Clinical update: gunshot wound ballistics

Low energy gunshot injuries: Does removal of retained bullet fragmentation at the time of internal fixation reduce the risk of fracture related infection?

OBJECTIVE

To examine the effects of RBF (Retained Bullet Fragment) removal at the time of long bone fixation on FRI (fracture related infection) rates in low energy GSI (Gunshot Injury) related fractures.

DESIGN

Retrospective Cohort Study SETTING: Level 1 Academic Trauma Center INTERVENTION: Retrospective review of the impact of RBFs on the risk of FRI when employing internal fixation in low energy GSI (Gunshot Injury) related fractures. In situations where the injury pattern requires surgical fixation, the question arises as to whether or not the RBFs need to be removed to prevent FRI.

MAIN OUTCOME MEASURES

Whether or not the RBFs removed in our patient population prevented short- and long-term fracture related infection after low-energy gunshot injury (FRI-LGI).

RESULTS

Of the 2,136 GSI related fractures, 131 patients met inclusion criteria, 81 patients underwent removal (R) of RBFs at the time of internal fixation while 50 patients did not undergo any removal (NR) at time of internal fixation. Among the patients who underwent surgical intervention, (Open Reduction Internal Fixation) ORIF was performed in 55 cases (R: 39; NR: 16), and (Intramedullary Nail) IMN was performed in 76 cases (R: 42; NR: 34). The overall rate of deep FRI-LGI was 6.9 % of the 131-patient cohort. We found that removal of RBFs had a statistically significant impact on the rate of deep FRI-LGI when compared to the NR group (p = 0.031). In the RBF removal group, only two patients (2.4 %) developed deep FRI-LGIs, whereas in the NR group, seven patients (14.0 %) developed deep FRI-LGIs. The incidence of early FRI-LGI was higher in the NR group (median 0.6 months) compared to the R group, which was associated with late FRI-LGIs (median 10.1 months) when they occurred.

DISCUSSION

In our study population, we found a statistically significantly increased incidence of deep and early FRI-LGI when RBFs are not removed at the time of extra-articular long bone internal fixation. The presence of retained bullet fragments following internal fixation may pose a risk factor for future development of deep FRI-LGI. We believe a surgeon should use their best judgment as to whether a RBF can safely be removed at the time of long bone fixation. Based on our findings, if safely permitted, RBF removal should be considered at the time of GSI long bone fixation resulting from low energy hand gun injuries.

Missile embolism from pulmonary vein to left ventricle: report of a case

Missile embolization is rare in penetrating trauma, occurring in 0.3% of cases. Bullet embolism into the left ventricle is less frequent, with few instances described in the literature. This paper describes an instance of left ventricular bullet embolism from the pulmonary venous system following gunshot chest trauma. A 7-year-old boy sustained a gunshot wound to his chest during an assault accident. Despite thoracic pain, he remained conscious and exhibited vital signs. A CXR and CT scan revealed a bullet in the left mediastinum. A left thoracotomy was performed to remove blood and clots from the pericardium. The patient was sent to a tertiary referral hospital for further investigation. The patient underwent elective surgery to remove the foreign body from inside the heart. The procedure involved a partial thymectomy and pericardial opening, and the patient was released from medical care after 14 days. After 6 months, there were no signs or symptoms of cardiothoracic infection or evidence of mitral valve regurgitation in echocardiography.

Ballistic long bone fracture pattern: an experimental study

When dealing with badly preserved cadavers or skeletal human remains, the assessment of death circumstances remains challenging. When forensic evidence cannot be taken from the skin and soft tissue, the information may only be deduced from more resistant elements such as bone. Compared to cranial gunshot injuries, reliable data on ballistic long bone trauma remains scarce. This study aims to define ballistic fracture characteristics in human long bones. The shaft of 16 femurs and 13 humeri from body donors was perpendicularly shot with a 9-mm Luger full metal jacket bullet at an impact velocity of 360 m/s from a distance of 2 m. Some bones were embedded in Clear Ballistics Gel®, and some were shot without soft tissue simulant in order to better visualise the fracture propagation on the high-speed camera. The fractures were examined macroscopically and compared between the sample groups. We consistently found comminuted fractures with a stellate pattern. Fracture details were classified into entrance, exit and general characteristics. For some traits, we detected different occurrence values in the group comparison. The results indicate that some of the traits depend on bone properties such as shaft diameter, bone length and cortical thickness. The presence of ballistic gel also influenced some fracture traits, emphasising the relevance of soft tissue simulant in osseous gunshot experiments. This study revealed new insights in the detailed fracture pattern of human long bones. These may serve as guidelines for the identification and reconstruction of gunshot trauma in human long bones.

The wounding potential of assault rifles: analysis of the dimensions of entrance and exit wounds and comparison with conventional handguns. A multicentric study

The appearance of a gunshot wound (GSW) is greatly influenced by the velocity of the projectile, where high-velocity projectiles (HVPs) are defined as ballistic agents reaching a muzzle velocity of > 600 m/s fired from assault rifles. The aim of the study is to present and explain the differences in the dimensions of entrance and exit wounds between the most used handguns and assault rifles and to propose a predictor of HVP, i.e., the ratio of exit and entrance wounds (EX/ENR). The surface area of entrance and exit GSWs and the EX/ENR were calculated. 66 perforating GSWs produced by NATO FMJ 7.62 × 52 mm and 5.56 × 42 mm fired from assault rifles were assigned to the HVP, while 64 lesions produced by conventional projectiles fired from revolvers and semi-automatic pistols were assigned to the low-velocity projectile (LVP) group. The dimensions of the exit wounds of the HVP group were significantly higher when compared to the LVP group (95% CI 0.9886-2.423, p < 0.05). The HVP group showed significantly higher values for the EX/ENR when compared to the LVP group (95% CI 2.617-7.173, p < 0.05). The evaluation of the EX/ENR can be considered an adequate tool to assess the type of weapon involved and to roughly estimate the associated wounding mechanisms, which can guide both the physician in the management and treatment of the patients affected by GSW, and the forensic pathologist in crime investigation.

Current concepts review: Management of civilian transpelvic gunshot fractures

INTRODUCTION

Civilian gunshot fractures of the pelvic ring represent a unique challenge for orthopaedic surgeons due to a high incidence of complicating associated injuries. Internationally accepted guidelines for these injuries are not available. The aim of this review is to summarize the available literature and to provide concise management recommendations.

METHODS

Literature search was performed using PubMed. The review focuses on civilian gunshot fractures of the pelvic ring and includes the acetabulum and hip joint only where it was deemed necessary for the understanding of the management of these patients.

