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 neurotoxicity anemia emesis abdominal colic 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 shot pattern load (size of individual pellet) distance from target 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 low velocity GSW with no bone involvement and clean wound edges local wound care, tetanus +/- short course of oral antibiotics indications low-velocity injury with no bone involvement or non-operative fractures technique primary closure contraindicated antibiotic use controversial but currently recommended if wound appears contaminated Operative treatment of other non-orthopedic injuries for trans-abdominal trajectories, laparotomy takes precedence over arthrotomy ORIF/external fixation indications unstable/operative fracture pattern in low-velocity gunshot injury technique treatment dictated by fracture characteristics similar to closed fracture without gunshot wound stabilize extremity with associated vascular or nerve injuries stabilize soft tissues in high velocity/high energy gunshot injuries grossly contaminated/devitalized wounds managed with aggressive debridement per open fracture protocol arthrotomy indications intra-articular missile may lead to local inflammation, arthritis and lead intoxication (plumbism) transabdominal GSW GSW to Hand/Foot Nonoperative antibiotics indications gross contamination joint penetration extent of contamination unclear Operative surgical debridement +/- ORIF/external fixation indications articular involvement unstable fractures tendon involvement superficial fragments in the palm or sole GSW to Femur Operative intramedullary nailing indications diaphyseal femur fracture secondary to low-velocity gunshot wound technique superficial wound debridement and immediate reamed nailing outcomes similar union and infection rates to closed injuries external fixation indications high-velocity gunshot wounds or close range shotgun blasts associated vascular injury temporize extremity until amenable to intramedullary nailing GSW to Spine Nonoperative broad spectrum IV antibiotics for 7-14 days indications gunshot wounds to the spine with associated perforated viscus bullets which pass through the alimentary canal and cause spinal cord injuries do not require surgical removal of the bullet Operative surgical decompression and bullet fragment removal indications when a neurologic deficit is present that correlates with radiographic findings of neurologic compression a retained bullet fragment within the spinal canal in patients with incomplete motor deficits is a relative indication for surgical excision of the fragment