Indications for bullet removal: overview of the literature, and clinical practice guidelines for European trauma surgeons

Endoscopic transnasal approach to remove an intraorbital bullet: systematic review and case report

Introduction

Intraorbital foreign bodies (IOFBs) represent a clinical challenge: surgical management can be controversial and different strategies have been proposed. When removal is recommended, depending on the location and nature of the IOFB both external and endoscopic approaches have been proposed, with significantly different surgical corridors to the orbit and different morbidities.

Methods

We performed a literature review of cases of IOFBs that received exclusive endoscopic transnasal surgical treatment to evaluate the role of this surgery in these occurrences. We also present a case of an intraorbital intraconal bullet that was successfully removed using an endoscopic transnasal approach with good outcomes in terms of ocular motility and visual acuity.

Results

A limited number of cases of IOFBs have been treated with an exclusive endoscopic transnasal approach. When in the medial compartment, this approach appears to be safe and effective. In our case, two months after surgery the patient showed complete recovery with no significant long-term sequelae.

Conclusions

When feasible, an endoscopic transnasal approach for intraorbital foreign bodies represents a valid surgical technique with optimal outcomes and satisfactory recovery.

Navigating the complexity of spinal cord injuries with retained foreign bodies and the diagnostic challenge of lead toxicity-a case reportaaa

INTRODUCTION

Retained shrapnel from gunshots is a common occurrence; however, retained shrapnel within the spinal canal is exceedingly uncommon. Guidelines for removal and treatment of these cases are a difficult topic, as surgical removal is not necessarily without consequence, and retention can lead to possible further injury or a secondary disease process of plumbism, which can be difficult to diagnose in this population.

CASE PRESENTATION

This case report provides a unique example of a young patient with retained shrapnel from a gunshot. This patient suffered an initial spinal cord injury due to a gunshot and secondarily presented with abdominal pain, fatigue, elevated blood lead levels, and was diagnosed with plumbism. This was addressed with operative removal of shrapnel and posterior instrumented spinal fusion, resulting in decreased lead levels and symptom resolution postoperatively.

DISCUSSION

Lead toxicity risk in patients with retained shrapnel, particularly in the spine, warrants vigilant monitoring. While management guidelines lack consensus, symptomatic lead toxicity may necessitate intervention. Residual neurological deficits complicate evaluation, emphasizing individualized management decisions.

Inflammatory low back pain with radiculopathy revealing epidural disintegration of a bullet complicated by lead poisoning

Inflammatory low back pain with radiculopathy is suggestive of cancer, infection or inflammatory diseases. We report a unique case of a 42-year-old patient with an acute inflammatory low back pain with bilateral radiculopathy associated with weight loss and abdominal pain, revealing the disintegration of a lead bullet along the epidural space and the S1 nerve root complicated by lead poisoning. Because of the high blood lead level of intoxication (>10 times over the usual lead levels) and the failure of repeated lead chelator cycles, a surgical treatment to remove bullet fragments was performed. It resulted in a significant decrease of pain and lead intoxication.

Gunshot Injuries of the Hand: Incidence, Treatment Characteristics, and Factors Associated With Healthcare Utilization

BACKGROUND

The objectives of this study are to: (1) describe the demographics, injury patterns, and treatment characteristics of patients who sustained a gunshot injury (GSI) of the hand; and (2) examine the utilization of healthcare resources in patients with a GSI of the hand.

METHODS

We retrospectively identified 148 adult patients who were treated for a GSI of the hand between January 2000 to December 2017 using multiple International Classification of Diseases Ninth and Tenth Edition (ICD-9 and ICD-10) codes. We used bivariate and multivariable analysis to identify which factors are associated with unplanned reoperation, length of hospitalization, and number of operations.

RESULTS

Multivariable logistic regression showed that fracture severity was associated with unplanned reoperation. Multivariable linear regression showed that fracture severity is associated with a higher number of hand operations after a GSI of the hand, and that a retained bullet (fragment) and patients having gunshot injuries in other regions than the hand had a longer length of hospitalization. Seventy (47%) patients had sensory or motor symptoms in the hand after their GSI, of which 22 (15%) patients had a transection of the nerve.