RESULTS

The management of civilian transpelvic gunshot fractures is complicated by potentially life-threatening associated injuries, the risk of contamination with bowel content and retained bullets in joints. The infection risk is higher compared to extremity gunshot fractures. There is no clear evidence for the use of antibiotics available. The studies focusing on civilian pelvic ring gunshot fractures reported no case of orthopaedic fracture fixation in their series. Routine wash-out and debridement of fractures is not warranted based on the literature but conflicting recommendations for surgical interventions exist.

CONCLUSION

There is limited evidence available for civilian transpelvic gunshot fractures. The high frequency of associated injuries requires a thorough clinical examination and multidisciplinary management. We recommend routine antibiotic prophylaxis for all transpelvic gunshots. For fractures with a high risk of infection, a minimum of 24 h broad-spectrum antibiotics is recommended. The indication for orthopaedic fixation of civilian transpelvic gunshot fractures is based on the assessment of the stability of the fracture and is rarely necessary. Although conflicting recommendations exist, routine wash-out and debridement is not recommended based on the literature. Bullets buried in bone without contact to synovial fluid do not warrant removal, unless they have traversed large bowel and are accessible without undue morbidity. Furthermore, bullets should be routinely removed if they are retained in the hip joint, if mechanical irritation of soft tissues by projectiles is expected or if the bullet traversed large bowel before entering the hip joint.

A Nationwide Analysis of Gunshot Wounds of the Head and Neck: Morbidity, Mortality, and Cost

BACKGROUND

Gun violence in the United States rose continuously from 2010 to 2022, spiking during the pandemic, and peaking in 2021 at 48,830 deaths (14.8 per 100,000). Previous reports investigated health and financial burden associated with gunshot wounds (GSWs) during 2004 to 2013; however estimates related specifically to head and neck (H&N) injuries have been lacking. This population-based study aims to examine incidence, morbidity, mortality, and health resource utilization of H&N injuries utilizing the Nationwide Inpatient Sample database.

METHODS

A population-based study was undertaken using the National (Nationwide) Inpatient Sample (NIS) database (2015Q4-2017Q4). The International Classification of Diseases, Tenth Revision (ICD-10) codes were used to create a composite variable (inclusive of brain, eye, facial nerve, and facial fractures) resulting from GSW to the H&N. Incidence per 100,000 hospitalizations and case fatality rates were calculated to determine the health burden of H&N injuries. Length of hospital stay, and inflation- adjusted hospital charges were compared among H&N and non-H&N injuries. Χ 2 (classical and bootstrapped) and Mann-Whitney tests were used to compare groups.

RESULTS

Of 101,300 injuries caused by firearms, 16,140 injuries (15.9%) involved H&N region. The average incidence of H&N injuries was 20.1 cases per 100,000 hospitalizations, with intentional injuries having the highest case fatality rates of 32.4%. Patients with H&N injuries had extreme loss of function (33.4% versus 18.3%, P <0.001) and extreme likelihood of mortality (27.0% versus 11.3%, P <0.001) than non-H&N injuries. Statistically significant differences in the median length of stay (4.8 d versus 3.7 d; P <0.001) and median inflation-adjusted hospital charges ($80,743 versus $58,946, P <0.001) were found among H&N and non-H&N injuries.

CONCLUSIONS

Injuries due to GSW remain an inordinate health care and financial burden, with trauma to the H&N carrying an especially high cost in dollars, morbidity, and mortality.

Treatment of gunshot wounds of the spine using full-endoscopic surgery: analysis of a small clinical series

Objective. To assess the effectiveness of the treatment of gunshot wounds of the spine using percutaneous full-endoscopic technique.

Material and Methods. Three patients with gunshot shrapnel wounds of the spine were treated using percutaneous full endoscopy.

Results. The patients underwent a removal of foreign bodies (metal fragments) at the cervical, thoracic and lumbosacral levels of the spine using percutaneous full endoscopic surgery. The operations were carried out without complications, with minimal additional trauma to soft tissues and the spinal motion segment. In all three cases, there was a positive dynamics in the form of regression of the pain syndrome. There were no infectious complications.

Conclusion. The successful use of percutaneous full endoscopy in the surgical treatment of blind shrapnel wounds of the spine is shown. The results indicate the expediency of further research and development of this area to address the issue of introducing the technique into the routine practice of treating gunshot wounds both in peacetime in neurosurgical hospitals and centers of spinal neurosurgery, and in wartime at the stages of specialized care.

Epidemiology of ballistic fractures in the United States: A 20-year analysis of the Firearm Injury Surveillance Study

INTRODUCTION

Ballistic (i.e., gunshot-induced) fractures present unique treatment challenges and can be associated with high rates of complications and considerable morbidity. Large-scale epidemiologic data on these types of fractures are scarce. There is concern that gun-related violence may be on the rise, potentially increasing the burden of ballistic orthopaedic trauma, but there are few contemporary studies on the topic. The aim of this study, therefore, was to investigate the incidence and demographics of patients with ballistic fractures in the United States (US) over the last 20 years.

MATERIALS AND METHODS

This descriptive epidemiology study retrospectively analyzed the Firearm Injury Surveillance Study to identify cases of ballistic fractures in the US from 2000 to 2019. Overall and annual numbers of fractures and fracture incidence rates (IRs), patient demographics, incident characteristics, and temporal trends were analyzed. Patients of all ages were included. Ballistic fractures were grouped by anatomic location for comparisons (non-spine axial, spine, upper extremity, lower extremity).

RESULTS

An estimated N = 240,555 patients (n = 8,322 unweighted cases) sustained ballistic fractures over the 20-year study period for an overall IR of 39.2 per 1,000,000 person-years at-risk (PYR). Overall, lower extremity fractures accounted for the largest percentage of cases (45.9%; IR=18.8 PYR), followed by upper extremity fractures (32.8%; IR=13.4 PYR), non-spine axial fractures (16.1%; IR=6.6 PYR), and spine fractures (5.2%; IR=2.1 PYR). Diaphyseal femur fractures were the most common ballistic fractures overall. Nearly three-fourths (71.2%) of all cases occurred in males in the second through fourth decades. The most common injury intent was assault (71.8%) and a majority of patients (71.2%) required hospital admission. Accounting for population growth yielded a significantly increasing incidence of all ballistic fractures over the study period from 15.7 PYR in 2000 to 96.8 PYR in 2019 (average annual percent change=10.3, p < 0.00001).

CONCLUSION

These data suggest that the nationwide burden of ballistic fractures in the US has increased significantly in the last two decades. Ballistic fractures are associated with significant morbidity and societal cost, and increasing injury rates highlight the need for future research aimed at better understanding the ideal treatment of these types of fractures and their outcomes.

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.

Civilian Gun Shot Wounds Associated With Spinal Injuries

STUDY DESIGN

Retrospective.

OBJECTIVE

To evaluate functional outcomes and characteristics associated with gunshot wound (GSW) to the spine.

