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1: Wound Ballistics e38

CHAPTER Wound Ballistics 263.1-1). In addition, a sonic pressure wave precedes the projectile
through tissue. The sonic pressure wave plays no part in wounding.7

e263.1 Jeremy J. Hollerman

Martin L. Fackler
Angle of Entry A missile crushes the tissue it strikes, thereby creating a
permanent wound channel (permanent cavity). If the bullet is traveling
GENERAL CONCEPTS with its pointed end forward and its long axis parallel to the longitudinal
axis of flight (0 degrees of yaw, the angle between the long axis of the bul-
Ballistic injury is associated with bullet velocity and mass, as well as other let and its path of flight), it crushes a tube of tissue approximately equal
bullet and tissue characteristics.1–3 Slow-moving bullets crush more tis- to its diameter. When the bullet yaws to 90 degrees, the entire long axis
sue, and fast-moving bullets cause more cavitation. Bullet mass, which is of the bullet strikes tissue. The amount of tissue crushed may be three
related to diameter and length, largely determines how deeply the bullet times greater at 90 degrees than at 0 degrees of yaw.
will penetrate tissue. Bullet construction (such as whether the bullet is Bullet Deformation When striking soft tissue with sufficient velocity,
solid lead with no bullet jacket, is partially jacketed, or has a full metal soft-point and hollow-point bullets deform into a mushroom shape.
jacket) largely determines if the bullet will deform or fragment. Bullet This increases surface area and the amount of tissue crushed. For
shape and center of mass (which determine how soon it will yaw in its most big-game hunting, soft-point and hollow-point bullets are used to
path through tissue), the thickness of the body part wounded (determin- increase the probability of prompt lethality rather than the creation of a
ing whether the bullet has a long enough path through tissue to deform nonlethal wound causing an animal prolonged suffering. If the mush-
or yaw; Figure 263.1-1), tissue type struck (e.g., femur vs. lung), tissue roomed diameter is 2.5 times greater than the initial diameter of the
elasticity, density, and internal cohesiveness [which determine how well bullet, the area of tissue crushed by the bullet is 6.25 times greater than
the tissue will withstand tissue stretch (temporary cavitation) forces] are the amount that would have been crushed by the undeformed bullet
all important factors in determining the nature of the wound produced. (the area encompassed by a circle is proportional to the circle’s radius
The amount of kinetic energy “deposited” in a victim wounded by a pro- squared).
jectile is not a reliable predictor of wound severity.4
An understanding of wound ballistics enables physicians to evaluate Bullet Fragmentation Bullet fragmentation also increases the volume of
and treat missile wounds effectively. Based on common misconceptions tissue crushed.1,4 After bullet fragmentation, bullet surface area is in-
about wound ballistics, some authors have suggested unnecessary and creased, and much more tissue is crushed. Multiple perforations weaken
possibly harmful treatment for gunshot wounds. An example of such a tissue and create focal points for stress (stress risers). Tissue tears are
harmful recommendation is that for mandatory surgical excision of the particularly likely to occur at stress risers during temporary cavitation
tissue surrounding the path of the projectile through tissue whenever an stretch.4 For large handgun (e.g., .44 Magnum) and rifle bullets, the
extremity wound is caused by a “high-velocity” bullet. This is based on striking of bone causes early bullet fragmentation.
the belief that these tissues will become necrotic. Clinical experience and Comminuted fractures may be created by rifle and large handgun bul-
research have demonstrated this to be false.5 lets striking bone. Bone fragments can become secondary missiles and
crush tissue. Many handgun bullets do not fragment bone significantly.
When a large bone is struck by a handgun bullet, it is likely that the bullet
WOUNDING POTENTIAL will expend its wounding potential in the victim and will not exit.
Bullet fragments and secondary missiles, such as bone fragments,
Every moving bullet has a maximum wounding potential determined by teeth, or coins, propelled by contact with the bullet can increase the se-
its mass and velocity. Bullets of equal wounding potential may produce verity of the wound.
wounds of very different type and severity, depending on bullet shape,
internal and external construction, and which tissues they traverse. Bullet Jackets Unjacketed lead bullets cannot be driven faster than about
A heavier, slower bullet crushes more tissue but induces less tempo- 2000 ft/s (610 m/s) without some of the lead stripping off in the barrel.
rary cavitation. Most of the wounding potential of a lighter, faster bullet Lead stripping is avoided if a jacket made of a harder metal (such as cop-
is likely to be used up forming a larger temporary cavity, but a fast bullet per or a copper alloy) is used to surround the lead. The jacket of a mili-
leaves a smaller permanent cavity (crushes less tissue).4,6 The larger, tary bullet completely covers the bullet tip (called a “full metal jacket”).
heavier, slower bullet strikes more tissue and causes a more severe Hollow-Point and Soft-Point Bullets Civilians often use hollow-point or
wound in elastic tissue than the lighter, faster bullet, which uses up much soft-point bullets. Hollow-point bullets have a hole in the jacket at the
of its wounding potential producing tissue stretch (temporary cavita- bullet tip, and soft-point bullets have some of the lead core of the bullet
tion). This tissue stretch may be absorbed with little or no ill effect by exposed at the bullet tip. These constructions weaken the bullet tip, caus-
elastic tissue such as lung or muscle. In less elastic tissue, such as liver or ing it to flatten on impact. Flattening often greatly increases bullet diam-
brain, the temporary cavity can produce a more severe wound. Penetra- eter, resulting in a mushroom-shaped projectile.
tion depth will usually be less with the lighter, faster bullet, and critical The hollow-point and soft-point bullets used by civilians are
structures such as the heart may not be reached. more damaging to tissue than are full-metal-jacketed military bul-
lets that do not deform.1,4,8 Because of this, wounds produced by ci-
MECHANISMS OF WOUNDING vilian hunting rifles, and large-caliber handguns are usually more
severe than wounds produced by military-rifle bullets of the same
Both missile and tissue characteristics determine the nature of the mass and velocity.8
wound. Missile characteristics are partly inherent (mass, shape, and con- Well-designed hollow-point and soft-point handgun bullets usually
struction) and are partly conferred by the weapon (longitudinal and deform into a mushroom shape. Poorly designed hollow-point and soft-
rotational velocity). Tissue characteristics (elasticity, density, and ana- point handgun bullets with an excessively stiff or thick bullet jacket can
tomic relationships) also strongly affect the nature of the wound. The se- fail to deform into a mushroom shape. Also, even well-designed bullets
verity of a bullet wound is influenced by the bullet’s orientation can fail to expand if fired from distances (greater than a few hundred
during its path through tissue and by whether the bullet fragments4 yards) at which their retained velocity is insufficient to provide the strik-
and deforms. ing force needed for bullet expansion.
Two major mechanisms of wounding occur: the crushing of the tissue When the tip of a hollow-point bullet is plugged with material such as
struck by the projectile (forming the permanent cavity) and the radial clothing or drywall, bullet expansion into a mushroom shape in tissue is
stretching of the projectile path walls (forming a temporary cavity; Figure usually delayed and sometimes prevented. This causes deeper penetra-

