Skin simulants for wound ballistic investigation - an experimental study

Gunshot wound analysis is an important part of medicolegal practice, in both autopsies and examinations of living persons. Well-established and studied simulants exist that exhibit both physical and biomechanical properties of soft-tissues and bones. Current research literature on ballistic wounds focuses on the biomechanical properties of skin simulants. In our extensive experimental study, we tested numerous synthetic and natural materials, regarding their macromorphological bullet impact characteristics, and compared these data with those from real bullet injuries gathered from medicolegal practice. Over thirty varieties of potential skin simulants were shot perpendicularly, and at 45°, at a distance of 10 m and 0.3 m, using full metal jacket (FMJ) projectiles (9 × 19 mm Luger). Simulants included ballistic gelatine at various concentrations, dental silicones with several degrees of hardness, alginates, latex, chamois leather, suture trainers for medical training purposes and various material compound models. In addition to complying to the general requirements for a synthetic simulant, results obtained from dental silicones shore hardness 70 (backed with 20 % by mass gelatine), were especially highly comparable to gunshot entry wounds in skin from real cases. Based on these results, particularly focusing on the macroscopically detectable criteria, we can strongly recommend dental silicone shore hardness 70 as a skin simulant for wound ballistics examinations.

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.

Observing the fragmentation of two expanding bullet types and a full metal-jacketed bullet with computed tomography-a forensic ballistics case study

Computed tomography (CT) may have a crucial role in the forensic documentation and analysis of firearm injuries. The aim of this forensic ballistics case study was to explore whether two types of expanding bullets and a full metal-jacketed bullet could be differentiated by inspecting bullet fragments and fragmentation pattern in CT. Three types of .30 caliber bullets (full metal-jacketed Norma Jaktmatch, expanding full-copper Norma Ecostrike, and expanding soft-point Norma Oryx) were test fired from a distance of 5 m to blocks of 10% ballistic gelatine. CT scans of the blocks were obtained with clinical equipment and metal artifact reduction. Radiopaque fragments were identified and fragmentation parameters were obtained from the scans (total number of fragments, maximum diameter of the largest fragment, distance between entrance and the closest fragment, length of the fragment cloud, and maximum diameters of the fragment cloud). The fragmentation patterns were additionally visualized by means of 3D reconstruction. In CT, the bullet types differed in several fragmentation parameters. While the expanding full-copper bullet Ecostrike left behind only a single fragment near the end of the bullet channel, the soft-point Oryx had hundreds of fragments deposited throughout the channel. For both expanding bullets Ecostrike and Oryx, the fragments were clearly smaller than those left behind by the full metal-jacketed Jaktmatch. This was surprising as the full metal-jacketed bullet was expected to remain intact. The fragment cloud of Jaktmatch had similar mediolateral and superoinferior diameters to that of Oryx; however, fragments were deposited in the second half of the gelatine block, and not throughout the block. This case study provides a basis and potential methodology for further experiments. The findings are expected to benefit forensic practitioners with limited background information on gunshot injury cases, for example, those that involve several potential firearms or atypical gunshot wounds. The findings may prove beneficial for both human and wildlife forensics.

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.

Perforation of the colon in response to the blast effect of an extraperitoneal gunshot injury

INTRODUCTION AND IMPORTANCE

Gunshot injury has many medical aspects, and the blast effect is a rare one that needs a precise first emergency examination.

CASE PRESENTATION

A 16-year-old male who was injured by a gunshot. Upon arrival at the emergency department, he was treated as a trauma call. There was only one bullet that entered from the outer edge of the right ASIS and exited inside the right buttock approximately 10 cm lower tangentially and no bullet entered the abdomen. Initial assessments and imaging revealed no underlying pathology findings, and the patient's vital signs were stable. Epigastric and RUQ tenderness and CT findings prompted us to perform a laparotomy. During laparotomy, we discovered a perforation in the hepatic flexure of the colon.

CLINICAL DISCUSSION

It is believed that as the peritoneal cavity is not touched by bullet, the colon is perforated because of the blast effect of the gunshot. Although blast effects from gunshots or shotguns are rare, especially in intact abdomens, clinical staff should keep this effect in mind. This will ensure that they don't misinterpret the bullet path and external torso and don't miss anything subtle during their initial clinical examination.

CONCLUSIONS

This case highlights the possibility of blast effect in gunshot cases and injury to organs that aren't in the bullet's path. Laparotomy is recommended if CT scan shows thickened colon wall in patients with extraperitoneal gunshot injury.

Complex suicides involving the use of firearms and hanging: A retrospective study and review of the literature

INTRODUCTION

Suicides are the second most common cause of non-natural death in Germany after accidents. Most common is death by hanging, followed by the use of firearms. More frequent "simple" suicides in which one suicide method is used are distinguished from rare "complex" suicides, in which several methods are applied, whereby the combination of gunshot and strangulation is frequently chosen. Such cases require a thorough criminalistic and forensic medical examination to check the plausibility of assumed sequences of events and to detect covered-up homicides.

MATERIAL AND METHODS

A retrospective analysis of 5,400 post-mortem examinations at the Institute of Legal Medicine Giessen (2009-2018) revealed three cases in which gunshot and hanging were used to commit a planned complex suicide.

RESULTS

Case 1: The body of a 66-year-old carcinoma patient was found hanging from a tree in a kneeling position with a bullet through the head. The post-mortem examination revealed a penetrating head shot, uninjured soft tissues of the neck, no injuries to the hyoid bone or larynx and no signs of congestion. After autopsy, the gunshot through the head was considered as cause of death. Case 2: An 82-year-old man was found dead with two bullet wounds in the chest, hanging in free suspension in a factory hall. The necropsy showed two chest entry wounds with injuries to the heart and lungs as well as a vital ligature mark and fractures of the hyoid bone and larynx without signs of congestion. The combination of hanging and the gunshot wounds was concluded as cause of death. Case 3: The body of an 81-year-old pain patient was found in his home next to a small-caliber rifle, with a noose around his neck, attached to a suspension torn from the wall. The autopsy revealed a tangential shot through the skull with superficial injury to the frontal brain and a vital cord mark on the neck with fractures of the hyoid bone and larynx without signs of strangulation. In this case, hanging was identified as cause of death.

CONCLUSION

Complex suicides are rare events, that require a thorough criminalistic and forensic medical examination Although being called complex suicides and one of the methods usually being suitable to cause death, the cause of death is not always a combined one.

Multi-stage management of a right hip gunshot injury; Case report

A 42-year-old hunter with no previous medical history suffered an accidental gunshot injury while hunting. Upon arrival at our Hospital, the following musculosceletal laesions were diagnosed during the primary survey: comminuted right trochanteric and femur neck fracture, femoral and sciatic nerve palsy. The immediate damage control surgery consisted of debridement, jet-lavage, PMMA-chain insertion and extrafocal fixation. Structural neural damage was disclosed. Primarily the skin wound was treated by delayed closure and later the healing was supported by Negative Pressure Wound Therapy. Six weeks after, the extrafocal fixation was removed and antibiotic spacer was inserted. Primary wound healing occurred without any sign of infection. Neurological recovery of the extremity took almost a year. Low grade infection were excluded by serial labs and culture samples. Finally the patient underwent total hip arthroplasty with excellent result.

Bursting of the upper jaw prosthesis and fractures of the lower jaw as indirect injury pattern caused by a headshot: a case report

Gunshots to the human body can cause direct and indirect injuries. Direct injuries are a consequence of the projectile guiding its way through the body, creating a permanent wound channel and thereby damaging the penetrated as well as the adjacent tissue. In addition, the temporary wound cavity is responsible for indirect injuries occurring distant to the actual wound tract. This can potentially affect different types of tissue, like blood vessels, organs, or bones, that are not directly passed through by the projectile. For this case report, we describe a suicidal headshot to the temporal area where the extension of the temporary wound cavity and its subsequent collapse led to massive energy transfer to the surrounding tissue leading to breakage of the upper dental prosthesis and fractures of the lower jaw. Thereby outlining the ballistic mechanisms causing indirect injury pattern that have to be considered when examining gunshot wounds.