METHODS

Patients with GSW to the spine managed at a Level 1 Trauma Center from January 2003 to December 2017 were enrolled. Patient demographics, diagnoses, level of injury, American Spinal Injury Association (ASIA) score, ambulatory status at follow-up, bowel and bladder function, clinical improvement, and mortality were evaluated. Clinical improvement was defined as a progression in ambulatory status category at latest follow up.

RESULTS

51 patients with GSW of the spine were identified. 48 (94.1%) were male and 3 (5.9%) were female, with a mean age of 27 years-old (range 15-56). 38 (74.5%) were Caucasian, 7 (13.7%) were African American, 1 (2.0%) Asian-American, and 5 (9.8%) were Other/Unknown. 46 (90.2%) patients had GSW related spinal fractures and 44 (86.3%) had neurological deficits. Among patients with neurologic deficits, 5 (9.8%) had Cauda Equina Syndrome, 1 (2%) had Brown-Sequard Syndrome, and 38 (74.5%) spinal cord injuries: ASIA A 26 (68.4%); ASIA B 3 (7.9%); ASIA C 7 (18.4%); ASIA D 2 (5.3%). At mean follow-up time of 4.2 years (SD 3.9), 27 (52.9%) patients were wheelchair bound, 11 (21.6%) were ambulating with assistance, and 13 (25.5%) had normal ambulation. ASIA grade (A or B) was significantly, P < 0.00001, associated with being wheelchair bound and having neurogenic bowel or bladder at follow-up.

CONCLUSIONS

Most spinal GSW patients (70.6%) did not have any clinical improvement in ambulatory status and most injuries were ASIA A.

Same-Admission Microvascular Maxillofacial Ballistic Trauma Reconstruction Using Virtual Surgical Planning: A Case Series and Systematic Review

Study Design

Retrospective case series; systematic review.

Objective

It is unknown whether the use of virtual surgical planning (VSP) to facilitate same-admission microsurgical reconstruction of the mandible following acute maxillofacial ballistic trauma (MBT) is sufficient to achieve definitive reconstruction and functional occlusion.

Methods

A single-center retrospective analysis was conducted for patients who underwent microsurgical reconstruction of the mandible using VSP after acute MBT. The PubMed/MEDLINE, Embase, ScienceDirect, and Scopus databases were systematically reviewed using blinded screening. Studies were evaluated via thematic analysis.

Results

Five patients were treated by same-admission and microsurgical reconstruction of the mandible using VSP. We observed an average of 16.4 ± 9.1 days between initial presentation and reconstruction, an average length of stay of 51.6 ± 17.9 days, 6.2 ± 2.8 operations, and 1.6 ± 0.9 free flaps per patient. Four types and 8 total flaps were employed, most commonly the anterior lateral thigh flap (37.5%). Care yielded complete flap survival. Each patient experienced at least 1 minor complication. All patients achieved centric occlusion, oral nutrition, and an approximation of their baseline facial aesthetic. Follow up was 191.0 ± 183.9 weeks. Systematic review produced 8 articles that adhered to inclusion criteria. Consensus themes in the literature were found for clinical goal and function of VSP when practicing MBT reconstruction, yet disagreement was found surrounding optimal treatment timeline.

Conclusions

Same-admission microsurgical reconstruction after MBT is safe and effective to re-establish mandibular form and function. VSP did not delay reconstruction, given the need for preparation prior to definitive reconstruction.

Influence of impact velocity and impact attack angle of bullets on damage of human tissue surrogate -- ballistic gelatin

PURPOSE

Terminal performance of a bullet in human body is critical for the treatment of gunshot injury and optimization of bullet design. The effects of the impact velocity (v₀) and the impact attack angle (δ₀) of the bullet on its terminal performance was investigated, using a new evaluation method (called expansion method) based on the expansion of cracks and the permanent cavity wall in ballistic gelatin.

METHODS

Ballistic gelatin was used to simulate human body. The 7.62 mm × 39 mm rifle bullets with different v₀ (600-760 m/s) and δ₀ (0°-6°) were fired into the gelatin blocks. The gelatin block was cut into slices of about 20 mm thickness. The cracks and the permanent cavity on each slice were obtained manually. The damaged gelatin was determined using two methods: expanding the permanent cavity but ignoring the cracks, and expanding both the permanent cavity and the cracks. The relations between the damaged gelatin and v₀ and δ₀ were obtained using linear fitting method.

RESULTS

According to the distribution of the damaged gelatin along the penetration depth, the damaged gelatin block could be divided into two parts: the less damaged part and the severely damaged part. The length of the less damaged part depends mostly on δ₀; while the average damaged area of this part depends on both δ₀ as well as v₀. The cracks contributed significantly to the total volume of damaged gelatin, particularly when the expansion was larger than 1.9 mm. The total damaged gelatin increases with v₀, δ₀ and the expansion extent. The average length of equivalent cracks grew with v₀ and δ₀ when considering the cracks, and decreased with v₀ when ignoring the cracks.

CONCLUSION

The expansion method is suitable to investigate the influence of different factors of bullets on their terminal performance. The characteristics of the damaged gelatin have a linear relationship with the initial attack angle (δ₀) and the initial velocity (v₀) of the bullet.

Gunshot injury to the chest wall with an unusual bullet trajectory: A rare case report

INTRODUCTION AND IMPORTANCE

Gunshot injuries are always a challenging case for a surgeon. Early assessment of trajectory of bullet leads to effective surgical plan. These cases require multidisciplinary approach for the satisfactory outcome.

CASE PRESENTATION

We present a case of 38-year-old male with gunshot injury over left anterior chest wall with an entry wound and no detectable exit wound. Contrast enhanced computed tomogram (CECT) thorax and abdomen was suggestive of an unusual route of a bullet from left anterior chest wall at the level of 5th costochondral junction to the right iliac fossa region. Emergency exploration for the bullet was performed based on CECT findings which confirmed bullet in subcutaneous plane in right iliac fossa. Patient was discharged on 3rd post-operative with satisfactory clinical improvement.

CLINICAL DISCUSSION

Unusual presentations of bullet trajectory in gunshot injury can create surgical and/or medico-legal diagnostic problems. An effective surgical plan requires an effective clinic-radiological assessment. Accurate detection of entry wound, exit wound, path and extent of tissue damage is significant in preoperative planning and prognosis of patient. However not every patient with gunshot injury has an unusual trajectory. But accurate radiological assessment in such challenging cases is a necessity. Multidisciplinary approach with preoperative planning is required for satisfactory outcome.

CONCLUSION

Management of patients of gunshot injury is challenging for the attending surgeon. Multidisciplinary approach for preoperative planning along with good post-operative care is required in such cases of gunshot injury with atypical course.

