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 Table of Contents  
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 138-143

Outcomes of fast-track primary internal fixation of open fractures in ballistic injuries – A single-center experience

1 Department of Orthopaedics, Base Hospital, Srinagar, Jammu and Kashmir, India
2 Department of Orthopaedics, Base Hospital, Delhi Cantt, India

Date of Submission04-Jun-2021
Date of Acceptance29-Nov-2021
Date of Web Publication27-Dec-2021

Correspondence Address:
Dr. Kailash P. D. Jaidev
Department of Orthopaedics, Base Hospital, Srinagar, Jammu and Kashmir
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jotr.jotr_46_21

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Background: Open fractures due to ballistic injuries (bullets and/or splinters due to grenade blasts) have increased in the last decade. Outcome of management of such injuries depends on various factors. Purpose of this study was to frame a management protocol for primary internal fixation of such fractures without significant complications. Materials and Methods: 105 patients (117 fractures) of ballistic injuries evacuated to the trauma care center of this hospital from July 2018 to July 2019 were enrolled. After initial evaluation and optimal resuscitation, patients were considered for primary internal fixation of the fractures followed by multidepartmental rehabilitation involving a physiotherapist, a psychiatrist, and a psychotherapist. Follow-up was done at 3 months, 6 months, and 1 year after the surgery. Results: 74 fractures were due to gunshot-related injuries and 43 due to splinters from grenade blasts. Average interval between time of injury and surgery was 5.68 h. Seventeen patients required repeat debridement after initial surgery, and the subsequent wound healing was uneventful. All fractures united except 15 patients who underwent bone grafting for aseptic nonunion (6–9 months after index surgery). Only six patients were followed telephonically, else there was no loss to follow-up. The study did not encounter any mortality or infection. Conclusions: Open fractures occurring due to ballistic injuries pose a unique challenge in management. Fast-track evaluation and urgent management of the fractures by careful wound debridement and primary internal fixation have shown excellent results, with absolute zero infection rate in 1-year follow-up.

Keywords: Ballistic injuries, open fractures, primary internal fixation

How to cite this article:
Jaidev KP, Bhaskarwar AP, Ghai A. Outcomes of fast-track primary internal fixation of open fractures in ballistic injuries – A single-center experience. J Orthop Traumatol Rehabil 2021;13:138-43

How to cite this URL:
Jaidev KP, Bhaskarwar AP, Ghai A. Outcomes of fast-track primary internal fixation of open fractures in ballistic injuries – A single-center experience. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2022 Aug 10];13:138-43. Available from: https://www.jotr.in/text.asp?2021/13/2/138/333564

  Introduction Top

Ballistic trauma poses a unique challenge in terms of musculoskeletal as well as associated injuries. Due to economic and human cost factor involved in the management of such injuries, it has a huge burden on the society.[1],[2],[3] Last decade, due to increase in low-intensity conflicts other than typical war zones and availability of wide verities of fire arms, there has been a gradual increase in the number of injuries, thus prompting clinicians for refinement of management protocols. Since most of such injuries involve other organ systems as well, an initial quick and multispecialty evaluation followed by urgent management is required for a decisive outcome. Ballistic injuries occurring to extremities may be complex involving bone, musculotendinous units, and vascular and nerve injuries.[4] When long bones are involved, the result is usually comminuted open fractures with high potential of infection, thus a challenge to orthopedic surgeons.[5] A wide range of methods of management ranging from Damage Control Orthopedics (DCO) via external fixation up to internal fixation by intramedullary nailing/plating have been used.[6],[7] Others have combined both, i.e., initial external fixation followed by delayed internal fixation.[8] This approach requires a long hospital stay of the patient, multiple procedures, loss of reduction at times, delayed functional recovery, frequent outpatient department visits, and prolonged period of disability, thereby posing an economical as well as psychological burden on the patient. Hence, a timely intervention with primary definitive fixation so as to reduce the time of recovery along with robust multifaceted rehabilitation protocol, to achieve high success rate and minimal complications, is the need of hour.

