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Background and Objectives: Patients with intracranial gunshot wounds (IC-GSWs) often present with severe neurological injuries requiring prompt neurological evaluation. Neurosurgical intervention is reserved for those with reasonable chances of survival. Handguns and long guns, such as shotguns and rifles, have differing mechanisms of injury which may influence surgical candidacy and outcomes. This study aims to compare rates and types of neurosurgical intervention and inpatient outcomes in patients with IC-GSWs handguns and long guns., Methods: The National Trauma Data Bank was retrospectively queried for patients with IC-GSWs from 2017 to 2019. Patients with long gun IC-GSWs were propensity score matched with those with handgun IC-GSWs based on patient demographics, comorbidities, insurance status, injury extent and severity, and hospital trauma level. Group differences were compared using Student's t-tests and Pearson's χ2 tests, and multivariable logistic regression was used to identify predictors of in-hospital mortality., Results: Overall, patients in the long gun group were more likely to undergo neurosurgical intervention (21% vs 17%, P = .02). Following propensity score matching, the long gun group had lower rates of in-hospital mortality (35% vs 43%, P < .01), lower rates of cardiac arrest (5% vs 8%, P = .02), and lower rates of reoperation (0% vs 2%, P = .02) than the handgun group. In multivariable regression, independent predictors of survival included long gun IC-GSWs (odds ratio [OR] 0.65, CI 0.52-0.83), neurosurgical foreign body removal (OR 0.44, CI 0.33-0.58), intracranial debridement (OR 0.47, 0.33-0.67), and craniectomy (OR 0.46, CI 0.34-0.63)., Conclusion: Patients with IC-GSWs present to the hospital with severe neurological injury. Neurosurgical intervention was independently associated with decreased mortality. After matching, patients with long gun IC-GSWs experienced lower in-hospital mortality rates compared with those from handguns. This study suggests that patients suffering from long gun IC-GSW may respond particularly well to neurosurgical intervention and firearm type should be considered when determining neurosurgical candidacy., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

The current state of the literature for a bullet embolization to the heart and/or pulmonary vasculature indicates the occurrence is rare but could increase due to the rise in civilian low-kinetic-energy firearm acquisition and use. We present the case of an older teenage male who sustained a gunshot wound to the left flank. The bullet entered the iliac vein, travelled through the heart and lodged in the pulmonary artery. Successful relocation of the bullet to the internal iliac vein was performed by the interventional radiologist. This article highlights the advancement of interventional radiology as a successful non-invasive endovascular technique for bullet embolus removal., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Case: Bean bag projectiles (BBPs) are less lethal munition composed of a cloth bag filled with lead pellets and marking powder housed in a plastic casing fired from a 12-gauge shot gun. Two patients sustained penetrating BBP injuries that resulted in open fractures and retained BBP. Patient clothing and all BBP components were found deep in the wounds with marking powder surrounding fracture edges. Both patients healed without infection., Conclusion: Surgical exploration of penetrating BBP injuries is recommended to remove marking powder, fabric, plastic, and potentially other forms of contamination. Fracture stabilization should adhere to existing guidelines pertaining to open contaminated wound conditions., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C427)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

A 7 yr old castrated male domestic shorthair presented for assessment of a chronic left head tilt, losses of balance, and positional nystagmus. A computed tomographic scan of the head revealed several fragments of a metallic foreign body in the left tympanic cavity. The foreign material was removed under endoscopic assistance through a minimally invasive ventral bulla osteotomy. No complications were noted during the immediate postoperative period. Follow-up 5 mo after surgery revealed complete resolution of the neurological signs with no evidence of recurrence. Foreign bodies associated with middle ear infection have not been previously reported in the cat. They should now be included in the differential diagnosis of vestibular disease. Endoscopic-assisted foreign body removal in the middle ear seems to be a safe and efficient way to retrieve small foreign bodies in bullae in cats., (© 2024 by American Animal Hospital Association.)

Introduction: Penetrating neck trauma (PNT) due to gunshot injuries is one of the challenging conditions with the potential for both significant morbidities and mortality., Research Question: There are significant concerns in the approach to patients with spinal gunshot injuries. Surgery indications, methods of surgery, and management of CSF leaks are the main concerns of these patients., Methods and Materials: An 11-year-old boy was referred to our center with a single gunshot wound to the left side of the posterior cervical region 2 days ago with cerebrospinal fluid leakage and left arm weakness., Results: The patient underwent surgery, and the pellet was removed. His left arm weakness fully recovered after the operation, and no new symptoms developed during the 1-year follow-up., Conclusion: Timely surgery could dramatically improve outcomes in PNT patients with mild symptoms and prevent worsening neurological defects., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background Context: Gunshot wounds (GSWs) to the vertebral column represent an important cause of morbidity and mortality in the United States, constituting approximately 20% of all spinal injuries. The management of these injuries is an understudied and controversial topic, given its heterogeneity and lack of follow-up data., Purpose: To characterize the management and follow-up of GSWs to the spine., Study Design/setting: A multi-institutional retrospective review of the experience of two urban Level 1 trauma centers., Patient Sample: Patients with GSWs to the spine between 2010-2021., Outcome Measures: Measures included work status, follow-up healthcare utilization, and pain management were collected., Methods: Charts were reviewed for demographics, injury characteristics, surgery and medical management, and follow-up. Statistical analysis included T-tests and ANOVA for comparisons of continuous variables and chi-square testing for categorical variables. All statistics were performed on SPSS v24 (IBM, Armonk, NY)., Results: A total of 271 patients were included for analysis. The average age was 28 years old, 82.7% of patients were black, 90% were male, and 76.4% had Medicare/Medicaid. The thoracic spine (35%) was most commonly injured followed by lumbar (33.9%) and cervical (25.6%). Cervical GSW was associated with higher mortality (p<.001); 8.7% of patients developed subsequent osteomyelitis/discitis, 71.3% received prophylactic antibiotics, and 56.1% of cervical GSW had a confirmed vertebral or carotid artery injury. ASIA scores at presentation were most commonly A (26.9%), D (20.7%), or E (19.6%), followed by C (7.4%) and B (6.6%). 18.8% of patients were unable to be assessed at presentation. ASIA score declined in only 2 patients, while 15.5% improved over their hospital stay. Those who improved were more likely to have ASIA B injury (p<.001). Overall, 9.2% of patients underwent spinal surgery. Of these, 33% presented as ASIA A, 21% as ASIA B, 29% as ASIA C, and 13% as ASIA D. Surgery was not associated with an improvement in ASIA score., Conclusions: Given the ubiquitous and heterogeneous experience with GSWs to the spine, rigorous attempts should be made to define this population and its clinical and surgical outcomes. Here, we present an analysis of 11 years of patients presenting to two large trauma centers to elucidate patterns in presentation, management, and follow-up. We highlight that GSWs to the cervical spine are most often seen in young black male patients. They were associated with high mortality and high rates of injury to vertebral arteries and that surgical intervention did not alter rates of discitis/osteomyelitis or propensity for neurologic recovery; moreover, there was no incidence of delayed spinal instability in the study population., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: The invasion of Ukraine by Russian troops on February 24, 2022, and the beginning of the full-scale war had huge humanitarian consequences. The major challenges facing the Ukrainian health care system included the disruption of medical infrastructure and logistics, the termination of the supply of expendable materials, significant migration, and a dramatic increase in high-velocity blast and gunshot injuries among combatants and civilians.The aim of the present study was to analyze the challenges and solutions in patient care faced by the Ukrainian system of maxillofacial surgery during the war in different regions of the country., Materials and Methods: A cross-sectional study was designed and implemented as an online survey to collect national data concerning maxillofacial surgeons' experiences and professional activities. The study was initiated and supported by Bogomolets National Medical University (Kyiv, Ukraine), the Ukrainian representative of AO CMF (Arbeitsgemeinschaft für Osteosynthesefragen Craniomaxillofacial Surgery) and the University of Helsinki (Finland).The questionnaire was developed by specialists in maxillofacial surgery and sociologists and contained 65 close-ended questions. Surgeons who had not worked in this specialty in inpatient departments of hospitals since at least the beginning of the full-scale war were excluded from the study. We received and analyzed 97 responses that met the abovementioned criteria. The geography of respondents covered all the regions and the main cities of Ukraine, expect for the occupied territories., Results: After a year of warfare, the percentage of surgeons who treated patients with blast and gunshot injuries increased from 43.4% to 86.6%. This percentage was higher in military hospitals and in regions located in the vicinity of the front line. We found that, during the war, 78.6% of respondents performed osteosynthesis in cases of high-velocity multifragmented facial bone fractures (in such cases, 58.3% of them strictly followed AO CMF recommendations, while 41.7% performed the fixation based on available hardware, existing technical possibilities and their own preferences). We found that 70.2% of respondents had the opportunity to apply Computer-Aided Design/Computer-Aided Manufacture technology and patient-specific implants for the treatment of gunshot injuries, 38.1% reported that their hospitals were able to perform microsurgical reconstructions for facial defects, 79.4% of respondents reported that their departments received humanitarian aid and support from volunteer organizations (either Ukrainian or international), which significantly facilitated the treatment process., Conclusions: According to this nationwide survey of Ukrainian maxillofacial surgeons during a year of the full-scale war, 86.6% of respondents were involved in the treatment of gunshot and ballistic injuries in civilians and combatants. The main problems reported by the respondents were (1) a lack of experience and knowledge related to the treatment of severe wounds, especially by secondary reconstruction, and (2) a deficit of resources (equipment, materials, and medications) under conditions of disrupted logistics and changes in the numbers and nosological distribution of patients. There were the opportunity to transfer the patients to European clinics (29.9%), online consultations (45.4%), collaboration with foreign surgeons who come to Ukraine asvolunteers (32%)., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