Using the Field Artificial Intelligence Triage (FAIT) tool to predict hospital critical care resource utilization in patients with truncal gunshot wounds

BACKGROUND

Tiered trauma triage systems have resulted in a significant mortality reduction, but models have remained unchanged. The aim of this study was to develop and test an artificial intelligence algorithm to predict critical care resource utilization.

METHODS

We queried the ACS-TQIP 2017-18 database for truncal gunshot wounds(GSW). An information-aware deep neural network (DNN-IAD) model was trained to predict ICU admission and need for mechanical ventilation (MV). Input variables included demographics, comorbidities, vital signs, and external injuries. The model's performance was assessed using the area under receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC).

RESULTS

For the ICU admission analysis, we included 39,916 patients. For the MV need analysis, 39,591 patients were included. Median (IQR) age was 27 (22,36). AUROC and AUPRC for predicting ICU need were 84.8 ± 0.5 and 75.4 ± 0.5, and the AUROC and AUPRC for MV need were 86.8 ± 0.5 and 72.5 ± 0.6.

CONCLUSIONS

Our model predicts hospital utilization outcomes in patients with truncal GSW with high accuracy, allowing early resource mobilization and rapid triage decisions in hospitals with capacity issues and austere environments.

Recidivism after orthopaedic trauma has diminished over time

PURPOSE

The purpose was to analyze our trauma population during two periods to assess for predictors of recidivism.

METHODS

Prior (2007-2011, n = 879) and recent (2014-2019, n = 954) orthopaedic trauma patients were reviewed. Recidivists were those returning with an unrelated injury. Recidivism rates were compared, and factors associated with recidivism were identified.

RESULTS

Recidivism decreased: 18.7% to 14.3% (p = 0.01). Mean age and sex of the two cohorts were not different. Recent recidivists were more likely to sustain gunshot wound (GSW) injuries (22.1% vs 18.9%, p = 0.09), and mental illness was more common (56.6% vs 28.1%, p < 0.0001). The recent recidivist population was less often married (12.9% vs 23.8%, p = 0.03), and both recidivist groups were often underinsured (Medicaid or uninsured: (60.6% vs 67.0%)).

CONCLUSION

Recidivism diminished, although more GSW and mental illness were seen. Recidivists are likely to be underinsured. The changing profile of recidivists may be attributed to socioeconomic trends and new programs to improve outcomes after trauma.

Ballistic diaphyseal forearm fractures result in high incidence of neurovascular injury and compartment syndrome but have low rates of early infection: A single level I trauma center experience

INTRODUCTION

Ballistic injuries to the upper extremity represent a small subset of injuries, and there is little data to provide guidance on management and outcomes. The purpose of this study is to assess the incidence of neurovascular injuries, compartment syndrome, and early postoperative infection, as well as patient and injury factors predictive of neurovascular injury following ballistic fractures of the forearm.

PATIENTS AND METHODS

A retrospective review of operatively treated ballistic forearm fractures at a single level I trauma center between 2010 and 2022 was performed. Thirty-three patients with 36 forearm fractures were identified. Only diaphyseal injuries in patients greater than 18 years old were included. Medical and radiographic records were reviewed to identify pre-injury patient-specific factors, including age, sex, smoking status, and history of diabetes. Injury characteristics, including the type of firearm used, forearm fracture location, and any associated neurologic or vascular injury, as well as compartment syndrome, were collected and analyzed. Short-term outcomes such as post-operative infection and recovery of neurologic function were also collected and analyzed.

RESULTS

The median age was 27 years (range: 18-62), with a majority of male patients (78.8%, n = 26). 4 patients (12.1%) sustained high-energy injuries. 4 patients (12.1%) were found to have compartment syndrome pre-operatively or intra-operatively. 11 patients (33.3%) had nerve palsies postoperatively with 8 patients (24.2%) continuing to have nerve palsies at their final follow-up (mean follow-up= 149.9 +/- 187.2 days). The median length of stay was 4 days. There were no patients with infection at follow-up.

CONCLUSION

Ballistic forearm fractures are complex injuries and can result in severe complications such as neurovascular injury and compartment syndrome. As such, a comprehensive evaluation and appropriate management of ballistic forearm fractures are essential to minimize the risk of severe complications and optimize patient outcomes. In our experience, when treated operatively, these injuries have a low rate of infection.

A global perspective on gun violence injuries

INTRODUCTION AND DEFINITIONS

Civilian gunshot violence is a growing public health issue on a global scale. Treatment of patients with gunshot injuries is based on algorithms derived from military studies, but the distinct differences in weaponry, energy of injury, timing and type of care, and environment translate to a gap in knowledge. With a focus on non-accidental gunshot trauma and excluding suicide etiologies, we propose to build a collaborative research group to address important questions focused on best practices for gunshot injury patients.

PRE-HOSPITAL CARE

There are important differences in the care of gunshot victims across the globe; some countries provide advanced interventions in the field and others deliver basic support until transport to a higher level of care in hospital. Some simple interventions include the use of extremity tourniquets and intravenous fluid support; others to consider are tranexamic acid, whole blood, and hemostatic agents.

ACUTE TREATMENT

Control of exsanguinating hemorrhage is a key priority for gunshot injuries. Military doctrine has evolved to prioritize exsanguination over airway or breathing as the critical first step. The X-ABC protocol focuses on exsanguinating hemorrhage, then standard evaluation of Airway, Breathing and Circulation (ABCs) to enhance survival in trauma patients. The timing of bony stabilization, in terms of damage-control vs definitive care, needs further study in this population, as does use of antibiotics for bony extremity injuries. Finally, recognition of the mental health effects of gun trauma, including post-traumatic stress disorder (PTSD), anxiety disorders, substance abuse and depression is important in advocating for prevention such as implementation of social support and specific interventions.

DEFINITIVE CARE

The need for abdominal closure after exploratory laparotomy, definitive fracture treatment, and other treatment all contribute to length of stay for gunshot injured patients. Optimizing stabilization allows earlier mobilization and decreases nosocomial complications. Nerve injuries are often a source of long-term disability and their evaluation and treatment require further investigation.

RESOURCES AND ETHICS

There are growing numbers of mass-casualty gunshot events, which require consideration of how to organize and use resources for treatment, including staff, operating room access, blood products, and order of treatment. Drills and planning for incident command hierarchy and communication are key to optimizing resource utilization. The ethics of choosing treatment priorities and resources are important considerations as well.

Successful topical treatment of a gunshot wound: A case report

Gunshot wound leads to deep soft tissue damages known as penetrating trauma. Wound healing in patient with the gunshot is a dynamic and complex process that requires a suitable approach to promote the healing process. The reason for this is that such wounds are usually deep and extensive. Modern wound dressing in perforated wounds without a fracture or neurovascular injury may be considered for wound healing of outpatients. We report on an 18-year-old girl patient with gunshot wound who was referred to the wound clinic. The symptoms of wound dehiscence in the periumbilical site were observed following to lose suture after primary surgery. Therefore, a new special dressing approach was adopted. Healing of periumbilical wound was successfully achieved at the end.

Penetrating thoracic injury requiring emergency pneumonectomy supported with two ECMO runs: A testament to multidisciplinary critical care medicine

Post-traumatic pneumonectomies are uncommon and, if necessary, carry significant mortality. The use of extracorporeal membrane oxygenation (ECMO) for lung injury in trauma patient has demonstrated efficacy with minimal bleeding complications. We report a case of a young man with a penetrating thoracic injury that required a pneumonectomy supported with two separate ECMO runs for pulmonary failure postoperatively.