Treatment of upper extremity palsies, gunshot wounds and scaphoid nonunion: my preferred approaches

The article reviews key considerations and our preferred methods in treating upper extremity palsies, gunshot wounds and scaphoid nonunion. For these three difficult conditions, I highlight the importance of a team approach when treating upper extremity neuromuscular disease, flexibility and creativity when treating gunshot wounds, and my personal protocol for dealing with scaphoid fracture nonunions.Level of evidence: V.

Post-mortem computed tomography in forensic shooting distance estimation: a porcine cadaver study

Objectives

Gunshot wounds are frequently studied using computed tomography (CT) to examine tissue damage. In this study, we aimed to test the potential of post-mortem CT (PMCT) in shooting distance estimation at distances 0–100 cm. We hypothesized that in addition to the wound channel, we could also potentially detect tissue damage caused by muzzle pressure on PMCT.

Results

A total of 59 gunshot wounds (23 contact shots, 21 close-range shots, 15 distant shots) were inflicted on eight piglet carcasses with a .22 Long Rifle handgun. PMCT scans were obtained using clinical equipment, and they were evaluated for wound characteristics by visual inspection and numeric measurements. In our data, contact shots could be clearly distinguished from close-range and distant shots by a hyperdense ring-shaped area surrounding the outermost part of the wound channel. Close-range and distant shot wounds did not have this feature and were difficult to distinguish from each other. The mean wound channel diameter ranged from 3.4 to 5.4 mm, being smallest in contact shots and largest in distant shots. These preliminary findings suggest that PMCT may aid the estimation of shooting distance. As this study only addressed low velocity gunshot wounds in carcasses, further studies are warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-022-05997-2.

Management of a Close-Range High-Velocity Gunshot Wound to the Pelvis with Posterior Pelvic Plating: A Case Report

CASE

A 31-year-old woman suffered a close-range, high-energy .30-rifle gunshot wound to her right ilium and sacrum resulting in an unstable pelvic ring injury with significant internal soft-tissue damage and bone loss. Given the limited amount of literature for managing this rare clinical scenario in a civilian setting, we described our protocol used on this patient to achieve a safe and effective result.

CONCLUSIONS

We present a civilian-inflicted high-velocity pelvic gunshot injury at close range. Although the patient had extensive pelvic bone loss and soft-tissue damage, she had excellent clinical results at 18-month follow-up after delayed posterior sacral bridge plating. Proper soft-tissue management and posterior sacral plating may yield good results for management of this type of injury.

Low-energy Gunshot-induced Tibia Fractures: What Proportion Develop Complications?

BACKGROUND

Gunshot injuries of the extremities are common in the United States, especially among people with nonfatal gunshot wounds. Controversy persists regarding the proper management for low-energy gunshot-induced fractures, likely stemming from varying reports on the likelihood of complications. There has yet to be published a study on a large cohort of patients with gunshot-induced tibia fractures on which to base our understanding of complications after this injury.

QUESTIONS/PURPOSES

(1) What percentage of patients with low-energy gunshot-induced tibia fractures developed complications? (2) Was there an association between deep infection and fracture location, injury characteristics, debridement practices, or antibiotic use?

METHODS

This was a multicenter retrospective study. Between January 2009 and December 2018, we saw 201 patients aged 16 years or older with a gunshot-induced fracture who underwent operative treatment; 2% (4 of 201) of those screened had inadequate clinical records, and 38% (76 of 201) of those screened had inadequate follow-up for inclusion. In all, 121 patients with more than 90 days of follow-up were included in the study. Nonunion was defined as a painful fracture with inadequate healing (fewer than three cortices of bridging bone) at 6 months after injury, resulting in revision surgery to achieve union. Deep infection was defined according to the confirmatory criteria of the Fracture-Related Infection Consensus Group. These results were assessed by a fellowship-trained orthopaedic trauma surgeon involved with the study. Complication proportions were tabulated. A Kaplan-Meier chart demonstrated presentations of deep infection by fracture location (proximal, shaft, or distal). Univariate statistics and multivariate Cox regression were used to examine the association between deep infection and fracture location, entry wound size, vascular injury, intravenous (IV) antibiotics in the emergency department (ED), deep and superficial debridement, the duration of postoperative IV antibiotics, and the use of topical antibiotics, while adjusting for age, race/ethnicity, smoking status, and BMI. A power analysis for the result of deep infection demonstrated that we would have had to observe a hazard ratio of 4.28 or greater for shaft versus proximal locations to detect statistically significant results at 80% power and alpha = 0.05.

RESULTS

The overall complication proportion was 49% (59 of 121), with proportions of 14% (17 of 121) for infection, 27% (33 of 121) for wound complications, 20% (24 of 121) for nonunion, 9% (11 of 121) for hardware breakage, and 26% (31 of 121) for revision surgery. A positive association was present between deep infection and deep debridement (HR 5.51 [95% confidence interval 1.12 to 27.9]; p = 0.04). With the numbers available, we found no association between deep infection and fracture location, entry wound size, vascular injury, IV antibiotics in the ED, superficial debridement, the duration of postoperative IV antibiotics, and the use of topical antibiotics.

CONCLUSION

In this multicenter study, we found a higher risk of complications in operative gunshot-induced tibia fractures than prior studies have reported. Infection, in particular, was much more common than expected based on prior studies. Consequently, surgeons might consider adopting the general management principles for nongunshot-induced open tibia fractures with gunshot-induced fractures, such as the use of IV antibiotics both initially and after surgery. Further research is needed to test and validate these approaches.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Gunshot wounds to the penis and scrotum: a narrative review of management in civilian and military settings

Gunshot wounds (GSW) to the penis and scrotum are present in two thirds of all genitourinary (GU) trauma, with a growing proportion of blast injuries in the military setting. Depending on the energy of the projectile, the injury patterns present differently for military and civilian GSWs. In this review, we sought to provide a detailed overview of GSWs to the external genitalia, from mechanisms to management. We examine how ballistic injury impacts tissues, as well as the types of injuries that occur, and how to assess these injuries to the external genitalia. If there is concern for injury to the deep structures of the penis or scrotum, operative exploration and repair is warranted. Relevant history and physical examination, role of imaging, and choice of conservative or surgical treatment options in the civilian and military setting are discussed, as well as guidelines for management set forth by the American Urological Association (AUA) and European Association of Urology (EAU).

Staged Surgical Management of Open Navicular Fracture Secondary to a Gunshot Injury

The management guidelines of gunshot wound (GSW) injuries to the lower extremities have primarily been described more recently in the literature. A navicular fracture with adjacent joint involvement is presented from a GSW with initial external fixation management to prevent loss of anatomical alignment and successful staged definitive treatment with internal fixation. Based on previous experiences with rearfoot joint involvement from GSW injuries, we were able to direct definitive treatment with arthrodesis of violated joints. After a 1-year follow-up, the patient has returned to normal activities without any limitations. This case report demonstrates a stepwise approach to management of an open navicular fracture secondary to a GSW.

