Journal of Clinical Orthopaedics and Trauma 12 (2021) 45e49

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Journal of Clinical Orthopaedics and Trauma

journal homepage: www.elsevier.com/locate/jcot

Epidemiology of orthopaedic fractures due to firearms

Dominick V. Congiusta a, *, Jason Paul Oettinger a, Aziz M. Merchant b,
Michael M. Vosbikian a, Irfan H. Ahmed a
a
Department of Orthopaedic Surgery, Rutgers University, New Jersey Medical School, 140 Bergen Street, D-1610, Newark, NJ, 07103, USA
b
Department of Surgery, Rutgers University, New Jersey Medical School, 185 South Orange Avenue, Newark, NJ, 07103, USA

a r t i c l e i n f o a b s t r a c t

Article history: The majority of firearm injuries involve the extremities and have concomitant orthopaedic injuries.
Received 12 August 2020 National data on the epidemiology of wounds caused by firearms may better inform physicians and
Received in revised form identify areas of public health intervention. We conducted an analysis of a national database to describe
23 October 2020
the epidemiology of orthopaedic firearm injuries in the United States. The Nationwide Inpatient Sample
Accepted 24 October 2020
Available online 26 October 2020
2001e2013 database was queried for adult patients with fractures excluding those of the skull using
injury billing codes. Characterization of injury was determined using External Cause of Injury billing
codes. Sociodemographic and geographic variables were reported. Chi square and multinomial logistic
regression analyses were performed to identify predictors of type of firearm implicated in injury. 334,212
firearm injuries were reported in the database and about half had concomitant orthopaedic fractures.
Most patients were between the ages 19 and 29, were African American, and were male. The most
frequent circumstance of injury was assault/homicide, the most common firearm used was a handgun,
and the most common fracture site was the femur. Patients without insurance and patients of lower
income were most commonly afflicted. Knowing this distribution of the burden of this class of injury
provides the opportunity to identify and intervene on behalf of at-risk populations, potentially reducing
injuries by promoting firearm safety to these groups and advocating sensible practices to reduce ineq-
uitable outcomes caused by these injuries.
© 2020 Delhi Orthopedic Association. All rights reserved.

1. Introduction the epidemiology and nature of wounds due to firearms. Under-

Gun violence has been the subject of recent contentious debate
in the United States. Approximately 29% of adult residents own
firearms,1 contributing to the comparatively high rates of gun-
related homicides and accidental deaths.2,3 In addition to the
high incidence of consequent mortality and disability, estimates on
healthcare expenditure on these injuries are greater than $2 billion
dollars annually4 and cause over $20 billion in lifetime work loss
and medical costs.5 National data suggests an increasing burden of
firearm related injuries in the United States, but the risk of injury is
not evenly distributed within society, with variations in race, social
status, gender, and geographic location.6e8 As the profession
responsible for treating these injuries, physicians must be aware of
* Corresponding author.
E-mail addresses: dvc33@njms.rutgers.edu (D.V. Congiusta), jason.oettinger@
rutgers.edu (J.P. Oettinger), am1771@njms.rutgers.edu (A.M. Merchant),
vosbikmm@njms.rutgers.edu (M.M. Vosbikian), ahmedi2@njms.rutgers.edu
(I.H. Ahmed).
standing the mechanism and nature of trauma in this way is
paramount to developing new practice guidelines on an individual
and public health level.
Musculoskeletal injuries constitute a large proportion of
firearm-related admissions, with reports of frequent involvement
of the hand (30%),9 extremities (48e76%),10,11 spine (26%),12 and
pelvis (31%).12 The majority of these injuries are caused by assault
or accident.5,12 Most of the available literature reports the epide-
miology of gunshot wounds in various subsets of patients, such as
pediatric patients,12,13 or in specific anatomic locations, such as the
spine14 or hand,9 or are limited to single institutions or small
geographic areas. Other studies in orthopaedics report national
trends but do not specify the specific bone involved in the frac-
ture.8,10 Few studies aggregate data on the type of firearm used,
nature of injury, and specific clinicopathologic factors on the same
set of patients to provide a comprehensive picture of firearm
epidemiology in the United States. We therefore performed an
analysis of a nationwide dataset that synthesizes this information
relevant to the study of orthopaedic firearm injuries.

https://doi.org/10.1016/j.jcot.2020.10.047
0976-5662/© 2020 Delhi Orthopedic Association. All rights reserved.
D.V. Congiusta, J.P. Oettinger, A.M. Merchant et al. Journal of Clinical Orthopaedics and Trauma 12 (2021) 45e49

