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CHAPTER e263.1
CHAPTER
e263.1

Wound Ballistics

Jeremy J. Hollerman Martin L. Fackler

GENERAL CONCEPTS

Ballistic injury is associated with bullet velocity and mass, as well as other bullet and tissue characteristics. 13 Slow-moving bullets crush more tis- sue, and fast-moving bullets cause more cavitation. Bullet mass , which is related to diameter and length, largely determines how deeply the bullet will penetrate tissue. Bullet construction (such as whether the bullet is solid lead with no bullet jacket, is partially jacketed, or has a full metal jacket) largely determines if the bullet will deform or fragment. Bullet shape and center of mass (which determine how soon it will yaw in its path through tissue), the thickness of the body part wounded (determin- ing whether the bullet has a long enough path through tissue to deform or yaw; Figure 263.1-1 ), tissue type struck (e.g., femur vs. lung), tissue elasticity, density, and internal cohesiveness [which determine how well the tissue will withstand tissue stretch (temporary cavitation) forces] are all important factors in determining the nature of the wound produced. The amount of kinetic energy “deposited” in a victim wounded by a pro- jectile is not a reliable predictor of wound severity. 4 An understanding of wound ballistics enables physicians to evaluate and treat missile wounds effectively. Based on common misconceptions about wound ballistics, some authors have suggested unnecessary and possibly harmful treatment for gunshot wounds. An example of such a harmful recommendation is that for mandatory surgical excision of the tissue surrounding the path of the projectile through tissue whenever an extremity wound is caused by a “high-velocity” bullet. This is based on the belief that these tissues will become necrotic. Clinical experience and research have demonstrated this to be false. 5

WOUNDING POTENTIAL

Every moving bullet has a maximum wounding potential determined by its mass and velocity. Bullets of equal wounding potential may produce wounds of very different type and severity, depending on bullet shape, internal and external construction, and which tissues they traverse. A heavier, slower bullet crushes more tissue but induces less tempo- rary cavitation. Most of the wounding potential of a lighter, faster bullet is likely to be used up forming a larger temporary cavity, but a fast bullet leaves a smaller permanent cavity (crushes less tissue). 4,6 The larger, heavier, slower bullet strikes more tissue and causes a more severe wound in elastic tissue than the lighter, faster bullet, which uses up much of its wounding potential producing tissue stretch (temporary cavita- tion). This tissue stretch may be absorbed with little or no ill effect by elastic tissue such as lung or muscle. In less elastic tissue, such as liver or brain, the temporary cavity can produce a more severe wound. Penetra- tion depth will usually be less with the lighter, faster bullet, and critical structures such as the heart may not be reached.

MECHANISMS OF WOUNDING

Both missile and tissue characteristics determine the nature of the wound. Missile characteristics are partly inherent (mass, shape, and con- struction) and are partly conferred by the weapon (longitudinal and rotational velocity). Tissue characteristics (elasticity, density, and ana- tomic relationships) also strongly affect the nature of the wound. The se- verity of a bullet wound is influenced by the bullet’s orientation during its path through tissue and by whether the bullet fragments 4 and deforms. Two major mechanisms of wounding occur: the crushing of the tissue struck by the projectile (forming the permanent cavity) and the radial s tretching of the projectile path walls (forming a temporary cavity; Figure

