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CLINICAL ORTHOPAEDICS AND RELATED RESEARCHNumber 408, pp. 92–100© 2003 Lippincott Williams & Wilkins, Inc.

One hundred patients had surgical treatment fora gunshot injury to the femur at the authors’ hos-pital. Each injury was classified (Grade 1–3)based on clinical and radiographic signs of deepsoft tissue necrosis. All patients were followed upfor a minimum of 6 months (average, 18 months;range, 6 months–72 months). Grade 1 injuriesare defined by small entry and exit wounds (< 2cm) and the absence of high-energy characteris-tics on plain radiographs. Grade 2 gunshot in-juries have small wounds (< 5 cm) and radio-graphic evidence of a high-energy injury. Grade3 gunshot injuries are diagnosed by physical ex-amination whenever necrotic muscle is present atthe fracture site. Radiographs show extensive su-perficial and deep soft tissue disruption and seg-mental bone destruction. Seventy-nine patientswith Grade 1 fractures had intramedullary nail-ing without wound exploration; all fracturesunited without infection. Seven patients withGrade 2 injuries had wound exploration; anecrotic cavity was discovered in five patientsand three (43%) patients had deep infection de-velop. Fourteen patients with Grade 3 injurieshad one or more debridements followed by skele-tal stabilization, and seven patients (50%) haddeep infection develop. Important decisions re-garding wound debridement and fracture stabi-

lization are determined by examination of thewound and radiographs, and not by determiningmuzzle velocity.

An orthopaedic surgeon practicing in theUnited States rarely will encounter a patientwith a femur fracture caused by a gunshot.Less than 1⁄2 of cases reported each year presentto urban trauma centers, whereas the remain-der present to community hospitals with littleor no experience treating these injuries. Guide-lines used today for the treatment of gunshotinjuries in civilians are based on the velocityof the projectile (KE ! 1⁄2 mv2).3,8,29 Weaponsare classified according to muzzle velocity aslow-velocity (" 600 m/s, most handguns) andhigh-velocity (# 600 m/s, most military ri-fles). In the military ballistics laboratory, thezone of soft tissue destruction expands asmuzzle velocity increases.10–13 Low-velocitygunshot wounds are classified as Gustilo TypeI injuries and high-velocity gunshot woundsare classified as Gustilo Type III injuries.15,16

The recommended treatment includes imme-diate nailing of Type I injuries.14 Debride-ment, broad-spectrum antibiotics, and delayednailing are recommended for Type III in-juries.23 Leffers and Chandler19 described in-termediate-energy gunshot injuries to thetibia (680–1627 N-m). These injuries werecharacterized by highly comminuted fracturesand they had complication rates similar to

Grading System for Gunshot Injuries tothe Femoral Diaphysis in Civilians

William T. Long, MD; Wayne Chang, MD; and Earl W. Brien, MD

From the Dr. Martin Luther King/Charles Drew MedicalCenter; Los Angeles, CA.Reprint requests to William T. Long, MD, Dr. MartinLuther King/Charles Drew Medical Center, 12021 S. Wilm-ington #3024, Los Angeles, CA 90059. Phone: 310–668-4534; Fax: 310–223-0733; E-mail: sputilong@aol.com.DOI: 10.1097/01.blo.0000052644.74302.3a

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high-velocity gunshot injuries. Knowledge ofmultiple factors is necessary for an adequateunderstanding of wound production. Factorssuch as bullet caliber, mass, yaw, shape, im-pact velocity, and target tissue density all mod-ify the severity of the wound formed.6,18,23,26 Acivilian physician who treats these emergen-cies has little information regarding these bul-let characteristics and no reliable method todetermine muzzle velocity. A classificationsystem is described that provides guidelinesfor emergency surgical treatment of patientswho sustain a gunshot injury to the femoraldiaphysis.

MATERIALS AND METHODS

One hundred patients had surgical treatment for agunshot injury to the femoral diaphysis at the au-thors’ hospital between January 1993 and December1996. The study group included every patient with agunshot injury to the femoral diaphysis who wastreated surgically. The femur is divided into threezones to emphasize the risk of joint violation (Fig 1).Zone I (hip at risk) includes fractures of the femurproximal to the distal end of the lesser trochanter.Zone II (the femoral diaphysis) is defined as a frac-ture distal to the distal end of the lesser trochanter andproximal to the distal metaphyseal diaphyseal junc-tion. Zone III (knee at risk) includes fractures belowthe distal metaphyseal diaphyseal junction. Everypatient in this study had a Zone II gunshot fracture.Patients ranged in age from 18 to 58 years (mean, 36years). There were 94 men and six women. Followupwas from 6 to 72 months (mean, 18 months).

