Ballistic limb trauma: lessons from a decade of french civilian and military experience.

BACKGROUND

Ballistic limb injuries are increasingly encountered in both civilian and military settings, yet robust collaborative cohorts remain limited.

METHODS

We conducted a retrospective, multicenter study across six French trauma centers (three civilian, three military) from 2014 to 2022, including consecutive patients aged ≥ 16 years with ballistic limb injuries. Data collected included demographics, context (civilian vs. combat/terror), projectile type and velocity, lesion characteristics, and early management. The primary outcome was early surgical site infection (SSI, < 30 days). Secondary outcomes were late and persistent infection, reoperations, fracture union, and infection-free survival. Univariate tests and multivariable logistic regression identified predictors of early SSI; Kaplan–Meier analysis assessed infection-free survival after initial infection.

RESULTS

Among 254 patients (mean age 33.3 ± 12.7 years), 238 (93.7%) were male and 203 (79.9%) were civilian cases. Bullets caused 178 injuries (70.1%), pellets 47 (18.5%), and fragments 29 (11.4%); 43 injuries (16.9%) were high-velocity. Lower limbs were affected in 127 cases (50.0%), and 136 patients (53.5%) had open fractures, including 33 (13.0%) Gustilo III. Damage-control orthopedics was applied in 98 patients (38.6%), and immediate skin closure in 153 (60.2%). Early SSI occurred in 42 patients (16.5%), late infection (> 30 days) in 26 (10.2%), and persistent infection at last follow-up in 12 (4.7%). On multivariable analysis, higher SAPS II (aOR 1.075 per point; 95%CI 1.00–1.15; p = 0.040) and leg fractures (aOR 16.82; 95%CI 1.6–176; p = 0.018) independently predicted early SSI (AUC 0.872). Among 42 patients with postoperative infection, 8 (19.0%) evolved toward persistence; restricted mean infection-free survival was 64.3 ± 6.1 months, with no median reached. Military injuries more often involved high-velocity projectiles, fragments, and damage-control or reconstructive strategies.

CONCLUSION

In this large French civilian–military cohort, early SSI affected one in six patients. Physiological severity and leg fractures were independent predictors. Despite frequent early infections, long-term persistence was uncommon, supporting early physiological optimization and fracture-centered strategies in ballistic limb trauma. LEVEL OF EVIDENCE: IV.