Skip to main content
SpringerLink
Log in

Antibiotics in the Treatment of Low-velocity Gunshot-induced Fractures: A Systematic Literature Review

  • Symposium: Civilian Gunshot Injuries
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Low-velocity gunshots are often associated with extremity fractures. There is no consensus, however, on the use of antibiotics for these injuries.

Questions/purposes

We performed a literature review to answer the following questions: (1) Are antibiotics needed for the treatment of these fractures? (2) Is gram-negative coverage necessary? (3) How long should antibiotics be administered? And (4) which is the optimal administration route?

Methods

We conducted a MEDLINE® search and found only two relevant prospective, randomized studies. Further searches identified all case series with information on the use of antibiotics in gunshot fractures. In total, 33 studies provided enough data to answer the study questions. An assessment of the quality of the identified studies was performed. Twenty-three studies met at least ½ of the quality items of the assessment tool.

Results

Antibiotics did not significantly reduce the infection rate for fractures treated nonoperatively (1.7% with antibiotics versus 5.1% without) with the numbers available. There was no significant difference in infection rates when gram-negative coverage was added, either in nonoperatively treated fractures (1.7% versus 2.8%) or in operatively treated fractures (0% versus 2.5%). Duration of antibiotic administration did not significantly affect the infection rate. No difference was found between intravenous and oral antibiotic administration for nonoperatively treated fractures.

Conclusions

This literature review could not demonstrate a significant benefit with the use of antibiotics for low-velocity gunshot fractures treated nonoperatively; however, the statistical power for these comparisons was low in the available literature, which is insufficiently strong to recommend a treatment. Gram-negative coverage did not alter the infection rates in gunshot fractures, nor did longer duration of antibiotic administration. For fractures treated nonoperatively, oral antibiotics are as efficacious as intravenous antibiotics.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Bartkiw MJ, Sethi A, Coniglione F, Holland D, Hoard D, Colen R, Tyburski JG, Vaidya R. Civilian gunshot wounds of the hip and pelvis. J Orthop Trauma. 2010;24:645–652.

    Article  PubMed  Google Scholar 

  2. Bartlett CS, Helfet DL, Hausman MR, Strauss E. Ballistics and gunshot wounds: effects on musculoskeletal tissues. J Am Acad Orthop Surg. 2000;8:21–36.

    PubMed  CAS  Google Scholar 

  3. Bergman M, Tornetta P, Kerina M, Sandhu H, Simon G, Deysine G, Alcindor F. Femur fractures caused by gunshots: treatment by immediate reamed intramedullary nailing. J Trauma. 1993;34:783–785.

    Article  PubMed  CAS  Google Scholar 

  4. Brand R. Editorial: CORR® criteria for reporting meta-analyses. Clin Orthop Relat Res. 2012;470:3261–3262.

    Article  PubMed  Google Scholar 

  5. Brettler D, Sedlin ED, Mendes DG. Conservative treatment of low velocity gunshot wounds. Clin Orthop Relat Res. 1979;140:26–31.

    PubMed  Google Scholar 

  6. Brien WW, Kuschner SH, Brien EW, Wiss DA. The management of gunshot wounds to the femur. Orthop Clin North Am. 1995;26:133–138.

    PubMed  CAS  Google Scholar 

  7. Cannada LK, Jones TR, Guerrero-Bejarano M, Viehe T, Levy M, Farrell ED, Ostrum RF. Retrograde intramedullary nailing of femoral diaphyseal fractures caused by low-velocity gunshots. Orthopedics. 2009;32:162.

    Article  PubMed  Google Scholar 

  8. CDC. Injury Prevention & Control: Data & Statistics (WISQARS™). Available at: http://www.cdc.gov/injury/wisqars/index.html. Accessed August 12, 2012.

  9. Cooper GJ, Ryan JM. Interaction of penetrating missiles with tissues: some common misapprehensions and implications for wound management. Br J Surg. 1990;77:606–610.

    Article  PubMed  CAS  Google Scholar 

  10. Dickey RL, Barnes BC, Kearns RJ, Tullos HS. Efficacy of antibiotics in low-velocity gunshot fractures. J Orthop Trauma. 1989;3:6–10.