Seventy-three patients who sustained a gunshotwound from January 1993 to December 1995 werestudied retrospectively. Twenty-seven patients in-jured from January 1996 to December 1996 werestudied prospectively, and data collection beganwhen these patients presented to the orthopaedicservice. All patients had followup until the fractureunited. The medical history and clinical informa-tion were obtained by reviewing medical recordsand radiographs. Missing or incomplete data wereobtained by telephone interview or by examinationin the orthopaedic clinic at the authors’ institution.In addition to routine information, evaluation ofgunshot injuries included a description of theweapon as a handgun, rifle, or assault weapon. Pa-

tients with shotgun injuries and injuries in Zones Iand III were excluded from the study. Physical ex-amination includes the basic principles of advancedtrauma life support. A complete evaluation of gun-shot victims includes turning the patient to exam-ine the gluteal folds and crease and the poplitealspace. Each wound is identified as an entry or exitwound. The size, location, and appearance of eachwound are recorded using a diagram.

Standard radiographs include an anteroposterior(AP) view of the pelvis and AP and lateral views ofthe femur and knee. A systematic evaluation of thesoft tissues, the bone, and the bullet will providevaluable signs to identify the fracture as low-energy or high-energy. The superficial soft tissueshadows are examined for defects in the skin andsubcutaneous tissue. The deep tissues are examined

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Fig 1. Zone I (hip at risk) includes fractures of thefemur proximal to the lesser trochanter. Zone II(the femoral diaphysis) is defined as a fracturedistal to the distal end of the lesser trochanter andproximal to the distal metaphyseal diaphysealjunction. Zone III (knee at risk) includes fracturesbelow the distal metaphyseal diaphyseal junction.Every patient in the current study had a Zone IIgunshot fracture.

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for disruption of muscle and infiltration with air,bullet, and bone debris. The bone is evaluated bycounting the number of small (" 3 cm) and largefracture fragments. A fracture with greater than 10large fragments and greater than 10 small frag-ments is described as severely comminuted. Seg-mental bone destruction describes a 7-cm area ofbone that cannot be reconstructed by all of the frag-ments present on the radiograph. A retained bulletis evaluated by estimating the caliber and recordingthe size, number, and distribution of metal frag-ments. Bullet fragments combined with bone parti-cles and air provides objective evidence regardingthe area of tissue violated by the gunshot wound.

The radiographs of a low-energy gunshot showan intact soft tissue shadow. Small air infiltratesmay be present along the bullet tract but they arenot dispersed widely throughout the tissues. Com-mon low-energy fracture patterns include obliquefractures with several large fragments and severalsmall cortical fragments around the point of bulletimpact. Segmental bone destruction is not charac-teristic of low-energy gunshot injuries of the femur.The low-energy bullet appears as a solid projectile,or it may be broken into several small fragmentsalong a narrow tract (Fig 2).

The radiographic signs that are most importantin identifying a Grade 3 gunshot injury are found inthe soft tissue. A large defect in the shadow thatoutlines skin and subcutaneous tissue represents anentry or exit wound. The muscle shadow is swollenand irregular. A mixture of bone fragments, bulletfragments, and air penetrate a wide area within thethigh. Severe comminution and segmental bone de-struction are fracture patterns that characterize aGrade 3 gunshot injury (Fig 3).

Each gunshot is classified as Grade 1, 2, or 3,based on examination of the wound and the ra-diographic findings (Table 1). Grade 1 is a low-energy injury with small (" 2 cm) entrance and exitwounds. No necrotic muscle is identified duringwound examination. Radiographs show intact skinand subcutaneous tissue, and no muscle disruptionor segmental bone destruction.

A gunshot injury is classified as Grade 2 whenthe entrance and exit wounds are small (# 5 cm);however, radiographs show ominous signs of deeptissue destruction (Fig 4). Severe comminution ofthe diaphysis and segmental bone destruction callattention to these injuries. Evaluation of the soft tis-sues reveals infiltration of the muscles with air, bul-let, and bone debris.