Case: A 25-year-old right-hand dominant male police officer presented to the emergency department with a gunshot wound to his left shoulder. Magnetic resonance imaging demonstrated an osteochondral defect overlying the humeral head along the mid to lower aspect of the glenohumeral joint. A staged operation with shoulder arthroscopy followed by an osteochondral allograft (OCA) of the humeral head was performed. During his 6-month postoperative visit, he had returned to full work duty with no restrictions and reported that his pain was well controlled., Conclusion: Humeral head OCA transplantation may be an effective treatment option for traumatic osteochondral lesions of the glenohumeral joint., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C417)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Objectives: The aim of this study was to evaluate the longterm outcomes of open tibia fractures treated using the Ilizarov external circular fixation (ECF) technique in the Military Medical Academy., Patients and Methods: Between January 1992 and December 2011, a total of 134 male military personnel (median age: 22.5 years; range, 18 to 36 years) with Gustilo-Anderson type 3 open tibia fractures treated with ECF were retrospectively analyzed. All patients underwent multiple surgeries and eventually Ilizarov fixation surgery. The radiological and functional outcomes were evaluated using the Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria, and complications were noted., Results: The median follow-up was 17.7 (range, 10 to 29) years. The median time to union was 4.7 (range, 3 to 8) months. All frames were removed from the limb, when union was observed. No re-fracture, limb length discrepancy more than 2.5 cm, or below-knee amputation after Ilizarov treatment was seen in any patient. Chronic osteomyelitis was observed at in 40% (n=54) of the patients at a median time ranging from 17 to 148 months. The overall ASAMI bone scores were excellent in 40 (30%), good in 20 (15%), fair in 20 (15%), and poor in 54 (40%) patients with osteomyelitis. The ASAMI functional scores were excellent in 40 (30%), good in 40 (30%), and fair in 54 patients (40%). No poor score was observed. Minor pin site infections were observed in 63 patients (47%)., Conclusion: Our long-term study results showed that all patients returned to their social life and were mobilized without support after treatment with the use of Ilizarov ECF method of open tibia fractures caused by high-energy ballistic injuries. However, complications such as pin tract infections and osteomyelitis after several years must be kept in mind in the treatment of comminuted bone fractures caused by firearms and ballistic missiles injuries.

» Gunshot injuries to the upper extremity (UE) have high likelihood for causing peripheral nerve injury secondary to the high density of vital structures. Roughly one-fourth of patients sustaining a gunshot wound (GSW) to the UE incur a nerve injury. Of these nerve injuries, just over half are neurapraxic. In cases of surgical exploration of UE nerve injuries, nearly one-third demonstrate a transected or discontinuous nerve.» Existing literature regarding surgical management of nerve injuries secondary to GSWs comes from both military and civilian injuries. Outcomes are inconsistently reported, and indications are heterogeneous; however, reasonable results can be obtained with nerve reconstruction.» Our proposed management algorithm hinges on 4 treatment questions: if there is a nerve deficit present on examination, if there is a concomitant injury in the extremity (i.e., fracture or vascular insult), whether the injured nerve would be in the operative field of the concomitant injury, and whether there was an identified nerve lesion encountered at the time of surgery by another surgeon?» Early exploration rather than continued expectant management may offer improved recovery from GSW nerve injuries in particular situations. When an UE nerve deficit is present, establishing follow-up after the initial GSW encounter and early referral to a peripheral nerve surgeon are pivotal., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/B120)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Purpose: This study aims to (1) devise a classification system to categorize and manage ballistic fractures of the knee, hip, and shoulder; (2) assess the reliability of this classification compared to current classification schemas; and (3) determine the association of this classification with surgical management., Methods: We performed a retrospective review of a prospectively collected trauma database at an urban level 1 trauma centre. The study included 147 patients with 169 articular fractures caused by ballistic trauma to the knee, hip, and shoulder. Injuries were selected based on radiographic criteria from plain radiographs and CT scans. The AO/OTA classification system's reliability was compared to that of the novel ballistic articular injury classification system (BASIC), developed using a nominal group approach. The BASIC system's ability to guide surgical decision-making, aiming to achieve stable fixation and minimize post-traumatic arthritis, was also evaluated., Results: The BASIC system was created after analysing 73 knee, 62 hip, and 34 shoulder fractures. CT scans were used in 88% of cases, with 44% of patients receiving surgery. The BASIC classification comprises five subgroups, with a plus sign indicating the need for soft tissue intervention. Interrater reliability showed fair agreement for AO/OTA (k = 0.373) and moderate agreement for BASIC (k = 0.444). The BASIC system correlated strongly with surgical decisions, with an 83% concurrence in treatment choices based on chart reviews., Conclusions: Conventional classification systems provide limited guidance for ballistic articular injuries. The BASIC system offers a pragmatic and reproducible alternative, with potential to inform treatment decisions for knee, hip, and shoulder ballistic injuries. Further research is needed to validate this system and its correlation with patient outcomes., Level of Evidence: Level III, Diagnostic Study., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: The management of femur and tibia fractures resulting from gunshot injuries is a challenge for orthopedic surgeons. One-stage and two-stage treatments are applied according to the anatomical location and severity of the injury. In this study, the importance of injury severity and anatomical location was evaluated in the choice of treatment method and its impact on prognosis in cases of lower extremity gunshot fractures., Methods: A total of 124 patients who met the study criteria were evaluated. They were grouped separately according to the anatomical location of the injury (femur, n = 73; tibia, n = 51) and the surgical method (one-stage, n = 77; two-stage, n = 47). The demographic characteristics of the patients, fracture classification, presence of neurological or vascular damage at the time of diagnosis, anatomical location of the injury, surgical procedure, and follow-up time were recorded. The time of union and the presence of malunion were evaluated radiologically. Finally, patients were assessed clinically with the New Injury Severity Score (NISS) and leg length discrepancy (LLD) calculated through measurements made on lower extremity orthoroentgenograms., Results: The rate of vascular injury and the number of Gustilo-Anderson type IIIB and IIIC cases were significantly higher in the two-stage treatment group (p = 0.001 and p = 0.000, respectively). The infection rate was also higher in the two-stage group; therefore, time to union was significantly longer (p = 0.004 and p = 0.05, respectively). LLD was higher among patients who received two-stage treatment (p = 0.015). According to the NISS scale used in clinical assessment, better scores were obtained for the one-stage group (p = 0.002). In comparisons made according to anatomical location, no significant difference was found between femur and tibia injuries., Conclusion: Regardless of anatomical location and treatment method, injuries of higher severity such as Gustilo-Anderson type IIIB and IIIC are correlated with higher rates of complications such as vascular injury, postoperative infection, delayed union, and LLD. Furthermore, in cases of severe injuries, a two-stage approach is commonly favored., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Introduction: Intraorbital foreign bodies (IOFBs) represent a clinical challenge: surgical management can be controversial and different strategies have been proposed. When removal is recommended, depending on the location and nature of the IOFB both external and endoscopic approaches have been proposed, with significantly different surgical corridors to the orbit and different morbidities., Methods: We performed a literature review of cases of IOFBs that received exclusive endoscopic transnasal surgical treatment to evaluate the role of this surgery in these occurrences. We also present a case of an intraorbital intraconal bullet that was successfully removed using an endoscopic transnasal approach with good outcomes in terms of ocular motility and visual acuity., Results: A limited number of cases of IOFBs have been treated with an exclusive endoscopic transnasal approach. When in the medial compartment, this approach appears to be safe and effective. In our case, two months after surgery the patient showed complete recovery with no significant long-term sequelae., Conclusions: When feasible, an endoscopic transnasal approach for intraorbital foreign bodies represents a valid surgical technique with optimal outcomes and satisfactory recovery., (Copyright © 2024 Società Italiana di Otorinolaringoiatria e Chirurgia Cervico-Facciale, Rome, Italy.)