Imaging Appearance of Ballistic Wounds Predicts Bullet Composition: Implications for MRI Safety

OBJECTIVE. The purpose of this article was to determine whether the radiographic and CT appearance of ballistic projectiles predicts their composition and to characterize the translational, rotational, and temperature effects of a 1.5-T MRI magnetic field on representative bullets. MATERIALS AND METHODS. Commercially available handgun and shotgun ammunition representing projectiles commonly encountered in a clinical setting was fired into ballistic gelatin as a surrogate for human tissue, and radiographs and CT images of these gelatin blocks were obtained. MR images of unfired bullets suspended in gelatin blocks were also obtained using T1- and T2-weighted sequences. Magnetic attractive force, rotational torque, and heating effects of unfired bullets were assessed at 1.5 T. RESULTS. Fired bullets were separated into ferromagnetic and nonferromagnetic groups based on the presence of a debris trail and deformation of the primary projectile in the gelatin blocks. Whereas ferromagnetic bullets showed mild torque forces and marked imaging artifacts at 1.5 T, nonferromagnetic bullets did not have these effects. Heating above the Food and Drug Administration limit of 2°C was not observed in any of the projectiles tested. CONCLUSION. Patients with ballistic embedded fragments are frequently denied MRI because the bullet composition cannot be determined without shell casings. We found that radiography and CT can be used to identify nonferromagnetic projectiles that are safe for MRI. We also present an algorithm for determining the triage of patients with retained bullets.

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.

Gunshot Wounds to The Hip

Gunshot wounds to the hip region are likely to cause complex peritrochanteric fracture. The fracture patterns are often highly comminuted and accompanied by injuries to local structures and abdominal viscera. Our case series analyses 25 orthopaedic procedures performed. The overall union rate for primary fixation was 66%. Two patients underwent revision surgery for failed primary fixation. Two cases where fixation had failed were revised to total hip replacement successfully. These types of injuries present a formidable challenge. Preservation of the femoral head should be prioritised to avoid arthroplasty. Long-term follow-up is necessary in assessing the success of these procedures.

The G2 research R.I.P. fragmenting bullet-radiographic features of a recently encountered projectile

Gunshot wounds (GSWs) are an important cause of disability and death in the USA. Although radiography is limited in its ability to detect bullet types, a projectile introduced during the last decade, the R.I.P. bullet by G2 Research, consists of a base slug connected to 6 to 8 sharp trocars designed to diverge within soft tissue following impact, resulting in what we believe to be a unique imaging appearance that can be confusing to those not familiar with this particular projectile. Furthermore, this bullet is 100% copper, which may allow for safe imaging with magnetic resonance imaging if correctly identified prior to scanning.

Treatment of traumatic losses of substance in the foot

Treatment of traumatic loss of bone and tissue substance in the foot necessitates special consideration of the anatomy and physiology of the segment. The causes of foot trauma are multiple and in many cases violent, leading to progressive tissue deterioration that may require multi-phased debridement. The therapeutic objective is to reconstruct a functional foot permitting painless pushing off, walking and footwear use by restoring a stable bone framework, with resistant covering satisfactorily adjusted to the different zones of the foot. While coverage of the back of the foot must be fine, coverage of the plantar zones will be padded. The reconstructive surgeon shall be particularly attentive to plantar sensitivity. To take up the surgical challenge, it is of paramount importance to fully master a wide-ranging therapeutic arsenal ranging from conventional grafts to composite free flaps in view of proposing the solution most suited to the type, size and location of the loss of substance, all the while striving to generate as few sequelae as possible at the donor site. In order for reconstruction to be successful, multidisciplinary collaboration between plastic surgeons, orthopedists and physician is highly recommended.

Injury and treatment patterns of ballistic pelvic fractures by anatomic location

INTRODUCTION

Pelvic ballistic injuries threaten critical gastrointestinal, vascular, and urinary structures. We report the treatment patterns and injury profiles of ballistic pelvic fractures and the association between location of ballistic fractures of the pelvis and visceral injuries.

METHODS

A prospectively collected database at an academic level I trauma center was reviewed for clinical and radiographic data on patients who sustained one or more ballistic fractures of the pelvis. Main outcomes compared included: procedures with orthopedic surgery, emergent surgery, concomitant intrapelvic injuries, and mortality.

RESULTS

Eighty-six patients were included. Eight patients (9.3%) underwent surgical debridement with orthopedic surgery, no ballistic pelvic fractures required surgical stabilization. The anatomical locations of ballistic pelvic fractures included: 10 (14.7%) anterior ring, 13 (19.1%) posterior ring, 27 (39.7%) anterior column, and 18 (20.9%) posterior column. There was a statistically significant association between anterior ring and rectal injury. The association between anterior ring injury and bladder injury approached significance.

CONCLUSIONS

This case series included 86 patients with a ballistic fracture of the pelvis, none requiring pelvic ring surgical stabilization. The unpatterned behavior of these injuries demands a high suspicion for visceral injury, with special attention to the rectum and bladder in the setting of anterior ring involvement.

LEVEL OF EVIDENCE

IV.

The risk of fracture to the tibia from a fragment simulating projectile

Penetrating injuries due to fragments energised by an explosive event are life threatening and are associated with poor clinical and functional outcomes. The tibia is the long bone most affected in survivors of explosive events, yet the risk of penetrating injury to it has not been quantified. In this study, an injury-risk assessment of penetrating injury to the tibia was conducted using a gas-gun system with a 0.78-g cylindrical fragment simulating projectile. An ovine tibia model was used to generate the injury-risk curves and human cadaveric tests were conducted to validate and scale the results of the ovine model. The impact velocity at 50% risk (±95% confidence intervals) for EF1+, EF2+, EF3+, and EF4+ fractures to the human tibia - using the modified Winquist-Hansen classification - was 271 ± 30, 363 ± 46, 459 ± 102, and 936 ± 182 m/s, respectively. The scaling factor for the impact velocity from cadaveric ovine to human was 2.5. These findings define the protection thresholds to improve the injury outcomes for fragment penetrating injury to the tibia.

Low-velocity Gunshot Injuries to the Femur: What Is the Utility of Stabilizing Incomplete Fractures?

INTRODUCTION

Extremity involvement is common among nonfatal gunshot injuries. Most of these injuries are low energy in nature and may be associated with fractures. Although displaced fractures of lower extremity long bones are often treated surgically, the purpose of this study was to review our experience in managing incomplete femur fractures caused by gunshot penetration and to develop treatment recommendations.

METHODS

We retrospectively reviewed clinical and radiographic data for 46 consecutive patients with incomplete femur fractures secondary to low-energy gunshot wounds. Fracture patterns included OTA/AO 31 (n = 7), 32 (n = 20), and 33 (n = 19). All fractures were nondisplaced and extra-articular. Type of treatment, clinical and radiographic healing, and related complications were recorded.

