Gunshot Wounds with Associated Long-Bone Fractures
DNB Orthopaedics • October 2023 • Paper IV • Question 7 • 10 Marks [3+7]
Introduction
Gunshot injuries produce tissue damage through a combination of direct tissue disruption, energy transfer, temporary cavitation, permanent cavitation, secondary missiles and contamination. The extent of musculoskeletal injury depends on the projectile characteristics, velocity, distance, tissue struck and the stability of the projectile in flight.
A gunshot-associated long-bone fracture should be approached as a combined trauma + open fracture + possible vascular/nerve injury, with management determined by physiological status, wound severity, fracture stability and soft-tissue damage.
First priority is not the fracture: ATLS resuscitation and control of life-threatening haemorrhage come first.
A. Pathophysiology of Gunshot Wounds [3 Marks]
1. Basic Ballistic Principle
Tissue damage largely depends on the amount of kinetic energy transferred from the projectile to the tissues.
Kinetic Energy = ½ × mass × velocity²
Because velocity is squared, an increase in projectile velocity produces a disproportionately large increase in kinetic energy.
Low- vs High-Energy Gunshot Injury
| Feature | Lower-Energy Injury | Higher-Energy Injury |
|---|---|---|
| Energy transfer | Limited | Extensive |
| Soft-tissue damage | Often localized | Extensive devitalization possible |
| Cavitation | Less pronounced | Marked temporary cavitation |
| Fracture pattern | May be relatively simple |