Wound ballistics of firearm-related injuries—Part 2: Mechanisms of skeletal injury and characteristics of maxillofacial ballistic trauma

A historical perspective on ballistic evolution and its implications for maxillofacial surgery

Ballistics has undergone significant evolution, shaping its role in both military and civilian contexts. This article explores the trajectory of ballistic advancements and their profound implications for maxillofacial surgery. From the early days of firearms in tenth-century China to the modern understanding of terminal ballistics, the study highlights how advancements in projectile technology have transformed injury mechanisms. Ballistic injuries, particularly in the head and neck regions, pose unique challenges, due to their complexity, often involving high-energy transfer and extensive tissue disruption. These injuries necessitate a multidisciplinary approach, incorporating ballistic principles into surgical planning to enhance outcomes. By examining 162 studies, including retrospective analyses, clinical trials, and ballistic research, this review identifies trends in ballistic trauma and its management. The findings reveal a shift in injury patterns, with firearm-related facial injuries decreasing, but exhibiting increased morbidity and mortality. The integration of knowledge on projectile dynamics, tissue response, and energy transfer empowers surgeons to anticipate complications, refine surgical techniques, and mitigate long-term sequelae. Advancements in ballistic technology have also influenced treatment protocols, emphasizing the need for interdisciplinary research and collaboration. Historical and modern scenarios, from the Battle of Thermopylae to conflicts in Lebanon and Ukraine, underscore the evolving nature of ballistic injuries. The study concludes that a comprehensive understanding of ballistics is essential for improving patient care in maxillofacial surgery, advocating for continued research to address emerging challenges and refine interventions for complex trauma cases.

Presentation and Management of Self-Inflicted Gunshot Wounds to the Face

Self-inflicted gunshot wounds (SI-GSW) to the head and face are associated with significant morbidity and mortality. Patients who do survive their injuries often face life-altering disfigurement and disability. To effectively care for these patients, providers must not only detect and address the immediate life-threatening injuries, but also plan for long-term definitive reconstruction. This review provides an overview of presentation and management of SI-GSW to the face, including initial stabilization and workup, assembly of a multidisciplinary care team, surgical reconstruction of soft tissue and bony defects, and long-term management to address aesthetic and functional goals. Emphasis is placed on the role of plastic and reconstructive surgeons in SI-GSW reconstruction; however, a better understanding of these complex injuries and their management can help all health care providers better optimize care for this high-risk population.

Evaluation of gunshot injuries to long bones from pneumatic weapons using a human thigh model. Part I. Introduction and assumptions. Discussion of shot ballistics. Human thigh model

Introduction

In accordance with the Polish law, pneumatic weapons are weapons that use compressed gas to set a bullet in motion and generate a discharge energy of more than 17J. In recent years, Poland has seen an increase in crimes committed with pneumatic weapons. The research aim of the present study was to measure the velocity of selected 5.5 mm and 6.35 mm caliber shot and to create a model of a human thigh using a pig femur.

Material and methods

This study used Air Arms Hi-Power Xtra FAC cal. 5.5 mm and FX Bobcat Mk II cal. 6.35 mm carbines and Haendler& Natterman's Spitzkugel, Hollow Point and Baracuda cal. 5.5 mm and 6.35 mm lead shot and Excite Apollo cal. 5.5 mm and Black Max Lead-Free cal. 6.35 mm lead-free shot. The velocity of the shot at a distance of 10 m was measured and its kinetic energy was calculated; pig femurs were measured and CT imaging was performed.

Results

The 5.5mm caliber shot reached velocities between 253 m/s and 278 m/s, obtaining energies between 27J and 44J. The 6.35 mm cal. shot reached velocities between 242 m/s and 254 m/s and energies between 52J and 59J. Pig femurs had an average weight of 410 g, a length of 239 mm, and a shaft diameter at mid-length of 30.6mm. The thickness of pig femur shaft walls was variable. A ballistic model of the human thigh was created using gelatin available in Poland.

Conclusions

1. The number of registered crimes with pneumatic weapons and the wide access to pneumatic devices with the possibility of design modifications justify the initiation of experimental studies on the assessment of gunshot injuries from pneumatic weapons. 2. The parameters of the shaft of a pig femur obtained from pigs weighing about 115 kg are similar to those of a human adult femur, which makes it possible to create a human thigh model. 3. Of the 5.5 mm cal. shot, the highest impact energies were generated by barracuda type shot, and of the 6.35 mm cal. shot, it was barracuda type and lead-free shot. 4. The thickness of the bony layer of the pig femur shaft is heterogeneous; the posterior wall of the shaft is the thickest, the lateral wall is the thinnest; however, it shows the greatest individual variability.