A Grade 3 gunshot can be defined by the sizeand appearance of the entry or exit wound or by ra-diographs alone. A patient with a large (# 5 cm)devitalized entry or exit wound is classified as hav-ing a Grade 3 injury. A patient with a smallerwound (2–5 cm) also is classified as having a Grade3 injury whenever devitalized muscle is identifiedin the wound. The radiographs usually show severecomminution or segmental bone destruction. Air,bullet and bone fragments provide images that ap-proximate the size of the wound cavity. To diag-nose a Grade 3 injury solely on the basis of a radio-graph, the image must show a large defect in theskin and subcutaneous tissue or clear evidence ofdevitalized muscle at the fracture site.

All patients are given intravenous antibiotics andtetanus prophylaxis in the emergency room. Patientsclassified as having a Grade 1 injury are treated withAncef (SmithKline Beecham, Philadelphia, PA) and

Clinical Orthopaedics94 Long et al and Related Research

Fig 2. Radiographs of a low-energy gunshotshow an intact soft tissue shadow. Scant air infil-tration is present along the bullet tract. The dia-physis is comminuted and there are several largeand small fragments. The projectile consists of asolid bullet plus a few small fragments along anarrow wound channel.

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immediate or early (" 48 hours) closed reamed in-tramedullary nailing. Patients with a Grade 2 injuryare given Ancef and taken to the operating room forwound exploration. Direct examination of the softtissues determines the presence or absence of mus-cle necrosis. Muscle is considered viable if it bleedswhen cut, and the color is not pale or dusky. Con-tractility is tested by squeezing the muscle bellylightly with forceps or stimulating it with a cauterytip. Intramedullary nailing is done immediately afterthe wound exploration if the surgeon determines thatthe soft tissues are viable. Operative skin incisionsare sutured closed if doing so does not produce un-due tension at the skin edges. The bullet entry andexit wounds are not sutured closed.

When a Grade 2 injury is explored and devital-ized muscle is discovered, the patient is treated ac-cording to the protocol for patients with high-energyGrade 3 injuries. This protocol includes tetanus pro-phylaxis, broad-spectrum intravenous antibiotics,and excision of all nonviable skin, subcutaneous tis-sue, fascia, muscle, and periosteum. Free-floatingfragments of the soft tissue, bone, and bullet are re-moved (Fig 5). Periosteum with attached bone frag-ments are preserved. During the first debridement, itoften is difficult to distinguish living from dead mus-cle, especially in large wounds with extensive cavi-tation. When the viability of muscle is in doubt, orwhen bone cannot be covered with healthy living tis-sue, the skin edges are approximated over drains orsterile gauze packing, and the fracture is stabilizedby skeletal traction or external fixation. The patientis scheduled to return the operating room in 2 to 3days for wound exploration and debridement. Inter-nal fixation is done when all necrotic tissue has been

Fig 3. A high-energy gunshot injury is identifiedradiographically by disruption of the soft tissue.The thigh muscles are swollen markedly and in-filtrated with air, bone, and metal debris along awide area. Segmental bone destruction is pre-sent with numerous small and large fragments.The bullet has disintegrated and dispersedthroughout a wide area of muscle and subcuta-neous tissue. This patient had a small entrywound, no exit wound, and initially was classifiedas having a Grade 2 injury. Wound explorationconfirmed the presence of a large cavity with de-vitalized muscle.

TABLE 1. Grades for Gunshot Fractures of the Femur

Gunshot Grade Wound size and appearance Radiographs

Grade 1 " 2 cm, no devitalized muscle No defect in skin or subcutaneous tissue. Narrow tract of metal, bone and air through muscle.

Comminution with several large and small fragments.

Grade 2 "5 cm, no devitalized muscle Muscle swelling and a wide area of infiltration with metal, bone and air. Severe comminution or segmental bone loss.

Grade 3 #5 cm or 2–5 cm with devitalized muscle Same as Grade 2, plus a defect in the skin and subcutaneous tissue.