Copyright © 2010 The McGraw-Hill Companies, Inc. All rights reserved.

e39 SECTION 21: Trauma

.22 long rifle (5.56 mm)
vel.= 1122 f/s (342 m/s)
wt.= 40 gr (2.59 gm) lead



0 5 10 15 20 25 30 36.5
A cm

C 22 Cal (5.6 mm) FMC

vel.= 3094 f/s (943 m/s)
FIGURE 263.1-1. Compare two .22 caliber bullets. A. A .22 long-rifle wt.= 55 gr (3.6 gm)
round (left) and an M16 round (right). B,C. Wound profiles in ballistic Final wt.= 35 gr (2.3 gm)
gelatin of the same .22 long-rifle (B) and .224 caliber M-193 round of the
M16A1 rifle (C). [Full metal case (FMC) is a synonym for full metal jacket,
Detached muscles 36% fragmentation
the type of bullet used in the military.] This figure shows that caliber (bul-
let diameter in decimals of an inch or in millimeters) is only one indicator Permanent
of wounding potential and not a very good one. Because of much higher cavity
velocity [3094 ft/s (943 m/s), as opposed to 1122 ft/s (342 m/s) for the
.22 long-rifle bullet], because it fragments in tissue, and because of
greater bullet mass, the M16 bullet has the potential to cause a much
more severe wound if the anatomic part struck is sufficiently thick. Note Temporary
that in the gelatin block, both the permanent cavity and the temporary fragments
cavity caused by the M16 bullet are much larger than those of the .22
long-rifle bullet. As is usual for a nondeforming bullet, the temporary and
permanent cavities caused by the .22 long-rifle bullet are largest when the 0 5 10 15 20 25 30 35
bullet is at 90 degrees of yaw. cm

