The firearm mortality rate in West Virginia (WV) increased over the past four years and is currently 50% higher than the national rate. These alarming statistics, combined with the urban-to-rural shift in firearm injuries, prompted this 10-year epidemiologic overview. To the best of the authors’ knowledge, the current study stands alone as the only report of its kind on firearm injuries in the rural setting of southern WV. Firearm injuries were common in White males within the age range of 20–49 years. Assault, which is typically identified as an urban problem, was found to be the most common injury in the study population. In our data series, injury severity score was the strongest predictor of mortality, followed by self-inflicted cause of injury and trauma to the neck/head region.