Gunshot vaginal trauma

Nonobstetric vaginal or vulva trauma is an extremely rare occurrence, with an incidence of < 0.2% of traumas. CT represents the gold standard in the diagnosis of gunshot lesions due to its ability to detect and stage injuries with very high sensitivity and specificity. A standardized protocol for penetrating trauma is still under debate for the use of intravenous contrast only or also rectal and oral contrast. Herein, we report a case of gunshot vaginal trauma in a 43-year-old patient presenting with vaginal bleeding. In our case, the protocol was "patient's tailored," the intravaginal selective use of air was administered due to symptoms (vaginal bleeding) and CT findings, this 2-step protocol increased diagnostic confidence and allow a correct and challenging diagnosis.

Self-inflicted craniomaxillofacial gunshot wounds by handguns are more deadly than those by shotguns: an NIS study

PURPOSE

The purpose of the present study is to determine whether handguns discharged at the craniomaxillofacial region are associated with greater fatality in suicide attempts relative to shotguns.

METHODS

The following retrospective cohort study was completed using the Nationwide Inpatient Sample (NIS), a Healthcare Cost and Utilization Project (HCUP) database. The primary predictor variable was the type of firearm (handguns vs. shotguns). The primary outcome variable was prognosis (fatality vs. no fatality). A binary logistic regression was performed to determine the risk of mortality of all predictor variables.

RESULTS

Our final sample consisted of 223 patients. Handguns (85.2%) were the most popular firearm. Relative to black patients, white patients were over three times more likely to die (p < 0.05). Compared to patients who were transferred in, patients not transferred in were eight times more likely to die (p = 0.000). Relative to patients who were admitted electively, patients who were not admitted electively were 16.7 times more likely to die (p < 0.01). Finally, relative to patients who used shotguns, patients who used handguns were 3.4 times more likely to die (p = 0.002).

CONCLUSION

Self-inflicted gunshot wounds to the maxillofacial region by handguns were more lethal than shotguns.

Spinal Gunshot Wound With an Air Rifle: A Case Report

Spinal gunshot injuries are one of the most serious injuries that can cause morbidity and mortality. We report a case of a nine-year-old boy, referred to our emergency department from another hospital, with lower limb weakness after being shot by an air gun in his back. After extensive investigation, it appeared that a foreign body representing the bullet was found in his spinal canal; the patient was taken to the operating room for surgical decompression and removal of foreign bodies. After that, the patient started to show partial improvement in his neurological deficits and is to be continued on physiotherapy.

Dental Management of Maxillofacial Ballistic Trauma

Maxillofacial ballistic trauma represents a devastating functional and aesthetic trauma. The extensive damage to soft and hard tissue is unpredictable, and because of the diversity and the complexity of these traumas, a systematic algorithm is essential. This study attempts to define the best management of maxillofacial ballistic injuries and to describe a standardized, surgical and prosthetic rehabilitation protocol from the first emergency stage up until the complete aesthetic and functional rehabilitation. In low-velocity ballistic injuries (bullet speed <600 m/s), the wound is usually less severe and not-fatal, and the management should be based on early and definitive surgery associated with reconstruction, followed by oral rehabilitation. High-velocity ballistic injuries (bullet speed >600 m/s) are associated with an extensive hard and soft tissue disruption, and the management should be based on a three-stage reconstructive algorithm: debridement and fixation, reconstruction, and final revision. Rehabilitating a patient with ballistic trauma is a multi-step challenging treatment procedure that requires a long time and a multidisciplinary team to ensure successful results. The prosthodontic treatment outcome is one of the most important parameters by which a patient measures the restoration of aesthetic, functional, and psychological deficits. This study is a retrospective review: twenty-two patients diagnosed with outcomes of ballistic traumas were identified from the department database, and eleven patients met the inclusion criteria and were enrolled.

Management of Maxillofacial Gunshot Injuries With Emphasis on Damage Control Surgery During the Yemen Civil War. Review of 173 Victims From a Level 1 Trauma Hospital in Najran, Kingdom of Saudi Arabia

Study Design

Studies on the concept of Damage Control Surgery (DCS) in the management of firearm injuries to the oral and maxillofacial region are still scarce, hence the basis for the current study.

Objectives

The objectives of the current study is to share our experience in the management of maxillofacial gunshot injuries with emphasis on DCS and early definitive surgery.

Methods

This was a retrospective study of combatant Yemeni patients with maxillofacial injuries who were transferred across the border from Yemen to Najran, Kingdom of Saudi Arabia. Demographics and etiology of injuries were stored. Paths of entry and exit of the projectiles were also noted. Also recorded were types of gunshot injury and treatment protocols adopted. Data was stored and analyzed using IBM SPSS Statistics for Windows Version 25 (Armonk, NY: IBM Corp).

Results

A total of 408 victims, all males, were seen during the study period with 173 (42.4%) males sustaining gunshot injuries to the maxillofacial region. Their ages ranged from 21 to 56 years with mean ± SD (27.5 ± 7.6) years. One hundred and twenty-one (70.0%) victims had extraoral bullet entry, while 53 (30.0%) victims had intraoral entry route. Ocular injuries, consisting of 25 (14.5%) cases of ruptured globe and 6 (3.5%) cases of corneal injuries, were the most commonly associated injuries. A total of 78 (45.1%) hemodynamically unstable victims had DCS as the adopted treatment protocol while early definitive surgery was carried out in 47(27.2%) hemodynamically stable victims. ORIF was the treatment modality used for the fractures in 132 (76.3%) of the victims.