tion of tissue, sometimes resulting in a perforating wound (having both fired from the AK-47, AK-74, and the NATO 7.62-mm rifle (U.S. ver-
an entrance and an exit). This may result in the injury of bystanders. sion), do not fragment unless they strike a large bone.
Bullet Velocity and Fragmentation Projectiles penetrate more deeply as If a bullet is jacketed, the bullet jacket usually cannot be distinguished
projectile velocity is increased, but only up to the point at which velocity from the lead core on standard radiographs because the entire bullet is
becomes sufficiently high to deform the projectile. Penetration depth de- metallic density. Sometimes, however, as the bullet deforms or frag-
creases markedly from that point on. The greater the bullet diameter ex- ments, the bullet jacket separates from the bullet and is identifiable on a
pansion from mushrooming, the less is the depth of penetration.9 radiograph. It is often less dense than the bullet fragments and may have
There is a critical range of velocity for each handgun hollow-point and a distinctive shape.
soft-point bullet within which the bullet may perform as expected. Below In extremity wounds, when a radiograph reveals an undeformed bul-
this velocity range, the bullet will have insufficient velocity to mushroom let lying in the soft tissues and no fracture is present, tissue disruption is
on impact, and at velocities above this range, the bullet may fragment af- usually minor. If a major vessel or nerve is divided, however, even a sim-
ter impact, resulting in many light bullet pieces crushing tissue at a su- ple wound can have a severe effect on the patient. The location of the
perficial depth. wound is the most important factor. A bullet of low wounding poten-
Military full metal jacket bullets do not flatten at the bullet tip (i.e., tial can cause a severe wound if it passes through a vital structure, such
they do not mushroom). Sometimes, they can break and fragment as a as the spinal cord.
result of yawing to 90 degrees. The stress on the bullet as its long axis
strikes tissue causes the sides of the bullet to flatten as if the bullet had ■ TEMPORARY CAVITATION (TISSUE STRETCH)
been squeezed in a vise. If the bullet breaks, it usually will do so at the Mechanism of Cavitation Fired from an appropriate, well-designed
cannelure, a circular groove around the bullet where it is crimped into weapon, a bullet flies in air with its nose pointed forward; it yaws only 1
the cartridge case. Although the M-193 military bullet of the M16 rifle to 3 degrees. Yaw occurs around the bullet’s center of mass. In pointed
fragments in soft tissue wounds with a characteristic pattern depending rifle bullets, the center of mass is behind the midpoint of the bullet’s long
on range,10 most other full metal jacket military bullets, such as those axis. Although the bullet’s most naturally stable in-flight orientation

Copyright © 2010 The McGraw-Hill Companies, Inc. All rights reserved.

