Early accounts of the challenges surrounding gunshot wounds (GSWs) to the elbow date back to the Great War when Lieutenant-Colonel Mansell Moullin at London General Hospital described complications such as “acute septic inflammation;” eventual ankylosis; and ultimately, “deplorable” outcomes [1]. To this day, ballistic fractures near the elbow present a management dilemma for orthopedic surgeons. The challenges are often amplified by the soft tissue density of the elbow and associated risk of concomitant neurovascular injury. Nerve injuries near the elbow occur more frequently with fractures than with any other kind of trauma [2]. The kinetic energy dissipated by a ballistic missile traversing the soft tissue may result in a spectrum of nerve injuries from transient neuropraxia to complete neurotmesis. Penetrating trauma to the upper extremity may also result in vascular injury requiring repair [3]. In rare instances, isolated penetrating trauma to the upper extremity may result in initiation of a massive transfusion protocol and even death [4].

Traditionally, ballistic fractures in the extremities have been managed with prophylactic antibiotics, early debridement, and definitive stabilization with internal fixation. Recently, there has been a trend toward early definitive fixation, primary bone grafting, and more limited use of prophylactic antibiotics [5]. However, literature on the subject is sparse; optimal management strategies and reconstructive techniques remain unknown. Treatment options for penetrating upper extremity trauma and associated juxta-articular fracture include external fixators (both uniplanar and circular) [6-8], open reduction and internal fixation (ORIF) [9], total elbow arthroplasty [10], and amputation [11]. The use of polymethylmethacrylate, primary bone grafting, the induced membrane technique, or vascularized bone transfer may be necessary in cases of significant bone loss; however, there is no consensus in the literature regarding the timing and choice of bone-filling techniques.

This uncertainty surrounding treatment of these complex injuries warrants further investigation to optimize care for these patients. The purpose of this investigation was to review our level I trauma center experience with gunshot fractures near the elbow to identify common fracture patterns, characterize associated soft tissue and neurovascular injuries, and determine the effectiveness of our current treatment strategies.

Approval from the Institutional Review Board of Baylor College of Medicine was obtained, and informed consent was not required due to the retrospective nature of the study. A retrospective review was performed to identify all patients who presented to a single urban level I trauma center from 2014 to 2018 with a periarticular gunshot fracture near the elbow. Demographic data, fracture pattern, and treatment type and outcomes were analyzed. Operative interventions, time to surgery, and antibiotic usage were recorded. Ballistic missile velocity was estimated by clinical history and radiographic fracture pattern. Low velocity was defined as less than 2,000 feet/sec and high velocity as greater than or equal to 2,000 feet/sec [12]. Fractures were classified using the AO classification system. Open fractures were classified according to the Gustilo-Anderson grading system [13]. Follow-up information was gathered if patients presented to the clinic after surgery.

Ninety-six periarticular fractures near the elbow presented to our level I trauma center during the 4-year collection period. Of these, 24 patients were identified with GSW-associated fractures. Demographic data are illustrated in Table 1. The average patient age was 38.3 years. Fourteen of the GSWs were considered low energy and 10 high energy. The location of fractures sustained are summarized in Table 2. Seven patients sustained isolated distal humerus fracture, 10 sustained isolated proximal ulna or proximal radius fracture, and seven had combined fracture pattern. Fractures are listed according to AO classification in Table 3.

Only five subjects (21%) sustained isolated GSWs to the elbow. The majority (79%) presented with multiple GSWs involving the chest, abdomen, spine, or additional extremity. Seven patients (30%) required emergent exploratory laparotomy upon arrival. Eleven patients (46%) were admitted directly to the surgical intensive care unit; the rest were admitted to lower-level nursing units.

GSWs to the elbow are challenging injuries to treat. Many factors must be considered in formulating a treatment plan, including soft tissue contamination, fracture pattern, articular involvement, the presence of nerve or vascular injury, and concomitant non-orthopedic injuries. While a relatively high number of these injuries is encountered at our level I trauma center, the overall rarity of this injury is reflected in the report by Brannon et al. [14], who described 29 GSWs to the elbow over a 10-year period.