CONCLUSIONS

Sensory and motor nerve deficits are common after a GSI of the hand. However, only 31% of patients with symptoms had a transection of the nerve. A retained bullet (fragment), having more severe hand fractures, and GSI in other regions than the hand are associated with a higher number of operation and a longer period of hospitalization.

Lead toxicity due to retained intracranial bullet fragments: illustrative case

BACKGROUND

Lead toxicity (plumbism) secondary to retained lead bullet fragments is a rare complication in patients with gunshot wounds. To the authors' knowledge, there has been no definitive case reported of lead toxicity due to retained intracranial bullet fragments.

OBSERVATIONS

The authors reported the case of a 23-year-old man who presented after being found down. Computed tomography scanning of the head revealed bullet fragments within the calvaria adjacent to the left transverse sinus. During follow-up, he developed symptoms of plumbism with paresthesias in his bilateral hands and thighs, abdominal cramping, labile mood, and intermittent psychosis. Plumbism was confirmed with sequentially elevated blood lead levels (BLLs). The patient opted for surgical removal of the bullet fragments, which led to reduction in BLLs and resolution of his symptoms.

LESSONS

Although rare, lead toxicity from retained intracranial bullet fragments should be considered in patients who have suffered a gunshot wound to the head and have symptoms of lead toxicity with elevated BLLs. For safe and accessible intracranial bullet fragments in patients with plumbism, surgical intervention may be indicated.

Retained bullets and lead toxicity: a systematic review

INTRODUCTION

Lead toxicity secondary to retained bullet(s) (RB) after a penetrating gunshot wound is a rare but likely underdiagnosed condition, given the substantial number of firearm injuries in the United States. There is currently no consensus on the indications for surveillance, chelation, or surgical intervention.

OBJECTIVE

The purpose of our review is to summarize the literature on systemic lead toxicity secondary to RBs to help guide clinicians in the management of these patients.

METHODOLOGY

The primary literature search was conducted in Medline (PubMed), EMBASE, Cochrane, and CENTRAL using the following MESH terms: "chelation" and "lead poisoning" or "lead toxicity" or "lead" and "bullet" or "missile" or "gunshot", or "bullet".

RESULTS

The search identified 1,082 articles. After exclusions, a total of 142 articles were included in our final review, the majority of which were case reports. Several factors appear to increase the risk of developing lead toxicity including the location of the RB, the presence of a fracture or recent trauma, number of fragments, hypermetabolic states, and bullet retention duration. Particularly, RBs located within a body fluid compartment like an intra-articular space appear to be at a substantially higher risk of developing lead toxicity. Even though patients with lead toxicity from RBs will have similar symptoms to patients with lead toxicity from other sources, the diagnosis of lead poisoning may occur months or years after a gunshot wound. Symptomatic patients with high blood lead levels (BLLs) tended to improve with a combination of chelation and surgical removal of RBs.

CONCLUSIONS

We suggest surveillance with serial BLLs should be performed. Patients with intra-articular RBs appear to be at increased risk of lead toxicity and if possible, early surgical removal of the RBs is warranted, especially given that signs of toxicity are vague, and patients may not have access to follow-up. Long-term chelation should not be used as a surgical alternative and management should be multidisciplinary.

Gunshot Wounds: Ballistics, Pathology, and Treatment Recommendations, with a Focus on Retained Bullets

As the epidemic of gunshot injuries and firearm fatalities continues to proliferate in the United States, knowledge regarding gunshot wound (GSW) injury and management is increasingly relevant to health-care providers. Unfortunately, existing guidelines are largely outdated, written in a time that high-velocity weapons and deforming bullets were chiefly restricted to military use. Advances in firearm technology and increased accessibility of military grade firearms to civilians has exacerbated the nature of domestic GSW injury and complicated clinical decision-making, as these weapons are associated with increased tissue damage and often result in retained bullets. Currently, there is a lack of literature addressing recent advances in the field of projectile-related trauma, specifically injuries with retained bullets. This review aims to aggregate the available yet dispersed findings regarding ballistics, GSW etiology, and treatment, particularly for cases involving retained projectiles.