CHAPTER e263.1: Wound Ballistics e40

would be with its heaviest part (its base) forward, for aerodynamically ef- Animal experiments using military rifle bullets5 have clearly dis-
ficient flight, it must fly point forward. proved the assertion that all tissue exposed to temporary cavitation is de-
During flight, bullet yaw is prevented by the bullet’s spin imparted to stroyed. Not only does the 14-cm-diameter temporary cavity produced
it by the spiral grooves (rifling) in the gun barrel. The longer (and heavi- by an AK-74 bullet not destroy a great amount of muscle, but the sizable
er) the bullet in relation to its diameter, the more rapidly it must be ro- stellate exit wound it causes in the uncomplicated thigh wound ensures
tated to avoid significant yaw in flight. A gun barrel intended to fire a excellent wound drainage, which assists healing.5 A history that the
heavier bullet has rifling that makes a full turn in fewer inches of barrel wound was caused by a “high-velocity” bullet does not mandate radical
length than the rifling in a barrel intended for a shorter, lighter bullet of excision of the wound path.11
the same caliber. This will cause a faster rate of bullet spin.
A gun with a shorter barrel will impart to the bullet a lower velocity than ■ BULLET YAW
would a weapon with a longer barrel when firing the same round. With Experiments with ballistic gelatin (which reproduces the projectile de-
shorter barrel length, the expanding gases of the burning gunpowder have formation and penetration depth of living animal muscle) have shown
less time to accelerate the bullet before they are discharged into the atmos- that most full metal jacket rifle bullets yaw significantly only at tissue
phere. A .22 long-rifle round fired in a rifle may produce a bullet with up depths greater than the diameter of human extremities.
to 300 ft/s more velocity than would the same round fired in a handgun. In the first 12 cm (the average thickness of an adult human thigh) of
Although the bullet’s spin is adequate to stabilize it (prevent yaw) in a soft tissue wound path, there is often little or no difference between
its flight through air, it is not adequate to stabilize it in its path through the wounding effect of “low”- and “high”-velocity bullets when the
tissue because of the higher density of the medium. A pointed bullet that “high”-velocity bullet is of the military full metal jacket type. This is par-
does not deform eventually yaws to a base-forward position (180 degrees ticularly true of the relatively heavier military-rifle bullets such as those
of yaw). Expanding bullets lose the physical stimulus to yaw because, af- fired by the AK-47 and NATO 7.62-mm (U.S. version) rifle. A wound
ter mushrooming, their heaviest part is forward. of an extremity caused by an AK-47 bullet that does not hit bone is often
Cavitation As a bullet passes through 90 degrees of yaw, or after it de- similar to a handgun bullet wound. No matter how “high” its velocity,
forms into a mushroom shape, it is crushing its maximal amount of tis- if a nondeforming, heavy bullet does not break, fragment, or hit a large
sue. It is slowed down rapidly as its wounding potential is used up. The bone, it will exit an extremity with much of its wounding potential un-
bullet creates a splash-type force in tissue, which spreads out radially. spent. These same bullets can be lethal in chest or abdominal wounds
This force creates the temporary cavity. This aspect of the wounding because the trunk is thicker than an extremity and allows the bullet a
process is analogous to the splash of a diver entering the water. sufficiently long path through tissue to become unstable and yaw. Max-
If a diver enters the water very straight and pointed forward (similar imal temporary cavitation induced by the AK-47 bullet usually occurs
to a bullet at 0 degrees of yaw), the splash is minimal. If the diver does a at a tissue depth of 28 cm, much greater than the diameter of a human
belly-flop (similar to a bullet at 90 degrees of yaw), a large splash is in- extremity.
duced. In tissue, this splash, the temporary cavity, can produce localized A soft-point or hollow-point bullet fired from a civilian center-fire ri-
blunt trauma.6 The temporary cavity reaches its maximum size several fle deforms soon after entering tissue and produces a much more severe