    Article  PubMed  CAS  Google Scholar 

  11. Dickson K, Watson TS, Haddad C, Jenne J, Harris M. Outpatient management of low-velocity gunshot-induced fractures. Orthopedics. 2001;24:951–954.

    PubMed  CAS  Google Scholar 

  12. Elstrom JA, Pankovich AM, Egwele R. Extra-articular low-velocity gunshot fractures of the radius and ulna. J Bone Joint Surg Am. 1978;60:335–341.

    PubMed  CAS  Google Scholar 

  13. Ferraro SP, Zinar DM. Management of gunshot fractures of the tibia. Orthop Clin North Am. 1995;26:181–189.

    PubMed  Google Scholar 

  14. Freeark RJ, Graivier L, Briney W, Ott R. Gunshot fractures. Q Bull Northwest Univ Med Sch. 1961;35:305–310.

    PubMed  CAS  Google Scholar 

  15. Geissler WB, Teasedall RD, Tomasin JD, Hughes JL. Management of low velocity gunshot-induced fractures. J Orthop Trauma. 1990;4:39–41.

    Article  PubMed  CAS  Google Scholar 

  16. Hall RF, Pankovich AM. Ender nailing of acute fractures of the humerus: a study of closed fixation by intramedullary nails without reaming. J Bone Joint Surg Am. 1987;69:558–567.

    PubMed  Google Scholar 

  17. Hansraj KK, Weaver LD, Todd AO, Taylor SM, Griffin MD, Dukhram KM, Judd TP, Hansraj MS. Efficacy of ceftriaxone versus cefazolin in the prophylactic management of extra-articular cortical violation of bone due to low-velocity gunshot wounds. Orthop Clin North Am. 1995;26:9–17.

    PubMed  CAS  Google Scholar 

  18. Hayden J, Cote P, Bombardier C. Evaluation of the quality of prognosis studies in systematic reviews. Ann Intern Med. 2006;144:427–437.

    Article  PubMed  Google Scholar 

  19. Hohmann E, Tetsworth K, Radziejowski MJ, Wiesniewski TF. Comparison of delayed and primary wound closure in the treatment of open tibial fractures. Arch Orthop Trauma Surg. 2007;127:131–136.

    Article  PubMed  CAS  Google Scholar 

  20. Hollmann MW, Horowitz M. Femoral fractures secondary to low velocity missiles: treatment with delayed intramedullary fixation. J Orthop Trauma. 1990;4:64–69.

    Article  PubMed  CAS  Google Scholar 

  21. Howland WS Jr, Ritchey SJ. Gunshot fractures in civilian practice: an evaluation of the results of limited surgical treatment. J Bone Joint Surg Am. 1971;53:47–55.

    PubMed  Google Scholar 

  22. Knapp TP, Patzakis MJ, Lee J, Seipel PR, Abdollahi K, Reisch RB. Comparison of intravenous and oral antibiotic therapy in the treatment of fractures caused by low-velocity gunshots: a prospective, randomized study of infection rates. J Bone Joint Surg Am. 1996;78:1167–1171.

    PubMed  CAS  Google Scholar 

  23. Leffers D, Chandler RW. Tibial fractures associated with civilian gunshot injuries. J Trauma. 1985;25:1059–1064.

    PubMed  CAS  Google Scholar 

  24. Lenihan MR, Brien WW, Gellman H, Itamura J, Kuschner SH. Fractures of the forearm resulting from low-velocity gunshot wounds. J Orthop Trauma. 1992;6:32–35.

    PubMed  CAS  Google Scholar 

  25. Levy AS, Wetzler MJ, Guttman G, Covall DJ, Fink B, Whitelaw GP, Kozin S. Treating gunshot femoral shaft fractures with immediate reamed intramedullary nailing. Orthop Rev. 1993;22:805–809.

    PubMed  CAS  Google Scholar 

  26. Long WT, Chang W, Brien EW. Grading system for gunshot injuries to the femoral diaphysis in civilians. Clin Orthop Relat Res. 2003;408:92–100.

    Article  PubMed  Google Scholar 

  27. McCormick P, McCarthy M, Broadie T, Yaw P, Glover J. Role of antibiotics in the treatment of extremity gunshot wounds. Indiana Med. 1987;80:470–472.