Low-velocity, civilian firearm extremity injuries-review and update for radiologists

Firearm injuries are a preventable epidemic in the USA. Extremities are commonly affected in gunshot injuries. Such injuries may be complex with concomitant osseous, soft tissue, and neurovascular components. The maximum wounding potential of a projectile is determined by its kinetic energy and the proportion of the kinetic energy that is transmitted to the target. Accurate assessment of ballistic injuries is dependent on utilizing the principles of wound ballistics, accurate bullet count, and ballistic trajectory analysis. The goals of this article are to review wound ballistics and the imaging evaluation of extremity civilian firearm injuries in the adult population, with emphasis on ballistic trajectory analysis, specific ballistic fracture patterns, and diffuse, secondary soft tissue ballistic injuries.

Air guns and their wider relevance to the dental profession

Crimes involving air guns have declined over the last 16 years in England and Wales; however, still represent a significant occurrence, with 3,028 crimes involving air guns reported in 2019 (just under one-third of all firearm crime). We aim to present points regarding air gun injuries and their wider relevance to the dental profession which have not been covered in previous publications.This article covers air gun licensing in the UK and the relevant safeguarding issues, as well as optimal imaging of suspected retained pellets in the head and neck.Whilst there are numerous case reports of retained air gun pellets found in various regions of the head and neck, only a handful of papers discuss the issues in leaving retained pellets or a surgical approach to removal of these pellets. This article summarises the current approaches and provides a suggested protocol for the management of pellets in the head and neck, as well as highlighting the need for further development in this field.Air gun pellets as retained foreign bodies may be identified on routine examination of the head and neck, both in general dental practice and in oral and maxillofacial surgery departments. This article acts as an overview and guide for dental professionals to gain a wider understanding of these injuries and their management.

Retained Bullets After Firearm Injury: A Survey on Surgeon Practice Patterns

Retained bullets are common after firearm injuries, yet their management remains poorly defined. Surgeon members of the Eastern Association for the Surgery of Trauma (N = 427) were surveyed using an anonymous, web-based questionnaire during Spring 2016. Indications for bullet removal and practice patterns surrounding this theme were queried. Also, habits around screening and diagnosing psychological illness in victims of firearm injury were asked. Most respondents were male (76.5%, n = 327) and practiced at urban (84.3%, n = 360), academic (88.3%, n = 377), Level 1 trauma centers (72.8%, n = 311). Only 14.5% (n = 62) of surgeons had institutional policies for bullet removal and 5.6% (n = 24) were likely to remove bullets. Half of the surgeons (52.0%, n = 222) preferred to remove bullets after the index hospitalization and pain (88.1%, n = 376) and a palpable bullet (71.2%, n = 304) were the most frequent indications for removal. Having the opportunity to follow-up with patients to discuss bullet removal was significantly predictive of removal (odds ratio (OR) = 2.25, 95% confidence interval (CI) = [1.05, 4.85], p = .04). Furthermore, routinely asking about retained bullets during outpatient follow-up was predictive of new psychological illness screening (OR = 1.94, 95% CI [1.19, 3.16], p = .01) and diagnosis (OR = 1.86, 95% CI = [1.12, 3.09], p = .02) in victims of firearm injury. Thus, surgeons should be encouraged to allot time for patients concerning retained bullet management so that a shared decision can be reached.

Orbito-Cranial Gunshot Injuries with Retained Sinonasal Bullets

Introduction

Gunshot injuries to the sino-orbital region are rare. In South Africa, where gunshot injuries are common, sino-orbital gunshot injuries are encountered. Sino-orbital gunshot injuries are associated with trauma to surrounding facial and intracranial structures. Therefore, the management of these injuries may be complex and often requires an interdisciplinary approach.

Aims

To review the management of orbito-cranial gunshot injuries with retained sinonasal bullets.

Patients and methods

Three cases of orbito-cranial gunshot injuries with retained sinonasal bullets were reviewed. Two cases were complicated by cerebrospinal fluid leaks with ensuing meningitis. The retained bullets in all three cases were successfully removed via a transnasal endoscopic approach.