  Materials and Methods Top

A prospective interventional study was conducted on 105 patients (117 fractures) sustaining ballistic injury (gunshots or splinters due to grenade blasts) brought to the tertiary care orthopedics center at Srinagar from July 2018 to July 2019. An initial approval from the institutional ethical committee was obtained vide approval No. 12/Jun/BHS/2018 dated June 15, 2018. The emphasis was to frame a protocol for primary internal fixation of such fractures without any significant complication.

Inclusion criteria

  • Patients with ballistic orthopedic injuries reporting to the trauma center which required fixation
  • Hemodynamically stable patients
  • Possible soft tissue cover
  • Salvageable limb (Ganga hospital score[9]of ≤14)
  • Patients reporting to this hospital within 8 h of injury[10] (golden hour concept).

Exclusion criteria

  • Ganga hospital score of 15 or more
  • Patients requiring urgent external fixation in view of major vessel injury, hemodynamic instability, or having associated major injury to other organ system (e.g., head, thorax, and abdomen)
  • Moribund patients.

All patients with ballistic injuries reporting at trauma care center were evaluated by a team of orthopedic surgeon, anesthetist, general surgeon, gastrointestinal surgeon, as well as vascular surgeon. A detailed primary and secondary survey along with initial resuscitation followed by clinical as well as radiological evaluation and documentation of injuries was done. Grading of open fracture was carried out according to Ganga hospital score,[9] and patients were shifted to the operation theater.

Surgical protocol


Patients were administered suitable anesthesia (general/regional). Regional anesthesia with nerve block was preferred mode for effective and prolonged postoperative pain relief which helped in early rehabilitation.

Associated injuries

Majority of the patients had musculoskeletal injuries only; however, some patients had associated injuries to face, chest, abdomen, or vascular injuries as well [Figure 1] and [Figure 2]. Their management was done after prioritization at the trauma center. More severe (life- or limb-saving) injuries were given priority.
Figure 1: Mode of injuries

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Figure 2: Distribution of injuries

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All wounds were washed initially with plenty of normal saline. A solution of 3% H2O2 and 5% povidone-iodine was used for a contact period of 3 min followed by saline wash and removal of damaged, dead, and devitalized skin and soft tissue to a healthy margin of soft issue.[11] Standard surgical approach was preferred for the fixation of fracture in patients where wounds were 5–7 cm away from the skin landmarks to avoid healing complications. Patients with wounds along the surgical approach were preferred fixation through the wound. Bullets/splinters which could be easily removed without causing any collateral damage, intra-articular splinters, and those obstructing fixation of the fractures were removed.

Orthopedic management

All fractures were managed by internal fixation with titanium implants, except for K-wires, which were of stainless steel (to maintain the uniformity of study). Distribution of implants used as per fractures are depicted in [Table 1]. Postfixation, all wounds were treated with the same concentration of H2O2 and povidone-iodine solution for 3 min of contact time and washed with a plenty of normal saline. Hemostasis was achieved and wounds closed primarily.
Table 1: Fracture region and management

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Wound closure

All patients were considered for primary closure of the wounds (at the time of surgery) or early closure (within 72 h of surgery) after achieving adequate hemostasis and without drain. Patients with possible soft tissue cover but skin loss were considered for early (within 2 weeks) reconstruction procedure (split skin graft [SSG]/fasciocutaneous flaps). Since all patients were considered for early wound closure with/without soft tissue cover, negative pressure therapy was not used.


All patients received injectable antibiotics including cefoperazone injection (1000 mg) with sulbactam (1000 mg) 12 hourly, amikacin injection (15 mg/kg/day) 24 hourly, and metronidazole injection (500 mg) 8 hourly postoperatively for 72 h. First wound inspection was done 48 h after the surgery. In case of satisfactory condition of the wound (dry suture line without any collection), the injectable antibiotics were stopped, else patients were subjected for repeat debridement and continued for another 72 h of injectable antibiotics.