RESULTS

Thirty-two patients (70%) were managed nonsurgically with progressive weight bearing from toe touch to full weight bearing by 6 weeks of follow-up, whereas 14 patients (30%) underwent prophylactic fixation of the femur. No differences in treatment were seen based on age, body mass index, fracture pattern, or the presence of other fractures or systemic injuries. Two of the 32 patients (6.2%) treated nonsurgically for femoral shaft fractures fell subacutely after the original injury and displaced their fractures. Both underwent reduction and fixation. All other fractures maintained alignment until union. No infections or nonunions were seen. Among patients who underwent prophylactic fixation, two underwent removal of prominent implants after union.

DISCUSSION

Only 6% of incomplete femur fractures treated at our hospital required later surgery for fracture displacement. Although incomplete fractures occur infrequently, nonsurgical management with limited weight bearing seems to be successful and cost-effective for most patients. We propose initial nonsurgical management of nondisplaced femoral fractures secondary to cortical penetration from low-energy gunshot wounds.

Don't Shoot Yourself in the Foot: Reconstruction of a Through-and-Through Gunshot Wound of the Foot

A 69-year-old man presented with an accidental, self-inflicted, through-and-through left foot gunshot wound. An entry wound on the dorsum of the foot was noted, with a larger exit wound on the plantar aspect. X-ray revealed comminuted fractures of the second, third, fourth, and fifth metatarsals with numerous foreign bodies. Immediate excisional debridement was performed, and negative-pressure wound therapy was applied. A second look was performed 48 hours later. Five days after initial debridement, a Kirschner wire was utilized for fixation of the second metatarsal fracture, and an external fixator applied to the fifth metatarsal due to extensive bone loss. A free gracilis muscle flap was used to fill the defect, with plans for a vascularized bone graft at a later date. The flap was tunneled through the wound to the plantar aspect of the foot, with an overlying split-thickness skin graft. The patient’s postoperative course was uncomplicated, and secondary bone grafting was not required. The gracilis flap was used to reconstruct the bony and soft tissue defects, and secondary muscle fibrosis appeared to provide adequate skeletal support. The patient was full weight-bearing by 4 months and has since returned to his preoperative activities, baseline gait, and regular footwear. The free gracilis muscle flap may serve as a valuable reconstructive option for through-and-through gunshot wounds to the foot, restoring both contour and function, while eliminating the need for secondary bone grafting.

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.

Development of a Puncture Technique for Implanting Temporary Vascular Shunts in a Porcine Model

BACKGROUND

Temporary vascular shunts (TVSs) are an effective tool for rapidly restoring blood flow to a limb or organ that has experienced vascular injury and ischemia and for which revascularization is not an immediate option. Usually, through an opening in the skin, the TVS is positioned within the proximal and distal stumps of the injured vessel, restoring perfusion and stopping the ischemia. The aim of this study is to compare standard TVS technique and a developed puncture technique for implanting TVS and to evaluate the utility and feasibility of this protocol after arterial lesions, in pigs.

METHODS

Vascular injuries were inflicted in both hind limbs of 30 pigs, and vascular interventions were performed, using standard and puncture TVS. Because each pig was implanted with both types of TVSs, it was possible to simultaneously monitor, analyze, and compare parameters such as, the mean arterial pressure (MAP, in mm Hg), blood flow (mL/min), and insertion times, in the same animal.

RESULTS

It was observed that the MAP in the limbs recovered and approached systemic MAP, in 100% of the experiments, in both groups. Analysis of the blood flow data showed that this parameter was significantly reduced in the puncture TVS group (110.36 ± 9.99 mL/min vs. 153.20 ± 18.57 mL/min, P = 0.001). On the other hand, the insertion time for the standard TVS was significantly greater than that of the puncture shunt (15.32 ± 3.08 min vs. 10.37 ± 1.7 min, P = 0.001). Furthermore, it was found that the primary and secondary patency and complication rates were similar for both TVS types.

CONCLUSION

Thus, given the adequate MAP recovery and reduction in implantation time observed in this experimental and in an animal model study, the use of the puncture TVS technique is effective and feasible.

A systematic approach to the interpretation of gunshot wound trauma to the cranium

This chapter employs the fracture assessment triad, a systematic analytical approach, as a vehicle to explore the components used to interpret gunshot trauma to the cranium. First, a list of pertinent observations associated with gunshot trauma to the cranium is presented with a brief description of each. These features include entrance and exit wound defect morphology, keyhole defect, gutter defect, radiating fractures, concentric fractures, bone plugs, and associated foreign material, debris and residue. Second, the intrinsic factors that govern the way bone responds to trauma can be surmised through a direct examination or knowledge of the skeletal case. Intrinsic factors rest primarily in bone being a viscoelastic material with anisotropic properties, but include other elements that affect fracture production, such as buttressing, bone architecture, sutures, and influences of age, sex and health. These influences may be discoverable and factored into the analysis. With direct observation of the defect/fracture pattern and an understanding of the intrinsic influences involved, the extrinsic factors can be deduced. Bullet velocity, mass, design and cavitation represent the major extrinsic factors involved in wound production. The interplay of each of these factors imparts varying amounts of kinetic energy to soft and hard tissues. The greater amount of kinetic energy conveyed, the larger the temporary cavity and the greater the potential for destruction. When interpreting gunshot trauma, precision is enhanced by the analyst's familiarity with firearms and ammunition, facilitating determination of firearm type (rifle/handgun or shotgun), bullet direction, range, sequence of fire, and potentially, speculations as to bullet velocity, mass and design. Neither caliber nor gauge can be determined from the entrance defect size, but elimination of certain calibers or gauges may be possible.

Is staged management with immediate conversion of external fixation to retrograde intramedullary nailing for combat-related Gustilo Type III supracondylar femur fractures safe and reliable method?

INTRODUCTION

Femur fractures due to bomb explosions and gunshots in battlefield require osseous stabilization as quickly as possible to expedite emergent conditions. İmmediate external fixation is the initial procedure as usual with planned early conversion to definitive treatment. The purpose of the current study is to determine the results of the early retrograde intramedullary nailing in combat-related injuries.

MATERIAL AND METHODS

Eighteen patients with comminuted supracondylar femur fractures, initially treated with external fixation followed by planned conversion to retrograde intramedullary nailing in a one-stage procedure, were evaluated in a retrospective review to gather demographic, injury, management, and fracture-healing data for analysis.

RESULTS

According to the system of Gustilo Anderson and Orthopedic Trauma Association, all fractures were open type III and 33-A3, respectively. The mean follow-up, operation time and union time were 1.8 years (range, 6 months to 2,6 years), 75 min (range, 60-100), and 3 months (range, 1.5-4), respectively. There was one complication of acute osteomyelitis which was successfully treated with antibiotic-load beams and aggressive bone debridement. No septic arthritis was observed.