Conclusion

Sino-orbital gunshot injuries are rare, but may be encountered in areas with high frequencies of gun violence. An associated anterior skull base fracture with CSF rhinorrhoea poses a risk for meningitis and a low threshold for diagnosis and treatment of meningitis should be maintained. Retained bullets in the paranasal sinuses do not pose an immediate risk and may be removed on an elective basis.

Multiple sites bullet embolism as a cause of acute abdomen

Bullet embolism (BE) is a rare and misdiagnosed phenomenon that can significantly affect the cardiovascular system. It occurs when a bullet enters and migrates through the body vessels in gunshot victims. We report in this article a case of a 25-year-old male patient, victim of penetrating trauma caused by a firearm projectile that presented two embolism destinations with acute ischemic repercussions: the right brachial artery and the branches of the superior mesenteric artery. We quickly performed surgical exploration to assess the level of ischemia and resect the foreign body. To the best of the authors' knowledge, this is the only case of acute vascular abdomen due to BE in the literature. There is no standard treatment for BE, and each case should be studied according to signs and symptoms while considering the risks of the destination vessel for the victim. Imaging is necessary for early diagnosis, and the medical team must be aware of multiple and extraordinary critical ischemia presentations when bullet trajectory suggests embolism.

A rare case of retained sabot after close-range shotgun injury

Background

Shotgun injuries are a relatively uncommon type of trauma, and therefore may present a challenge in management for trauma surgeons. This is particularly true in the case of surgeons unfamiliar with the unique characteristics of shotgun wounds and the mechanics of shotguns. In many cases, the shot pellets are the primary source of injury. However, a broad understanding of shotgun mechanics is important in recognizing alternative presentations. This article details a case of sabot (a stabilization device used with certain projectiles) retention after a close-range shotgun injury, reviews underlying shotgun mechanics, and discusses strategies for the detection and mitigation of these injuries. The aim of this case report is to increase awareness of and reduce the potential morbidity of close-range shotgun injuries.

Case presentation

A middle-aged female presented to the Emergency Department with wounds to her right hip and flank after suffering a shotgun injury. A contrast computed tomography scan demonstrated no evidence of hollow viscous or vascular injury, but was otherwise severely limited by scatter artifact from the numerous embedded pellets. The patient was admitted for wound care and discharged 2 days later with a clean wound bed and no evidence of tissue necrosis. Six days after injury, she reported an “unusual” smell associated with severe pain in her right hip wound. She was evaluated in clinic where examination revealed a retained foreign body, identified to be a shotgun shell sabot, which was removed in clinic. She presented again several days before scheduled follow-up with a persistent foul smell from her wound and was noted to have necrotic tissue at the base and margins of the wound that required hospital readmission for operative debridement and closure with negative pressure wound therapy. The patient had an uncomplicated recovery after surgical debridement.

Conclusions

Although shotgun sabot penetration and retention are rare, they are associated with significant morbidity. Sabot penetration should be considered if injury narrative, physical examination, or radiographic characteristics indicate a distance from shotgun to patient of less than 2 m. A high degree of suspicion is indicated at less than 1 m.

The impact of retained bullet fragments on outcomes in patients with gunshot wounds

BACKGROUND

Nationally, 115,000 non-fatal firearm injuries occurred in 2017, with many such victims possessing retained bullet fragments (RBFs); however, the impact of RBFs has not been well studied.

METHODS

An institutional trauma database from an urban, level one trauma center was queried for patients presenting with gunshot wounds (GSWs) to the ED in 2017. GSWs were stratified by the presence or absence of RBFs. Groups were compared using t-tests, chi-squared, and logistic regression.

RESULTS

Of 674 patients with GSWs who met inclusion criteria, 394 had RBFs versus 280 with no RBFs. Patients with RBFs were more likely admitted from the ED (57.4% vs. 41.8%, p < 0.001), had significantly higher rates of return to the ED within six months (30.7% vs. 18.6%, p < 0.001), and higher rates of subsequent GSW in the next year (5.1% vs. 1.8%, p = 0.03). On return to ED, 17.6% of those with a RBF had symptoms associated with their RBF.