As GSW contamination is not always apparent in the emergency department or trauma bay, the extent of surgical debridement necessary may not be known until the patient is in the operating room. All present cases underwent meticulous surgical debridement of all devitalized tissue and foreign material. Of the 24 patients treated, one was managed with staged ORIF, one required delayed definitive fixation due to preexisting deep infection and extensive fasciotomy, and 22 underwent early definitive ORIF at the time of debridement. The one staged case involved a high-velocity IIIA open fracture of the distal humerus with segmental bone loss. The surgeon determined at the time of surgery that temporary external fixation with antibiotic bead application was prudent. The patient subsequently underwent ORIF and an induced membrane technique to address the bone gap. None of the 21 cases that underwent ORIF at the time of debridement became infected. This finding suggests that early definitive fracture fixation is safe and effective in the treatment of ballistic fractures near the elbow.

Antibiotics were administered in all cases upon presentation and were discontinued within 24 hours after the last surgery. Several studies have questioned the need for IV antibiotics in the treatment of open fractures due to low-velocity GSWs [15-18]. However, since the bullet is not sterilized at the time of combustion [6,19,20] and may be a vector of infection, all ballistic fractures at our institution are managed with IV antibiotics. We typically employ a regimen of a 4th-generation cephalosporin and vancomycin. Notably, there were no cases of postoperative infection in our cohort.

The average time from presentation to surgery was just over 3 days, and in one case the patient was not cleared for surgery until 10 days after presentation. The limiting factor to orthopedic surgery was the presence of concomitant nonorthopedic injury requiring emergent surgery and/or resuscitation. These findings suggest that, in the setting of concomitant injury, surgery for an open ballistic fracture to the elbow may be safely delayed several days to allow sufficient patient stabilization and resuscitation.

Eleven patients (46%) had preoperative nerve palsy affecting the ulnar, median, and/or radial nerve. Ten of the 11 nerves were explored at the time of definitive fixation. Two of the 10 explored nerves were completely transected, while eight were in continuity. This finding confirms the contention that most nerve palsies in the context of GSWs are neuropraxic or axonotmesis but not neurotmetic injuries [21,22]. Omer [23] noted a 70% rate of spontaneous recovery in GSWs. Unfortunately, our limited patient follow-up does not allow us to comment on the rate of spontaneous recovery.

Based on the observed nerve injury patterns, our current practice is to abstain from exploring nerve injuries in the context of low-velocity GSWs to the elbow at the time of ORIF unless nerve exposure is required as part of the surgical dissection. However, we observed complete transection of the PINs in two patients with a proximal radius fracture. Although overall rates of nerve transection were low, we recommend exploration in cases of PIN palsy occurring in the context of a proximal radius fracture. Electrodiagnostic studies are not useful to distinguish between neuropraxic and axonotmetic injury [24], and we prefer to rely on serial physical examination to assess recovery. Intervention is considered if there is no noticeable improvement by 3 months after injury.

An estimated 15% of penetrating injuries to the upper extremity result in vascular injury [25]. Two patients (8%) in our cohort sustained a brachial artery injury and underwent repair. While the incidence of vascular injury is relatively low, a high level of suspicion is required due to the severity and devastating consequences of this injury. In our experience, the diagnosis of a brachial artery injury is not easy, as the patient may not present with clear signs of a dysvascular limb and distal perfusion may be present via collateral circulation. Patients with arterial injury at the level of the elbow may present in hypovolemic shock, which can lead to death [26]. When an arterial injury is present, we advocate the use of direct pressure to control hemorrhage [27]. The use of a tourniquet will compromise the collateral perfusion that is likely responsible for continued distal perfusion in cases of major arterial injury [28]. The surgical sequence of events, “fracture first” or “vascular first,” is somewhat controversial [29-31]. We prefer to proceed with rapid external fixation prior to vascular repair to protect future repair. When duration of ischemia establishes distal perfusion a priority, a temporary shunt should be applied first. Then fracture stabilization followed by definitive vascular repair can be performed.

This investigation highlights the current management principles of ballistic fractures near the elbow at a busy urban level I trauma center. Early definitive fixation without staged debridement and intravenous antibiotic administration were utilized with results similar to those reported in the literature. The study highlights many of the commonly encountered challenges in managing GSWs near the elbow, including associated nerve injury, bone loss, and follow-up impediments in this patient population. However, quantification of the impact of these factors on overall outcome is difficult.