2. Methods was extracted. Sociodemographic, geographic, insurance, and me-

2.1. Data set
A retrospective analysis was conducted on the Nationwide
Inpatient Sample (NIS) 2001e2013 database. The NIS is a national
database created by the Agency for Healthcare Research and
Quality and maintained by the Healthcare Cost and Utilization
Project (HCUP). It approximates a 20% stratified sample of all dis-
charges from U.S. community hospitals, including specialty hospi-
tals and academic medical centers while excluding rehabilitation
centers, surgical centers, and long-term acute care hospitals.15 The
NIS is the largest publicly available all-payer inpatient database in
the United States, and its utilization continues to increase due to its
accessibility and validated methodology.16
Its unique design requires specific methodological consider-
ations that are detailed in the available online tutorials and docu-
mentation prior to analysis.17 In particular, a change in sampling
strategy took place beginning with 2012 data, resulting in the need
to apply trend weights for all subsequent years. Following these
recommendations, data were weighted using HCUP provided trend
and discharge weights for their appropriate years.
The NIS 2001e2013 dataset was queried for adult patients dis-
charged with a diagnosis of a fracture of bones excluding those of
the skull using ICD-9 diagnosis codes. Mechanism and character-
ization of injury was determined by using ICD-9 External Cause of
Injury codes (E-codes, Table 1). The ICD-9 E-code system specifies
type of firearm used, including handgun, shotgun, hunting rifle,
military firearm, and air gun, and classification of injury, including
assault/homicide, suicide, accident, or legal intervention. Patients
were only included if they had E-codes specifically related to fire-
arms. Patients with missing E-code data were not included, as the
cause of injury was not specified. As this study does not involve
human subjects, it was exempt from Institutional Review Board
(IRB) approval as per our institution’s policy.
2.2. Outcomes and statistical analysis
In order to assess epidemiology of firearm related fractures, the
frequency of implicated firearm type and characterization of injury
dian income quartile data were also extracted. In each case, the
presence of fracture was assumed to be caused by the firearm
specified in the corresponding E-code. We also analyzed our data
for variables associated with type of firearm implicated in the
injury through chi square and multinomial logistic regression an-
alyses. Significance was defined as p < 0.05.
3. Results
3.1. Demographic data
There 334,212 gunshot injuries were reported in the NIS data-
base, and 162,424 (50%) had concomitant orthopaedic fractures.
Patients between the ages of 19 and 29, African Americans, and
males were the predominant demographics in this population. The
majority of patients were uninsured and were admitted in the
South Atlantic region, though only 18% had data available on
geographic location (Table 2).
3.2. Firearm-related data
Mortality was low in our study population (0.4%). Weekend
admissions comprised 37% of the cohort, and the most frequent
circumstance of injury was assault/homicide. The most common
firearm used was a handgun, and the most common fracture site
was the femur (Table 3). After accounting for other sociodemo-
graphic variables, African American patients were more likely to
have been injured by handguns, shotguns, and military-style fire-
arms when compared to Caucasians. Patients who were uninsured
had increased likelihood of injury by handguns, shotguns, and
hunting rifles compared to those with private insurance. Patients
with Medicare had decreased likelihood of injury by shotgun, and
patients with Medicaid had decreased likelihood of injury by
hunting rifles. Patients in the highest income quartile had
decreased risk of injury across all firearm types (Table 4).
4. Discussion
This study presents a comprehensive epidemiologic study of

Table 1
Definitions of external cause of injury codes used for data extraction.

E code Description

E922.0 Accident caused by handgun

E922.1 Accident caused by shotgun
E922.2 Accident caused by hunting rifle
E922.3 Accident caused by military firearms
E922.4 Accident caused by air gun
E955.0 Suicide and self-inflicted injury by handgun
E955.1 Suicide and self-inflicted injury by shotgun
E955.2 Suicide and self-inflicted injury by hunting rifle
E955.3 Suicide and self-inflicted injury by military firearms
E955.4 Suicide and self-inflicted injury by other and unspecified firearm
E955.6 Suicide and self-inflicted injury by air gun
E965.0 Assault by handgun
E965.1 Assault by shotgun
E965.2 Assault by hunting rifle
E965.3 Assault by military firearms
E965.4 Assault by other and unspecified firearm
E970 Injury due to legal intervention by firearms
E985.0 Injury by handgun, undetermined whether accidently or purposely inflicted
E985.1 Injury by shotgun, undetermined whether accidently or purposely inflicted
E985.2 Injury by hunting rifle, undetermined whether accidently or purposely inflicted
E985.3 Injury by military firearms, undetermined whether accidently or purposely inflicted
E985.4 Injury by other and unspecified firearm, undetermined whether accidently or purposely
E985.6 Injury by air gun, undetermined whether accidental or purposely inflicted

46
D.V. Congiusta, J.P. Oettinger, A.M. Merchant et al. Journal of Clinical Orthopaedics and Trauma 12 (2021) 45e49

Table 2 Table 3
Demographic data. Descriptive data on firearm injuries.