Background: Although several society guidelines exist regarding emergency department thoracotomy (EDT), there is a lack of data upon which to base guidance for multiple gunshot wound (GSW) patients whose injuries include a cranial GSW. We hypothesized that survival in these patients would be exceedingly low., Methods: We used Pennsylvania Trauma Outcomes Study data, 2002 to 2021, and included EDTs for GSWs. We defined EDT by International Classification of Diseases codes for thoracotomy or procedures requiring one, with a location flagged as emergency department. We defined head injuries as any head Abbreviated Injury Scale (AIS) score of ≥1 and severe head injuries as head AIS score of ≥4. Head injuries were "isolated" if all other body regions have an AIS score of <2. Descriptive statistics were performed. Discharge functional status was measured in five domains., Results: Over 20 years in Pennsylvania, 3,546 EDTs were performed; 2,771 (78.1%) were for penetrating injuries. Most penetrating EDTs (2,003 [72.3%]) had suffered GSWs. Survival among patients with isolated head wounds (n = 25) was 0%. Survival was 5.3% for the non-head injured (n = 94 of 1,787). In patients with combined head and other injuries, survival was driven by the severity of the head wound-0% (0 of 81) with a severe head injury ( p = 0.035 vs. no severe head injury) and 4.5% (5 of 110) with a nonsevere head injury. Of the five head-injured survivors, two were fully dependent for transfer mobility, and three were partially or fully dependent for locomotion. Of 211 patients with a cranial injury who expired, 2 (0.9%) went on to organ donation., Conclusion: Although there is clearly no role for EDT in patients with isolated head GSWs, EDT may be considered in patients with combined injuries, as most of these patients have minor head injuries and survival is not different from the non-head injured. However, if a severe head injury is clinically apparent, even in the presence of other body cavity injuries, EDT should not be pursued., Level of Evidence: Therapeutic/Care Management; Level IV., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Heart failure due to high cardiac output rarely occurs. Few cases of post-traumatic arteriovenous fistula (AVF) as a cause of high-output failure were reported in the literature., Methods: Herein, we report a case of 33-year-old male who was admitted to our institution due to symptoms of heart failure. He reported a gunshot injury of the left thigh 4 months earlier, when he had been shortly hospitalized and discharged 4 days later. Since the gunshot injury he had exertional dyspnea and left leg edema, so the diagnostic procedures were performed., Results: Clinical examination revealed distended neck veins, tachycardia, slightly palpable liver, left leg edema, and thrill over the left thigh. Due to high clinical suspicion, duplex ultrasonography of the left leg was performed that verified femoral AVF. Operative treatment of AVF was made with prompt resolution of symptoms., Conclusions: This case wants to emphasize the importance of proper clinical examination, and duplex ultrasonography in all cases of penetrating injuries., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: High-energy casualties such as firearm injuries may result in extensive loss of soft tissue and bone in the lower extremities. Although the primary aim in these types of injuries is the preservation of the extremity, repeated surgical procedures for extremity salvage and subsequent restoration of function could have detrimental effects on the patient both physically and psychologically. The main aim of this study is to evaluate the physical and psychological outcomes of patients who underwent lower extremity amputation in the early period after a firearm injury compared with the results of patients who underwent amputation in the late period. We also evaluated the factors affecting the prognosis in patients undergoing late below-knee amputation (BKA)., Methods: This retrospective study included patients who underwent BKA following a lower extremity injury caused by firearms between March 2016 and March 2022. Patients who underwent emergency BKA at the first center they were taken to immediately after the injury constituted the early amputation (EA) group. Patients who were transferred to our tertiary-level referral center for continuation of treatment after the first intervention at another center and later underwent BKA constituted the late amputation (LA) group. The patients were evaluated regarding age, gender, amputation side, presence of phantom limb pain (PLP), and post-traumatic stress disorder (PTSD)., Results: Information was available from hospital records for a total of 35 patients; 16 in the EA group and 19 in the LA group. All patients were male. The mean age at the time of injury was 25.5±5.3 years (range, 20-45 years), and the mean follow-up period was 37±17 months (range, 25-84 months). In the comparison of PLP experienced, the difference between the groups was statistically significant, with PLP experienced by 1 (10%) patient in the EA group and by 9 (90%) in the LA group (p=0.010). PTSD was diagnosed in 3 (23%) patients in the EA group and 10 (77%) patients in the LA group (p=0.039)., Conclusion: Patients who underwent late BKA were found to be affected by PLP and PTSD at a higher rate. When deciding on extremity-preserving surgery for patients with severe open injuries to the lower extremity, it is crucial to consider the poor outcomes associated with late BKA. Patients should be thoroughly informed about these negative outcomes.