    PubMed  CAS  Google Scholar 

  28. Molinari RW, Yang EC, Strauss E, Einhorn TA. Timing of internal fixation in low-velocity extremity gunshot fractures. Contemp Orthop. 1994;29:335–339.

    PubMed  CAS  Google Scholar 

  29. Nicholas RM, McCoy GF. Immediate intramedullary nailing of femoral shaft fractures due to gunshots. Injury. 1995;26:257–259.

    Article  PubMed  CAS  Google Scholar 

  30. Nowotarski P, Brumback RJ. Immediate interlocking nailing of fractures of the femur caused by low- to mid-velocity gunshots. J Orthop Trauma. 1994;8:134–141.

    Article  PubMed  CAS  Google Scholar 

  31. Ordog GJ, Wasserberger J, Balasubramanium S, Shoemaker W. Civilian gunshot wounds—outpatient management. J Trauma. 1994;36:106–111.

    Article  PubMed  CAS  Google Scholar 

  32. Parisien JS. The management of gunshot fractures of the extremities. Bull Hosp Jt Dis Orthop Inst. 1981;41:28–36.

    PubMed  CAS  Google Scholar 

  33. Patzakis MJ, Harvey JP, Ivler D. The role of antibiotics in the management of open fractures. J Bone Joint Surg Am. 1974;56:532–541.

    PubMed  CAS  Google Scholar 

  34. Roth AI, Fry DE, Polk HC. Infectious morbidity in extremity fractures. J Trauma. 1986;26:757–761.

    Article  PubMed  CAS  Google Scholar 

  35. Ryan JR, Hensel RT, Salciccioli GG, Pedersen HE. Fractures of the femur secondary to low-velocity gunshot wounds. J Trauma. 1981;21:160–162.

    Article  PubMed  CAS  Google Scholar 

  36. Thoresby FP, Darlow HM. The mechanisms of primary infection of bullet wounds. Br J Surg. 1967;54:359–361.

    Article  PubMed  CAS  Google Scholar 

  37. WHO. Chapter 2: Youth violence. Available at: http://www.who.int/violence_injury_prevention/violence/global_campaign/en/chap2.pdf. Accessed August 12, 2012.

  38. Wisniewski TF, Radziejowski MJ. Gunshot fractures of the humeral shaft treated with external fixation. J Orthop Trauma. 1996;10:273–278.

    Article  PubMed  CAS  Google Scholar 

  39. Wiss DA, Brien WW, Becker V. Interlocking nailing for the treatment of femoral fractures due to gunshot wounds. J Bone Joint Surg Am. 1991;73:598–606.

    PubMed  CAS  Google Scholar 

  40. Wolf AW, Benson DR, Shoji H, Hoeprich P, Gilmore A. Autosterilization in low-velocity bullets. J Trauma. 1978;18:63.

    Article  PubMed  CAS  Google Scholar 

  41. Woloszyn JT, Uitvlugt GM, Castle ME. Management of civilian gunshot fractures of the extremities. Clin Orthop Relat Res. 1988;226:247–251.

    PubMed  Google Scholar 

  42. Wright DG, Levin JS, Esterhai JL, Heppenstall RB. Immediate internal fixation of low-velocity gunshot-related femoral fractures. J Trauma. 1993;35:678–681; discussion 681–682.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, University of Southern California, Keck School of Medicine, 1200 N State Street, GNH-3900, Los Angeles, CA, 90033, USA

    Efthymios Papasoulis MD, Michael J. Patzakis MD & Charalampos G. Zalavras MD, PhD

Authors
  1. Efthymios Papasoulis MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Michael J. Patzakis MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Charalampos G. Zalavras MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Charalampos G. Zalavras MD, PhD.

Additional information

Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

About this article

Cite this article

Papasoulis, E., Patzakis, M.J. & Zalavras, C.G. Antibiotics in the Treatment of Low-velocity Gunshot-induced Fractures: A Systematic Literature Review. Clin Orthop Relat Res 471, 3937–3944 (2013). https://doi.org/10.1007/s11999-013-2884-z

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-013-2884-z

Keywords

Search

Navigation