From the Department of Orthopaedic Surgery, The MetroHealth System, Case Western Reserve University, Cleveland, OH.
J Am Acad Orthop Surg. 2019 Sep 15;27(18):685-689. doi: 10.5435/JAAOS-D-17-00849.
Extremity involvement is common among nonfatal gunshot injuries. Most of these injuries are low energy in nature and may be associated with fractures. Although displaced fractures of lower extremity long bones are often treated surgically, the purpose of this study was to review our experience in managing incomplete femur fractures caused by gunshot penetration and to develop treatment recommendations.
We retrospectively reviewed clinical and radiographic data for 46 consecutive patients with incomplete femur fractures secondary to low-energy gunshot wounds. Fracture patterns included OTA/AO 31 (n = 7), 32 (n = 20), and 33 (n = 19). All fractures were nondisplaced and extra-articular. Type of treatment, clinical and radiographic healing, and related complications were recorded.
Thirty-two patients (70%) were managed nonsurgically with progressive weight bearing from toe touch to full weight bearing by 6 weeks of follow-up, whereas 14 patients (30%) underwent prophylactic fixation of the femur. No differences in treatment were seen based on age, body mass index, fracture pattern, or the presence of other fractures or systemic injuries. Two of the 32 patients (6.2%) treated nonsurgically for femoral shaft fractures fell subacutely after the original injury and displaced their fractures. Both underwent reduction and fixation. All other fractures maintained alignment until union. No infections or nonunions were seen. Among patients who underwent prophylactic fixation, two underwent removal of prominent implants after union.
Only 6% of incomplete femur fractures treated at our hospital required later surgery for fracture displacement. Although incomplete fractures occur infrequently, nonsurgical management with limited weight bearing seems to be successful and cost-effective for most patients. We propose initial nonsurgical management of nondisplaced femoral fractures secondary to cortical penetration from low-energy gunshot wounds.
非致命性枪伤常累及四肢。这些损伤大多为低能量损伤，可能与骨折有关。虽然下肢长骨的移位骨折通常需要手术治疗，但本研究的目的是回顾我们处理由枪击穿透引起的不完全股骨骨折的经验，并制定治疗建议。
我们回顾性分析了 46 例连续低能枪击伤所致不完全股骨骨折患者的临床和影像学资料。骨折类型包括 OTA/AO 31 型（n = 7）、32 型（n = 20）和 33 型（n = 19）。所有骨折均为无移位和关节外骨折。记录治疗方式、临床和影像学愈合情况以及相关并发症。
32 例（70%）患者采用非手术治疗，在随访 6 周时逐渐从足尖负重过渡到完全负重，14 例（30%）患者预防性固定股骨。治疗方法的选择与年龄、体重指数、骨折类型或其他骨折或全身损伤的存在无关。32 例非手术治疗股骨干骨折患者中有 2 例（6.2%）在原损伤后亚急性跌倒并发生骨折移位。这两例均行复位和固定。所有其他骨折均保持对线至愈合。未见感染或骨折不愈合。在接受预防性固定的患者中，有 2 例在愈合后取出了突出的植入物。
在我们医院治疗的不完全股骨骨折中，只有 6%需要后期手术治疗骨折移位。尽管不完全骨折很少见，但对于大多数患者来说，采用有限负重的非手术治疗似乎是成功且具有成本效益的。我们建议对低能枪击伤引起的皮质穿透所致的无移位股骨骨折进行初始非手术治疗。