Patients were discharged from the hospital after suture removal and further assessment were done at 3, 6, and 12 months after the index surgery [Figure 3], [Figure 4], [Figure 5]. An additional follow-up was advised accordingly.
Figure 3: Case 1. (a) Gunshot wound with open fracture bilateral femur. (b) Follow-up images of Case 1

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Figure 4: Case 2. (a) Gunshot wound left forearm with fracture shaft of radius. (b) Follow-up images after 12 months

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Figure 5: Case 3. Gunshot wound with open fracture shaft of humerus

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  Results Top

A total of 105 male patients (117 fractures) sustaining ballistic orthopedic injuries (gunshots or splinter injuries due to grenade blast) were enrolled for the study as per the inclusion criterion. Average age of the patients was 32.19 years. As per Gustilo–Anderson classification, out of total 117 fractures, 110 fractures were open GD III A, 6 fractures GD III B, and 1 fracture GD III C (associated vascular injury). Average time interval between the time of injury and surgery was 5.68 h (ranging from 1 h to maximum of 8 h), which included time taken for evacuation and evaluation. Various parameters were noted and subjected to statistical analysis [Table 2].
Table 2: Patient characteristics

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Primary bone grafting (fibular strut graft) was done in one patient of metacarpal fracture with bone loss [Figure 6]. Out of 105 patients, 17 patients (4 × fracture shaft femur, 2 × distal femur, 2 × proximal humerus fracture, 2 proximal tibia fracture, 4 shaft radius fractures, and 3 metatarsal fractures) required repeat debridement due to hematoma formation. Samples were sent for culture; however, no organism growth was detected. Subsequent wound inspection done after 48 h showed a dry wound with no signs of inflammation/infection. All wounds healed within 18 days postsurgery. Six patients required reconstruction surgery in the form of SSG or fasciocutaneus flap. Graft uptake was uneventful. We did not encounter infection in any of our case.
Figure 6: Case 4: Gunshot wound with open fracture third metacarpal with bone loss and extensor tendon injury

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Radiological assessment

Fifteen patients required bone grafting for delayed union (4 × femur fracture, 3 × tibia fracture, 1 × shaft radius, 3 × metatarsal fracture, 4 × metacarpal fractures) which was done after 6–9 months of the initial surgery. Union pattern in case of humerus – 73% of cases achieved union before 24 weeks and 27% showed union before 32 weeks and no nonunions.

However, in case of femur fractures, 64% achieved union by 24 weeks, 14% united before 32 weeks, and 22% had nonunion. Tibia fractures showed union in 84% cases before 24 weeks and 16% nonunion. In case of metacarpals, metatarsals, and phalanges, 70% of cases showed union before 24 weeks, 13% showed union before 32 weeks, and 17% had nonunion. All nonunions on evaluation were found to be aseptic and were managed by autologous bone grafting, resulting in subsequent union.


Patients underwent supervised rehabilitation by a team of physiotherapist, psychiatrist, and the psychological counselor during hospitalization period followed by assessment on subsequent visits.

Lost to follow-up

Out of 117 cases managed, six patients were followed telephonically, along with clinical evaluation at different centers and assessment of pictures of X-ray shared on a regular interval.

  Discussion Top

Ballistics have been discussed a lot in the past to understand the mechanism and guide treatment of orthopedic trauma.[12],[13] The amount of damage in such cases depends on various factors such as type of weapon, size and velocity of missile, and distance between the victim and weapon. Resulting damage to the soft tissue and bone is usually greater than visible, especially in the first 24 h, and thus affects the management as well as outcome of such patients when being considered for primary internal fixation. Due to the extensive nature of ballistic injuries, they have high potential of risk of infection, healing of soft tissues, and fracture union. For this reason, Gustilo and Anderson described ballistic orthopedic injuries in a “special category” (within Grade 3). Besides, variables such as time since injury, force transmitted, associated injuries, and contamination of the wound also contribute in deciding the treatment of such injuries. Although DCO being the standard of care for managing open fractures, patient's discomfort due to the external frame, pin track complications, loss of reduction (at times), and delayed union leads to longer period of recovery.[14]