[Bullet fragment in the interventricular septum : Is surgery always obligatory ?]

INTRODUCTION

Cardiac gunshot injuries are fatal and very challenging to manage for surgeons. Unfortunately, there is no consensus regarding the management of these patients.

CASE PRESENTATION

We report an unusual case of a cardiac injury after an indirect gunshot to the heart. The 59 years-old male was hemodynamically stable which allowed us to do further investigations revealing a bullets fragment in the interventricular septum without other complication. Conservative management was decided with a careful regular follow-up.

CONCLUSION

Cardiac gunshot injuries must be managed aggressively in hemodynamically unstable patients. In stable patients, further investigations can be done to allow decision-making.

Management of gunshot-related forearm bone defect by sequential internal fixation and deferred bone grafting: experience from a tertiary hospital in Mogadishu

Gunshot-related forearm fractures are rare injuries, usually incurring bone defect. The aim of the study was to report clinical and radiological results for sequential internal fixation and bone grafting in acute civilian forearm gunshot fractures with bone defect. The procedure involves staged techniques consisting of bone debridement, soft-tissue closure and temporary intramedullary Kirschner wire fixation, followed by deferred bone grafting. To our knowledge, the present study is the first to investigate this surgical sequence in such injuries. Between June 2018 and September 2019, 6 civilian cases (5 male, 1 female) with a mean age of 26 years (range, 19-36 years) were operated on by sequential internal fixation and bone grafting for acute forearm gunshot fractures with segmental bone defect. Demographics, injury characteristics and surgical features were recorded. The Tang classification system was used to evaluate clinical and radiological results at final follow-up. Mean follow-up was 27 months (range: 21-32 months). Defect location was in the radius in 4 patients and in the ulna in 2, with a mean defect size of 3.75 cm (range, 2-8 cm). Union was achieved in 5 patients, at a mean 7 months (range, 4-10 months). Functional outcome was excellent in 4 patients, good in 1 and fair in 1. Sequential internal fixation and bone grafting seems a reliable option in the treatment of acute forearm gunshot fractures with bone defect. LEVEL OF EVIDENCE: Level IV - Retrospective study.

Gunshot injury to the colon by expanding bullets in combat patients wounded in hybrid period of the Russian-Ukrainian war during 2014-2020

BACKGROUND

A gunshot wound to the colon is a frequent injury in armed conflicts. An example of a high-energy modern weapon is hollow-point bullets, which is associated with increased tissue damage and lethal outcome. The aim of this study was to evaluate gunshot injuries to the colon in combat patients and to assess the difference in clinical features of patients with colon injuries by hollow-point versus shape-stable bullets.

PATIENTS AND METHODS

Analyses of clinical data were performed on 374 male soldiers from the Armed Forces of Ukraine with gunshot abdominal wounds with injury to the colon in East Ukraine between 2014 and 2020. Out of 374 injured, 112 (29.9%) patients were diagnosed with penetrating gunshot bullet wounds: 69/112 (61.6%) were injured by shape-stable bullets, and the hollow-point bullets injured 43/112 (38.4%) patients.

RESULTS

More severe hemorrhagic shock stages were in patients injured by hollow-point bullets: shock stages III-IV was in 25 (58.1%) patients injured by the hollow-point bullets vs. 17 (24.6%) patients injured by shape-stable bullets (p = 0.0004). Left colon parts were more frequently injured as compared to the right colon side or transverse colon: 21 (48.8%) patients were injured by the hollow-point bullets (p < 0.0001), and 41 (59.4%) patients were injured by the shape-stable bullets (p = 0.032). A significant difference was identified for the frequent injury to the middle colon within the entire cohort (p = 0.023). Patients injured by the hollow-point bullets demonstrated a higher frequency of 3-5 areas of colon gunshot defects, which was detected in 18 (41.8%) patients injured by hollow-point bullets and none with shape-stable bullets injury (p = 0.0001). Colon Injury Scale (CIS) IV was detected in 7 (16.3%) patients injured by the hollow-point bullets as compared to 2 (2.9%) patients injured by shape-stable bullets (p = 0.011). Colostomy was performed in 14 (69%) patients injured by shape-stable bullets and in 12 (27.9%) patients injured by hollow-point bullets (p > 0.05). 15 (35%) patients died after injury by the hollow-point bullet, whereas 9 (13%) patients after damage by the shape-stable bullets (p = 0.0089).

CONCLUSIONS

All patients should be suspected to have an injury by bullet with expanding properties in case of penetrating abdominal injury (absent of outlet wound) and careful revision of the abdomen must be performed to identify possible multiorgan injury as well as multiple gunshot defects of the intestine.

Epidemiological characteristics and comparative outcome of blast versus gunshot injuries of the extremities in Somalia

BACKGROUND

War conflicts and terror-related injuries constitute a significant public health problem in Somalia. We aim to characterize and compare the injury characteristics of gunshot and blast injuries of the extremities.

METHODS

The data of 333 patients with gunshot and blast injuries of the extremities over three years were retrospectively reviewed. The demographics, injury characteristics, and outcomes were analyzed.

RESULTS

Most of the patients had injuries due to gunshot casualties compared with blast victims (n = 222, 66.7% vs. n = 111, 33.3%). Patients with gunshot wounds (GSW) had a more significant proportion of males than those with blast wounds (BW) (95.5% vs. 85.6%, P < 0.001). There were more open extremity fractures in GSW casualties (96.4% vs. 81.1%). The BW victims had significantly higher associated injuries (52.3% vs. 18.5%, P < 0.001). The BW group had a higher injury severity score (ISS ≥ 16 in 55%, P < 0.001). The need for an intensive care unit (ICU) admission was significantly higher in the BW patients (18% vs. 6.3%, P < 0.001); as well as the length of hospital stay (LOS) was higher in the BW group compared with the GW patients (> 2-week hospital stay in 31% vs. 19%, P < 0.04). About a 2.7% mortality rate was observed in BW (P < 0.014).

CONCLUSION

Gunshot and explosion injuries comprise the majority of war and terror-related trauma of the extremities. These injury mechanisms differ in the body regions involved, the severity of the injury, duration of hospital stay, need for ICU admission, and mortality. Assessment and management of such devastating casualties require a complex and multidisciplinary approach.

Atypical wound trajectory after a tangential pistol shot

Three intermediate-range shots from a Browning, model 1955, 7.65 mm caliber, pistol were fired from the driver's seat of a car at a woman in the passenger seat. She sustained three wounds: An, ultimately fatal, penetrating head wound, a graze wound across her forehead, and a tangential, perforating, wound, with bullet entry over the medial sternum and exit through the right flank. Neither postmortem CT nor forensic autopsy discovered bony thoracic injuries or perforations of the thoracoabdominal cavities. There was pulmonary contusion in the medial lobe of the right lung and hemorrhage in the adipose tissue around the right kidney. The tangential bullet had left an almost 40-cm-long wound channel through a pronounced layer of subcutaneous fat. Based on 3D reconstructed CT-data determinations, a straight bullet trajectory between entry and exit wounds would have traversed the abdominothoracic cavities, right lung, and liver. The actual trajectory, however, described a prominent curve, without signs of deflection by bone. Postulated explanations for this unusual bullet track are that the woman was twisting her body in a dynamic scene when the bullet struck; further, due to its shallow angle of incidence on the skin, the bullet was deflected to an intracutaneous path. Additionally, soft tissue resistance may have caused the bullet to yaw. Caution should, thus, be exercised when reconstructing bullet trajectories solely from entry and exist wounds, also for bullet wounds through basically homogenous soft tissues.