Conclusions

We observed that 42.4% of the war victims sustained gunshot injuries. DCS with ORIF was the main treatment protocol adopted in the management of the hemodynamically unstable patients.

Craniofacial injuries by firearms projectiles: An analysis of 868 deaths in the five regions of Brazil

Firearms injuries have a legal and medico-legal importance, and are especially lethal when they reach the craniofacial regions of the victim. The present study aims to identify the characteristics of craniofacial lesions resulting from firearm projectiles, to register the most affected craniofacial regions by this type of injury and to verify the demographic profile of the victims. A retrospective study was carried out on the autopsy records produced in the first semester of 2015, in five Institutes of Legal Medicine in Porto Velho, situated in the cities of João Pessoa, Vitória, Porto Alegre and Brasília. Data extracted included sex, skin color and age of the victim, craniofacial region reached, shooting distance, shape and size of the injuries and manner of death (homicide, suicide or accident). Based on the 868 reports analyzed, it was possible to observe 1700 entrance lesions of firearm projectiles in craniofacial regions. Among cases of known manner of death, homicides were the most frequent (97.0%). It was observed a higher frequency of male victims (93.3%), mixed race (62.0%), between the ages of 12 and 29 years (59.4%). In all cases considered as suicide or accident there was only one entrance wound, but in 82.8% of the homicides there were multiple gunshot wounds. The craniofacial most affected regions were temporal (25.2%) and occipital (19.8%). The most common sites of projectiles exit were the temporal (25.3%) and parietal (16.1%). All cases of suicide were related to contact shot (69.2%) or close-range shot (30.8%), and among the homicides the distant range shots were more frequent (54.0%). The shape of entrance wounds was mostly circular (56.8%) and oval (31.3%), and among the exit injuries, the lesions were irregular (43.3%) and starry (24.1%). The entrance wounds showed smaller sizes than the exit lesions (p < 0.0001). The data obtained are useful for guiding research that takes into account craniofacial trauma caused by firearm projectiles, makes it possible to compare this data with those of other countries and can base investigative conclusions based on the analyzes discussed in the present work.

Early Reconstruction of Gunshot Mandible Fracture: A Modified Approach

The management of victims of gunshot fractures is a challenge for surgeons, mainly due to the complexity of the injury itself and degree of bone comminution. The titanium functionally dynamic bridging plate has often been used in reconstructive surgery after mandibular fractures. The classic indication for bridge plate use is comminuted fractures with or without associated substance losses. The aim of this article is report the case of gunshot victim and to discuss the bridge plate technique utilized for treatment. A 21 years-old, melanoderma, male patient was victim of a firearm-related assault, with comminutive fracture of the mandibular body. The protocol for the bridging plate technique was performed. The patient is in postoperative follow-up of eight months, not present aesthetic or functional complaints, stable occlusion, satisfactory mouth opening and no clinical signs of infection.

Gun-related eye injuries: A primer

Gun-related eye injuries are relatively common in the context of gunshot wounds to the head and neck. Many of the fundamental principles of gunshot wound management apply to the care of these patients, but the complex anatomy and functional relationships of the periocular region do pose special challenges. We provide a focused primer for physicians seeking a more in-depth understanding of gun-related eye injuries and present 3 representative cases outlining the spectrum of pathology, provide a focused review of the relevant ballistics concepts, and discuss the management of injuries to the periocular soft tissues, orbital structures, and globe. We found that good cosmetic and functional results can often be achieved with appropriate early intervention, but visual prognosis may remain guarded despite optimal treatment.

Anthropological analysis of projectile trauma to the bony regions of the trunk

Ballistics literature often focuses on soft tissue injures and projectile trauma to the cranium. Minimal details on the bony characteristics of projectile trauma to the thorax/abdomen regions have been published. This study aims to analyse projectile trauma to the bony trunk region including the ribs, vertebrae, scapula, sternum and the hip bone to form a better understanding of the characteristics and biomechanics of skeletal trauma caused by a projectile and contribute to the existing database on skeletal trauma caused by projectiles. Fourteen cases of documented projectile trauma to the bony regions of the trunk from the Hamman-Todd Human Osteological Collection at the Cleveland Natural History Museum, Ohio were analysed. Of the 14 individuals with gunshot wounds examined, 40 wounds occurred to the bones. Twenty- four injuries to the ribs, 1 ilium, 11 vertebrae, 3 scapulae, and 1 sternum. Fracture patterns, heaving and bevelling can be used to determine the direction of travel of the projectile which can be evident on the ribs, sternum, scapula and ilium. It is critical to understand the wounding patterns associated with projectile trauma to the torso region as this is often targeted, due to being the centre of mass.