CONCLUSIONS

We concluded that immediate retrograde intramedullary nailing in combat-related supracondylar femur fractures regardless of contamination even in Gustilo type III is a safe and reliable treatment method.

Stability of the Subaxial Spine after Penetrating Trauma: Do Classification Systems Apply?

OBJECTIVE

Blunt spinal trauma classification systems are well established and provide reliable treatment algorithms. To date, stability of the spine after civilian gunshot wounds (CGSWS) is poorly understood. Herein, we investigate the validity of trauma classification systems including the Thoracolumbar Injury Classification and Severity Score (TLICS), Subaxial Cervical Spine Injury Classification and Severity Score (SLIC), and Denis' three-column model when applied to spinal penetrating trauma from gunshots, while secondarily evaluating stability of these injuries.

METHODS

Gunshot injuries to the spine were identified from an institutional database from ICD-nine codes. Trauma scorings systems were applied using traditional criteria. Neurologic compromise and spinal stability were evaluated using follow-up clinic notes and radiographs.

RESULTS

Thirty-one patients with CSGSW were evaluated. There was an equal distribution of injuries amongst the spinal levels and spinal columns. Twenty patients had neurological deficits at presentation. Eight patient had a TLICS score >4. Three patients had a SLIC score >4. One patient had surgical treatment. Nonoperative treatment did not lead to spinal instability or adverse outcomes in any cases. The posterior column had a high correlation with neurologic compromise, though not statistically significant (p=.118).

CONCLUSIONS

The TLICS, SLIC, and three-column classification systems cannot be applied to CSGSW to quantify injury severity, predict outcomes, or guide treatment decision-making. Despite significant neurologic injuries and disruption of multiple spinal columns, CSGSW do not appear to result in unstable injuries requiring operative intervention. Further research is needed to identify the rare spinal gunshot injury that would benefit from immediate surgical intervention.

Defining animal welfare standards in hunting: body mass determines thresholds for incapacitation time and flight distance

Shooting is an important tool for managing terrestrial wildlife populations worldwide. To date, however, there has been few quantitative methods available enabling assessment of the animal welfare outcomes of rifle hunting. We apply a variety of factors to model flight distance (distance travelled by an animal after bullet impact) and incapacitation from the moment of bullet impact. These factors include body mass, allometric and isometric scaling, comparative physiology, wound ballistics and linear kinematics. This approach provides for the first time a method for quantifying and grading the quality of shooting processes by examining only body mass and flight distance. Our model is a universally applicable tool for measuring animal welfare outcomes of shooting regimes both within and among species. For management agencies the model should be a practical tool for monitoring and evaluating animal welfare outcomes regarding shooting of mammalian populations.

Primary Intra-Medullary Nailing of Open Tibia Fractures Caused by Low-Velocity Gunshots: Does Operative Debridement Increase Infection Rates?

BACKGROUND

Although gunshot-induced extremity fractures are typically not considered open fractures, there is controversy regarding wound management in the setting of operative fixation to limit infection complications. Previous studies have evaluated the need for a formal irrigation and debridement (I&D) prior to intra-medullary nailing (IMN) of gunshot-induced femur fractures but none have specifically evaluated tibias. By comparing primary IMN for tibial shaft fractures caused by low-velocity firearms additionally treated with a formal operative I&D (group 1) with those without an I&D (group 2), we sought to identify whether there are: differences in treatment group infection rates; particular fracture patterns more prone to infection; and patient characteristics more prone to infections.

PATIENTS AND METHODS

Retrospective cohort study at a single level I trauma center of gunshot-induced tibial shaft fractures managed primarily with IMN in 39 patients from October 1, 2008 to October 30, 2016. The following were studied: demographics, follow-up, fracture characteristics, injury management, and patient outcome. Fractures were categorized based on the Orthopaedic Trauma Association (OTA) classification system for diaphyseal tibia/fibula fractures. All patients had intravenous antibiotic agents at presentation and received three days of post-operative intravenous antibiotic agents per institutional protocol.

RESULTS

In group 1, 6 of 23 patients (26.1%) developed superficial infections and 4 of 23 patients (17.4%) developed deep infections. In group 2, none of 16 patients (0%) developed superficial infections and 1 patient (6.25%) developed a deep infection, making the total cohort infection rate 28.2% (11/39). Superficial infections were associated with a formal I&D whereas deep infections were not. Tobacco smokers and type 42-A fractures had higher infection rates when treated with a formal I&D.

CONCLUSION

A formal debridement, followed by primary IMN in tibia fractures caused by low-velocity firearms is associated with an increased risk of superficial infection that is well managed with antibiotic agents, but the incorporation of a debridement does not affect rate of deep infection. A formal I&D during IMN fixation should be avoided in patients that are smokers and have type 42-A tibia fractures as these are factors associated with increased infection rates.

What Factors Necessitate Removal of Retained Ballistic Fragments in the Head and Neck?

PURPOSE

The purpose of this study was to estimate the frequency of retained ballistic fragment (RBF) removal and to identify factors associated with an increased risk for RBF removal. To date, there are no studies focused on identifying factors associated with removal of RBFs localized to the maxillofacial region.

MATERIALS AND METHODS

Using a retrospective cohort study design, the authors enrolled a sample composed of patients with RBFs localized to the maxillofacial region. The predictor variables included bullet size, location, involvement of bone, involvement of sinus, antibiotics, multiple antibiotics, and multiple locations. The primary outcome variable was RBF retrieval. The secondary outcome variables were timing of operative retrieval, fragment site infection, and migration of RBF. Appropriate uni- and bivariate statistics were computed and logistic regression modeling was used.

RESULTS

The sample was composed of 20 patients (mean age, 30 yr; 80% male) and 55% (11 patients) required or desired object removal overall. The number of projectiles ranged from 1 to 19 (total, 48) in the 20 patients. The logistic model identified larger size, final location of bone, final location of soft tissue, and final location of sinus as having a higher probability of removal that was statistically significant (P < .05); however, size was the only variable with a substantial odds ratio (OR; 1.96; P < .05). There was no evidence of migration and a low rate (2.3%) of infection was noted at subsequent follow-up radiography and clinical examination.

CONCLUSION

Size was the only statistically significant predictor variable with a substantial OR (1.96; 95% confidence interval, 1.31-3.40; P < .05). There was a low risk of infection even when considering oral pharyngeal contamination and low risk of migration. Further studies could focus on prudent antibiotic use and larger patient populations.