Demographics, Radiological Findings, and Predictors of Prolonged Hospitalization in Civilian Gunshot Wound Patients

Objective

This study aims to characterize the demographic, clinical, and radiological features of gunshot wound (GSW) patients as well as identify predictors of prolonged hospitalization.

Methods

In this retrospective study, a consecutive sampling method was used, including all patients with GSWs in any anatomical region. Data collection included demographic and clinical information, radiological findings, treatment specifics, and outcome variables, such as hospitalization length of stay (LOS) as the primary outcome. To identify predictive factors associated with prolonged LOS, logistic regression analysis was used.

Results

We studied 212 GSW cases, including 95.8% were men and 4.2% were women. The mean age of the studied group was 30.17±7.80 years. GSWs occurred in extremities (80.2%), abdomen (9.0%), thorax (4.7%), and head or neck (5.2%). Two patients (0.9%) had both abdominal and thoracic GSWs. The most prevalent radiological study was an X-ray (83.0%). Patients with head and neck GSWs had the longest emergency department stay, while patients with abdominal GSW patients had the shortest (p=0.068). The highest rates of blood product transfusion were observed in abdominal GSWs (63.2%), emergency surgery (63.2%), and ICU admission (42.1%). Head and neck GSWs had the longest hospitalization LOS (7.5 days). Longer LOS was significantly associated with abnormalities in radiological findings, receiving blood products, and ICU admission (p≤0.001). Significant predictors of prolonged LOS were major abnormalities in radiological findings [odds ratio (OR)=5.3; 95% confidence interval (CI):2.8-10.2], head and neck GSWs (OR=6.1; 95% CI:1.2-31.9), and blood product transfusion (OR=4.1; 95% CI: 1.0-16.3).

Conclusion

This study provides insights into factors influencing prolonged hospitalization in GSW patients, highlighting the importance of radiological findings, head and neck injuries, and blood product transfusion.

Civilian penetrating traumatic brain injury: A 5-year single-center experience

Background

The aim of this study was to report the demographics and clinical features of patients with penetrating traumatic brain injury (PTBI) during the past 5 years in Rajaee Hospital, a tertiary referral trauma center in Shiraz, southern Iran.

Methods

We conducted a 5-year retrospective evaluation of all patients diagnosed with PTBI who were referred to Rajaee Hospital. We retrieved the following items from the hospital's database and PACS system: patients' demographics, on-admission Glasgow Coma Scale (GCS), presence of trauma to other organs, duration of the hospital and ICU stay, the neurosurgical interventions, any necessity of tracheostomy, duration of ventilator dependency, the entrance point of the trauma in the skull, type of assault, length of trajectory in the brain parenchyma, the number of remaining objects in the brain, the occurrence of any hemorrhagic phenomenon, the cross of the bullet from the midline or coronal suture, and the presence of the pneumocephalus.

Results

A total of 59 patients with a mean age of 28.75 ± 9.40 had PTBI over the 5 years. The mortality rate was 8.5%. Stab wounds, shotguns, gunshots, and airguns were the cause of injury in 33 (56%), 14 (23.7%), 10 (17%), and 2 (3.4%) patients, respectively. The median initial GCS of patients was 15 (3-15). Intracranial hemorrhage was observed in 33 cases, subdural hematoma in 18 cases, intraventricular hemorrhage in eight cases, and subarachnoid hemorrhage in four cases. The mean duration of hospitalization was 10.05 ± 10.75 (ranging from 1 to 62 days). Furthermore, 43 patients experienced ICU admission with mean days of 6.5 ± 5.62 (1-23). The temporal and frontal regions were the most common entrance points, in 23 and 19 patients, respectively.

Conclusion

The incidence of PTBI is relatively low in our center, possibly due to the prohibition of possession or using warm weapons in Iran. Further, multicenter studies with larger sample sizes are needed to determine prognostic factors associated with worse clinical outcomes after PTBI.

Minimally invasive retrieval of a bullet settling into the thoracic spinal canal in a pediatric patient: A case report

A 10-year-old boy presented to neurosurgery department after a gunshot wound to the upper thoracic spine. The bullet entered through the right deltoid muscle and lodged inside the spinal canal at T1 level. The patient arrived conscious and obeying commands; however, he experienced a loss of sensation below T3 level, loss of reflexes below the injured T1 level, loss of anal sphincter tone and paraplegia in the lower limbs (American Spinal Injury Association grade-A). Imaging studies revealed an intra-canalicular metallic bullet at the T1 level. The patient underwent urgent operation using a tubular retractor system and the microscope. Subsequently, the bullet was successfully retrieved. Postoperatively, the patient made a significant recovery and by the end of the 6th month, he was able to walk independently despite some gait instability. A minimally invasive approach for intra-canalicular bullet removal in the thoracic region is a safe and effective technique in pediatric patients.

Gunshot injuries: experience in a tertiary health facility in the Niger Delta Region of Nigeria

Introduction

the incidence of gunshot injuries and its negative socio-economic impact has assumed an alarming dimension in our environment in recent times as a result of increase in various criminal activities arising largely from poverty including armed robbery, insurgencies, banditry, kidnappings, political thuggery and the like. We share our experience in our centre.

Methods

a retrospective study of cases of gunshot injuries seen, admitted and managed at our health facility over a three-year period. Relevant information including: biodata, circumstances surrounding shooting, type/caliber of gun used, etc. were obtained from patient's case notes and other sources. Data were analysed using SPSS version 18.

Results

forty-one gunshot injury patients made up of 37 males and 4 females were studied. About 68% of the patients fell within the age group of 20-39 years. Students were the most commonly affected group (21%). Armed robbery was the most common aetiology of GSI in our patients (43.9%). Low-velocity guns were largely used (46%). The extremities were the most commonly injured (65.9%). Fractures occurred in 63.4% of patients the femur being the most frequently fractured (22.6%). Patients received various treatment modalities including, wound debridement (78%) and exploratory laparotomies (26.8%) while 3 (7.35%) of them died.

Conclusion

armed robbery and other criminal activities continue to constitute important factors responsible for GSI in our environment. There is need for government and all stakeholders to do more in terms of fighting crime in addition to placing policies to alleviate socioeconomic deprivation.

The economic impact of gunshot wounds on an urban level 1 trauma center

INTRODUCTION

Firearm-related injuries impact the healthcare system, taxpayers, and injured patients due to lost productivity and reduced quality of life. The goal was to quantify the economic costs related to hospitalization for gunshot wounds (GSWs) at a single urban level 1 trauma center.

MATERIALS AND METHODS

941 patients over 27 months were treated for GSW. Elements related to hospitalization including length of stay, surgical procedures, medications and therapies, and subsequent readmission were identified, and costs were determined, inclusive of fixed and variable direct and indirect costs of facility care. Costs were classified based on body region: abdominal, chest, soft tissue, extremity or pelvic girdle, and head/neck/face.

RESULTS

Mean age was 30 years, with 94% male. Most patients (81%) were admitted, and 8% sustained fatal injuries. Overall, 12% were seen previously or subsequently for additional, unrelated GSWs. Mean costs per patient were: $66,780 for abdominal GSWs; $3,986 for chest; $3,509 for soft tissue; $19,875 for extremities; $64,533 for head or neck, and means of $25,249 for two regions and $26,638 for three regions. Over the prospective period, 941 individuals sustained GSWs (approximately 35 per month). 37% were to the extremities, 23% were within the skin/subcutaneous tissue, 7% to the abdomen, 7% to the chest, 6% to the head or neck, and 20% to two or more body regions. Total facility costs for these 941 GSWs was $18.9 million, or $698,960 per month. 55% of the patients had Medicaid, and 33% were uninsured, resulting in substantial uncompensated expenses for the trauma center.