Background: Although treatments have improved dramatically in recent years, mortality following gunshot wounds (GSW) to the pelvis continue to range between 3 and 20 %. This project was designed to determine the incidence and risk factors associated with pelvic fracture-related infection (FRI) following GSWs to the pelvis given the paucity of evidence regarding this complication., Methods: A retrospective review of 13 years (1/2010-12/2022) of patients with GSW to the pelvis was performed. Patients meeting inclusion criteria underwent chart review for the development of pelvic FRI and the following additional data elements were extracted: demographics, presence and type of bowel injury, operations performed, complications, use of postoperative antibiotics (≤24 h vs. >24 h), surgical osseous debridement, presence of retained bullet fragments, and bullet trajectory. Discrete variables were analyzed using Wilcoxon rank-sum test, chi-square, and Fischer's exact test. Pearson correlation coefficients were calculated for continuous variables., Results: 242 patients were included in the study. Concomitant bowel injury was present in 108 patients (45 %). Eleven patients (4.5 %) developed FRI, all of whom had a concomitant bowel injury (p < 0.001). Neither the presence of retained bullet fragments nor the bullet trajectory (through bowel before the bone) was associated with FRI. Antibiotic duration >24 h was not associated with a lower rate of pelvic FRI., Conclusion: Development of FRI after a GSW to the pelvis occurs in 4.5 % of patients and is significantly associated with concomitant bowel injury, specifically colonic injury. These findings can be used to help guide further studies on the role of prophylactic antibiotics or other strategies to prevent pelvic FRI., Competing Interests: Declaration of competing interest Dr Thomas Carver is a consultant for InnoVital, Inc and Cytovale, Inc, but these relationships are not relevant to the submitted work. None of the other authors have any conflicts of interest to disclose., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

The Russia-Ukraine war is associated with critical and severe thoracoabdominal injuries. A more specific approach to treating patients with thoracoabdominal injury should also include minimally invasive technologies. It remains unclear about the utility of using video-assisted thoracoscopic surgery (VATS) and laparoscopy in patients with thoracoabdominal injury. The aim of this study was to investigate and evaluate the utility of video-assisted thoracoscopic surgery, laparoscopy as well as magnetic tool applications for the management of severe thoracoabdominal injury in combat patients injured in the ongoing war in Ukraine and treated in the Role 2 deployed hospital. Patients and methods 36 male combat patients thoracoabdominal injury were identified for the study during the first 100 days from February, 24 2022. These individuals were diagnosed with thoracoabdominal GSW in the Role 2 hospital (i.e. deployed military hospital) of the Armed Forces of Ukraine. Video-assisted thoracoscopy surgery (VATS) and laparoscopy with application of surgical magnetic tools were applied with regards to the damage control resuscitation and damage control surgery. Results In 10 (28%) patients, VATS was applied to remove the metal foreign body fragments. Both thoracotomy and laparotomy were performed in 20 (56%) hemodynamically unstable patients. Of these 20 patients, the suturing of the liver was performed in 8 (22%) patients, whereas peri-hepatic gauze packing in 12 (33%) patients. Massive injury to the liver and PI 2.0-3.0 were diagnosed in 2 (6%) patients. Lethal outcome was in 1 (2.8%) patient. Conclusions Thoracoabdominal gunshot injuries might be managed at Role 2 hospitals by using video-assisted thoracoscopy (VATS) and laparoscopy accompanied by surgical magnetic tools. Damage control surgery and damage control resuscitation must be applied for patients in critical and severe conditions., (© 2024. The Author(s).)

Retroperitoneal abscess as a sequela of penetrating trauma can pose a difficult clinical scenario for surgeons and literature to inform decision making is sparse. It is logical to follow a "step-up" approach applied to other etiologies of infected retroperitoneal fluid collections, such as infected pancreatic necrosis and perinephric abscess. Video-assisted retroperitoneal debridement (VARD) is a well-established approach in infected pancreatic necrosis when surgical debridement is warranted. Minimally invasive retroperitoneal approaches have emerged in a broadening range of etiologies and specialties. We describe our experience utilizing VARDs in two patients that developed retroperitoneal abscesses following gunshot injuries to bowel and proximal urinary system. Both failed a conservative approach including antibiotic and percutaneous drains. Rapid improvement and subsequent discharge were observed within days of VARD procedure. We believe VARD to be a viable approach to post-trauma retroperitoneal abscesses when surgical drainage is indicated, and anatomy is favorable., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

A 27-year-old U.S. military active duty male sustained an accidental, self-inflicted left knee gunshot injury with an unsalvageable medial femoral condyle injury. The patient underwent bulk osteochondral allograft transplantation. Nine months post-operation, the patient was fit for full military duties with no reported functional limitations and remained on active duty. Severe knee medial femoral condyle bone loss after accidental firearm injury is uncommon. Bulk knee osteochondral allograft transplantation to the medial femoral condyle provided a successful treatment option for an active duty U.S. military member with multicompartment osteochondral defects and severe medial femoral condyle bone loss due to a gunshot injury., (© The Association of Military Surgeons of the United States 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Lactic acid is well studied in the trauma population and is frequently used as a laboratory indicator that correlates with resuscitation status and has thus been associated with patient outcomes. There is limited literature that assesses the association of initial lactic acid with post-operative morbidity and hospitalization costs in the orthopedic literature. The purpose of this study was to assess the association of lactic acid levels and alcohol levels post-operative morbidity, length of stay and admission costs in a cohort of operative lower extremity long bone fractures, and to compare these effects in the ballistic and blunt trauma sub-population., Methods: Patients presenting as trauma activations who underwent tibial and/or femoral fixation at a single institution from May 2018 to August 2020 were divided based on initial lactate level into normal, (< 2.5) intermediate (2.5-4.0), and high (> 4.0). Mechanism of trauma (blunt vs. ballistic) was also stratified for analysis. Data on other injuries, surgical timing, level of care, direct hospitalization costs, length of stay, and discharge disposition were collected from the electronic medical record. The primary outcome assessed was post-operative morbidity defined as in-hospital mortality or unanticipated escalation of care. Secondary outcomes included hospital costs, lengths of stay, and discharge disposition. Data were analyzed using ANOVA and multivariate regression., Results: A total of 401 patients met inclusions criteria. Average age was 34.1 ± 13.0 years old, with patients remaining hospitalized for 8.8 ± 9.5 days, and 35.2% requiring ICU care during their hospitalization. Patients in the ballistic cohort were younger, had fewer other injuries and had higher lactate levels (4.0 ± 2.4) than in the blunt trauma cohort (3.4 ± 1.9) (p = 0.004). On multivariate regression, higher lactate was associated with post-operative morbidity (p = 0.015), as was age (p < 0.001) and BMI (p = 0.033). ISS, ballistic versus blunt injury mechanism, and other included laboratory markers were not. Lactate was also associated with longer lengths of stay, and higher associated direct hospitalization cost (p < 0.001) and lower rates of home disposition (p = 0.008)., Conclusion: High initial lactate levels are independently associated with post-operative morbidity as well as higher direct hospitalization costs and longer lengths of stay in orthopedic trauma patients who underwent fixation for fractures of the lower extremity long bones. Ballistic trauma patients had significantly higher lactate levels compared to the blunt cohort, and lactate was not independently associated with increased rates of post-operative morbidity in the ballistic cohort alone., Level of Evidence: III., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Orbital reconstruction following orbital trauma, tissue sacrifice from cancer resection, or other tissue loss poses a unique challenge for surgeons. Factors to consider include the patient's systemic health status, potential for adjuvant radiation, final composition, and strength of the graft, infection risk, graft rejection, status of visual function, and cosmetic outcome. In settings where a permanent artificial implant is avoided due to exposure or infection risk, potential tissue utilized includes xenografts, allografts, and autografts-each with variable benefits and drawbacks, depending on the surgical goals of the repair. We describe a case of orbital reconstruction after a gunshot wound to the left orbit using tri-layer Kerecis (decellularized intact North-Atlantic cod fish skin) with excellent globe position and maintenance of ocular motility., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2024 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Background: 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., Methods: 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., Results: 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)., Conclusion: 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., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The IRB approved for this study falls under the East Carolina University and Medical Center IRB (UMCIRB) with identification number 19-003148 and title: “Outcomes in Hand and Facial Trauma Surgery.”