CONCLUSION

RBFs may represent an unrecognized risk factor for both repeat ED visits and subsequent bullet injury.

Abdominal Aorta Bullet Embolism: Presentation and Management

Penetrating cardiac injury (PCI) secondary to a gunshot wound presents with several complications and a mortality rate of 94% before reaching the hospital. Current literature search reveals that embolism of bullet fragments after gunshot wounds are exceptionally rare. Additionally, no reported case was found regarding bullet embolism following left atrium penetration at the time of this case report. This case describes a 34-year-old male who presented to a level I trauma center after sustaining a gunshot wound to the posterior torso. Imaging demonstrated several fragments in the mid-thoracic region in addition to the primary bullet fragment located within the aorta at the bifurcation of the iliac arteries likely due to left atrial penetration and subsequent embolization.

Retained Shotgun Pellets in the Vulva: Case Report

BACKGROUND

Vulvar trauma is relatively uncommon and typically occurs in accidental or sports-related injuries. There is limited literature for management of penetrating trauma to the vulva.

CASE

A 38-year-old G9, P9 woman presented to the gynaecology service for assessment of vulvar injury after a gunshot wound to the right lateral thigh. She underwent initial stabilization and operative management by the Trauma and Plastic Surgery services for predominantly soft-tissue injuries. Multiple gunshot pellets were found embedded in the right labia majora and medial thigh. On assessment, surgical removal was deemed necessary on the basis of symptoms and potential for functional impairment.

CONCLUSION

We present the first reported case on the management of vulvar injury secondary to penetrating trauma. The principles of non-obstetrical vulvar trauma management are discussed.

Management of upper extremity war injuries in the subacute period: A review of 62 cases

OBJECTIVE

In this study, we aimed to describe the relationship between the localization of rarely seen upper extremity war injuries and their complications in the subacute period, and define our preferences for surgery and antibiotic use.

METHODS

Patients with an upper extremity war injury who presented to our institution between 2015 and 2018 were retrospectively evaluated. Data regarding demographics, time between injury and presentation, location of injury, type of damage, complications, treatment methods, infection rates and antibiotic use were recorded. Tissue defects, fracture fixation, neurovascular damage, infection development and treatment approaches were analyzed.

RESULTS

Sixty-two male patients with isolated upper extremity injuries (mean age: 31.66 ± 8.28 years) were included in the study. The average time between trauma and hospitalization was 14 days. The mean hematocrit (Hct) level at presentation was 36.3 ± 6.8%. Patients had been followed up for an average period of 95.6 ± 32.1 days. Twenty-nine patients (46.8%) had nerve injury, eight (12.9%) had arterial injury that required repair, and 23 had infection (37.1%), of which five developed osteomyelitis. Infection was polymicrobial in nine cases and monobacterial in 14. A positive correlation was found between the presence of fracture and nerve injury (p = 0.013). The frequency of nerve injuries due to gunshot wounds was higher in the mid-section and lower part of the arms and in the proximal forearm when compared to other regions (p = 0.011). The infection rates were significantly higher in patients with fractures (p = 0.033). The mean hematocrit (Hct) level at presentation of the patients with infection (32.1 ± 6.3%) was significantly lower than that of those who did not have infection (38.8 ± 5.9%) (p<0.001).

CONCLUSION

Upper extremity war injuries require case-specific solutions. Microbiological samples should be taken prior to empirical antibiotic treatment for infection management and rational antibiotic use principles should be applied according to the culture and antibiogram results. The holistic and ambiguous character of nerve injuries often requires early exploration and combined reconstructive interventions. Arterial injuries can be overlooked by physical examination alone and thus routine angiography should be performed. Completion of the bone and soft tissue reconstructions in the same session using a holistic approach minimizes the possible risks.