milliseconds after the bullet has passed through the tissue. Because forc- extremity wound than will a military full metal jacket bullet that does not
es follow paths of least resistance, temporary cavitation can be asymmet- break and fragment.
ric: it can separate tissue planes. The more recently developed, smaller-caliber AK-74 fires a bullet that
The temporary cavity caused by common handgun bullets is generally is lighter than the AK-47 bullet and yaws earlier.12 Its maximal tempo-
too small to be a significant wounding factor in all but the most sensitive rary cavity occurs at a tissue depth of 11 cm. Extremity wounds from the
tissues (brain and liver). Center-fire rifle bullets and large handgun bul- AK-74 can be expected to be more severe than those from the AK-47.12
lets (e.g., .44 Magnum) often induce a large temporary cavity [10- to 25- The lighter, smaller AK-74 round allows a soldier to carry many more
cm (4- to 10-in.) diameter] in tissue. This can be a significant wounding rounds of ammunition. This was the primary motivation for develop-
factor depending on the characteristics of the tissue in which it forms. ment of the M16 and the AK-74. An additional benefit is their light re-
Near-water density, less-elastic tissue (such as brain, liver, or spleen), coil, which makes them easier to shoot accurately.
fluid-filled organs (including the heart, bladder, and GI tract), and dense
tissue (such as bone) may be damaged severely when a large temporary ■ CALIBER
cavity displaces them or forms within them. More elastic tissue (such as A bullet’s caliber (bullet diameter in decimals of an inch or in millime-
skeletal muscle) and lower-density elastic tissue (such as lung) are less af- ters) is not a valid indicator of wounding potential. A bullet’s mass, its
fected by the formation of a temporary cavity. structure, and its striking velocity are all significant considerations that
Although the formation of a large temporary cavity often has highly must be considered in determining a bullet’s wounding potential.
disruptive effects in the brain or liver, its effect in wounds of the extrem- Commonly used weapon and bullet designations are often mislead-
ities frequently has been exaggerated.11 Fracture of large bones not hit by ing. As an example, the .38 special and the .357 Magnum use bullets that
the bullet and tearing of major vessels or nerves by the temporary cavity have the same diameter [.357 inches (9.07 mm)] (Table 263.1-1). The
are mentioned often in the literature but are rare in clinical experience. longer cartridge case of the Magnum can hold more powder, giving a
Most of the permanent damage done in wounds of the extremities is bullet the potential for higher velocity and greater wounding potential.
the result of structures being hit by the intact bullet, bullet fragments,
or secondary missiles. As in all blunt trauma, shear forces develop and ■ GUNSHOT FRACTURES
tear structures at points where one side is fixed and the other side is free
Handgun wounds of the extremities yield characteristic fracture pat-
to move. The temporary cavity is no exception.6 In the unlikely event
terns. Frequently seen are divot fractures of cortical bone, drill-hole frac-
that the blunt trauma caused by the temporary cavity tears a vessel wall,
tures, butterfly fractures, and double butterfly fractures.3 Nondisplaced
this is particularly likely to occur at the vessel origin.
fracture lines sometimes radiate from these defects. These usually heal
well. The bullet hole itself can act as a stress riser.
BALLISTIC PROPERTIES AND THE WOUND PRODUCED Spiral fractures extending proximally or distally from the bullet hole
may result from the dissipation of stress forces at the bullet hole. Occasion-
The characteristics of the wounded tissue; the thickness of the body part; ally, remote spiral fractures at some distance proximal or distal to the bony
the point in the path of the bullet at which deformation into a mushroom gunshot wound also occur, probably because of the presence of stress ris-
shape or yaw or fragmentation occurs; and other factors strongly influ- ers, such as vascular channels in the bone, and the fact that the bone was
ence the wound produced. under load and often torsional stress at the time of impact.13

