this group. Early fasciotomy to prevent compartment syndrome is important, when needed.

At some hospitals, outpatient treatment is being used successfully for extremity fractures caused by handguns, if no significant neurologic or vascular compromise has occurred.21

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