In modern orthopedic trauma, ballistic fractures make up a significant portion of fractures seen in the emergency department, particularly in hospitals located in more urban areas. With 60,000–80,000 gunshot injuries annually in the United States, and half of hospital admissions for gunshot wounds needing fracture care, many orthopedic surgeons will care for a patient with a ballistic fracture. This chapter draws from our experience at our institution in combination with scientific principles to provide a framework for the management of ballistic fractures. The initial triage of these injuries, the need for antibiotics, formal wound debridement, lead poisoning considerations, the treatment of ballistic fractures associated with underlying visceral injury, and strategies for fixation are discussed.