CHAPTER e263.1: Wound Ballistics

e38

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

CRUSHING OF TISSUE

Angle of Entry A missile crushes the tissue it strikes, thereby creating a permanent wound channel (permanent cavity). If the bullet is traveling 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- let and its path of flight), it crushes a tube of tissue approximately equal to its diameter. When the bullet yaws to 90 degrees, the entire long axis of the bullet strikes tissue. The amount of tissue crushed may be three times greater at 90 degrees than at 0 degrees of yaw. Bullet Deformation When striking soft tissue with sufficient velocity, soft-point and hollow-point bullets deform into a mushroom shape. This increases surface area and the amount of tissue crushed. For most big-game hunting, soft-point and hollow-point bullets are used to increase the probability of prompt lethality rather than the creation of a nonlethal wound causing an animal prolonged suffering. If the mush- roomed diameter is 2.5 times greater than the initial diameter of the bullet, the area of tissue crushed by the bullet is 6.25 times greater than the amount that would have been crushed by the undeformed bullet (the area encompassed by a circle is proportional to the circle’s radius squared). Bullet Fragmentation Bullet fragmentation also increases the volume of tissue crushed. 1,4 After bullet fragmentation, bullet surface area is in- creased, and much more tissue is crushed. Multiple perforations weaken tissue and create focal points for stress (stress risers). Tissue tears are particularly likely to occur at stress risers during temporary cavitation stretch. 4 For large handgun (e.g., .44 Magnum) and rifle bullets, the striking of bone causes early bullet fragmentation. Comminuted fractures may be created by rifle and large handgun bul- 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 will expend its wounding potential in the victim and will not exit. Bullet fragments and secondary missiles, such as bone fragments, teeth, or coins, propelled by contact with the bullet can increase the se- verity of the wound.

Bullet Jackets Unjacketed lead bullets cannot be driven faster than about 2000 ft/s (610 m/s) without some of the lead stripping off in the barrel. Lead stripping is avoided if a jacket made of a harder metal (such as cop- per or a copper alloy) is used to surround the lead. The jacket of a mili- tary bullet completely covers the bullet tip (called a “full metal jacket”).

Hollow-Point and Soft-Point Bullets Civilians often use hollow-point or soft-point bullets. Hollow-point bullets have a hole in the jacket at the bullet tip, and soft-point bullets have some of the lead core of the bullet exposed at the bullet tip. These constructions weaken the bullet tip, caus- ing it to flatten on impact. Flattening often greatly increases bullet diam- eter, resulting in a mushroom-shaped projectile. The hollow-point and soft-point bullets used by civilians are 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- vilian hunting rifles, and large-caliber handguns are usually more severe than wounds produced by military-rifle bullets of the same mass and velocity. 8 Well-designed hollow-point and soft-point handgun bullets usually deform into a mushroom shape. Poorly designed hollow-point and soft- point handgun bullets with an excessively stiff or thick bullet jacket can fail to deform into a mushroom shape. Also, even well-designed bullets can fail to expand if fired from distances (greater than a few hundred yards) at which their retained velocity is insufficient to provide the strik- ing force needed for bullet expansion. When the tip of a hollow-point bullet is plugged with material such as clothing or drywall, bullet expansion into a mushroom shape in tissue is usually delayed and sometimes prevented. This causes deeper penetra-

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

e39

SECTION 21: Trauma

e39 SECTION 21: Trauma A FIGURE 263.1-1. Compare two .22 caliber bullets. A. A .22 long-rifle

A

FIGURE 263.1-1. Compare two .22 caliber bullets. A. A .22 long-rifle round ( left ) and an M16 round ( right ). B,C. Wound profiles in ballistic 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, 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 of wounding potential and not a very good one. Because of much higher 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 that in the gelatin block, both the permanent cavity and the temporary 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 bullet is at 90 degrees of yaw.

B .22 long rifle (5.56 mm) vel.= 1122 f/s (342 m/s) wt.= 40 gr (2.59
B
.22 long rifle (5.56 mm)
vel.= 1122 f/s (342 m/s)
wt.= 40 gr (2.59 gm) lead
Permanent
cavity
Temporary
cavity
0 5
10
15
20
25
30
36.5
cm C 22 Cal (5.6 mm) FMC vel.= 3094 f/s (943 m/s) wt.= 55 gr
cm
C
22 Cal (5.6 mm) FMC
vel.= 3094 f/s (943 m/s)
wt.= 55 gr (3.6 gm)
Final wt.= 35 gr (2.3 gm)
Detached muscles
36% fragmentation
Permanent
cavity
Temporary
Bullet
cavity
fragments
0 5
10
15
20
25
30
35

