Ballistic injuries of the pelvis and acetabulum: a narrative review

Ballistic trauma to the pelvis and acetabulum represents a small but resource-intensive subset of orthopaedic injuries. Civilian firearm violence has risen over the past two decades, with pelvic gunshot wounds (GSWs) comprising approximately 10-20% of orthopaedic ballistic injuries. Unlike military high-velocity ballistic trauma, civilian injuries are predominantly low-velocity handguns, with morbidity largely driven by associated bowel, genitourinary, vascular, and neurologic injuries. This narrative review synthesizes contemporary evidence on civilian low-velocity pelvic and acetabular GSWs, focusing on epidemiology, associated injuries, antibiotic strategies, management, and outcomes. A comprehensive search of PubMed, Embase, and Google Scholar (January 2005-January 2026) identified English-language clinical studies, systematic reviews, and case series involving pelvic or acetabular GSWs. These findings were qualitatively summarized. Extra-articular pelvic fractures are frequently stable anterior ring or iliac wing injuries managed nonoperatively after hemodynamic stabilization and contamination control. Fixation is reserved for unstable pelvic ring injuries or displaced weight-bearing structures. Operative intervention for acetabular GSWs is indicated for displaced dome involvement, instability, or intra-articular debris, while some elderly patients may benefit from acute arthroplasty. Fracture-related infection rates are low (approximately 3-9%) and primarily associated with hollow-viscus injury. Antibiotic courses longer than 24-48 hours confer no demonstrated benefit following definitive contamination control. Long-term outcomes are largely dictated by neurologic injury and post-traumatic hip arthritis. We propose a pragmatic management algorithm emphasizing early hemorrhage control, selective debridement, short-course antibiotics, stability-based fixation, and structured rehabilitation. Prospective multicenter studies are needed to refine antibiotic protocols and determine long-term functional outcomes.