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Civilian Gunshot Fractures of the Acetabulum

Background: Treatment strategies for acetabulum fractures caused by civilian firearms must
include the assessment of infection risk due to frequently associated abdominal injuries and
maintenance of joint function. Scarce literature is available on low-energy civilian gunshot
fractures of the acetabulum. The aim of the study was to increase the body of knowledge by
describing their characteristics and management at a high-volume tertiary hospital.

Materials and Methods: All adult patients admitted between January 2009 and December
2022 with civilian gunshot fractures of the acetabulum were included in this retrospective
study.

Results: We treated 52 adult patients with low-energy civilian gunshot fractures of the
acetabulum in the study period. Thirty patients (57,7%) had associated intraabdominal or
urological injuries. Fracture patterns were mostly stable fractures with minor joint
displacement (50/96,2%). Orthopaedic surgical interventions were performed in 15 patients
(28,8%) with removal of bullets in contact with the hip joint as most frequent procedure
(13/25,0%). Only one patient underwent an arthrotomy for wash-out only (1,9%) and one
patient underwent total hip replacement (1,9%). Most patients received antibiotics on
admission (47/90,4%). Infections were noted in four patients (7,7%) with two cases of septic
arthritis (3,8%). All patients with infection had bowel and/or bladder injuries. Among the 15
orthopaedic surgical interventions, there was a 13,3% infection rate. Among the patients with
infections, there were more trajectories crossing the midline, more blood products used and
more bowel before bone trajectories compared to patients without infection, statistically nonsignificant.
Among the patients with abdominal injuries, there was a higher infection rate
among the orthopaedic operative patients (22,5%) compared to non-operative (9,5%),
without statistical significance.

Conclusions: We present the largest series of civilian acetabulum gunshot fractures in the
literature. There was a frequent association with abdominal injuries (57,7%) and 7,7%
infection rate. In comparison to the literature on bowel content contaminated acetabulum
gunshot fractures, there was a lower rate of infections.
The main reason for orthopaedic surgical intervention is bullet removal. Only prospective
studies can finally answer the question of which civilian acetabulum gunshot fractures should
be washed out. Nevertheless, in absence of other indications for surgery (intraarticular bullets,
displaced fractures), we recommend careful consideration of wash-out based on risk factors
for septic hip arthritis in our study and the literature: large bowel before bone trajectories,
delay to diagnosis of hip involvement, delay of faecal diversion if the hip communicates with
injured bowel, and displaced fracture types.
 

Dr Esmee Engelmann

Research: Assessment of orthopaedic injuries caused by gunshots.