Review Question - QID 217516

Ballistic injuries to the leg causing tibia fractures are high energy and have similar rates of infection and nonunion to blunt open tibia fractures. They should be treated as open fractures when there is exposed bone.

Tibial shaft fractures are the most common long bone fracture. The mechanism may be either a low-energy torsional injury or a high-energy mechanism such as a fall from height or ballistic injury. The controversy surrounding whether ballistic injuries should be treated as open fractures has long been debated. Recent studies have suggested that outcomes are similar to blunt open injuries, particularly when there is comminution or exposed bone. Treatment for a ballistic tibial shaft fracture typically involves thorough irrigation and debridement and intramedullary nailing.

Metcalf et al. retrospectively reviewed 211 tibia fractures and compared outcomes between closed, open, and gunshot wounds (GSWs). They found a 1% infection rate in closed injuries, 9% in GSWs, and 20% in open injuries. GSWs with large wounds, exposed tibia, and comminution had a significantly higher nonunion rate compared with blunt injuries. They concluded that GSWs with exposed bone and comminution have high complication rates and should be treated as open fractures.

Prather et al. retrospectively reviewed tibia fractures treated with an intramedullary nail and compared by a mechanism including 44 ballistic, 179 blunt closed, and 179 blunt open injuries. Compared with blunt closed injuries, ballistic injuries had more operations, more soft tissue reconstructions, and a higher incidence of compartment syndrome. Compared with open injuries, ballistic injuries had similar soft tissue reconstructions, nonunion, and infection, with a higher incidence of compartment syndrome. They concluded that outcomes from ballistic tibia fractures are comparable to open fractures and there should be a high index of suspicion for compartment syndrome.

Figure A is an oblique radiograph of the proximal tibia showing a highly comminuted fracture of the proximal third tibial shaft.

Incorrect Answers:
Answer 1: Ballistic injuries have similar rates of infection compared to blunt open injuries.
Answer 2: Ballistic tibia fractures have similar rates of soft tissue reconstruction compared to blunt open fractures.
Answer 3: Ballistic tibia fractures have a higher rate of compartment syndrome than blunt closed fractures.
Answer 4: Ballistic tibia fractures require more operations than blunt closed fractures.