The vast majority of bone injuries should be suspected by physical exam following penetrating trauma. Similar to blunt trauma, fractures produce soft-tissue swelling and hematoma, as well as significant pain. Pulsatile bleeding from the wound is generally considered a hard sign of vascular injury and should prompt early exploration. Extremities in which fractures are suspected should be splinted for comfort and to reduce bleeding during the remainder of the investigation and resuscitation. Early in the secondary survey, the extremities should be examined for adequacy of distal perfusion. If there is any concern about concomitant vascular injury, measuring an ankle-brachial index (ABI) will be helpful. Bony injury can produce spasm in the adjacent blood vessels. However, any degree of impaired perfusion should be assumed to be a named vascular injury until proven otherwise. The generally accepted threshold is an ABI of 0.9. Injuries to the upper extremities may make measuring an ABI difficult. In that case, using an uninjured lower extremity as a reference point is equally effective.

Plain films of the extremity are usually adequate to make the diagnosis of the bony injury. As with blunt trauma, all fractures are not created equal. Radiographs should be examined for fracture location, as well as degree of angulation, displacement, and comminution. In some locations, plain films may underestimate the degree of bony injury. This is most common around the knee and pelvis. Pelvic fractures secondary to gunshot wounds may not be visible on a screening pelvic x-ray. In addition, fractures of the proximal tibia, particularly the tibial plateau, may not be easily discerned on a plain x-ray. In most cases, a CT scan without IV contrast can be quite helpful in defining injury anatomy. This is fortuitous as many of these patients will undergo CT scanning for other reasons. For instance, double- or triple-contrast CT is commonly used to rule out both intra-abdominal and retroperitoneal visceral injuries in the abdomen and pelvis. Therefore, the possibility of a pelvic fracture can also be investigated. In addition, popliteal vascular injuries are relatively common with penetrating injury around the knee. CT angiography is commonly used as an investigation. Fractures of the proximal tibia can then be diagnosed concurrent with the vascular evaluation.

While all fractures following penetrating injury are technically open, they usually do not have the same degree of soft-tissue injury and exposed bone, as do open fractures following blunt trauma. Thus, a short course of antibiotic prophylaxis is probably wise and all that is needed. The urgency to stabilize open fractures or at least to perform an incision for drainage is not the same as it exists with blunt injuries. An injury from a high-velocity rifle may be an exception.

Patients with the combination of vascular and bony injuries are a special subset. Revascularization is an extremely high priority to prevent muscle ischemia and/or limb necrosis. However, bony stabilization is likewise important. A number of characteristics of injury anatomy should be taken into account when planning an operative strategy. Patients with a threatened extremity require urgent revascularization. However, those with some degree of distal perfusion do not have the same risks of muscle ischemia. This is most often determined by physical exam and/or examination with a Doppler.

The bony anatomy is likewise important. Patients with nondisplaced fractures are different than those with badly comminuted and angulated fractures in which the extremity is shortened. While it may make sense to do definitive revascularization first to prevent distal ischemia, the vascular anastomosis and/or bypass graft may then be at risk when the fracture is brought out to length. This can create tension on the anastomosis, causing thrombosis and/or complete disruption.