Copyright © 2010 The McGraw-Hill Companies, Inc. All rights reserved.

e41 SECTION 21: Trauma

TABLE 263.1-1 Cartridge Case Name and Actual Bullet Diameter Used
Cartridge Cases Actual Bullet Diameter (inches) Cartridge Cases Actual Bullet Diameter (inches)
Of common interest 240 Weatherby Magnum .243
32 Auto (ACP) .312 256 Winchester Magnum .257
380 Auto (ACP) .355 250/300 Savage .257
9-mm Luger (9-mm Parabellum) .355 257 Roberts .257
38 Super .355 25/06 Remington .257
38 Special .357 257 Weatherby Magnum .257
357 Magnum .357 30-06 .308
44 Special .4295 30-30 Winchester .308
44 Magnum .4295 30 M1 Carbine .308
444 Marlin .4295 7.62-mm X 39-mm (AK-47) .308
Others of interest 30/40 Krag .308
22 Hornet .223 and .224 7.5-mm X 55-mm Swiss (Schmidt-Rubin) .308
218 Bee .224 300 Savage .308
219 Donaldson Wasp .224 7.62-mm Russian .308
219 Zipper .224 308 Winchester .308
221 Remington Fireball .224 7.62-mm NATO .308
222 Remington .224 30-06 Springfield .308
221 Remington Magnum .224 300 H & M Magnum .308
223 Remington .224 30-338 .308
224 Weatherby Magnum .224 300 Winchester Magnum .308
225 Winchester .224 308 Norma Magnum .308
22-250 Remington .224 300 Weatherby Magnum .308
220 Swift .224 303 British .311
243 Winchester .243 7.65-mm Mauser .311
244 Remington/6-mm Remington .243 7.7-mm Japanese .311
Note: Often the numerical designation associated with the bullet and the cartridge case does not reflect exact measurement. As an example, the 44 Remington Magnum Pistol uses a bullet
with a 0.43-in. diameter. Both the .38 special and the .357 Magnum use bullets that have the same diameter [0.357 in. (9.07 mm)]. When trying to determine bullet type from a radiograph, in
addition to correcting for magnification or deformation, one must look up actual bullet diameter rather than relying on the bullet name for its size.
Abbreviation: ACP = Automatic Colt Pistol.

In gunshot fractures from rifles and large handguns, a greater extent Whenever a gunshot wound traverses the midline of the neck or the
of comminution may be seen. These fractures often have complications mediastinum, perforation of the esophagus should be suspected. Esoph-
because of the soft tissue damage these bullets cause.3 The vascular com- ageal evaluation should not be overlooked after angiographic evaluation
promise associated with these comminuted gunshot fractures in- of the neck or chest.
creases the likelihood of delayed union or nonunion of the fracture.
Wound infections are more common in this group. Monitoring for com- ■ HEAD WOUNDS
partment syndrome and early fasciotomy, when needed, is important. In skull wounds, as elsewhere in bone gunshot fractures, inward beveling
At some hospitals, outpatient treatment is being used successfully for of the calvarial defect at the bullet entrance and outward beveling of the
extremity fractures caused by handguns if no significant neurologic or skull at the exit wound are typical.2,14 This is due partly to the geometry of
vascular compromise has occurred. the skull and partly to the bullet–bone interaction. Characteristic fracture
patterns of the skull can be used to identify entrance and exit wounds.14
■ TRUNK WOUNDS When there is a cranial exit wound, skull fractures propagate across the
Bullets are not sterilized by the heat of firing. They can carry bacteria calvarium faster than the bullet travels through the brain, producing char-
from the body surface or body organs, such as a perforated colon, deep acteristic patterns of fracture. These fracture patterns sometimes allow dif-
into the wound. ferentiation of entrance and exit wounds.14 Radial pattern fractures often
In trunk wounds, an analysis of the bullet path is needed to deter- spread out in a star pattern from the entrance and, to a lesser extent,
mine if a laparotomy is needed. Table 263.1-2 lists diagnostic tests from the exit holes in the skull. Concentric heaving fractures may occur,
helpful for assessing the presence of the bullet and its resultant injuries.
If peritoneal penetration by a bullet is suspected, laparotomy is indi-
cated. The morbidity and mortality rates associated with an exploratory
laparotomy that shows no significant intra-abdominal injury are low
compared with those of missed intestinal injury. CT is useful, especially TABLE 263.1-2 Diagnostic Tests for Assessing Injury and Bullet Location
when an exclusively body wall or retroperitoneal path is suspected. Any Two radiographs in planes separated by 90 degrees
bullet wound below the nipple line should raise the question of wheth- CT
er the diaphragm or abdomen has been penetrated. CT sometimes can
be used to make this determination. Laparotomy is required if peritoneal
penetration cannot be excluded. Diagnostic peritoneal lavage