Variable Frequency Variable Frequency Variable Frequency

Age Nature of Injury Admission month

19-29 39,237 (47.6%) Accident 23,402 (28.4%) January 5841 (7.1%)
30-50 25,119 (30.5%) Assault/Homicide 51,710 (62.8%) February 4588 (5.6%)
51-60 3858 (4.7%) Suicide 1738 (2.1%) March 5409 (6.6%)
61-79 2203 (2.7%) Legal Intervention 1477 (1.8%) April 6035 (7.3%)
80 306 (0.4%) Undetermined 4201 (5.1%) May 6477 (7.9%)
Race Firearm Used June 6521 (7.9%)
Caucasian 16,878 (20.5%) July 7231 (8.8%)
African American 36,703 (44.5%) Handgun 26,296 (31.9%) August 6928 (8.4%)
Hispanic 11,242 (13.6%) Shotgun 5558 (6.7%) September 6687 (8.1%)
Other 3131 (3.8%) Hunting Rifle 2621 (3.2%) October 6231 (7.6%)
Unknown 14,435 (17.5%) Military 302 (0.4%) November 6485 (7.9%)
Gender Air gun 230 (0.3%) December 6579 (8.0%)
Female 7294 (8.9%) Unspecified 46,759 (56.8%)
Median Income Quartiles Location of Fracture Mortality 367 (0.4%)
1 42,152 (51.2%)
2 19,357 (23.5%) Clavicle 1176 (1.4%) Weekend Admission 30,071 (36.5%)
3 12,391 (15%) Radius/Ulna 9408 (11.4%)
(highest) 4 5863 (7.1%) Humerus 9251 (11.2%)
Insurance Status Spine 8743 (10.6%)
Private 18,286 (22.2%) Carpal 1196 (1.5%)
Medicaid 22,240 (27%) Metacarpal 5503 (6.7%)
Medicare 3309 (4.0%) Phalanx 5633 (6.8%)
Uninsured 27,941 (33.9%) Sacrum/Coccyx 160 (0.2%)
Other 9682 (11.8%) Rib 3464 (4.2%)
Region Scapula 3259 (4.0%)
New England 325 (0.4%) Pelvis 4564 (5.5%)
Middle Atlantic 1855 (2.3%) Femur 21,044 (25.5%)
East North Central 2505 (3%) Patella 1765 (2.1%)
West North Central 890 (1.1%) Tibia/Fibula 14,740 (17.9%)
South Atlantic 3405 (4.1%) Foot/Ankle 7111 (8.6%)
East South Central 1345 (1.6%) Multiple/Ill-Defined 954 (1.2%)
West South Central 1665 (2%)
Mountain 830 (1%)
Pacific 1960 (2.4%)
Missing 67,609 (82.1%) be effective when provided with free or low-cost safety
devices.26e28
Patients in our population were often uninsured (34%) or had
publicly funded health insurance (31% Medicare and Medicaid,
bone fractures caused by firearms using a nationally representative combined), which has also been found in pediatric populations.11
dataset. Our data highlight the magnitude, mechanism, and Most patients were also in the lowest income quartile (51%),
epidemiology of these injuries. We find that half of firearm-related fitting with existing data on firearm violence and income
injuries involve orthopaedic fractures and that there is considerable levels.29,30 It is well established that patients with low income are
variability in the sociodemographic and clinicopathologic charac- at an increased risk for interpersonal violence.26 This discrepancy is
teristics of these injuries. corroborated by our findings and, in addition to differences in ed-
Studies investigating firearm violence report a disproportion- ucation and housing, may represent a target area of public health
ately large majority of injuries among non-Caucasian patients, intervention. Although the majority of patients with available
immigrants, and those in low-income areas.5,18,19 This contributes, geographic data were in the southern United States (43%), similar to
among many other factors, to the lower life expectancy of African other studies,5 most data were missing, so meaningful conclusions
Americans males compared to that of Caucasian males.20 This effect cannot be made.
may be explainable by differing life experiences in children of Mortality was low in our study population (0.4%). While some
different races. In environments where gun violence is more studies report the majority of firearm deaths are caused by sui-
prevalent, children may have more interactions with firearms, cide,5,31 we find that only 13% of deaths were by means of suicide.
increasing the likelihood of injury.21 While ethnic minorities are However, most suicides caused by firearms involve wounds to the
more likely to experience violence from firearms, Caucasians are at head and oral cavity,31 which were not identified in this dataset,
increased risk of unintentional harm and/or suicide.21 Public health and are often fatal, with only about one-third of patients surviving
interventions that target these group are needed to address long enough to arrive at a hospital.32 Of those that died in our
structural differences in society related to gun injuries. population, 75% (n ¼ 272) involved fractures to the spine and 53%
Our data on age and gender is in further agreement with the were by means of assault/homicide. We therefore show that most
existing literature,9,22,23 with the majority of patients being patients with firearm-related orthopaedic fractures survive their
younger (48% between age 19 and 29) and male (91%). Younger injuries but are at greatest risk of mortality if spinal injuries are
patients may be more likely to sustain injuries due to inexperience present. A possible mechanistic explanation might be that spinal
in handling firearms, behavioral factors, or improper transport of injuries are more likely to have concomitant injuries to the nearby
weapons. Notably, studies have shown that children develop a critical organs and vessels.
curiosity for firearms at a young age,24 emphasizing the importance The most common firearm implicated in these injuries is a
of proper handling and storage of firearms.25 While our study did handgun (32%). The majority of firearms owned in the United States
not include pediatric patients, education about gun safety may be are handguns,31 but studies show shotguns are also used in a large
necessary to preventing unnecessary injury and has been shown to number of suicides and homicides.33,34 We find that assault/