Bladder stones represent approximately 5% of all cases of urolithiasis and are typically identified and managed long before causing irreversible renal injury. We present a case of a man in his 40s with a prior history of a gunshot wound to the abdomen who presented with leakage from a previously healed suprapubic tube tract and was found to have a giant bladder stone with a resulting renal injury. He subsequently underwent a combined open cystolithotomy and vesicocutaneous fistulotomy during his hospitalisation, which helped to improve his renal function. In addition to there being few reported cases of bladder stones >10 cm, this represents the first report in the literature of an associated decompressive 'pop-off' mechanism through a fistulised tract., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Retained shrapnel from gunshots is a common occurrence; however, retained shrapnel within the spinal canal is exceedingly uncommon. Guidelines for removal and treatment of these cases are a difficult topic, as surgical removal is not necessarily without consequence, and retention can lead to possible further injury or a secondary disease process of plumbism, which can be difficult to diagnose in this population., Case Presentation: This case report provides a unique example of a young patient with retained shrapnel from a gunshot. This patient suffered an initial spinal cord injury due to a gunshot and secondarily presented with abdominal pain, fatigue, elevated blood lead levels, and was diagnosed with plumbism. This was addressed with operative removal of shrapnel and posterior instrumented spinal fusion, resulting in decreased lead levels and symptom resolution postoperatively., Discussion: Lead toxicity risk in patients with retained shrapnel, particularly in the spine, warrants vigilant monitoring. While management guidelines lack consensus, symptomatic lead toxicity may necessitate intervention. Residual neurological deficits complicate evaluation, emphasizing individualized management decisions., (© 2024. The Author(s), under exclusive licence to International Spinal Cord Society.)

Background and Importance: Nonpowder firearm injuries to the head pose major health risks, with retained fragments potentially causing harmful sequelae that require neurosurgical intervention., Clinical Presentation: We report the case of 2-year-old girl who sustained an accidental gunshot wound to the head. She sustained a penetrating ballistic intracranial injury caused by a BB shot from a rifle. At presentation, she was neurologically intact with a punctate laceration on her left forehead. Head CT demonstrated a small depressed left frontal skull fracture, a small intracerebral hematoma, and a 5-mm metallic bullet fragment in the deep left frontal lobe near the frontal horn of the left lateral ventricle. She was admitted to the hospital and managed nonoperatively with levetiracetam and intravenous antibiotics, and discharged home in good condition. Follow-up CT in 1 week showed slight migration of the metallic bullet fragment to the left, placing it at the anterior horn of the lateral ventricle. Six weeks later, follow-up CT showed migration of the bullet to the temporal horn of the left lateral ventricle. Intraventricular migration of the bullet raised concern that it could move further to obstruct the foramen of Monro or cerebral aqueduct. Therefore, we removed the bullet through a small left temporal craniotomy with image guidance using a microsurgical approach through a translucent tube., Conclusion: The authors discuss the rationale and technique for removing a nonpowder firearm bullet that has migrated within the cerebral ventricles., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives: Uniformly classifying long bone open fractures is challenging. The purpose of this study was to propose a modified Orthopaedic Trauma Society (OTS) Open Fracture Classification System, developed in a setting with a high incidence of civilian gunshot fractures., Methods: From our prospectively collected database, we identified all patients with open tibia and femur fractures treated with intramedullary nailing over a 4 year period. All open fractures were retrospectively reclassified from the Gustilo-Anderson Classification system to the OTS Open Fracture Classification System., Results: One hundred and thirty-seven cases were identified. Ninety per cent of subjects were males. Their mean age was 34 years. The most common mechanism of injury was low-velocity civilian gunshot wounds (GSW) in 54.7% of cases. Soft tissue management was primary closure in 23.4% and soft tissue reconstruction in 24.1%. In 52.6% of cases (these all being secondary to civilian GSW), soft tissue management was healing via secondary intention. This is not included as a soft tissue management option in the OTS classification system. Fracture reclassification using the OTS Open Fracture Classification System was only possible in 47.5% of cases (Simple in 23.4%, Complex B in 24.1%)., Conclusion: We conclude that the OTS Open Fracture Classification System is not inclusive of all open tibia and femur fractures as it does not cater for gunshot fractures. We propose a modification as follows: alter 'wound debridement' to 'appropriate wound care' and to subcategorise 'Simple' into type A and B: healing via secondary intention and primary closure, respectively., (© 2024. The Author(s).)