Gunshot induced injuries in orthopaedic trauma research. A bibliometric analysis of the most influential literature

A growing burden of gunshot injuries demands evidence-based ballistic trauma management. No comprehensive systematic overview of the current knowledge is available to date. This study aims to identify and analyze the most influential publications in the field of orthopedic ballistic trauma research. All databases available in the Thomson Reuters Web of Knowledge were searched to conduct this bibliometrical study. The most cited orthopedic ballistic trauma articles published between 1950 and 2015 were identified by use of a multi-step approach. Publications with ten citations and more were analyzed for citations, journal, authorship, geographic origin, area of research, anatomical site, study type, study category, and level of evidence. Citations of the 128 included studies ranged from 113 to 10. These were published in fifty different journals between 1953 and 2011. Most publications (n=106; 83%) originated from the USA, were retrospective (n=85; 66.4%), level IV studies (n=90; 70.3%), reported on spinal gunshot injuries (n=49; 38.33%) and were published between 1980 and 2000 (n=111; 86.7%). This bibliometric study provides the first comprehensive overview of influential publications in the field of orthopedic ballistic trauma research. More prospective studies and high-quality systematic reviews are needed. Centres with a high burden of gunshot injuries from the developing world need to share their experience in form of international publications, to provide a more comprehensive picture of the global gun-related orthopedic injury burden.

TYPE OF STUDY

bibliometric analysis: level III.

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.

Unusual route of a bullet: From scapula to eye

Herein, an awkward case of globe perforation with a bullet-entering from the right posterior scapular region and leaving the body from the right orbit through the eye - is reported. Route of the bullet could be devastating - as it passed through the neck and the maxillofacial region-however by chance no vital damage occurred. Its path was assessed by plain radiography and computed tomography scans. Sometimes prediction of the trajectory is very difficult without additional radiological investigations. Especially, in the case of any high velocity projectile wounding, physician must be aware of the fact that the bullet's course will not be a linear but most probably a complicated one. Prognosis of the injury depends on the path of the bullet or shrapnel fragment, close clinical observation, an open-minded approach, and the multidisciplinary care. Moreover, even the crime investigation might be needed.

The pattern of the Syrian refugee's injuries managed in King Abdullah University Hospital (Jordan)

OBJECTIVE

This study was conducted to assess the pattern, the magnitude, the severity, the distribution, and the results of the management of the injured Syrian refugees at King Abdullah University Hospital (KAUH).

METHODS

The medical records of 90 consecutive injured Syrian patients admitted to KAUH at the beginning of the Syrian conflict in 2012-2013 were reviewed. Information regarding the age, the sex, the antomical regions, the organs injured, the operations performed, the complications, and the weapons used were recorded.

RESULTS

Of the 90 cases, 86 (95.6%) were males and 4 (4.4%) were females. The age of patients ranged between 6 and 64 years with: 8 children (6-18) years old, 81 young adults (18-48) years old, and only 1elderly patient (64) years old. The distributions of the injuries were: 54.5% in extremities, 47.8% head and neck, 15.5% chest, and 14.4% abdomen with involvement of more than one injured region in several patients. The injuries were inflected by explosives in 49 cases, bullets in 45 cases, and both in 4 cases. The most frequently performed operations were: fractures fixations, fasciotomies, laparotomies, and craniotomies. Musculoskeletal and neurological deficits occurred in 11.1 and 8.8% of cases, respectively. The mortality rate was 2.2%. The average hospital stay was 19 days. The overall management costs were more than half million US Dollars.

CONCLUSIONS

Extremities and head and neck were the most injured regions. The referral from the forward centers and the procedures performed in our hospital improved the management outcomes. The management required long hospital stay and was costly.

Unique neuro-ophthalmic presentation of gun pellet injury

We describe a unique case of orbital gunshot injury with isolated intraorbital pellets lodged symmetrically in the two apices, causing identical clinical presentation, and absence of any associated globe or cerebral injury. He developed bilateral complete third nerve palsy with bilateral traumatic optic neuropathy. The optic nerve strut prevented the pellets from going into the brain on both the sides.

The early hospital management of gunshot wounds. Part 1: head, neck and thorax

The management of gunshot wounds is an increasing problem for UK emergency doctors, but not to an extent where it has become routine or allowed individuals to gain significant experience in their treatment. This article reviews the pathophysiology of gunshot injury in general before examining the evidence available concerning the management of gunshot wounds to the head neck and thorax.

Bone mineral density and wounding capacity of handguns: implications for estimation of caliber

Methodologies that improve estimation of caliber from cranial bone defects are necessary to meet the ever increasing admissibility standards. The relationship between caliber, wound diameter, and bone mineral density (BMD) was examined. The formation of the permanent cavity is influenced by bullet yaw, velocity, distance, and tissue properties. The hypothesis was that including BMD, wound diameter could be explained by differences in caliber. The sample consists of 68 autopsy sections and 101 specimens from Phelps (1898). A subsample of 18 was scanned using dual energy x-ray absorptiometry (DEXA) for BMD measurement to test whether an increase in BMD affects wound diameter. Pearson product-moment correlations of the subsample indicate the strongest correlation is between BMD and minimum diameter (r = 0.7101), followed by a correlation between minimum diameter and caliber (r = 0.6854). Despite the previous use of thickness as a proxy for BMD, no correlation was found between BMD and thickness (r = 0.0143). A multivariate analysis of variance (MANOVA) detected a significant influence of BMD and minimum diameter on caliber size (Prob > F = 0.0003). The logistic regression shows that caliber can be estimated from minimum diameter. Using the subsample, the results show that the inclusion of BMD strengthens the model for estimating caliber from entrance gunshot defects.

The early management of gunshot wounds Part II: the abdomen, extremities and special situations

The management of gunshot wounds of the abdomen and extremities is evolving with centres who treat large volumes of such injuries tending to the application of a policy of selective non-operative management. This article discusses the management of gunshot wounds to the abdomen and extremities and reviews the evidence supporting these changing practices. Special situations such as wounding by shotguns or air rifles are also examined as are the special considerations needed when dealing with the gunshot injured pregnant women or in a child.

SPINE GUNSHOT WOUNDS AT THE CENTRAL MILITARY HOSPITAL IN MEXICO

ABSTRACT Objective: To compare the measurement of the Cobb angle in printed radiographs and digitalized radiographs displayed with the "PixViewer" tool. Methods: Pre-operative radiographs of 23 patients were performed in printed films and using the software "PixViewer". The same evaluator, a spine surgeon, chose the proximal and distal end vertebrae at the limit of the main curve in printed radiographs without identifying patients, and measured the Cobb angle based on these parameters. The same parameters and measurements were performed in digitalized radiographs. The measurements were compared, as well as the choice of end vertebrae. Results: The average change in the Cobb angle between the methods was 1.48±1.73°. The intraclass correlation coefficient (ICC) was 0.99, demonstrating excellent reproducibility. Conclusion: The Cobb method can be used to evaluate scoliosis through the "PixViewer" tool with the same reliability of the classic method on printed radiographs.