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Clinical Orthopaedics96 Long et al and Related Research

Fig 4A–B. (A) A radiograph shows a patient with a 5-cm entry wound and necrotic muscle. The radio-graphs of this Grade 3 injury show a wide area of muscle infiltrated by bullet and bone fragments. Thearrows indicate a large pocket of air where the soft tissues have been displaced or destroyed. (B) Gun-shot fractures to the femur typically heal rapidly with abundant callus. Despite severe comminution, thebone fragments maintain their blood supply and most of the periosteum remains viable.

A B

Fig 5A–B. (A) This patient had an injury that was classified as Grade 2 because the entry and exitwounds were small but the radiographs showed signs of a high-energy injury. The thigh had a 1-cmentry wound and a 2-cm exit wound and numerous small exit wounds caused by exiting fragments ofbullet and bone. (B) Exploration of the exit wound revealed a large deep cavity filled with necrotic sub-cutaneous tissue, muscle fragments, and pieces of bullet and bone. This patient’s injury shows thathigh-energy gunshot wounds do not always have large entry and exit wounds.

A B

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removed and when the bone is covered with healthysoft tissue. No patient in this study had soft tissue re-construction with a muscle flap. High-energy frac-tures with extensive soft tissue wounds initially werestabilized in traction or with external fixation. Inwounds that became infected plate and screws fixa-tion was done when the infection was resolved.

RESULTS

Thirty-four of 100 patients (34%) were able toprovide a description of the weapon as a hand-gun, rifle, or assault weapon whereas the re-maining patients could not describe the weaponresponsible for the injury. Eighty-five patientshad entry wounds and 15 had entry and exitwounds. All 79 patients with a Grade 1 injuryhad a 1- to 2-cm (small) wound. Two patientswith Grade 2 injuries had a small (" 2 cm)wound, and five patients had medium wounds(" 5 cm). Twelve patients with a Grade 3 gun-shot injury had large wounds (# 5 cm) and twopatients had medium wounds with devitalizedmuscle visible in the wound. Exit wounds werepresent in five patients with Grade 1 injuries, intwo patients with Grade 2 injuries, and in eightpatients with Grade 3 injuries. Four of the pa-tients with Grade 3 injuries and one of the pa-tients with a Grade 2 gunshot injury had multi-ple exit wounds caused by secondary missiles,bone, and metal fragments created when a high-energy bullet strikes the bone.

Seventy-nine patients were classified ashaving Grade 1 injuries; none of these patientshad a deep infection. Seven patients were clas-sified as having Grade 2 injuries; all of the pa-tients had wound exploration and deep tissuenecrosis was seen in five patients. Three pa-tients (43%) with a Grade 2 injury had a deepinfection develop. Two of these infections oc-curred in patients who had two or more de-bridements followed by intramedullary nail-ing. The third Grade 2 infection occurred in apatient who was treated with one-stage de-bridement and intramedullary nailing.

Fourteen patients had a Grade 3 injury andseven (50%) had a deep infection develop.Nine patients with Grade 3 femur fractures

were treated with multiple debridements. De-finitive treatment was external fixation in twopatients, plate fixation in two patients, and anintramedullary nail in five patients. There werefour deep infections in the nine patients withGrade 3 injuries who were treated with multipledebridements. Two patients had large necroticwounds that continued to drain despite multi-ple debridements and traction. The wounddrainage resolved and both fractures unitedafter stabilization using external fixation. Athird patient with an infected fracture wastreated with multiple debridements and an ex-ternal fixator. The fracture had no evidence ofhealing 5 months after the injury. The soft tis-sue wound was closed and dry when the frac-ture fixation was converted to a plate andscrews. Four months after the injury the frac-ture was united. A fourth patient was diag-nosed with having an infection after two de-bridements and intramedullary nailing. Thepatient had constant thigh pain, a fever, andpersistent serosanguineous drainage from thebullet entry site. After the infection was diag-nosed, the patient had three additional de-bridements with the nail in place and a 6-weekcourse of intravenous antibiotics. The fracturehealed and the nail was removed 6 months af-ter the injury.