cm

tion of tissue, sometimes resulting in a perforating wound (having both an entrance and an exit). This may result in the injury of bystanders. Bullet Velocity and Fragmentation Projectiles penetrate more deeply as projectile velocity is increased, but only up to the point at which velocity becomes sufficiently high to deform the projectile. Penetration depth de- creases markedly from that point on. The greater the bullet diameter ex- pansion from mushrooming, the less is the depth of penetration. 9 There is a critical range of velocity for each handgun hollow-point and soft-point bullet within which the bullet may perform as expected. Below this velocity range, the bullet will have insufficient velocity to mushroom on impact, and at velocities above this range, the bullet may fragment af- ter impact, resulting in many light bullet pieces crushing tissue at a su- perficial depth. Military full metal jacket bullets do not flatten at the bullet tip (i.e., they do not mushroom). Sometimes, they can break and fragment as a 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 been squeezed in a vise. If the bullet breaks, it usually will do so at the cannelure, a circular groove around the bullet where it is crimped into the cartridge case. Although the M-193 military bullet of the M16 rifle fragments in soft tissue wounds with a characteristic pattern depending on range, 10 most other full metal jacket military bullets, such as those

fired from the AK-47, AK-74, and the NATO 7.62-mm rifle (U.S. ver- sion), do not fragment unless they strike a large bone. If a bullet is jacketed, the bullet jacket usually cannot be distinguished from the lead core on standard radiographs because the entire bullet is metallic density. Sometimes, however, as the bullet deforms or frag- ments, the bullet jacket separates from the bullet and is identifiable on a radiograph. It is often less dense than the bullet fragments and may have a distinctive shape. In extremity wounds, when a radiograph reveals an undeformed bul- let lying in the soft tissues and no fracture is present, tissue disruption is usually minor. If a major vessel or nerve is divided, however, even a sim- ple wound can have a severe effect on the patient. The location of the wound is the most important factor. A bullet of low wounding poten- tial can cause a severe wound if it passes through a vital structure, such as the spinal cord.

TEMPORARY CAVITATION (TISSUE STRETCH)

Mechanism of Cavitation Fired from an appropriate, well-designed weapon, a bullet flies in air with its nose pointed forward; it yaws only 1 to 3 degrees. Yaw occurs around the bullet’s center of mass. In pointed rifle bullets, the center of mass is behind the midpoint of the bullet’s long axis. Although the bullet’s most naturally stable in-flight orientation

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

would be with its heaviest part (its base) forward, for aerodynamically ef- ficient flight, it must fly point forward. During flight, bullet yaw is prevented by the bullet’s spin imparted to it by the spiral grooves (rifling) in the gun barrel. The longer (and heavi- er) the bullet in relation to its diameter, the more rapidly it must be ro- tated to avoid significant yaw in flight. A gun barrel intended to fire a heavier bullet has rifling that makes a full turn in fewer inches of barrel

length than the rifling in a barrel intended for a shorter, lighter bullet of

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

would a weapon with a longer barrel when firing the same round. With

shorter barrel length, the expanding gases of the burning gunpowder have

less time to accelerate the bullet before they are discharged into the atmos-

phere. A .22 long-rifle round fired in a rifle may produce a bullet with up to 300 ft/s more velocity than would the same round fired in a handgun. Although the bullet’s spin is adequate to stabilize it (prevent yaw) in

its flight through air, it is not adequate to stabilize it in its path through tissue because of the higher density of the medium. A pointed bullet that does not deform eventually yaws to a base-forward position (180 degrees of yaw). Expanding bullets lose the physical stimulus to yaw because, af-

ter mushrooming, their heaviest part is forward.

Cavitation As a bullet passes through 90 degrees of yaw, or after it de- forms into a mushroom shape, it is crushing its maximal amount of tis- sue. It is slowed down rapidly as its wounding potential is used up. The

bullet creates a splash-type force in tissue, which spreads out radially. This force creates the temporary cavity. This aspect of the wounding process is analogous to the splash of a diver entering the water.

