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Guiding the Treatment of Ballistic Fractures: A New Report Offers Education and Support for Orthopedic Surgeons

Guiding the Treatment of Ballistic Fractures: A New Report Offers Education and Support for Orthopedic Surgeons 1024 620 Alaina Doklovic

Despite firearm injury incidence and severity in children, no guidelines for orthopedic surgeons existed – until now.

Firearm-related injury is the leading cause of death in the United States among children and adolescents aged 1 to 19. Despite this alarming statistic, there were no current or up-to-date general guidelines for orthopedic surgeons on the management and treatment of ballistic fractures.

One effort to change this comes from Sean Tabaie, MD, MBA, pediatric orthopedic surgeon at Nationwide Children’s Hospital, and his collaborators. They hope to establish a new clinical and educational baseline for orthopedic surgeons. Their recent review on the topic is published in the Journal of the American Academy of Orthopaedic Surgeons.

“We developed a workforce within the Pediatric Orthopedic Society of North America trying to determine what is causing the increase in gun violence, and how we can educate our workforce and our patients and their families on things to look out for through prevention measures and risk,” says Dr. Tabaie. “We really wanted to establish a new baseline of information for current and future orthopedic practitioners.”

At Nationwide Children’s, orthopedic surgeons play a critical role in the immediate response to gunshot wounds. When bone involvement is suspected, the orthopedic team assesses and manages the injury. However, the process can be complex, especially when bone damage isn’t immediately apparent.

“This review helps clarify protocols and responsibilities,” says Dr. Tabaie. “Applying what we’ve learned from this review can help ensure care is both timely and effective.”

Unique Challenges of Ballistic Fractures

The severity of an injury often depends on factors such as:

  • fracture instability
  • risk of infection
  • proximity to critical structures including the spine, nerves or blood vessels

In children, injuries near growth plates, joints or soft tissue areas often require special attention, particularly when large bullets impact small bones or when lead contamination is a concern. The growth plate is the weakest part of a child’s bone, and injuries to these areas can disrupt the growth process. This can cause short, bent or misshapen limbs. Children younger than 10 years are more likely to experience growth issues when ballistic injuries occur near a growth plate.

The kinetic energy of a bullet plays a critical role in the severity of the injury and the level of tissue damage. Factors such as the bullet mass, initial velocity, distance from the target, and the angle deviation from the bullet’s axis determine the kinetic energy and therefore the classification of the injury. However, this kind of information is rarely available in emergency situations, so the classification of ballistic injuries should rely on wound presentation rather than the firearm category, as there is a wide variability in weapon types in these cases.

Long-term Impacts of Firearm Injuries

The review’s key findings also underscore the long-term impact of firearm injuries on children — not just physically, but psychologically. In 2024, The Centers for Disease Control and Prevention classifies firearm-related injuries as adverse childhood experiences. Prolonged stress from these experiences extend treatment, and, according to the review, can negatively affect a child’s brain development, immune response and stress-response system.

“Sadly, firearm injuries are a reality, but it’s our job to best prepare ourselves to treat the pediatric patients we see that come in with ballistic fractures,” says Dr. Tabaie. “We must always think about the lifelong impact of firearm injuries whether they are the physical impacts on the growing skeleton or the emotional and psychological impacts on the child’s well-being.”

With all firearm injuries, Dr. Tabaie and colleagues say the orthopedic community must adapt and respond. This review serves as a foundation for future research, education, and policy — ensuring surgeons are equipped to manage these complex cases and contribute to a broader movement for prevention and care.

 

References

Tabaie S, Kapadia A, Gu A, DeBritz J. Diagnosis and Management of Pediatric Ballistic Fractures. J Am Acad Orthop Surg. 2025;33(12):627-635. doi:10.5435/JAAOS-D-24-01431

 

About the author

Alaina Doklovic is a Marketing Specialist for Research Communications at Nationwide Children’s Hospital. She received her BS in medical anthropology and English from The Ohio State University. Her passions for science and health, combined with her desire to help others, motivated her to pursue a career in which she could actively help improve patient outcomes and scientific research through writing.

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