CONCLUSION

Firearm-related injuries generate considerable expense. Our data underestimated cost, as professional services and indirect costs associated with lost economic productivity of patients and caregivers were excluded. No objective assessment of the disastrous personal and social impact was projected. Moving forward, interventions to prevent initial injury and recidivism in this high-risk population are crucial.

LEVEL OF EVIDENCE

Level III.

Early results of low-velocity ballistic femoral shaft fractures

INTRODUCTION

Ballistic femur fractures are a common injury treated at United States civilian trauma centers. This study investigates the outcomes of these injuries by comparing the rates of infection, nonunion, secondary operations, and associated injuries from low-velocity gunshot (GSW) injuries with fractures sustained by blunt trauma.

METHODS

A retrospective cohort comparative study was performed at a Level 1 trauma center. 345 patients with closed blunt or GSW femoral shaft fractures over 10 years were included. All were treated with intramedullary nail fixation. Superficial and deep infection, vascular injury, compartment syndrome, nonunion, and secondary operations were identified.

RESULTS

148 patients in the GSW group and 197 patients in the blunt trauma group had overall mean age 33.5 years and 80% were male. Deep infection rates were similar There were no nonunions in the GSW group, contrasted with 8 (4.4%) nonunions in the blunt trauma group (p = 0.02). The rate of compartment syndrome was higher in the GSW group (6.1% vs 0, p < 0.001). Arterial injury occurred in 9% following GSW (vs 0, p < 0.001). Overall, secondary unplanned procedure rates were the same: 8.1% for both groups.

DISCUSSION

Ballistic femoral shaft fractures are often equated with open injuries; however, rates of infection and secondary operations closely mirror that of closed injuries resulting from blunt force trauma. Nonunions may be more common after blunt injury, and compartment syndrome and arterial injury are substantially more common following GSW, warranting careful clinical assessment.

LEVEL OF EVIDENCE

Prognostic, level III.

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 during a period of increased violence: Experience in a single orthopedic training centre

OBJECTIVE

Firearm violence has a high economic impact, representing the third most expensive injury and associated with the fourth highest hospitalisation cost. This study was performed to determine the clinical and epidemiological characteristics of patients with injuries due to firearm projectile during a period of increased violence related to organised crime in our country.

METHODS

A retrospective study (2010-2017) was conducted to analyse the clinical data of patients admitted due to firearm projectile injury. Clinical and epidemiological characteristics of each patient were recorded, and patients were stratified by sex and age. Compared low-energy versus high-energy gunshot injuries, complications and treatment.

RESULTS

A total of 1309 gunshot wounds in appendicular skeleton and spine fractures. The mean age of the patients was 29±11.5 years. Upper extremities wounds in 358 cases, lower extremities wounds in 727 cases and 224 fractures in spine region. There were no significant differences between low-velocity and high-velocity projectiles in anatomic affected region, complications and treatment.

CONCLUSIONS

We concluded that firearm projectiles cause a variety of injuries both in soft and bone tissues and caused a major rate of complications in our patients even with low- or high-energy weapons. The majority of patients affected were the civilian population. Most patients with gunshot wounds were young males. We observed a low mortality rate in our patients.

LEVEL OF EVIDENCE

III; retrospective cohort study.

CIVILIAN GUNSHOT OROFACIAL INJURY IN A NIGERIAN TERTIARY HOSPITAL: A 10-YEAR RETROSPECTIVE REVIEW

Background

Gunshot related injuries to the face are relatively rare in peacetime. This study reported the pattern of presentation and management of orofacial civilian gunshot injuries at a Nigerian tertiary hospital.

Methodology

Medical records of 25 patients who sustained gunshot injuries to the face and were managed at the Obafemi Awolowo University Teaching Hospitals Complex, Ile Ife between 2010 and 2019 were reviewed. Patients' demographics, wounding mechanisms, clinical presentations and treatment administered were retrieved from the patients' case record. Patient records with incomplete information were excluded. Data generated were inputed into IBM-SPSS version 26 and analysed.

Results

A total of 2,847 patients were admitted through our department over the study period and 28 of them sustained orofacial gunshot injuries, giving a prevalence of 0.98%. Twenty-five out of the 28 retrieved case files met the inclusion criteria. There were 22 males and 3 females; with a male to female ratio of 7.3:1. The mean age was 37.60 ± 11.86 years with highest prevalence at fourth decade of life. About two-thirds of these injuries were intentionally inflicted by others with the use of Dane guns on highways. Majority (64%) of these injuries involved the middle third of the face. Definitive treatments ranged from simple to complex reconstructive procedures to restore pre-injury form and functions.

Conclusion

Gunshot injury involving the maxillofacial region is uncommon during peace time. The male gender was predominantly affected and the middle third facial skeleton was the most involved anatomic site. Most of the injuries were intentionally inflicted by others using Dane gun.

Simultaneous retrograde venous and anterograde arterial bullet embolism: a case report

Background

Bullet embolus is a rare condition following gunshot injuries and represents a clinical challenge regarding both diagnosis and management.

Case presentation

We report the case of a 35-year-old Iranian (Middle-Eastern) male patient with a shotgun injury to both buttocks, which traveled to the heart and the popliteal area through the femoral vein and superficial femoral artery, respectively. Surgical intervention was applied for the popliteal pellet, and the patient was discharged without further complications.

Conclusion

Although bullet emboli can be a clinical challenge, with the advent of modern procedures, removal has become safer. X-ray, computed tomography, and transthoracic and/or transesophageal echocardiography may be used as adjuncts to help establish the diagnosis.

Isolated ballistic femoral condyle fractures: a case series of eighteen patients

PURPOSE

Ballistic fractures of the femoral condyles are rare injuries with limited literature to help guide treatment. The purpose of this study is to report on the presentation, management, and outcomes for patients with isolated ballistic condylar fractures.

METHODS

Eighteen patients between ages 16 and 65 with low-energy ballistic injuries isolated to the femoral condyles (OTA 33B) were included, 15 with CT imaging. Clinical records and imaging were reviewed, as well as treatment strategy. Fractures were classified by AO/OTA classification. Outcome and follow-up data were gathered at outpatient appointments and telephone calls.

RESULTS

Of the 18 patients, 78% were treated operatively (61% with open reduction and internal fixation, 17% with removal of foreign body alone). There were two instances of traumatic vascular injury and no neurologic injuries. Furthermore, there were no identified infections. Only 58% of the patients had follow-up for more than 6 weeks with average KOOS Jr. Score of 50, and average VAS pain score of 5.2.

CONCLUSIONS

Ballistic femoral condyle fractures are rare Orthopaedic injuries seen in relatively high frequency at our institution. Most (78%) were treated operatively and with few complications. These fractures are not easily classified according to common classification schemes and may benefit from more rigorous study to guide treatment and anticipate outcomes.

Chest wall reconstruction in a young man after high-velocity gunshot using a combination latissimus dorsi flaps and titanium plates: A case report

Chest trauma, penetrating or blunt, is common in this era of road traffic accidents, terrorism, and hunting in Iraq. During the last decade, many novel surgical procedures and materials were used to reconstruct or stabilize the chest wall to improve integration, maintain the stability of the chest wall, and reduce infections. However, no precise guidelines for managing chest wall diseases are still available to date. Here, we present a 24-year-old male who underwent chest wall reconstruction using a combination of latissimus dorsi flap and titanium plates, which were to cover the chest wall after a high-velocity gunshot. This patient was in shock too, with a lung contusion and massive hemorrhage. The sucking open chest wound lead to grossly disturbed respiratory mechanics. Such patients usually die on the way due to hemodynamic instability. In this particular case, adequate resuscitation and prompt thoracotomy saved the patient's life. This case report is important because, as we already mentioned, thoracic trauma alone is the cause of death in 25% of patients, and in another 25%, it's a contributing factor in a polytrauma death. This amounts to very high mortality. Our patient received a major laceration of the left lung. Our patient had a full recovery from this life-threatening situation.