Objective: To examine the effects of RBF (Retained Bullet Fragment) removal at the time of long bone fixation on FRI (fracture related infection) rates in low energy GSI (Gunshot Injury) related fractures., Design: Retrospective Cohort Study SETTING: Level 1 Academic Trauma Center INTERVENTION: Retrospective review of the impact of RBFs on the risk of FRI when employing internal fixation in low energy GSI (Gunshot Injury) related fractures. In situations where the injury pattern requires surgical fixation, the question arises as to whether or not the RBFs need to be removed to prevent FRI., Main Outcome Measures: Whether or not the RBFs removed in our patient population prevented short- and long-term fracture related infection after low-energy gunshot injury (FRI-LGI)., Results: Of the 2,136 GSI related fractures, 131 patients met inclusion criteria, 81 patients underwent removal (R) of RBFs at the time of internal fixation while 50 patients did not undergo any removal (NR) at time of internal fixation. Among the patients who underwent surgical intervention, (Open Reduction Internal Fixation) ORIF was performed in 55 cases (R: 39; NR: 16), and (Intramedullary Nail) IMN was performed in 76 cases (R: 42; NR: 34). The overall rate of deep FRI-LGI was 6.9 % of the 131-patient cohort. We found that removal of RBFs had a statistically significant impact on the rate of deep FRI-LGI when compared to the NR group (p = 0.031). In the RBF removal group, only two patients (2.4 %) developed deep FRI-LGIs, whereas in the NR group, seven patients (14.0 %) developed deep FRI-LGIs. The incidence of early FRI-LGI was higher in the NR group (median 0.6 months) compared to the R group, which was associated with late FRI-LGIs (median 10.1 months) when they occurred., Discussion: In our study population, we found a statistically significantly increased incidence of deep and early FRI-LGI when RBFs are not removed at the time of extra-articular long bone internal fixation. The presence of retained bullet fragments following internal fixation may pose a risk factor for future development of deep FRI-LGI. We believe a surgeon should use their best judgment as to whether a RBF can safely be removed at the time of long bone fixation. Based on our findings, if safely permitted, RBF removal should be considered at the time of GSI long bone fixation resulting from low energy hand gun injuries., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Benjamin Best DO reports statistical analysis was provided by Ascension St John Hospital. Benjamin Best DO reports a relationship with Ascension St John Hospital that includes: employment., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Case: A 23-year-old right-hand dominant man presented with a high-velocity gunshot wound injury to the right thumb with severe soft-tissue damage, vascular injury, and large osseous defect of the right thumb metacarpal. The patient was successfully treated with metacarpophalangeal joint arthrodesis and metacarpal reconstruction using definitive external fixation, an intramedullary Kirschner wire, and use of the Masquelet bone grafting technique., Conclusion: The authors' treatment approach for a mangled thumb injury with definitive external fixation and utilization of the Masquelet technique resulted in restoration of a large osseous defect, avoidance of infection, and limited loss of mobility., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C311)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background Context: Civilian gunshot wounds to the spine are an increasingly common injury in the USA. A majority of the available research is focused on a military population suffering high energy missile injury. Minimal research has focused on civilian ballistic injuries to the lumbosacral spine as the available studies focus on the entire spine due to limited numbers., Purpose: Characterize ballistic injuries to the lumbosacral spine and develop a model to predict the presence of neurological deficit based upon a patients presenting fracture morphology., Study Design: Retrospective chart review., Patient Sample: One hundred forty-eight consecutive patients that were presented to an urban level 1 trauma center with ballistic injures to the spine involving the levels L1-S2., Outcomes Measures: Neurological status at presentation and final follow up using the American Spinal Injury Association (ASIA) Impairment Scale., Methods: IRB approval was obtained, and retrospective chart review was performed. Extracted data included patient demographics, neurological status on presentation and final follow-up, fracture morphology, assessment of stability, other associated injuries, and surgical procedures performed. Proportional analysis was performed to characterize the fractures and their associated neurological injuries. Chi-square testing was done to identify fracture characteristics associated with neurologic injury. A multiple logistical regression was performed using fracture characteristics highly associated with neurological deficit to develop a model to predict neurologic deficit. The model was then validated with a receiver operator curve., Results: Of the 148 patients, 14 patients underwent spinal surgery with the most common indication being decompression and foreign body removal. There was a high incidence of intra-abdominal injury (73.6%). Fractures were characterized by level, affected vertebral component, and spinal canal involvement. Neurological injury was classified using the ASIA scale at presentation and final follow up. Odds-ratios of vertebral fracture characteristics showed neurologic deficit was highly associated with pedicle fractures (OR=9.07 [4.14-21.54] - 95% CI), lamina fractures (OR=6.42 [3.16-13.62] - 95% CI), facet fractures (OR=5.95 [2.90-12.79] - 95% CI), intra-canal bone (OR=12.79 [5.98-29.05] - 95% CI), and an intra-canal trajectory (OR=1078 [4.48-28.98]) - 95% CI. Multiple logistic regression was performed to construct a predictive model of neurologic deficit which showed that intra-canal trajectory, pedicle fracture and facet fracture are associated with neurologic deficit. An ROC curve was made with an area of 0.849 ([0.7853 to 0.9128 - 95% CI], p<.0001) demonstrating a good model fit., Conclusions: Ballistic injuries to the lumbosacral spine involve complex injury patterns in an often polytraumatized patient. Fractures involving the pedicle, lamina, and facet are highly associated with neurologic injury, as is a trans-canal trajectory. A patients fracture morphology can be used to predict if a neurologic deficit is present., Competing Interests: Declaration of Competing Interest One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Penetrating trauma to the head and neck has increased during the past decade in Sweden. The aim of this study was to characterize these injuries and evaluate the outcomes for patients treated at a tertiary trauma center., Methods: Swedish trauma registry data were extracted on patients with head and neck injuries admitted to Karolinska University Hospital (Stockholm, Sweden) between 2011 and 2019. Outcome information was extracted from hospital records, with the primary endpoints focusing on the physiological outcome measures and the secondary endpoints on the surgical and radiological outcomes., Results: Of 1436 patients with penetrating trauma, 329 with penetrating head and neck injuries were identified. Of the 329 patients, 66 (20%) had suffered a gunshot wound (GSW), 240 (73%) a stab wound (SW), and 23 (7%) an injury from other trauma mechanisms (OTMs). The median age for the corresponding 3 groups of patients was 25, 33, and 21 years, respectively. Assault was the primary intent, with 54 patients experiencing GSWs (81.8%) and 158 SWs (65.8%). Patients with GSWs had more severe injuries, worse admission Glasgow coma scale, motor, scores, and a higher intubation rate at the injury site. Most GSW patients underwent major surgery (59.1%) as the initial procedure and were more likely to have intracranial hemorrhage (21.2%). The 30-day mortality was 45.5% (n = 30) for GSWs, 5.4% (n = 13) for SWs, and 0% (n = 0) for OTMs. There was an annual increase in the incidence and mortality for GSWs and SWs., Conclusions: Between 2011 and 2019, an increasing annual trend was found in the incidence and mortality from penetrating head and neck trauma in Stockholm, Sweden. GSW patients experienced more severe injuries and intracranial hemorrhage and underwent more surgical interventions compared with patients with SWs and OTMs., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

A systematic review was performed to compare adverse maternal and neonatal outcomes among pregnant patients with gunshot wounds (GSW) to the abdominopelvic vs other region(s) at > 20 weeks gestation. A search of Medline Ovid, Elsevier Embase, EBSCO CINAHL, and Cochrane Library in July 2022 and reference searches resulted in 1742 studies, which were screened. The 41 included studies reported outcomes for 59 pregnant patients with GSW, of which 31 (52.5%) had an isolated abdominopelvic GSW and 28 (47.5%) had an extremity, thorax, head/neck, back/spine, poly-site, or other/unknown GSW. Stillbirth occurred in 26.7% of abdominopelvic GSW and 26% of non-abdominopelvic GSW. Maternal death occurred in 3.7% of abdominopelvic GSW and 10.7% of non-abdominopelvic GSW. Neonatal death occurred in 9.1% of abdominopelvic GSW and 5.3% of non-abdominopelvic GSW. Further research is needed to standardize the approach for the evaluation and management of patients with GSW in pregnancy., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background and Aims: Abdominal gunshot wounds (GSWs), a clinically devastating injury, can result in a variety of severe and lethal complications. Traditionally, exploratory laparotomy is the first-line approach for the management of abdominal GSWs, but it is associated with a considerable amount of unnecessary surgeries. At present, selective non-operative management (SNOM) of abdominal GSWs is becoming an effective and well-recognized approach, but it remains widely disputed since many surgeons are skeptical about the validity of SNOM in clinical practice. This meta-analysis aims to estimate the outcomes of SNOM and immediate laparotomy in patients with GSWs by collecting the currently available evidence., Methods: The PubMed , EMBASE , and Cochrane Library databases were searched. A random-effects model was employed. A pooled proportion with 95% confidence intervals (CIs) was calculated. Heterogeneity was evaluated using Cochran's Q test and I2 statistics., Results: Overall, 53 studies involving 60 291 participants were included. The pooled proportions of SNOM and SNOM failure were 27.0% (95% CI=24.0-30.0%) and 10.0% (95% CI=7.0-13.0%), respectively. The pooled mortality after SNOM and SNOM failure were 0.0% (95% CI=0.0-1.0%) and 0.0% (95% CI=0.0-0.0%), respectively. The pooled proportions of immediate laparotomy and unnecessary immediate laparotomy were 73.0% (95% CI=70.0-76.0%) and 10.0% (95% CI=8.0-13.0%), respectively. The pooled mortality after immediate laparotomy and unnecessary immediate laparotomy was 10.0% (95% CI=8.0-13.0%) and 0.0% (95% CI=0.0-1.0%), respectively. Heterogeneity was statistically significant in nearly all meta-analyses., Conclusion: Immediate laparotomy is still the mainstay approach for the management of abdominal GSWs. Approximately one-third of patients with abdominal GSWs undergo SNOM. SNOM failure is not frequent, and its related mortality is also rare., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Advisability of magnets in neurotrauma is due to pattern of patients admitted to neurosurgical departments of military hospitals with wounds accompanied by intracranial fixation of foreign metallic ferromagnetic bodies., Objective: To study dimensions, mass and magnetic properties of fragments extracted from gunshot wounds inflicted by modern weapons; to assess the feasibility of devices and instruments for removing foreign bodies., Material and Methods: We analyzed foreign bodies extracted after gunshot wounds. Shape, dimension, weight and magnetic properties were studied. We estimated 532 foreign bodies (497 surgeries) extracted at the Kirov Military Medical Academy and 83 foreign bodies (79 surgeries) extracted at the Burdenko Military Clinical Hospital. Distribution by anatomical regions was established for both groups. We intraoperatively used cylindrical neodymium magnets 3×20 and 5×20 mm to extract magnetic foreign bodies. These magnets were brought to the target using standard surgical tweezers or original devices., Results: The median mass of removed fragments was 0.385 (Q 1 -Q 3 =0.12-1.435; min-max≤0.01-30.5) g at the Kirov Military Medical Academy and 0.4 (Q 1 -Q 3 ≤0.001-1.6; min-max≤0.01-11.4) g at the Burdenko Military Clinical Hospital. Magnetic foreign bodies were found in 501 (94.2%) and 74 (94.8%) cases, respectively. In 8.8% of cases, foreign bodies were not removed due to difficult-to-reach location accompanied by higher risk of adverse outcomes after extraction., Conclusion: Extracted foreign bodies after combat injuries have magnetic properties in 94% of cases. Intraoperative magnet allows for safe extraction of fragments in 91% of cases. Devices with adjustable magnetic field strength seem perspective. Further analysis of indications for removal of wounding projectiles in primary and, especially, repeated surgical treatment of craniocerebral wounds is needed.

