Management of high-energy wartime ballistic trauma is well established, but strategies for low-energy civilian injuries remain debated. This study analyzed injury patterns and treatment approaches for low-energy ballistic limb trauma in civilian and military French trauma centers (TCs).

We conducted a retrospective multicenter study in five Level 1 TCs (2 civilian, 3 military), including adults treated for low-energy ballistic limb injuries between 2012 and 2022. Demographics, injury mechanism and context, injury characteristics, surgical management, and outcomes were analyzed.

Among 178 patients with a mean age of 33.4 years, 124 (70%) were treated in civilian TCs and 54 (30%) in military TCs. Most injuries were bullet-related (98%), predominantly due to urban violence (86%). The patients totalized 196 injuries including 103 (53%) soft-tissue injuries and 93 (47%) open fractures. Early total care was applied in 137 (70%) cases, and damage control orthopedics (DCO) in 59 (30%). The mean ISS was significantly higher in the DCO group. Early infection occurred in 20 cases, with 13 septic recurrences. At 25-month mean follow-up, bone union was achieved in 83%, with four persistent bone infections. Upper limb injuries more frequently involved nerves and temporary stabilization with splint. DCO was used more often in military TCs, but bone union and infection rates were comparable between groups.

Despite variability in surgical strategies, outcomes were generally favorable. Low-energy ballistic limb injuries in civilian practice can often be managed according to standard open fracture principles; however, DCO may be warranted when patient-related factors (particularly associated injuries) or the clinical context require a staged approach.

IV; case series.