Ballistic peripheral nerve injuries: basic concepts, controversies, and proposal for a management strategy

Ballistic injuries to peripheral nerves are devastating injuries frequently encountered in modern conflicts and civilian trauma centers. Such injuries often produce lifelong morbidity, mainly in the form of function loss and chronic pain. However, their surgical management still poses significant challenges concerning indication, timing, and type of repair, particularly when they are part of high-energy multi-tissue injuries. To help trauma surgeons, this article first presents basic ballistic concepts explaining different types of missile nerve lesions, described using the Sunderland classification, as well as their usual associated injuries. Current controversies regarding their surgical management are then described, including nerve exploration timing and neurolysis's relevance as a treatment option. Finally, based on anecdotal evidence and a literature review, a standardized management strategy for ballistic nerve injuries is proposed. This article emphasizes the importance of early nerve exploration and provides a detailed method for making a diagnosis in both acute and sub-acute periods. Direct suturing with joint flexion is strongly recommended for sciatic nerve defects and any nerve defect of limited size. Conversely, large defects require conventional nerve grafting, and proximal injuries may require nerve transfers, especially at the brachial plexus level. Additionally, combined or early secondary tendon transfers are helpful in certain injuries. Finally, ideal timing for nerve repair is proposed, based on the defect length, associated injuries, and risk of infection, which correlate intimately to the projectile velocity.

An analysis of child suicide from three centers (2008-2017)

Although the overall suicide rate worldwide has changed minimally over the past 100 years, different trends have been observed over time in the USA, Australia, and New Zealand (NZ). However, few studies have focused on suicides in children (< 18 years), making evaluation of possible trends difficult. The last 20 years has also seen an increase in childhood obesity, eating disorders, and body image issues for children in many developed nations; however, few studies have shown whether a significant proportion of child suicides have an abnormal BMI. The current study evaluates child suicides (from 2008 to 2017) in South Australia (Australia), compared with the jurisdictions of Auckland (NZ) and Hennepin County (USA). Demographic data (age, sex, ethnicity), body mass index (BMI), the number of cases of youth suicide, and the method of suicide from these three regions were collected and analyzed. Across the 10-year period, the jurisdiction of Auckland had a downward trend, while Hennepin County and South Australia had increasing numbers of cases. The most common method of child suicide in all centers was hanging, occurring in > 80% of cases in South Australia and Auckland and 56% in Hennepin County. Hennepin County had a greater proportion of suicides using firearms (28%), compared to 1.9% in Auckland and 5.1% in South Australia. Unusual means of suicide were used less frequently by youth than previously.

Intracranial gunshot wounds in utero: case report and review

BACKGROUND AND IMPORTANCE

We present a rare case of an in utero intracranial gunshot wound with survival of the baby and neurosurgical intervention in the first 6 h of life.

CLINICAL PRESENTATION

A pregnant 19-year old sustained multiple gunshot wounds and underwent an emergency cesarean section. At the time of delivery, there was a penetrating wound noted to the uterus and to the left side of the baby's head. The baby was taken urgently for craniotomy. Thorough washout was performed, and a pericranial graft was harvested from the frontal vertex to assist in dural closure. The largest displaced bone fragment was soaked in betadine and sutured back into place. The baby was observed for several days and then discharged home with normal neurological examination.

CONCLUSION

There are scattered reports of in utero intracranial gunshot wounds in the literature dating back to the nineteenth century; however, our case appears to be the first reported that involved urgent surgical intervention.

Anterograde venous bullet embolism from the left facial vein to the right ventricle

A young man presented to the emergency department reporting he had been recently shot in the face and chest with an unknown weapon. Initial physical examination only found bruising by the left hemimandible, but CT angiography of the thorax revealed a BB in the right ventricle. A subsequent CT angiography of the head and neck showed no major arterial injury but noted stranding and irregularity of the left facial vein directly deep to the injury site. The findings favoured anterograde venous bullet embolism from the left facial vein to the right ventricle. To our knowledge, this is the first report of a relatively small diameter and superficial vein of the face resulting in this phenomenon.

Annular distribution patterns of .357 Magnum fragments in soft tissue simulants after striking hard material that prevented the bullet from exiting

The distribution of bullet fragments inside the body can provide information for the reconstruction of events in shooting incidents. The formation of an annular distribution pattern of bullet fragments was recently presented in a case report. The fragments were scattered radially around an exit-re-entrance wound resulting from collision of the bullet with a floor tile immediately after perforating the body. Such an annular distribution pattern of bullet fragments around an exit-re-entrance wound would indicate that a body was in close contact with hard material, for instance, lying on hard ground or leaning against a concrete wall, when the shot was fired. The aim of this experimental study was to investigate the formation and reproducibility of the annular distribution pattern of bullet fragments. It was assumed that the distribution pattern would be formed when hard material blocks a bullet from exiting a soft tissue simulant. Furthermore, the dependency of this distribution pattern on the impact angle was assessed. For this purpose, .357 Magnum bullets were fired at ballistic soap blocks with a steel plate at the rear end of the soap block. Six shots were performed at an impact angle of 90° (experiment 1), and six shots were performed at an impact angle of 45° (experiment 2). The distribution pattern of the fragments inside the individual soap blocks was examined via computed tomography (CT). In experiment 1, the bullets burst, and large fragments formed annular distribution patterns with a radial extent of approximately 4.9 cm and a maximum depth of approximately 2.3 cm. In experiment 2, the bullets ricocheted from the steel plate, and tiny fragments formed small annular distribution patterns at the points of ricochet with a radial extent of approximately 1.5 cm and a maximum depth of approximately 1.2 cm. The end position of the large main fragments was approximately 9.7 cm distant from the point of ricochet at a mean depth of 2.7 cm. The mean kinetic energy of the bullets at the time of impact was 580 J in experiment 1 and 394 J in experiment 2. Distribution patterns of bullet fragments in the body may provide information not only on the impact angle of a bullet but also on whether the body was in contact with a hard material that blocked the bullet from exiting the body. CT proved to be an appropriate imaging method for such investigations.

Prolonged tactical tourniquet application for extremity combat injuries during war against terrorism in the Sahelian strip

PURPOSE

This study reports on complications following extended tourniquet application in patients with combat extremity injuries treated by the French Military Health Service in the Sahelian strip.

METHODS

A retrospective review was performed in a French forward medical treatment facility deployed in Gao, Mali, between 2015 and 2020. All patients treated for an extremity injury with the application of at least one tourniquet for a minimum of 3 h were included. Prehospital data were injury pattern, associated shock, tourniquet location, and duration. Subsequent complications and surgical procedures performed were analyzed.

RESULTS

Eleven patients with a mean age of 27.4 years (range 21-35 years) were included. They represented 39% of all patients in whom a tourniquet was applied. They had gunshot wounds (n = 7) or multiple blast injuries (n = 4) and totaled 14 extremity injuries requiring tourniquet application. The median ISS was 13 (interquartile range: 13). Tourniquets were mostly applied proximally on the limb for a mean duration of 268 min (range 180-360 min). Rhabdomyolysis was present in all cases. The damage control surgeries included debridement, external fixation, vascular repair, and primary amputation. Ten injuries were complicated by compartment syndrome requiring leg or thigh fasciotomy in the field or after repatriation. Two severely injured patients died of their wounds, but the others had a favorable outcome even though secondary amputation was sometimes required.

CONCLUSIONS

Extended and proximal tourniquet applications led to significant morbidity related to compartment syndrome and rhabdomyolysis. Hemorrhagic shock, mass casualty incident, and tactical constraints often precluded revising the temporary tourniquet applied under fire.