Five patients with Grade 3 gunshot woundshad one-stage debridement and internal fixa-tion; three of these patients had a deep infec-tion develop. One of the infections was diag-nosed after intramedullary nailing in a patientwho had continued pain, serosanguineousdrainage, fever, and positive intraoperativewound cultures. The patient was treated withmultiple debridements and a 6-week course ofintravenous antibiotics. Eight months after theinjury the fracture was united but the patientwould not consent to another operation to havethe nail was removed. At 5 years followup, thepatient continued to have intermittent serosan-guineous drainage from the incision site. Thesecond patient was diagnosed with infection36 months after one-stage nailing of a seg-mental femur fracture. The patient presentedwith constant pain and drainage from the me-

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dial side of the proximal thigh. After the nailwas removed cultures confirmed infection withStaphylococcus aureus. The wound drainageand thigh pain resolved after a 6-week courseof intravenous antibiotics. The third infectionoccurred in a patient who had debridement andimmediate plate fixation of the femur after re-construction of the superficial femoral arterynear the adductor hiatus. The patient had atransfusion with 58 units of blood productswithin 48 hours of sustaining multiple gunshotinjuries. The patient had persistent serosan-guineous drainage from the thigh incision butthe fracture united 3 months after the injury.The plate was removed 7 months after the in-jury; however, 4 years after hardware removalthe patient continued to have intermittentepisodes of drainage from the incision site.

DISCUSSION

Historically, gunshot wounds have been clas-sified as low-velocity (" 600 m/s) or high-velocity (# 600 m/s). Orthopaedic surgeonshave long observed that high-velocity bulletsproduce larger wounds and are associated withmore infections than injuries caused by low-velocity bullets. Experiments done in ballis-tics laboratories have established the correla-tion between bullet velocity and soft tissuenecrosis.1,17 When the patient describes theweapon as a rifle or an assault weapon, thisshould alert the physician to the potential pres-ence of deep, devitalized tissue. Sixty-six per-cent of the patients in the current study couldnot describe the weapon that caused the femurfracture. Billings et al5 reviewed 44 civilianswith gunshot injuries to the upper and lowerextremities and found that information regard-ing the weapon that caused the injury wasrecorded only 47% of the time. A classifica-tion system for gunshot injuries in civiliansshould not rely on a description of the weaponbecause more than 1⁄2 of the patients cannotidentify the weapon and in many cases thedescription is unreliable. Knowledge of theweapon type does not always equal knowl-edge of muzzle velocity. Muzzle velocity may

be compromised by poor weapon maintenanceand old ammunition. After a bullet leaves themuzzle, it can ricochet or pass through an ob-ject before striking the victim. A high-velocityweapon can result in the production of a low-energy wound.

More serious consequences occur when alow-velocity weapon causes deep tissue de-struction that is characteristic of a high-velocityinjury. In 1988, Fackler12 used wound pro-file experiments to challenge the widespreadclaims that all high-velocity projectiles causewounds that must be treated by extensive ex-cision of tissue, whereas low-velocity bulletwounds never need debridement. The woundprofile data suggested that low-velocity bul-lets can cause large permanent cavities be-cause of the projectile-tissue interaction. Thebullet motion, shape, and fragmentation pat-tern have a marked impact on tissue disrup-tion.3 Target tissue density plays an importantrole in wound channel production, becausemore elastic tissues such as skin and musclewill stretch and sustain relatively less damagethan a nonelastic tissue such as the liver.

When the treating physician makes a deci-sion regarding treatment without knowing thetype of weapon, the appearance of the wounddictates the course of treatment. Patients withlarge devitalized wounds are treated accordingto the protocol for patients with high-energyopen femur fractures. Patients with small en-try and exit wounds are classified as havinglow-energy injuries and treatment includesearly nailing without debridement. Experiencewith more than 2000 gunshot injuries eachyear at the authors’ institution had brought at-tention to a significant number of patients whohave small bullet wounds associated with ra-diographic signs of high-energy fractures. Inthese cases, the bullet pierces the skin leavinga small entry wound. After penetrating theskin the projectile can flatten, begin to tumble,or break apart. Destructive energy is releasedinto the deep tissues creating a large perma-nent cavity. Grade 2 injuries are identified byhigh-energy radiographic features. Damageinflicted to muscle is related to the passage of

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the projectile through tissue, a secondary shockwave, and temporary cavitation. Negative pres-sure draws air and contamination into the af-fected limb and air infiltrates seen on the ra-diographs help to show the zone of tissuedisruption. The large wound cavity also isshown by the distribution of bullet and bonefragments throughout the soft tissues. Theseradiographic signs clearly show areas of tissuethat were affected by the gunshot wound. Di-rect examination of the tissues is the most ef-fective method to determine their viability.