If a diver enters the water very straight and pointed forward (similar

to a bullet at 0 degrees of yaw), the splash is minimal. If the diver does a belly-flop (similar to a bullet at 90 degrees of yaw), a large splash is in- duced. In tissue, this splash, the temporary cavity, can produce localized blunt trauma. 6 The temporary cavity reaches its maximum size several milliseconds after the bullet has passed through the tissue. Because forc- es follow paths of least resistance, temporary cavitation can be asymmet-

ric: it can separate tissue planes.

The temporary cavity caused by common handgun bullets is generally

too small to be a significant wounding factor in all but the most sensitive

tissues (brain and liver). Center-fire rifle bullets and large handgun bul-

lets

(e.g., .44 Magnum) often induce a large temporary cavity [10- to 25-

cm

(4- to 10-in.) diameter] in tissue. This can be a significant wounding

factor depending on the characteristics of the tissue in which it forms. Near-water density, less-elastic tissue (such as brain, liver, or spleen), fluid-filled organs (including the heart, bladder, and GI tract), and dense tissue (such as bone) may be damaged severely when a large temporary cavity displaces them or forms within them. More elastic tissue (such as skeletal muscle) and lower-density elastic tissue (such as lung) are less af- fected by the formation of a temporary cavity.

Although the formation of a large temporary cavity often has highly disruptive effects in the brain or liver, its effect in wounds of the extrem- ities frequently has been exaggerated. 11 Fracture of large bones not hit by

the

bullet and tearing of major vessels or nerves by the temporary cavity

are

mentioned often in the literature but are rare in clinical experience.

Most of the permanent damage done in wounds of the extremities is the result of structures being hit by the intact bullet, bullet fragments, or secondary missiles. As in all blunt trauma, shear forces develop and

tear structures at points where one side is fixed and the other side is free to move. The temporary cavity is no exception. 6 In the unlikely event that the blunt trauma caused by the temporary cavity tears a vessel wall,

this is particularly likely to occur at the vessel origin.

BALLISTIC PROPERTIES AND THE WOUND PRODUCED

The characteristics of the wounded tissue; the thickness of the body part;

the point in the path of the bullet at which deformation into a mushroom

shape or yaw or fragmentation occurs; and other factors strongly influ- ence the wound produced.

CHAPTER e263.1: Wound Ballistics

e40

Animal experiments using military rifle bullets 5 have clearly dis- proved the assertion that all tissue exposed to temporary cavitation is de- stroyed. Not only does the 14-cm-diameter temporary cavity produced by an AK-74 bullet not destroy a great amount of muscle, but the sizable stellate exit wound it causes in the uncomplicated thigh wound ensures excellent wound drainage, which assists healing. 5 A history that the wound was caused by a “high-velocity” bullet does not mandate radical excision of the wound path. 11

BULLET YAW

Experiments with ballistic gelatin (which reproduces the projectile de- formation and penetration depth of living animal muscle) have shown

that most full metal jacket rifle bullets yaw significantly only at tissue depths greater than the diameter of human extremities.

In the first 12 cm (the average thickness of an adult human thigh) of

a soft tissue wound path, there is often little or no difference between

the wounding effect of “low”- and “high”-velocity bullets when the “high”-velocity bullet is of the military full metal jacket type. This is par- ticularly true of the relatively heavier military-rifle bullets such as those fired by the AK-47 and NATO 7.62-mm (U.S. version) rifle. A wound of an extremity caused by an AK-47 bullet that does not hit bone is often

similar to a handgun bullet wound. No matter how “high” its velocity,

if a nondeforming, heavy bullet does not break, fragment, or hit a large

bone, it will exit an extremity with much of its wounding potential un- spent. These same bullets can be lethal in chest or abdominal wounds because the trunk is thicker than an extremity and allows the bullet a sufficiently long path through tissue to become unstable and yaw. Max- imal temporary cavitation induced by the AK-47 bullet usually occurs at a tissue depth of 28 cm, much greater than the diameter of a human extremity.