Pediatric firearm-associated fractures: Analysis of management and outcomes

BACKGROUND

Firearm-associated injuries (FAIs) are among the leading causes of morbidity and mortality in children living in the United States. Most victims of such injuries survive, but may experience compromised function related to musculoskeletal injuries. Although complex firearm-associated fractures (FAFs) often require specialized orthopaedic, vascular, and plastic surgical intervention, there is minimal research describing their management and outcomes. The purpose of this study is to describe the epidemiology and presentation of pediatric FAFs, as well as evaluate the management and outcomes of these injuries.

AIM

To describe the epidemiology and presentation of pediatric FAFs, as well as evaluate the management and outcomes of these injuries.

METHODS

A retrospective chart review was performed at a major, pediatric level 1 trauma center. The study included patients aged 18 or younger who presented with FAIs between 2008-2018. Additional data was collected on patients with FAFs including demographic and clinical data such as age, sex, race, payor type, fracture location, injury severity score (ISS), and radiographic and clinical outcomes. The management of FAFs was analyzed as well as need for readmission and reoperation. Descriptive statistics were used to summarize the results and univariate analyses were performed to assess differences between groups.

RESULTS

Between 2008 and 2018, there were a total of 61 patients who presented with FAIs. In this cohort, 21 patients (34%) sustained FAFs (25 fractures) with a mean age of 11 (Range: 10 mo to 18 years old) at the time of presentation. Approximately 52% (n = 11) of patients with FAFs were male, 76% (n = 8 and n = 8, respectively) identified as black or other, and 71% (n = 15) had government insurance. FAFs were most commonly noted in the upper extremity (n = 7) and lower extremity (n = 6). In patients with FAFs, the mean ISS at presentation was 11.38 (Range: 2-38), and 24% of patients (n = 5) were classified as having a major trauma. There were no significant differences in age, sex, race, and payor type in FAF patients that presented with and without major trauma (P > 0.05). When comparing FAF and non-FAF patients, there was a statistically significant difference in ISS (11.38 vs 14.45, P = 0.02). In total, 33% (n = 7) of patients with FAFs required orthopaedic surgical management, which was most commonly comprised of debridement (n = 6/7, 86%), and 14% (n = 1/7) of these patients required coordinated care with plastic and/or vascular surgery. There were no significant differences in age and payor type in patients with FAFs treated with and without orthopaedic surgery. Of the patients with FAFs, 52% (n = 11) had a minimum 90-d follow-up, and 48% (n = 10) had a minimum 2-year follow-up. Two patients were readmitted within 90-d, while one patient required a reoperation within 2-years.

CONCLUSION

Over 25% of FAIs in pediatric patients result in FAFs. FAFs often present to pediatric trauma centers and the majority of these injuries occur in non-Caucasian males with government insurance. Most FAFs do not need orthopaedic surgical management; 14% of these injuries require subspecialty care by orthopaedic surgery, vascular surgery, or plastic surgery. Patients with FAFs also have lower ISS compared to patients who sustained FAIs without fracture. Thus, these patients should be treated at pediatric trauma centers with specialty care and additional research is needed to focus prevention efforts, understand reasons for poor follow-up, and evaluate outcomes after injury.

Environmental and health hazards of military metal pollution

An increasing body of literature has demonstrated that armed conflicts and military activity may contribute to environmental pollution with metals, although the existing data are inconsistent. Therefore, in this paper, we discuss potential sources of military-related metal emissions, environmental metal contamination, as well as routes of metal exposure and their health hazards in relation to military activities. Emission of metals into the environment upon military activity occurs from weapon residues containing high levels of particles containing lead (Pb; leaded ammunition), copper (Cu; unleaded), and depleted uranium (DU). As a consequence, military activity results in soil contamination with Pb and Cu, as well as other metals including Cd, Sb, Cr, Ni, Zn, with subsequent metal translocation to water, thus increasing the risk of human exposure. Biomonitoring studies have demonstrated increased accumulation of metals in plants, invertebrates, and vertebrate species (fish, birds, mammals). Correspondingly, military activity is associated with human metal exposure that results from inhalation or ingestion of released particles, as well as injuries with subsequent metal release from embedded fragments. It is also notable that local metal accumulation following military injury may occur even without detectable fragments. Nonetheless, data on health effects of military-related metal exposures have yet to be systematized. The existing data demonstrate adverse neurological, cardiovascular, and reproductive outcomes in exposed military personnel. Moreover, military-related metal exposures also result in adverse neurodevelopmental outcome in children living within adulterated territories. Experimental in vivo and in vitro studies also demonstrated toxic effects of specific metals as well as widely used metal alloys, although laboratory data report much wider spectrum of adverse effects as compared to epidemiological studies. Therefore, further epidemiological, biomonitoring and laboratory studies are required to better characterize military-related metal exposures and their underlying mechanisms of their adverse toxic effects.

The Impact of a Mobile Phone Application for Retention of Bleeding Control Skills

BACKGROUND

The American College of Surgeons Bleeding Control Course (B-Con) empowers bystanders with hemorrhage control skills to manage prehospital emergencies, but demonstrates poor skill retention. The point of care use of a free Stop the Bleed mobile phone application on the retention of hemorrhage control skills from the B-Con Course was explored.

METHODS

Convenience sample of college students previously trained in B-Con were randomized into mobile application (MA) or control groups. The use of a mobile application during a simulated emergency scenario with tourniquet and situational awareness skills was assessed. Wound packing skill retention without intervention was also assessed. Survey data allowed for comparison of participant perceptions of skills with actual performances.

RESULTS

MA (n = 30) was superior to control (n = 32) in correct tourniquet application (62.5% versus 30.0%; P = 0.01) with longer placement times (163 sec versus 95 sec; P < 0.001) and in calling 911 (31.3% versus 3.3%, P = 0.004). Participants maintain inflated perceptions of their skills, but generally feel underprepared for a future bleeding emergency.

CONCLUSIONS

Mobile apps improve tourniquet and situational awareness skills and may serve as potential aids to improve bystander hemorrhage control skills in real-time, but require further prospective investigation into its use.

Gunshot and stab wounds in France: descriptive study from a national trauma registry

PURPOSE

Severe trauma is a major problem worldwide. In France, blunt trauma (BT) is predominant and few studies are available on penetrating trauma (PT). The purpose of this study was to perform a descriptive analysis of severe gunshot (GSW) and stab wounds (SW) in patients who were treated in French trauma centers.

METHODS

Retrospective study on prospectively collected data in a national trauma registry. All adult (> 15 years) trauma patients primarily admitted in 1 of the 17 trauma centers members of the Traumabase between January 2015 to December 2018 were included. Data from patients who had a PT were compared with those who had suffered a BT over the same period. Due to the known differences between GSW and SW, sub-group analyses on data from GSW, SW and BT were also performed.

RESULTS

8128 patients were included. Twelve percent of the study group had a PT. The main mechanism of PT was SW (68.1%). Five hundred and eighty patients with PT (59.4%) required surgery within the first 24 h. Severe hemorrhage was more frequent in penetrating traumas (11.2% vs. 7.8% p < 0.001). Hospital mortality following PT was 8.9% vs 11% for blunt trauma (p = 0.047). Among PT the mortality after GSW was ten times higher than after SW (23.8% vs 2%).

CONCLUSION

This work is the largest study to date that has specifically focused on GSW and SW in France, and will help improving knowledge in managing such patients in our country.

