We reviewed ninety-three civilian transpelvic gunshot wounds from 1998 to date. The patients were all recruited through our Trauma Unit. The first sixty were seen on a referral basis, yet for the subsequent patients we were informed on admission. Based on our earlier findings we promoted bullet tract washout, bullet removal when passed through hollow viscus, rectal stump washout and early removal of juxta-articular bullets. We review the nature of associated injuries and outcomes in relation to osteitis, osteoarthritis, nerve injuries and vascular injuries.

Fifty-seven patients had an entry wound in the buttock. This is associated with a high incidence of sciatic nerve damage (14%), extra peritoneal rectal injury (21%), juxta-articular bullets (73%) and osteitis (12%). There were fifty patients with hollow viscus injuries in various combinations. Thirteen patients overall developed osteitis (14%), of these twelve had hollow viscus injuries. Of these extra-peritoneal rectal injuries carry the highest proportion of osteitis (33%) as a complication, followed by colonic injuries (25%) and bladder (21%). Small bowel injuries (29) were not associated with any osteitis.

Peri and intra-articular injuries were grouped together totalling fifty-nine. Seven of these developed osteitis, leading to secondary osteoarthritis in all. The sciatic nerve was damaged in nine patients, and only three recovered fully. There were two femoral nerve injuries with no significant sequelae. In extra-peritoneal rectal injuries those who had early rectal stump wash-out (5/12) did not develop osteitis and yet of those not washed (5/12) three developed osteitis (60%). Tract washout has similar results. Of bullets that passed through a hollow viscus and were removed late 45% (8/18) were infected.

Our preliminary results suggest that all missile tracts should be washed out and debrided, that all bullets traversing a hollow viscus should be removed, that all peri-articular bullets be removed, and that the rectal stump be washed out in extra-peritoneal rectal injuries.

Between June 1998 and April 2006, 93 patients with trans-pelvic gunshot injuries were admitted to our hospital. Initially the management was done by general surgeons, without any orthopaedic consultation. Later a good working relationship between general surgeons and orthopaedic surgeons developed, and good co-operation was achieved.

We felt it was important to determine the direction of the bullet tract. A detailed history was taken to try and position the assailant, and the action taken by the victim. We tried to establish the number of shots that were fired, and whether any pervious gunshot injury had been sustained. We then drew an imaginary straight line between the entry and exit wound, in order to try and determine the anatomical structures that were likely to be injured by the bullet.

When x-rays were not helpful in identifying the bony injury, then a CT scan with 3D reconstruction was performed. Contrast studies such as a sinogram, a cystogram and intravenous pyelogram, combined with contrast CT, was also helpful in determining the bullet tract.

At laparotomy the entire bullet tract has to be debrided. All injured viscera are repaired, and the abdominal cavity thoroughly washed out. Any extra-peritoneal rectal injury requires a proximal colostomy, and rectal stump washout. All bullets lodged near or into a joint must be removed early, within 4 days of injury. We feel that using antibiotics alone for contaminated bullet tracts, without debriding the tract and removing the bullet from bone, does not prevent sepsis.

The purpose of the study was to assess the accuracy of prereduction and postreduction obturator oblique radiographic views in the diagnosis of simple posterior hip dislocation, and to ascertain whether, in differentiating simple posterior hip dislocations from fracture dislocation, obturator oblique views are a safe diagnostic tool in the hands of junior registrars, trauma officers and community service doctors.

A sample group of prereduction and postreduction radiographs of patients who had sustained posterior hip dislocations (Thompson and Epstein type I to III) was collected. All patients then had CT scans of the hip to confirm the plain radiographic findings.

Shown only the radiographs, all junior doctors involved in the study correctly differentiated between simple posterior hip dislocations and fracture dislocations.

This has implications for savings in both time and money. If CT scans are unnecessary in simple posterior hip dislocation, the need for transfer and tertiary level hospitalisation is obviated.

This paper highlights the fact that full length labral tears are a cause of instability in posterior fracture-dislocations of the hip.

From July 1994 to March 2001, 133 consecutive posterior fracture-dislocations of the hip were surgically treated. On admission, all patients were initially subjected to closed reduction, and in some cases skeletal or skin traction was applied. Pelvic radiographs were taken to confirm relocation, and CT done to look for intra-articular bone fragments. Intra-operative findings and surgical technique were recorded.

Redislocation occurred in eight patients, whose surgical notes were reviewed to determine the cause. Despite 9 kg of skeletal traction, one patients’s hip redislocated the day after closed reduction. In the other seven, redislocation occurred postoperatively. The time to redislocation varied from one day to 16 weeks, and because redislocation was sometimes painless, not all patients reported it immediately.

Two patients, whose radiographs showed very small fragments at the superior-posterior position, would normally have been treated conservatively. On one, surgery was performed because the fragment was lodged at the weight-bearing area of the joint. The hip of the other redislocated on skeletal traction the day after closed reduction. At surgery, it was noted that both patients had extensive soft tissue stripping and full length tears of the labrum. The other six patients had clear posterior wall fractures requiring surgical reconstruction. The fragments were often attached to the capsule but were too small to fix with screws, so buttress plating was used alone.

Full-length labral tears in posterior dislocations of the hip cause instability, and failure to address this adequately at surgery may result in redislocation.

We treated 133 traumatic posterior dislocations surgically between July 1994 and March 2001. In 16 patients, labral tears had occurred.

Operating on posterior hip dislocations, initially we fixated the posterior wall with screws and/or buttress plate, depending on the size of the fragment, and did suture the torn labrum, relying rather on the buttress plate or intact posterior wall for stability.

We began repairing the torn labrum when we realised that any small fragments still attached to the labrum simply pull out from under the buttress plate, allowing the hip to redislocate. Once the wall has been reconstructed, interrupted sutures are passed through the labrum, with the hip internally rotated to prevent shortening of the capsule when sutures are tied. A one-third tubular plate is placed over the sutures lying on the posterior wall and fixed with screws. The sutures are then tied individually over the plate. Postoperatively the patient is kept in bed for six weeks, with the hip abducted and knee extended.

Seven patients in whom the labrum was not repaired experienced redislocation. We performed second operations on two of them, repositioning the plates and reconstructing the posterior wall, but redislocation again occurred. The redislocated femoral heads were damaged because they rubbed against the plate and screws. In the other nine patients, we sutured the labrum, and in a 3 month to 2.5 year follow-up, no redislocation has occurred. .

Labral repair restores stability, and tying interrupted sutures over a buttress plate is an easy and effective method of repair.