Copyright © 2010 The McGraw-Hill Companies, Inc. All rights reserved.

CHAPTER e263.1: Wound Ballistics e42

connecting the arcs of the radial pattern fractures around both the en- ■ ASSESSMENT OF MISSILE TYPE
trance and exit holes, if sufficient temporary cavitation forces are generat- On a radiograph, assessment of missile caliber is difficult because of
ed inside the brain to cause significant outwardly directed tissue splash magnification and missile deformation. If an undeformed bullet is seen
forces inside the skull, pushing out the calvarium.14 Because a fracture will in two views at 90 degrees and its degree of magnification is known, the
not cross a preexisting fracture line, the temporal sequence of the occur-
approximate caliber of the bullet can be determined. Some bullets are
rence of the fractures sometimes can be determined from the pattern of the
difficult to distinguish because their diameter is equal to, or similar to,
others (Table 263.1-1). Sometimes, deformed bullets can be character-
Brain tissue properties include near-water density, very little elasticity,
ized accurately radiologically to determine original bullet caliber and
enclosure in the rigid cranial vault, and poor tissue cohesiveness, so the
brain is extremely sensitive to disruption by temporary cavitation forces. Many radiographs show only fragments of the bullet and cannot de-
termine the type of weapon and projectile that caused the wound. How-
■ SHOTGUN PELLET WOUNDS ever, certain bullets deform or fragment in a characteristic pattern that
Compared with a pointed rifle bullet, spherical pellets slow down more can aid in identification. Bullets with characteristic deformation patterns
rapidly in their flight through air or tissue. The entire wounding poten- include the M16 military bullet, the Winchester Black Talon (now desig-
tial of a shot pellet at its entrance velocity is likely to be delivered to nated the SXT) handgun bullet, and the .357 Magnum 125-grain
the target tissue, with no exit wound. At close range (<3 m), shotgun Remington semi-jacketed soft-point bullet. Deformation of large lead
pellets remain tightly clustered. Therefore, shot pellet size makes little shotgun pellets (e.g., 00 buckshot) by contact with bone may cause shot-
difference because the entire load of the pellets functions as a unit, with gun pellets to be confused with deformed bullet fragments.
a velocity virtually equal to muzzle velocity. Shotgun wounds at ranges
of <5 m consist of multiple parallel wound channels. This grossly dis- MISSILE EMBOLIZATION
rupts the blood supply to tissue between the wound channels.
The most severe civilian firearm wounds typically seen are those in- If the bullet’s path from the entrance wound is not consistent with the
flicted by a shotgun from close range. After a close-range or contact bullet’s current location, the bullet may have reached its present loca-
shotgun wound to the trunk, external examination of the patient, partic- tion by embolization. Bullets and shotgun pellets can embolize through
ularly after adequate volume resuscitation, often does not disclose the se- the venous or arterial system. Bullets have been noted to move within
verity of the internal injuries present. the subarachnoid space in the head and spine. Bullets and pellets have
Major neural injury after shotgun wounding of the extremities may embolized from the heart to the head during cardiopulmonary resusci-
be more important than fracture or major vascular injury in determin- tation, causing stroke. Even small missiles can cause morbidity from
ing the final outcome.15 Fractures and vascular injuries have a higher like- embolization. Bullets loose in the pleural space or peritoneal cavity can
lihood of being successfully repaired than do major neural injuries. also move because of the effect of gravity (not embolization).
During surgical exploration of a close-range shotgun wound, it is im- A missile freely floating within a cardiac chamber should be removed
portant to search for wadding, the plastic shot cup, and surface materials to prevent embolization. Missiles clearly embedded in chamber walls are
carried into the wound (e.g., clothing, glass, or wood). Many of these are relatively safe.19 Echocardiography may be useful in determining wheth-
radiolucent.3 er a missile is embedded in a chamber wall. CT and MRI (for nonmag-
Diagnosing long-range injury based on the pattern of pellet spread is netic missiles) also have a role. On chest radiographs, blurring of the
difficult. When shotgun pellets are tightly clustered or widely spread out, margins of a pericardiac missile or fragment is a reason to suspect that
close-range injury or long-range injury (respectively) is usually suspected. the missile is in, or next to, the heart.16
However, in close-range injuries, the billiard-ball effect may cause con- Whenever a bullet is not found on radiographs of the body part pre-
siderable pellet spread.16 When the tightly clustered group of shot at close dicted based on the entrance wound, the bullet’s location is not cur-
range contacts the skin, the pellets at the front of the group are slowed. The rently known, and there is no exit wound, additional radiographs or
pellets behind them in the group strike the pellets in front, with an effect fluoroscopy to find the bullet are mandatory. Immediately before sur-
like a billiard-ball break. This causes much more pellet spread in tissue gery for missile removal, repeat radiographic confirmation of the exact
than would be expected at close range. On radiographs, particularly in location of the missile is usually indicated.
trunk wounds, this effect can simulate the pellet spread of a longer-range Interventional radiologic techniques are useful in bullet removal, in-
injury.16 Correlate the physical examination with the radiologic findings. cluding the removal of intravascular and intrarenal bullets. Significant
If there is only one entrance wound hole, it is a close-range injury. If the deformation of an intravascular bullet is a relative contraindication to
distribution of the multiple skin entrance wounds is the same as the pellet retrieval using a transarterial catheter because of potential damage to the
spread on the radiograph, the injury occurred at longer range. vessel intima. Arthroscopy sometimes can be used for removing bullets
Newer generation BB guns and air guns that fire small pellets have from joints, especially the knee.
considerably higher muzzle velocity [600 ft/s (183 m/s) or more] than
older guns of this type. Penetrating injuries from these weapons can be ■ BULLET RICOCHET
fatal. Air guns should not be considered toys. A BB pellet wound may
Most bullets follow straight paths through the body, but sometimes a bul-
appear to cause a simple scalp wound when in fact the pellets have pen-
let, particularly a handgun bullet, will ricochet off body structures. Rico-
etrated the scalp, skull, and brain.17
chet is especially possible with bone injuries, or bullets may ricochet as
they follow fascial or tissue planes. Bullets traveling <1100 ft/s (335 m/s)
ASSESSMENT OF MISSILE TYPE are the ones most likely to be deflected by anatomic structures or to follow