Adequate (6 to 72 months) followup wasavailable to determine the rate of fractureunion (100%) and the incidence of deepwound infection (10%) in the 100 patients in-cluded in the current study. There were nodeep infections and no wound complicationsin 79 consecutive patients with Grade 1 in-juries. Wiss et al28 observed no infections in56 patients treated with intramedullary nail-ing of the femur for fractures caused by low-velocity gunshots. The observed low risk ofinfection in this and other studies encouragescontinued treatment of Grade 1 gunshot in-juries to the femur as closed fracture equiva-lents.7,8,14,20,22,24

There were 10 deep infections in the 100patients studied. All of the infections occurredin patients who had high-energy characteris-tics on plain radiographs. Nine of the patientswith infected femurs had a large necrotic cav-ity at the time of the initial wound debridementand the tenth patient had an ipsilateral superfi-cial femoral artery transection. The key radio-graphic findings to determine wound grade arefound in the soft tissues.26,28

There previously have been no clear guide-lines to evaluate radiographic features of thesoft tissues in gunshot injuries. No one ra-diographic finding defines a high-energy gun-shot wound. Comminution is common in low-velocity gunshot fractures of the femur andshould not be used alone as the criteria to di-agnose a high-velocity gunshot wound. Whenconsidered together, the combination of air,bullet, and bone particles provides an excel-lent radiographic image of a wound cavity or

tract. Seven patients with unremarkable woundshad wound exploration because the radio-graphs showed signs of deep tissue disruption.Two patients had wound exploration, the mus-cles appeared healthy and viable, and therewas no cavity. When this occurred, the pa-tients had one-stage wound exploration andintramedullary nailing. These two fractureshealed without any complications. In fiveother patients with Grade 2 injuries, the largedevitalized cavity was found during woundexploration. In each of these cases, surgicalexploration provided early removal of devital-ized, contaminated tissue. This approach isconsistent with the accepted principals oftreatment of other open femur fractures.4,9,25,27

In the current series, the Grade 3 gunshotinjuries were not difficult to diagnose becausedevitalized tissue was apparent by direct ex-amination of the wound. The description ofthe wound appearance and radiographic signsassociated with high-energy injuries havebeen consistent among previous authors. Thecurrent classification provides specific criteriaby which one can make the diagnosis of ahigh-energy injury based solely on radio-graphs. Treatment recommendations are basedon principles of open fracture treatment forother contaminated high-energy wounds. Ex-cision of the devitalized tissue, broad-spectrumintravenous antibiotics, and repeated debride-ment is recommended. Internal fixation shouldbe done when the wound is free of necrotic tis-sue, and the fracture is covered with healthysoft tissue.

Assessment of penetrating trauma to theextremities has its foundation in history, phys-ical examination, plain radiographs, and sur-gical wound exploration. The femur is a large,well-vascularized bone covered with thicklayers of muscle. Gunshot injuries to other ar-eas such as the sole of the foot and the spinehave unique anatomic considerations that areimportant in surgical decision-making.2,21 Thecorrelation between wound appearance, ra-diographic findings, and infection found in thefemoral diaphysis may not apply to otheranatomic regions. Additional research is indi-

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cated to determine the role of this classifica-tion system in fractures in other extremities.

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wounds to the lower extremity: Principles and treat-ment. J Foot Surg 26:228–232, 1987.

2. Ashby ME: Low-velocity gunshot wounds involvingthe knee joint: Surgical management. J Bone JointSurg 56A:1047–1053, 1974.

3. Barach E, Tomlanovich M, Nowak R: Ballistics: Apathophysiologic examination of the wounding mech-anisms of firearms: Part I. J Trauma 26:225–235,1986.

4. Behrman SW, Fabian TC, Kudsk M, Taylor JC: Im-proved outcome with femur fractures: Early vs. de-layed fixation. J Trauma 30:792–798, 1990.

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6. Brav E, Jeffress VH: Modified intramedullary nail-ing in recent gunshot fractures of the femoral shaft. JBone Joint Surg 35A:141–152, 1953.

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