Treatment of secondary hip arthritis from shell fragment and gunshot injury in the Syrian civil war

Background

In gunshot and shell fragment injuries to the hip joint, orthopedic intervention includes wound assessment and care, osteosynthesis of fractures, and avoiding of infection and osteoarthritis. Individuals injured in the Syrian civil war were frequently transferred to the authors’ institution in neighboring city. Orthopedic trauma exposures were determined in approximately 30% of these patients. The aim of this study was to evaluate the outcomes of the patients with secondary hip arthritis due to prior gunshot and shell fragment (shrapnel) injuries who underwent primary total hip arthroplasty.

Methods

This retrospective study reviewed 26 patients (24 males, 2 females) who underwent hip arthroplasty due to prior gunshot and shell fragment injuries from November 2013 to January 2019. For all patients, the Harris Hip Score (HHS) was evaluated preoperatively and after surgery.

Results

Mean age was 31.5 (range, 19–48) years. The mean preoperative HHS was 52.95 points, and the mean postoperative HHS was 79.92 points at the final follow-up after surgery. Patients with shell fragment injuries to the hip joint had higher infection rates, but it is not statistically significant.

Conclusions

An anatomic reduction of the fracture may not be possible in these cases as a result of significant bone and/or cartilage loss. Total hip arthroplasty can be done after gunshot- and shell fragment-related posttraumatic arthritis. It is an effective treatment choice to reduce pain and improve function, but the surgeon must be very careful because of high rate of infection.

The Tumbling Bullet: Subacute Intestinal Obstruction due to a Retained Bullet

A 29-year-old female presented with multiple gunshot wounds to the back and bilateral lower extremities. The patient underwent an exploratory laparotomy with small-bowel resection of two segments with primary stapled anastomosis and partial nephrectomy. The postoperative course showed prolonged intermittent bowel obstruction secondary to the bullet, which lodged in the distal ileum. The patient eventually passed the bullet; it, however, led to a delay in recovery.

Penetrating thoracic injury from a bean bag round complicated by development of post-operative empyema

Bean bag guns were developed as a nonlethal means for law enforcement personnel to subdue individuals. The large surface area and lower velocities of the bean bag round theoretically result in transfer of most of the energy to the skin/subcutaneous tissue and minimize the likelihood of dermal penetration, thereby 'stunning' intended victims without causing injury to deeper structures. However, this technology has been associated with significant intra-abdominal and intrathoracic injuries, skin penetration and death. We present a 59-year-old man who sustained a penetrating thoracic injury from a bean bag gun. Although the bean bag was successfully removed, the patient developed a postoperative empyema requiring operative management. We discuss the unique aspects of thoracic trauma from bean bag ballistics as well as considerations in management of patients with this uncommon mechanism of injury.

Lead toxicity from retained bullet fragments: A systematic review and meta-analysis

BACKGROUND

Firearm injury remains a public health epidemic in the United States. A large proportion of individuals with gunshot wounds subsequently have retained bullet fragments (RBF). There are no standard medical guidelines regarding bullet removal and the full extent of the consequences of RBF remains unknown.

OBJECTIVE

To determine whether there is an association among RBF, elevated blood lead levels (BLL) and lead toxicity in survivors of firearm injury 16 years and older.

METHODS

PubMed, EMBASE, CINAHL, Scopus, Cochrane Library, and Sociological Abstracts electronic databases were searched for all randomized controlled trials, prospective and retrospective cohort, case-control and cross-sectional studies published in the English language between 1988 and 2018. Quality assessment and risk of bias was evaluated using the Newcastle Ottawa Scale. A meta-analysis was performed using a random-effects model.

RESULTS

The search yielded 2,012 articles after removal of duplicates. Twelve were included after full article review. Eleven studies supported an association between elevated BLL and RBF. Bony fractures were associated with increased risk of elevated BLL in three studies. A positive relationship between BLL and the number of RBF was also shown in three studies, with one study demonstrating 25.6% increase in BLL for every natural-log increase in RBF (1-228, p < 0.01). Meta-analysis demonstrated BLL significantly higher in individuals with RBF as compared to controls (5.47 μg/dL, p < 0.01).

CONCLUSION

Patients with bony fractures or multiple RBF, who are at higher risk of elevated BLL, should be monitored for BLL in intervals of 3 months within the first year of injury. For patients who return with BLL above 5 μg/dL, all efforts must be undertaken to remove fragments if there is no potential to worsen the injury.

