Introduction Gun shot wounds are high energy injuries that contribute to extensive soft tissue damage and comminuted bony fractures. Epidemiology Incidence gun shot wounds represent the second-leading cause of death for youth in United States. Etiology Pathoanatomy wounding capability of a bullet directly related to its kinetic energy damage caused by passage of missile secondary shock wave cavitation exponential increase in injury with increasing velocity and efficient energy transfer fractures may be caused even without direct impact Associated conditions lead intoxication (plumbism) may be caused by intra-articular missile systemic effects include login to view 4 more bullets GSW to hip and acetabulum are most commonly associated with bowel perforation > vascular injury > urogenital injuries Classification Low velocity muzzle velocity <350 meters per second or < 1,200 feet per second most handguns except for magnums wounds comparable to Gustillo-Anderson Type I or II Intermediate velocity muzzle velocity 350-650 meters per second or 1,200-2,000 feet per second shotgun blasts highly variable depending on distance from target can reflect wounding potential of high velocity firearms from close range (less than 21 feet) or multiple low velocity weapons wound contamination/infection with close range injuries due to shotgun wadding wounding potential depends on 3 factors login to view 3 more bullets High velocity muzzle velocity >600 meters per second or >2,000 feet per second military (assault) and hunting rifles wounds comparable to Gustillo-Anderson Type III regardless of size high risk of infection secondary to wide zone of injury and devitalized tissue Presentation Symptoms pain, deformity Physical exam perform careful neurovascular exam clinical suspicion for compartment syndrome secondary to increased muscle edema from higher velocity wounds examine and document all associated wounds massive bone and soft tissue injuries occur even with low velocity weapons Imaging Radiographs obtain to identify bone involvement and/or fracture pattern CT scan identify potential intra-articular missile detect hollow viscus injury that may communicate with fracture high index of suspicion for pelvis or spine fractures given increased risk of associated bowel injury Treatment General Nonoperative local wound care indications login to view 1 more bullet local wound care, tetanus +/- short course of oral antibiotics indications login to view 2 more bullets technique login to view 2 more bullets Operative treatment of other non-orthopedic injuries for trans-abdominal trajectories, laparotomy takes precedence over arthrotomy ORIF/external fixation indications login to view 1 more bullet technique login to view 5 more bullets arthrotomy indications login to view 3 more bullets GSW to Hand/Foot Nonoperative antibiotics indications login to view 3 more bullets Operative surgical debridement +/- ORIF/external fixation indications login to view 4 more bullets GSW to Femur Operative intramedullary nailing indications login to view 1 more bullet technique login to view 1 more bullet outcomes login to view 1 more bullet external fixation indications login to view 3 more bullets GSW to Spine Nonoperative broad spectrum IV antibiotics for 7-14 days indications login to view 2 more bullets Operative surgical decompression and bullet fragment removal indications login to view 2 more bullets