Injury from a firearm is now the leading cause of death of children and youth under age 19 in the United States (U.S.) [1] and the incidence of these deaths continues to increase each year [2]. For every death from firearm violence, there are several young people who have been injured by a bullet but not killed. As pediatric surgeons, we are on the front lines of treating these young patients. We have the unforgettable memories of delivering the horrible news to parents in "quiet rooms." [3]. As these injuries fall within our scope of practice, it is incumbent on us as professionals to work to prevent these injuries, apply best practices and work for the best pathways to recovery for our patients who do survive. There is a diverse community of pediatric surgeons tackling this public health problem in a variety of ways [4]. In a pre-meeting symposium at the APSA 2023 Annual meeting, we brought together a community of pediatric surgeons working on this critical area. The following summarizes the presentations of the symposium, with topics including Risk Factors, Injury Prevention, Treatment, Public Initiatives, and National Collaborative Efforts. TYPE OF STUDY: Review Article, Proceedings of a Symposium. LEVEL OF EVIDENCE: 1 through 4 all presented., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: We aimed to reveal the protective effect of body mass index (BMI) and subcutaneous adipose tissue thickness (SATT), together with scores covering the abdomen, in patients with penetrating abdominal trauma., Methods: The data of 234 abdominal penetrating trauma patients over the age of 16 who applied to the emergency general sur-gery unit of Istanbul Medipol Hospital between 2017 and 2021 were analyzed retrospectively. Sex, age, types of penetrating injuries, BMI, need for blood transfusion and intensive care unit (ICU), mortality, Injury Severity Score (ISS), Penetrating Abdominal Trauma Index (PATI), and Flint Colon Injury Score (FCIS) were recorded., Results: The patients were divided into two groups: Gunshot Wound (GW) and Stab Wound (SW).While there was no significant difference in all parameters examined in all patients and GW patients in terms of BMI, a statistically significant difference was found in terms of blood transfusion need in SW patients (p=0.035). As a result of the Receiver Operating Characteristic curve analysis for the SATT variable, the cutoff value between mortality (p=0.866) and SATT (mm) values in all patients was 11 mm for all patients and 12 mm for GW patients. A significant difference was found in all patients and separately in GW and SW groups in terms of ICU and blood transfusion need, length of stay, ISS, PATI, and FCIS scores in non-operated patients (p<0.05). When all patients were examined, a statistically significant difference was found in terms of mortality (p=0.002)., Conclusion: It is the first study to evaluate penetrating abdominal injuries with both BMI and SATT comprehensively and with all abdominal scores. A cutoff value to be determined for SATT with larger and multicenter studies can take its place as a parameter in the penetrating trauma algorithm.

Introduction: The management of thoracoabdominal (TA) gunshot wounds (GSW) remains challenging. This study reviewed our experience with treating such injuries over a decade., Materials and Methods: A retrospective study was conducted at a major trauma centre in South Africa over a ten-year period from December 2012 to January 2022., Results: Two hundred sixteen cases were included (male: 85 %, mean age: 33 years). Median RTS: 8 and median ISS: 17 (IQR: 10-19). The mean value of physiological parameters: Heart Rate (HR): 98/min, Systolic Blood Pressure (SBP): 119 mmHg, Temperature (T): 36.2 °C, pH: 7.35, Lactate 3.7 mmol/l. Ninety-nine (46 %) underwent a CT scan of the torso. One hundred fifty-four cases (69 %) were managed operatively: thoracotomy only [5/154 (3 %)], laparotomy only [143/154 (93 %)], and combined thoracotomy and laparotomy [6/154 (4 %)]. Those who had surgery following preoperative CT had a lower rate of dual cavity exploration (2 % vs 4 %, p = 0.51), although it did not reach statistical significance. The overall morbidity was 30 % (69). 82 % required intensive care (ICU) admission. The mean length of hospital stay was 14 days. The overall mortality was 13 % (28). Over the 10-year study period, there was a steady increase in the number of cases of TA GSWs managed at our institution. Over the study period, an increasing use of CT was noted, along with a steady reduction in the proportion of operations performed., Conclusions: Thoraco-abdominal GSWs remain challenging to manage and continue to be associated with significant morbidity and mortality. The increased use of CT scans has reduced the degree of clinical confusion around which body cavity to prioritize, leading to an apparent decrease in dual cavity exploration, and has allowed for the increased use of minimalistic and non-operative approaches., Competing Interests: Declaration of Competing Interest The authors report no conflicts of interest., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Air guns, particularly BB (ball-bearing or bullet ball) guns, have gained significant power and velocity over the last few decades. More than 145,000 pediatric patients suffered injuries attributed to air guns in the United States between 2001 and 2011, and approximately 22,000 pediatric emergency department visits are attributed to air gun-related injuries annually (Hyak et al., 2020 [1]). This study aims to describe an effective surgical technique in addressing maxillofacial injuries caused by BB gun projectiles in the pediatric population. We present a detailed surgical approach for endoscopic endonasal retrieval of a transorbital projectile in a 13-year-old male who sustained a maxillofacial BB gun injury, with the goal of restoring sinonasal function in a minimally invasive fashion., Competing Interests: Declaration of competing interest The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: There is a paucity of literature on infections in civilian gunshot associated with long bone fractures with the reported rates ranging from 0-15.7%.This study aimed to investigate the rates of infection associated with long bone fractures caused by civilian gunshots. The specific objectives were to determine if certain extremities were at a higher risk for infection and to identify the types of bacteria present in these infections by analyzing culture isolates., Methods: We conducted a retrospective review of consecutive patients aged 18-64 who sustained gunshot-associated long bone fractures at an urban Level I trauma centre from 2010 to 2017. Patient selection was based done through a institutional trauma centre database using international classification of diseases (ICD) 9 and 10 codes. We included patients who underwent surgical treatment, specifically fracture fixation, at our institution and excluded patients with fractures involving the pelvis, spine, foot, and hand. A total of 384 gunshot-associated long bone fractures in 347 patients were identified for analysis. Relevant patient-, injury-, and treatment-related variables were extracted from clinical records and radiographic reviews. Outcomes of interest included bony union, repeat operative procedures, and the development of deep infection., Results: 347 patients with 384 long bone fractures were included. 32 fractures in 32 patients developed an infection for an incidence of 9.3% of patients and 8.3% of fractures. Gram-positive bacteria were present in 23/32 (72.0%) culture isolates, gram-negative bacteria in 10/32 (31.3%) culture isolates, and six infections were polymicrobial. Staphylococcus 16/32 (50.0%) and Enterobacter 6/32 (18.8%) species were the most common isolates. Of the Staphylococcus species, 5/16 (31.3%) were MRSA. Lower extremity fractures had a greater risk for infection compared to the upper extremity (11.7% vs 3.7% p < 0.01) and fractures that developed an infection had a larger average zone of comminution (63.9 mm vs 48.5 mm p < 0.05)., Conclusion: This study investigated the rates of infection associated with long bone fractures caused by civilian gunshots. The overall infection rate observed in our series aligns with existing literature. Gram-positive bacteria were the predominant isolates, with a notable incidence of MRSA in our patient population, highlighting the need for considering empiric coverage. Additionally, gram-negative organisms were found in a significant proportion of infections, and a notable percentage of infections were polymicrobial. Our findings emphasize the importance of carefully assessing highly comminuted lower extremity fractures and implementing appropriate antibiotic coverage and operative debridement for patients with gunshot-related long bone fractures. While current prophylaxis algorithms for open fractures lack specific inclusion of gunshot wounds, we propose incorporating these injuries to reduce the incidence of infections associated with such fractures., (© 2023. The Author(s) under exclusive licence to SICOT aisbl.)