LEVEL OF EVIDENCE

Systematic review, Meta-analysis, level III.

Migrated bullet in the bladder presenting 18 years after a gunshot wound

Gunshot wounds to the genitourinary system are relatively rare, and it is even rarer a retained bullet migrates into the urinary tract. We describe a case where the bullet migrated into the bladder and formed a bladder stone eighteen years after the injury. This presentation is unique as it is one of the longest times from gunshot wound to presentation in the current literature.

Gunshot Wounds to the Upper Extremity

Upper extremity gunshot wounds result in notable morbidity for the orthopaedic trauma patient. Critical neurovascular structures are particularly at risk. The fractures are often comminuted and may be associated with a variable degree of soft-tissue injury. The literature lacks consensus regarding antibiotic selection and duration, and indications for surgical débridement. Bullets and/or bullet fragments should be removed in cases of plumbism, intra-articular location, nerve impingement, location within a vessel, and location in a subcutaneous position within the hand and/or wrist. Gunshot fractures generally do not follow common fracture patterns seen in blunt injuries, and the complexity of certain gunshot fractures can often be a challenge for the treating orthopaedic surgeon. Common plate and screw constructs may not adequately stabilize these injuries, and innovative fixation techniques may be required. The treatment for bone defects varies by location and severity of injury, and typically requires staged treatment. Nerve injuries after gunshot wounds are common, but spontaneous nerve recovery is expected in most cases.

Systematic review of civilian intravascular ballistic embolism reports during the last 30 years

BACKGROUND

Intravascular ballistic embolization is a rare complication of missile injury. Because of its rarity, much remains to be known about its presentation, pathophysiology, complications, and management. In this study, we analyze case reports of ballistic embolization in the last 30 years and available cases from our institution to determine the likely patient, the nature of the embolization, the possible complications, and a general management strategy.

METHODS

A PubMed search was performed in search of missile embolization cases from 1988 to 2018 in the English language, including only cases of intravascular emboli. Cases resulting from combat and explosive devices were excluded. In addition, five cases from our institution were included in the analysis.

RESULTS

A total of 261 cases were analyzed. The most common presentation was that of a young man (reflecting the demographics of those sustaining gunshot wound injuries) with injury to the anterior torso from a single gunshot wound. Venous entry was most common, most often through large-caliber vessels. There was roughly equal involvement of the right and left circulation. Left circulation emboli were frequently symptomatic, with ischemia being the most frequent sequela. In contrast, a right circulation embolus was rarely associated with significant complications.

CONCLUSIONS

Despite its rarity, ballistic embolization should be considered in gunshot injury with known large-vessel injury when an exit wound is not identified. In particular, signs of ischemia distant from the injury site warrant timely investigation to maximize tissue salvageability. We present a management strategy model for consideration.

Open Transcervical Fracture of Femur Resulted from Gunshot Injury: A Case Report

Gunshot injury (GSI) is rare in Hong Kong, and local experience on the management of GSIs is limited. There is yet a worldwide consensus on the classification system or management guidelines for the management of GSIs. We report a case of open transcervical fracture of right femur resulting from a GSI. The management of GSIs, including the classification of these injuries, corresponding fracture and soft tissue management, the indications of bullet removal and antibiotics use will be discussed.

Embolization by Bullet Dislodged from the Heart

Embolization by a dislodged projectile is a rare complication that may occur in cases of gunshot cardiac injuries. We report a case of a firearm projectile cardiac injury that evolved, with dislocation of the projectile during cardiac surgery, into embolization of the right external carotid artery.

[Left ventricular projectile migration after an accidental close-range gunshot wound]

We report the case of a 24-year-old female after sustaining a shotgun wound in the left upper extremity and chest. Initial emergency diagnostics revealed numerous shotgun pellets scattered throughout the left-side soft tissue, chest and upper lung lobe with one pellet having migrated into the left ventricle of the heart.Due to the devastating injury pattern, gunshot wounds are interdisciplinarily challenging and should include extended initial diagnostics, such as contrast agent CT. The potential toxicity of elevated lead blood levels have to be taken into further account.