The trajectory of a low-velocity bullet from the chest to the pituitary gland

The diagnosis and treatment of gunshot injuries requires an understanding of the trajectory of the bullet in each individual case. The majority of gunshot wounds present with easily understandable trajectories resulting in a concise, stream-lined work-up. Occasionally, the initial work-up may reveal a trajectory that is atypical. This can be due to internal bullet deflection, bullet embolism, or bullets that traverse multiple body cavities. Here we present the case of a gentleman who was shot in the left posterior chest, with the bullet ultimately lying-in profile with the patient's pituitary gland. The patient suffered injuries to his left lung, left internal jugular vein, and right optic nerve. On hospital day 1, he required neurosurgical operative intervention for increased somnolence and computed tomography findings which revealed tension pneumocephalus. On hospital day 15, he was discharged home after making a full recovery with the exception of continued blindness in the right eye. Gunshot wounds involving multiple body cavities can increase the complexity of a patient's injury pattern and require increased vigilance and complete history, physical examination, and imaging to ensure optimal outcomes.

Deep learning in forensic gunshot wound interpretation-a proof-of-concept study

While the applications of deep learning are considered revolutionary within several medical specialties, forensic applications have been scarce despite the visual nature of the field. For example, a forensic pathologist may benefit from deep learning-based tools in gunshot wound interpretation. This proof-of-concept study aimed to test the hypothesis that trained neural network architectures have potential to predict shooting distance class on the basis of a simple photograph of the gunshot wound. A dataset of 204 gunshot wound images (60 negative controls, 50 contact shots, 49 close-range shots, and 45 distant shots) was constructed on the basis of nineteen piglet carcasses fired with a .22 Long Rifle pistol. The dataset was used to train, validate, and test the ability of neural net architectures to correctly classify images on the basis of shooting distance. Deep learning was performed using the AIDeveloper open-source software. Of the explored neural network architectures, a trained multilayer perceptron based model (MLP_24_16_24) reached the highest testing accuracy of 98%. Of the testing set, the trained model was able to correctly classify all negative controls, contact shots, and close-range shots, whereas one distant shot was misclassified. Our study clearly demonstrated that in the future, forensic pathologists may benefit from deep learning-based tools in gunshot wound interpretation. With these data, we seek to provide an initial impetus for larger-scale research on deep learning approaches in forensic wound interpretation.

Civilian gunshot injuries in orthopaedics: a narrative review of ballistics, current concepts, and the South African experience

The incidence of civilian gunshot injuries is on the rise worldwide.Unfortunately, there is a lack of high-level evidence guiding management. The treatment of orthopaedic injuries from gunshots is complex and requires consideration of multiple aspects, including energy transfer to the tissue, severity of the wound, possible contamination, presence of fractures and associated injuries. With this narrative review we aim to discuss some of the relevant ballistics, current concepts, and controversies in the general management of civilian gunshot-related orthopaedic injuries based on the available evidence and personal experience. Important points which will be highlighted are the initial management in the emergency room, the assessment and management of soft tissue injuries, associated injuries, use of antibiotics, indication and techniques for fracture fixation, and gunshot injuries to joints.

Outcomes of patients with thoraco-abdominal gunshot wounds operatively managed at a district hospital in Cape Town, South Africa

AIM

Trauma is a leading cause of morbidity and mortality in the first four decades of life. Thoracoabdominal gunshot wounds carry a significant risk of mortality. This risk of death is reduced if patients are managed in dedicated units. This study examines the outcome of these patients managed in a district level hospital.

METHOD

In this retrospective review, patients with thoracoabdominal gunshot wounds were identified from operating room registry for the period of January 2015 to December 2018. Data was collected retrospectively from folders and analysed for the primary outcome of mortality.

RESULTS

Sixty-eight thoracoabdominal gunshot wounds were managed operatively over the period described. Only six patients were female. The median age was 29.5 years. Fourteen patients required postoperative transfer to a level 1 trauma unit. Thirteen patients died, nine at the district hospital and four at the level 1 unit. Significant differences in organ injuries were noted in the patients that died compared to the survivors.

DISCUSSION

The in-hospital mortality rate of patients managed at the district hospital was 13.2% which is comparable to international rates of 12-18%. However, the subset of patients that required postoperative transfer to a level 1 trauma unit had a high mortality rate of 28.6%. The DH is committed to managing unstable and unresponsive patients once they present. Improved mortality rates will only occur with better prehospital transport policies and by equipping the DH to manage these patients postoperatively.

CONCLUSION

Management of these patients can be successful at a district hospital. However, significant obstacles exist to their optimal care, as demonstrated by the high mortality patients requiring postoperative transfer.

Functional outcomes of internal fixation of scapula fractures due to high-velocity gunshot injuries

BACKGROUND

Open fractures of the scapula are relatively rare and only a few studies are interested in this subject. This study aims to demonstrate the results of internal fixation of open scapula fractures due to gunshot injuries.

MATERIALS AND METHODS

Eight patients who had open scapula fractures and were treated by internal fixation through the conventional Judet approach included in this study. Patients were followed up monthly in the first 6 months and every 2 months in the rest of the follow-up. Shoulder range of motion, Constant Shoulder Score, and Disabilities of the Arm, Shoulder, and Hand score were used for functional evaluation.

RESULTS

The average follow-up period was 34.6 ± 11.9 months. The average time between injuries and the surgery was 10.5 ± 5.1 days. The average shoulder abduction of the patients was 135.6 ± 18.8°, the average forward flexion of the shoulder was 160 ± 19.2°. The average internal and external rotations of the shoulders were 80 ± 14.1° and 63.1 ± 17.3°, respectively. CSS was calculated as 79.8 ± 14.4, and DASH was calculated as 14.1 ± 14.9.

CONCLUSIONS

In the treatment of open scapula fractures due to gunshot injuries, an internal fixation is a reliable option and the results were comparable with previous studies.

Air Gun Ballistic Projectile Lodged in the Interventricular Septum of an Asymptomatic Dog

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A gunshot to a dog embedded a metallic projectile in the interventricular septum.

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Direct cardiac penetration or venous embolism to the heart were hypothesized.

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No effusion, shunting, arrhythmia, or hemodynamic compromise was present.

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Serial echocardiography to monitor for delayed cardiac complications was elected.

Gunshot suicides caused by cane-gun and alarm garden gun cannon: Two cases report."

Obtaining a firearm is not always easy, which is why some firearms that are antique or whose use is not intended to kiss are modified for suicide purposes. The two cases report a suicide with an original historical firearm as the canegun, a walking stick which conceals a firearm and a suicide with a modified alarm cannon, which is a small cannon, which fires blanks to scare away garden animals. The aims of the study were to describe the scene, the corpse external examination and the autopsy to understand the death mechanism. We wish to highlight the importance of the forensic pathologist's fieldwork, especially in complex or atypical suicides.

CT and MRI of a transcardiac gunshot wound with an annular distribution of bullet fragments surrounding an exit-re-entrance wound after the bullet burst from a floor tile upon exiting the lying body

This case report describes medicolegal examinations of a decedent with a fatal gunshot wound. The decedent lied on the floor as a bullet was fired into his chest. Computed tomography (CT) and magnetic resonance imaging (MRI) were performed as part of the judicial investigation. The MRI examination was valuable for delineating the wound channel through the left ventricle, which was deemed the main cause for internal bleeding and fatal blood loss. The diagnostic value of CT for the detection of injuries was low in this case. However, CT allowed for the virtual investigation of bullet fragments. According to CT-based dual-energy index calculations, it could be inferred that the fragments were most likely made of lead matching .357 Magnum R-P cartridges that were found at the scene. The bullet fragments were located underneath the skin at the suspected exit wound. The exit wound was actually an exit-re-entrance wound, as it can be assumed that the fragments re-entered the body after the bullet burst from hard ground upon exiting the body of the decedent, who was lying on the floor. CT visualized an uncommon annular distribution pattern for the bullet fragments surrounding the exit-re-entrance wound. The formation of such an annular distribution pattern of bullet fragments and the relevant conclusions that may be drawn from such a distribution pattern are discussed in this article.