ORIGINAL ARTICLE Management of Gunshot Pelvic Fractures With Bowel Injury: Is Fracture Debridement Necessary? Saqib Rehman, MD, Colin Slemenda, BS, Christopher Kestner, MD, and Siddharth Joglekar, MD Background: Low-velocity pelvic gunshot injuries occur commonly in urban trauma centers, occasionally involving concomitant intestinal viscus injury leading to potential fracture site contamination. Surgical debridement of the fractures may be necessary to prevent osteomyelitis, although not routinely performed in many centers. The purpose of this study was to determine whether fracture debridement should be done to prevent osteomy- elitis in these injuries. Methods: A 5-year retrospective review of all patients older than 12 years with low-velocity gunshot pelvic fractures was performed at an urban Level I trauma center. Medical records and radiographs/computed tomographic scans were reviewed, and data regarding fracture location, concomitant intestinal viscus injury, orthopedic surgical intervention, antibiotic treatment, and bone and/or joint infection were recorded. Results: Of a total of 103 patients identified, 19 had expired within 48 hours and were excluded, resulting in a total of 84 study subjects for review. Fifty of 84 patients (59%) had a perforated viscus with 31 large bowel injuries and 30 small bowel injuries. Eighteen patients (21%) had intra-articular fractures, 15 of which involved the hip joint. Orthopedic surgical fracture debridement was done only in intra-articular fractures with retained bullet fragments (seven cases). Deep infection occurred in one patient with a missile injury to the hip joint with concomitant intestinal spillage. Immediate joint debride- ment was performed in this case, but successful missile fragment removal was not achieved until the second debridement after 48 hours. No infections occurred in any extra-articular fractures, regardless of the presence of intestinal spillage. Conclusions: Extra-articular gunshot pelvic fractures do not require formal orthopedic fracture debridement even in cases with concomitant intestinal viscus injury. However, debridement with bullet removal should be done in cases with intra-articular involvement, particularly if there are retained bullet fragments in the joint, to prevent deep infection. Key Words: Gunshot fracture, Pelvic fracture, Infection, Firearm. (J Trauma. 2011;71: 577–581) L ow-velocity gunshot injuries from civilian firearms con- tinue to be a problem in inner city America. As a result, orthopedic surgeons are continually confronted with complex fractures of the extremities and occasionally fractures of the pelvis and spine from firearms. Although irrigation and de- bridement are frequently indicated with missile injuries with intra-articular penetration, this is not routinely done for extra- articular injuries. Management of low-velocity extra-articular gunshot injuries to the extremities is frequently done without formal operative debridement of the wound and fracture. 1 Treatment with antibiotics alone or even without antibiotics and only local wound care has been shown to be safe. Missile injuries to the pelvis and abdomen can potentially penetrate the intestines leading to fecal spillage requiring laparotomy, irrigation, and debridement, with intestinal repair or colos- tomy and antibiotic treatment. 2–7 When this same missile also penetrates the bony pelvis, there is the potential risk of fecal contamination of the pelvic fracture site, potentially requiring orthopedic fracture debridement that is not typically done as a routine part of the laparotomy. The aim of this study is to determine whether orthopedic debridement of a gunshot pel- vic fracture is necessary in cases of concomitant intestinal hollow viscus injury by performing a retrospective review at an urban Level I trauma center. MATERIALS AND METHODS An Institutional Review Board-approved retrospective chart and radiographic review of all patients older than 12 years presenting to an inner city Level I trauma center in the United States during the period 2003–2008 was performed. Both an orthopedic inpatient database and a trauma database (Pennsylvania Trauma Systems Foundation [PTSF] database) were searched for pelvic fractures with gunshot injuries. The orthopedic inpatient database did not exist before 2004, so no data from this database are available from 2003 to late 2004. Each list was cross-checked for duplicate entries. Patients were excluded if death occurred within 48 hours of injury or if the firearm was obviously a shotgun. Patients were also excluded if there was no evidence of a gunshot pelvic fracture on radiographic and computed tomographic review. To be included, a fracture of the ilium, ischium, pubis, or sacrum was required. Lumbar spine fractures were not included. Any cases with a gunshot through the pelvis to the hip joint were included. The following data were compiled after both chart and radiographic/computed tomographic review: patient age, sex, location and type of fracture, hip joint involvement, infection, presence of abdominal viscus injury, general sur- gical treatment, and orthopedic surgical treatment. Infection as diagnosed clinically and confirmed by positive cultures was a major outcome parameter. Only infections diagnosed during the index admission or requiring readmission were Submitted for publication June 18, 2010. Accepted for publication August 12, 2010. Copyright © 2011 by Lippincott Williams & Wilkins From the Department of Orthopaedic Surgery (R.R., C.S., C.K., S.J.), Temple University Hospital, Philadelphia, Pennsylvania. Presented at the Annual Meeting of the American Academy of Orthopaedic Surgeons, March 2010, New Orleans, LA. Address for reprints: Saqib Rehman, MD, Department of Orthopaedic Surgery, Temple University Hospital, 6th Floor, Outpatient Building, 3401 North Broad Street, Philadelphia, PA 19140; email: saqib.rehman@tuhs.temple.edu. DOI: 10.1097/TA.0b013e3181f6f2ff The Journal of TRAUMA ® Injury, Infection, and Critical Care • Volume 71, Number 3, September 2011 577