Infectious risk for suicide bomber attack victims: management of penetrative wounds in French Army personnel

INTRODUCTION

In suicide bomber attacks (SBAs), the explosive forces may disperse fragments from the body of the bomber to which the device is attached. This biologic material can cause physical injury to bystanders and may represent a source of severe infectious diseases.

PATIENTS AND METHODS

Two French soldiers, victims of an SBA in Africa, were managed in the Percy Military Teaching Hospital. They sustained multiple injuries, including some caused by bony fragments converted into projectiles by the explosion. One patient had multiple superficial wounds managed conservatively. The other was treated surgically by serial debridement with removal of a bony piece related to the suicide bomber. The decision not to prescribe antiretroviral therapy was determined after discussion with infectious disease specialists.

RESULTS

Blood tests for HIV, HCV and HBV were taken at months zero, three and six; all were negative.

CONCLUSION

In the French Military Health Service, guidelines are based on evaluation of the viral status of the bomber and on the regional HIV prevalence breakpoint. There is no indication for HCV post-exposition prophylaxis (PEP). Accessible human foreign bodies related to an SBA should be removed as soon as possible, in association with antibiotic medication and a possible HIV PEP. These infectious risks have been discussed in some military and law enforcement literature. It should be a risk-based decision supported by medical intelligence.

Ballistic Reconstruction of a Migrating Bullet in the Parapharyngeal Space

A 21-year-old male suffering from severe throat pain after being hit by a bullet in Syria claimed that he was shot through his eye and that the bullet subsequently descended behind his throat. Even though the first medical report stated that this course is implausible, meticulous workup provided evidence that the bullet might have entered the parapharyngeal space in a more cranial position than the one it was found eight months later. Our case highlights that bullets are able to move within the body, rendering ballistic reconstruction difficult. However, after removal of the bullet the patient's symptoms completely resolved.

CHRONICALLY EMBEDDED LEAD PROJECTILES IN WILDLIFE: A CASE SERIES INVESTIGATING THE POTENTIAL FOR LEAD TOXICOSIS

Research has demonstrated that intramuscularly embedded lead in humans and rats may cause direct plumbism, albeit rarely, and has identified risk factors to this end. To the authors' knowledge, this has not been investigated in wildlife, despite a high incidence of embedded lead in these animals secondary to cynegetic activities. Fourteen wildlife cases submitted to the National Fish and Wildlife Forensics Laboratory for cause-of-death determination had chronically embedded lead projectiles that were unrelated to the cause of death. Tissue lead levels were measured in all cases and revealed clinically significant hepatic lead levels in two cases. The results corroborate comparative literature and suggest that embedded lead fragments carry a low risk for direct plumbism, even in the face of risk factors such as fractures, inflammation, and projectile fragmentation. Wildlife morbidity and mortality from embedded lead is more commonly realized secondary to incidental ingestion and ballistic trauma rather than by direct toxicity.

The Serum Lead level in Patients With Retained Lead Pellets

Background:

Patients, who survived from shotgun injuries, often have some retained lead pellets in their bodies. Several cases of lead toxicity have been reported regarding these patients.

Objectives:

This study seeks to compare the serum lead level in patients who have retained lead pellets in their bodies with the control group.

Patients and Methods:

In this case-control study, we gathered the serum lead levels of 25 patients with some retained lead pellets in their bodies due to shotgun and 25 volunteers without similar lead exposure and compared them in view of the age, gender, and living place.

Results:

While the mean serum lead level in both groups was lower than the standard level (i.e. 40 µg/dL) , the mean ± SD of serum lead level were 29 ± 12.8 µg/dL and 25.3 ± 6.4 µg/dL in the case and control groups, respectively without any significant difference (P = 0. 30) . However, a positive relationship was seen between serum lead level, and the number of retained lead pellets (r = 0.447, P = 0. 025) .

Conclusions:

Although extensive surgery to remove the lead pellets is not recommended in patients injured with shotguns, those with many retained lead pellets in their bodies should be considered at risk for lead poisoning and monitored carefully.