Radiographic localization of the bullet requires two views at 90 de- LEAD FRAGMENTS AND LEAD POISONING
grees or a tomographic image. CT of the head and body is often useful
for analysis of bullet path.3 Lead fragments in soft tissue usually become encapsulated with fibrous
The CT digital scout radiograph, which can be used for missile local- tissue and do not cause problems. Bullet-induced lead poisoning is
ization, usually can be taken in anteroposterior and lateral projections most common with intra-articular, disk space, and bursal locations of
without moving the patient. The ability to manipulate the display win- bullet fragments because of the solubility of lead in synovial fluid.20,21
dow and center enables localization of bullets seen through dense struc- Lead fragments in the brain are usually relatively benign unless they are
tures such as the shoulders and pelvis. copper-plated (as are many civilian .22 caliber bullets).22 Copper-plated

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e43 SECTION 21: Trauma

lead pellets produced a sterile abscess or granuloma in the brain of cats handgun bullets. Infectious diseases, such as hepatitis and human im-
surgically implanted with missiles of this type.22 This can result in down- munodeficiency virus, could pass from the victim to the health care pro-
ward migration of the missile, resorption of copper from the surface of vider as a result of skin punctures from these sharp edges.
the missile, progressive neurologic deficit, and, sometimes, death.
Intra-articular fragments should be removed to avoid both the me-
chanical trauma and the destructive synovitis lead can cause.20 Signif- REFERENCES
icant damage to the articular cartilage visible at surgery may be present 1. Hollerman JJ, Fackler ML, Coldwell DM, Ben-Menachem Y: Gunshot wounds: 1. Bul-
as a result of lead synovitis, even when the only radiographic finding is lets, ballistics and mechanisms of injury. AJR Am J Roentgenol 155: 685, 1990.
bullet fragments.20 If large fragments are present in the joint, they can 2. Hollerman JJ, Fackler ML: Gunshot wounds: radiology and wound ballistics. Emerg
cause severe mechanical trauma during motion. This motion can lead to Radiol 2: 171, 1995.
3. Hollerman JJ, Fackler ML, Coldwell DM, Ben-Menachem Y: Gunshot wounds: 2.
further lead fragmentation. Radiology. AJR Am J Roentgenol 155: 691, 1990.
Whether lead poisoning occurs depends largely on the surface area of 4. Fackler ML, Surinchak JS, Malinowski JA, Bowen RE: Bullet fragmentation: a major
the retained lead particles and their location in the body.21 Sometimes, cause of tissue disruption. J Trauma 24: 35, 1984.
the onset of clinical lead poisoning can be quite rapid, but usually, it 5. Fackler ML, Breteau JP, Courbil LJ, et al: Open wound drainage versus wound exci-
sion in treating the modern assault rifle wound. Surgery 105: 576, 1989.
takes years. 6. Hollerman JJ: Wound ballistics is a model of the pathophysiology of all blunt and
Patients with retained lead pellets or lead bullet fragments should be penetrating trauma. Emerg Radiol 5: 279, 1998.
advised that, on rare occasions, a fragment may erode into a bursa or 7. Harvey EN, Korr IM, Oster G, McMillen JH: Secondary damage in wounding due to
joint space and cause lead poisoning. Assure patients that lead poisoning pressure changes accompanying the passage of high-velocity missiles. Surgery 21: 218,
poses a threat only if unrecognized and untreated. Advise patients to seek
8. DeMuth WE Jr: Bullet velocity and design as determinants of wounding capability: an
treatment for problems such as headache, abdominal pain, personality experimental study. J Trauma 6: 222, 1966.
change, or neurologic symptoms. Once lead poisoning is considered, a 9. Wolberg EJ: Performance of the Winchester 9-mm 147-grain subsonic jacketed hollow
lead level can easily confirm or exclude the diagnosis. point bullet in human tissue and tissue simulant. Wound Ballistics Rev 1(1): 10, 1991.
10. Fackler ML: Wounding patterns of military rifle bullets. Int Defense Rev 22: 59, 1989.
11. Fackler ML: Civilian gunshot wounds and ballistics: dispelling the myths. Emerg Med
EVIDENTIARY CONCERNS Clin North Am 16: 17, 1998.
12. Fackler ML, Surinchak JS, Malinowski JA, Bowen RE: Wounding potential of the Rus-
Physicians and nurses must preserve evidence in patients being resusci- sian AK-74 assault rifle. J Trauma 24 :263, 1984.
13. Smith HW, Wheatley KK Jr: Biomechanics of femur fractures secondary to gunshot
tated after penetrating trauma. Do not cut through bullet holes or knife wounds. J Trauma 24: 970, 1984.
holes in clothing when removing it. Do not incise through skin wounds 14. Smith OC, Berryman HE, Lahren CH: Cranial fracture patterns and estimate of
unless absolutely necessary. To preserve powder marks, do not scrub direction from low velocity gunshot wounds. J Forensic Sci 32: 1416, 1987.
wounds unless necessary. Whenever possible, take photographs before 15. Deitch EA, Grimes WR: Experience with 112 shotgun wounds of the extremities. J
Trauma 24: 600, 1984.
initiating wound treatment.
16. Messmer JM, Fierro MF: Radiologic forensic investigation of fatal gunshot wounds.
EMS systems and EDs should have a protocol for collecting clothing Radiographics 6: 457, 1986.
and other evidence and keeping it secure. Do not describe wounds as 17. Lucas RM, Mitterer D: Pneumatic firearm injuries: trivial trauma or perilous pitfalls?
entry or exit wounds; instead, describe the appearance of wounds in J Emerg Med 8: 433, 1990.
detail, without interpretation. Describe the location, size, and shape 18. Bixler RP, Ahrens CR, Rossi RP, Thickman D: Bullet identification with radiography.
Radiology 178: 563, 1991.
of all gunshot wounds. Include the presence or absence of a soot ring, 19. Robison RJ, Brown JW, Caldwell R, et al: Management of asymptomatic intracardiac
skin, or subcutaneous tissue tattooing with gunpowder, or the presence missiles using echocardiography. J Trauma 28: 1402, 1988.
of subcutaneous gas (such as from a contact wound with injection into 20. Sclafani SJ, Vuletin JC, Twersky J: Lead arthropathy: arthritis caused by retained intra-
the subcutaneous tissues of gases from burning gunpowder). When a articular bullets. Radiology 156: 299, 1985.
21. Linden MA, Manton WI, Stewart RM, et al: Lead poisoning from retained bullets:
bullet or fragment is encountered, do not pick it up with a metallic clamp pathogenesis, diagnosis, and management. Ann Surg 195: 305, 1982.
because the clamp can alter ballistic markings. Take care to avoid injury 22. Sights WP, Bye RJ: The fate of retained intracerebral shotgun pellets: an experimental
from the sharp bullet jacket edges of some soft-point and hollow-point study. J Neurosurg 33: 646, 1970.

Copyright © 2010 The McGraw-Hill Companies, Inc. All rights reserved.