Case: A 50-year-old man presented with chronic refractory symptoms of radiating leg pain with muscle cramps because of a retained bullet in the calf after being shot in 1990. Radiographs confirmed the bullet lodged in posterolateral aspect of calf abutting proximal fibula. An intraoperative point-of-care ultrasound aided in accurate localization of bullet, thereby facilitating precise planning of surgical incision and subsequent removal., Conclusions: Ultrasound can be used as an alternative tool for safe surgical extraction of deep-seated metallic object with minimal tissue dissection, obviating the need for C-arm., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C191)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: Civilian gunshot fractures of the pelvic ring represent a unique challenge for orthopaedic surgeons due to a high incidence of complicating associated injuries. Internationally accepted guidelines for these injuries are not available. The aim of this review is to summarize the available literature and to provide concise management recommendations., Methods: Literature search was performed using PubMed. The review focuses on civilian gunshot fractures of the pelvic ring and includes the acetabulum and hip joint only where it was deemed necessary for the understanding of the management of these patients., Results: The management of civilian transpelvic gunshot fractures is complicated by potentially life-threatening associated injuries, the risk of contamination with bowel content and retained bullets in joints. The infection risk is higher compared to extremity gunshot fractures. There is no clear evidence for the use of antibiotics available. The studies focusing on civilian pelvic ring gunshot fractures reported no case of orthopaedic fracture fixation in their series. Routine wash-out and debridement of fractures is not warranted based on the literature but conflicting recommendations for surgical interventions exist., Conclusion: There is limited evidence available for civilian transpelvic gunshot fractures. The high frequency of associated injuries requires a thorough clinical examination and multidisciplinary management. We recommend routine antibiotic prophylaxis for all transpelvic gunshots. For fractures with a high risk of infection, a minimum of 24 h broad-spectrum antibiotics is recommended. The indication for orthopaedic fixation of civilian transpelvic gunshot fractures is based on the assessment of the stability of the fracture and is rarely necessary. Although conflicting recommendations exist, routine wash-out and debridement is not recommended based on the literature. Bullets buried in bone without contact to synovial fluid do not warrant removal, unless they have traversed large bowel and are accessible without undue morbidity. Furthermore, bullets should be routinely removed if they are retained in the hip joint, if mechanical irritation of soft tissues by projectiles is expected or if the bullet traversed large bowel before entering the hip joint., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Over 20% of United States adolescents are obese. A thicker layer of subcutaneous adiposity might provide a protective "armor" layer against penetrating wounds. We hypothesized that adolescents with obesity presenting after isolated thoracic and abdominal penetrating trauma have lower rates of severe injury and mortality than adolescents without obesity., Methods: The 2017-2019 Trauma Quality Improvement Program database was queried for patients between 12 and 17 years old presenting with knife or gunshot wounds. Patients with body mass index (BMI) ≥30 (obese) were compared to patients with BMI <30. Sub-analyses were performed for adolescents with isolated abdominal trauma and isolated thoracic trauma. Severe injury was defined as an abbreviated injury scale grade >3. Bivariate analyses were performed., Results: 12,181 patients were identified; 1603 (13.2%) had obesity. In isolated abdominal gunshot or knife wounds, rates of severe intra-abdominal injuries and mortality were similar (all P > .05) between groups. In isolated thoracic gunshot wounds, adolescents with obesity had a lower rate of severe thoracic injury (5.1% vs 13.4%, P = .005) but statistically similar mortality (2.2% vs 6.3%, P = .053) compared to adolescents without obesity. In isolated thoracic knife wounds, rates of severe thoracic injuries and mortality were similar (all P > .05) between groups., Discussion: Adolescent trauma patients with and without obesity presenting after isolated abdominal or thoracic knife wounds had similar rates of severe injury, operative intervention, and mortality. However, adolescents with obesity presenting after an isolated thoracic gunshot wound had a lower rate of severe injury. This may impact the future work-up and management of adolescents sustaining isolated thoracic gunshot wounds., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Management of infected distal radius nonunion with a bone defect and radiocarpal and distal radio-ulnar joint arthritis is considered an orthopaedic challenge. Although several methods have been described but none provide a satisfactory solution. Free vascularised fibula bone graft constitutes a good option to eradicate the infection, correct the deformity, compensate for the shortening and maintain motion., Material and Methods: This study included 15 cases with infected distal radius nonunion associated with bone defects. Nine cases were males and six were females. The average age of the patient was 20 years (range 8 - 60 years). The right wrist was involved in 10 patients and left was affected in 5 patients. Nine cases resulted from a motor vehicle accident, four cases after a firearm injury and two cases due to falling from a height. The average number of previous surgical procedures was three (range 2 -6). The principle of treatment was debridement, excision of distal radius and trimming of the proximal part of radius back to healthy bleeding bone, inserting the free vascularised proximal fibular bone graft to compensate the defect and fixation of the graft., Results: The procedure was successful in 13 of 15 cases. Bone union was achieved at an average of 4 months. No clinical evidence of osteomyelitis or or infection at final follow-up. Pain was completely relieved in all cases. Wrist joint range of motion averaged flexion 50˚, extension 45˚ and handgrip was the same as the normal site. Twelve cases out of 15 returned to their daily activities., Conclusion: Free vascularised proximal fibula bone graft is a new indication for the treatment of an infected distal radius nonunion with a bone defect., Competing Interests: Declaration of Competing Interest No conflict of interest., (Copyright © 2020. Published by Elsevier Ltd.)

Aim: The aim of this study is to evaluate utility and reliability of chest CT as a standalone screening modality for stable patients with thoracic GSWs and potential transmediastinal trajectories., Methods: All patients with thoracic GSWs over a 5-year period were identified. Unstable patients requiring immediate surgery were excluded and the remaining underwent chest CT with intravenous contrast. Sensitivity and specificity for clinically significant injuries were tested against an aggregate gold standard of discharge diagnosis including imaging, operative and clinical findings., Results: A total of 216 patients met inclusion criteria and underwent chest CT. After imaging, 65 (30.1%) had indication for immediate surgery, of which 10 (4.6%) underwent a thoracic procedure for chest injuries while 151 (69.9%) were selected for nonoperative management (NOM). 11 (5.1%) required a delayed thoracic operation, none due to injuries missed on CT. The remaining 140 (64.8%) underwent successful NOM. Up to 195 (90.3%) patients had successful NOM of thoracic injuries. Only 9.2% required additional imaging, all negative. CT identified a cardiac injury in one case and a vascular injury in two cases, all confirmed by surgery, while one thoracic IVC injury missed on CT was found intraoperatively. 2 patients had CT suspicious for esophageal injury, ruled out by following investigations. There was one death in the total cohort, none in the NOM group., Conclusions: Modern high-quality CT provides highly accurate and reliable screening modality for penetrating chest and mediastinal injuries and can be used as a standalone study in most patients or to guide further tests. Chest CT facilitated successful NOM., (© 2023. The Author(s).)