47
D.V. Congiusta, J.P. Oettinger, A.M. Merchant et al. Journal of Clinical Orthopaedics and Trauma 12 (2021) 45e49

Table 4
Predictors of type of firearm implicated in injury.

Handgun Shotgun Hunting Rifle Military

OR (95% CI) P value OR (95% CI) P value OR (95% CI) P value OR (95% CI) P value
Age (years) 1.05 (1.04e1.07) <0.001a 1.05 (1.03e1.06) <0.001a 1.04 (1.02e1.05) <0.001a 1.06 (1.04e1.07) <0.001a
Race
Caucasian Reference
Hispanic 0.96 (0.66e1.39) 0.822 0.86 (0.59e1.26) 0.437 0.21 (0.14e0.32) <0.001a 0.93 (0.54e1.62) 0.800
African American 4.98 (3.18e7.79) <0.001a 2.72 (1.73e4.28) <0.001a 1.17 (0.74e1.85) 0.513 5.52 (3.2e9.53) <0.001a
Other 0.53 (0.33e0.84) 0.008a 0.53 (0.33e0.86) 0.010a 0.21 (0.13e0.36) <0.001a 1.19 (0.61e2.32) 0.615
Males (vs. Females) 0.42 (0.22e0.82) 0.011a 0.41 (0.21e0.81) 0.010a 0.43 (0.22e0.85) 0.016a 0.29 (0.14e0.62) 0.001a
Insurance Status
Private Reference
Uninsured 1.97 (1.29e3.01) 0.002a 2.64 (1.72e4.07) <0.001a 1.74 (1.12e2.69) 0.014a 1.38 (0.79e2.43) 0.257
Medicare 0.47 (0.22e1) 0.051 0.41 (0.19e0.9) 0.025a 0.63 (0.29e1.37) 0.244 e e
Medicaid 0.89 (0.62e1.29) 0.543 1.28 (0.88e1.87) 0.191 0.61 (0.41e0.91) 0.014a 0.87 (0.52e1.46) 0.594
Other 3.08 (1.57e6.06) 0.001a 3.4 (1.71e6.72) <0.001a 2.2 (1.1e4.41) 0.026a 7.29 (3.41e15.57) <0.001a
Median Income Quartile
1 Reference
2 0.79 (0.55e1.14) 0.211 0.71 (0.49e1.03) 0.072 0.71 (0.49e1.05) 0.083 1.09 (0.68e1.75) 0.715
3 1.03 (0.66e1.6) 0.913 0.84 (0.53e1.32) 0.448 0.67 (0.42e1.07) 0.093 1.4 (0.8e2.43) 0.236
4 (highest) 0.44 (0.28e0.67) <0.001a 0.36 (0.23e0.56) <0.001a 0.36 (0.23e0.57) <0.001a 0.1 (0.04e0.27) <0.001a
D
Reference.
- Not included due to insufficient numbers for analysis.
a
Indicates significance defined as p < 0.05 with air gun as reference category.