The present study observes the effect of primary definitive internal fixation of fractures due to ballistic injuries. The study group was young active males and high-demand individuals with great professional commitment. Hence, an early definitive fixation of the open fracture was considered to ensure the early rejoining of professional activities. Our protocol while managing the ballistic injuries has shown promising results in terms of zero infection rate, reduced requirement of repeat surgeries, shortened hospital stay, raised patient's acceptance, as well as fracture union in majority of the cases (except 15 cases which required bone grafting for aseptic nonunion). Protocol includes (1) immediate evacuation to nearest medical facility (within 8 h); (2) early administration of first dose of antibiotics; (3) effective wound debridement and primary wound closure following fracture fixation; and (4) rehabilitation including physiotherapist and psychologist. All patients in our study were attended by medical personal at the site of injury. A prompt initial wound care (antiseptic dressing) along with an initial dose of intravenous antibiotics, as well as fastest possible evacuation, was ensured. The same fact has been reflected in a 2004 Cochrane systematic review along with few other studies showing reduced risk of infection by 59% following early administration of antibiotics in open fractures.[15],[16]

Wound debridement is the most important aspect of this protocol, especially when the fracture is being considered for internal fixation. Based on our experience of handling more than 100 ballistic cases, golden hour for primary internal fixation can be extended up to 8 h. Since the impact of such injuries is usually more than what is visible and actual demarcation is evident by 72–96 h, a thorough debridement to achieve a healthy margin is necessary. For this reason, we maintained the standard of removing a minimum of 5 mm of skin as well as muscles which otherwise looked healthy to avoid the need for repeat debridement. Initial lavage of the wound with a solution of 5% povidone-iodine + 3% H2O2 for a contact period of 3 min followed by plenty of normal saline helps to remove debris from the depth of wound (detergent action of H2O2), achieves hemostasis (coagulant action of H2O2), and also provides aseptic environment in presence of povidone-iodine.[17] Same lavage is repeated before closure of the wound so as to remove any debris if left. Emphasis should also be on judicious use of retractors, dabbing of surgical field with wet mop instead of mopping, and minimal instrumentation of soft tissue to preserve the already compromised biology. Wounds should be closed primarily with or without drains and wherever necessary a soft tissue cover (SSG or flap) in the same setting is always helpful. Studies have shown that open fractures often get contaminated with nosocomial organisms (i.e., Pseudomonas) and an early closure may help prevent these infections.[18],[19] Furthermore, immediate closure of open tibia fractures has resulted in decreased infection rates, reoperations, and time to bony union in a number of studies.[20],[21] Our study had similar results in 06 patients who underwent SSG/fasciocutaneous flap with average graft uptake period (less than 18 days). A multidisciplinary rehabilitation during immediate postoperative period ensures the physical as well as psychological balance of such patients. Minor anxiety ailments noticed during immediate postoperative period in few of our patients were managed by counseling and group therapies; however, no medication was warranted.

  Conclusion Top

Management of fractures due to ballistic injuries is a vast spectrum to be explored. Our study involving a careful debridement protocol followed by definitive primary internal fixation of such fractures showed excellent outcome with shorter hospital stay, with less operation theater visits, and without significant complications, thereby making this an effectual mode of management.


As the study population consisted of only young active males and also the total number of patients with similar fractures was small, the extrapolation of the outcome is not possible. Further, the study does not represent patients from all age group as well as socioeconomic strata. Thus, a diverse study group with prolonged follow-up will help substantiate the findings.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

No financial implications since this being a Government Services Hospital, the implants used were those supplied via Priced Vocabulary Medical Store and not procured separately for the purpose of study.

Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2]


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