homicide was the most common mechanism of injury (63%), and
the most frequently used firearm was a handgun (83% of assault/
homicide victims with a record of a specified firearm), though 63%
of cases did not have a specified firearm. Similarly, of patients who
attempted suicide and had record of a specified firearm, handguns
were most frequently implicated (66%).
The healthcare burden of firearms extends well beyond the
immediate consequences of the injury. Patients hospitalized with
gunshot wounds often have long term sequelae, such as permanent
disability,35 early osteoarthritis and bone loss,36 and development
of post-traumatic mental health disorders.37 We find that a large
proportion of fractures took place in the hand (15%), upper ex-
tremity (39%), and lower extremity (54%), reflecting the impact
these injuries have on lifestyle and executive function. Manage-
ment typically involves fracture fixation, debridement, revascular-
ization, amputations, replantations, nerve repair, bone lengthening,
or tendon transfers and is not without considerable risk. Medium to
poor functional outcomes can occur in up to 31% of patients with
extremity injuries caused by shotguns or rifles, and these patients
are also at risk for ICU admission, reoperation, and infection,38
reflecting the burden these fractures have on patients and the
healthcare system.
Numerous initiatives have been developed to target use of
firearms in the United States in recent years, which reflects a
change from previous policy. Congressional restrictions have
prevented research and study of firearm violence for the past
several decades.39e41 In patient populations that are afflicted by
firearm violence, however, knowledge of firearm-related injuries
can be invaluable in creating policies directed at education about
proper handling of firearms and the development of appropriate
access to them. Physicians where permitted may consider
screening patients for gun ownership, knowledge of proper
handling, substance use, and general safety in their environment.
Such data will also allow for proper resource allocation and
development of programs to improve organization and socio-
economic status of community members, both independent risk
factors for gun violence.42
There are several important limitations to our study. While the
NIS database offers the advantage of providing national epidemi-
ologic information on firearm-related injuries, it does not provide
detailed, granular information about each patient. Furthermore,
48
some variables of interest were missing from a large number of
patients, such as geographic area and type of firearm used, which
may have altered our results if they were included. As our study
focused primarily on orthopaedic fractures (i.e., fractures below the
skull), patients with head trauma were not specifically evaluated,
which may affect our mortality data. The database also has inherent
selection bias, since data only comes from patients who have been
treated as inpatients. Finally, the reliability of our data is dependent
on the accurate reporting of all studied variables. While use of ICD-
9 and E-codes are highly useful for analysis, it is important to
remember that limitations in the codes’ specificity or in the coders’
ability to gauge the situation may impact their accuracy. Impor-
tantly, it may not always be apparent the type of weapon used in
the injury, which adds some small degree of uncertainty to the
conclusion. The NIS reports billing data from a patient’s discharge
record, so any errors made during this process may change our
conclusions.
5. Conclusions
African Americans and males between the ages of 19 and 29
were the demographic populations most commonly afflicted with
firearm injuries. The most common location of fracture was the
femur and the mechanism is most commonly by assault or homi-
cide with a handgun. These patients are often from a low-income
background and commonly do not have insurance. The
geographic and demographic diversity of the data set used will
hopefully provide physicians and educators with a more complete
picture of the orthopaedic impacts of firearms.
These data may better inform the debate about the magnitude
of gun violence in the United States and lead to sound public health
interventions that can be applied to clinical practice. With a clearer
image of the landscape, this may also be the basis of further work to
develop treatment algorithms targeted toward specific subsets of
these injuries.
Funding sources
None.
D.V. Congiusta, J.P. Oettinger, A.M. Merchant et al.
CRediT authorship contribution statement
Dominick V. Congiusta: Conceptualization, Investigation,
Methodology, Project administration, Writing - original draft,
Writing - review & editing, Resources. Jason Paul Oettinger:
Investigation, Writing - original draft, Writing - review & editing,
Resources. Aziz M. Merchant: Conceptualization, Project adminis-
tration, Writing - original draft, Writing - review & editing, Su-
pervision. Michael M. Vosbikian: Conceptualization, Project
administration, Writing - original draft, Writing - review & editing,
Supervision. Irfan H. Ahmed: Conceptualization, Project adminis-
tration, Writing - original draft, Writing - review & editing,
Supervision.
Declarations of competing interest
None.
Acknowledgements
None.
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