A soft-point or hollow-point bullet fired from a civilian center-fire ri-

fle deforms soon after entering tissue and produces a much more severe

extremity wound than will a military full metal jacket bullet that does not break and fragment. The more recently developed, smaller-caliber AK-74 fires a bullet that

is lighter than the AK-47 bullet and yaws earlier. 12 Its maximal tempo-

rary cavity occurs at a tissue depth of 11 cm. Extremity wounds from the

AK-74 can be expected to be more severe than those from the AK-47. 12 The lighter, smaller AK-74 round allows a soldier to carry many more rounds of ammunition. This was the primary motivation for develop- ment of the M16 and the AK-74. An additional benefit is their light re- coil, which makes them easier to shoot accurately.

CALIBER

A bullet’s caliber (bullet diameter in decimals of an inch or in millime-

ters) is not a valid indicator of wounding potential. A bullet’s mass, its structure, and its striking velocity are all significant considerations that must be considered in determining a bullet’s wounding potential. Commonly used weapon and bullet designations are often mislead- ing. As an example, the .38 special and the .357 Magnum use bullets that have the same diameter [.357 inches (9.07 mm)] ( Table 263.1-1 ). The longer cartridge case of the Magnum can hold more powder, giving a bullet the potential for higher velocity and greater wounding potential.

GUNSHOT FRACTURES

Handgun wounds of the extremities yield characteristic fracture pat- terns. Frequently seen are divot fractures of cortical bone, drill-hole frac- tures, butterfly fractures, and double butterfly fractures. 3 Nondisplaced fracture lines sometimes radiate from these defects. These usually heal well. The bullet hole itself can act as a stress riser. Spiral fractures extending proximally or distally from the bullet hole may result from the dissipation of stress forces at the bullet hole. Occasion- ally, remote spiral fractures at some distance proximal or distal to the bony gunshot wound also occur, probably because of the presence of stress ris- ers, such as vascular channels in the bone, and the fact that the bone was 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 of comminution may be seen. These fractures often have complications because of the soft tissue damage these bullets cause. 3 The vascular com- promise associated with these comminuted gunshot fractures in- creases the likelihood of delayed union or nonunion of the fracture. Wound infections are more common in this group. Monitoring for com- partment syndrome and early fasciotomy, when needed, is important. At some hospitals, outpatient treatment is being used successfully for extremity fractures caused by handguns if no significant neurologic or vascular compromise has occurred.

TRUNK WOUNDS

Bullets are not sterilized by the heat of firing. They can carry bacteria from the body surface or body organs, such as a perforated colon, deep into the wound. In trunk wounds, an analysis of the bullet path is needed to deter- mine if a laparotomy is needed. Table 263.1-2 lists diagnostic tests 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 when an exclusively body wall or retroperitoneal path is suspected. Any bullet wound below the nipple line should raise the question of wheth- 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.

Whenever a gunshot wound traverses the midline of the neck or the mediastinum, perforation of the esophagus should be suspected. Esoph- ageal evaluation should not be overlooked after angiographic evaluation of the neck or chest.

HEAD WOUNDS

In skull wounds, as elsewhere in bone gunshot fractures, inward beveling of the calvarial defect at the bullet entrance and outward beveling of the skull at the exit wound are typical. 2,14 This is due partly to the geometry of 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 When there is a cranial exit wound, skull fractures propagate across the calvarium faster than the bullet travels through the brain, producing char- acteristic patterns of fracture. These fracture patterns sometimes allow dif- ferentiation of entrance and exit wounds. 14 Radial pattern fractures often spread out in a star pattern from the entrance and, to a lesser extent, from the exit holes in the skull. Concentric heaving fractures may occur,

TABLE 263.1-2

Diagnostic Tests for Assessing Injury and Bullet Location

Two radiographs in planes separated by 90 degrees CT Ultrasonography Diagnostic peritoneal lavage

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connecting the arcs of the radial pattern fractures around both the en- trance and exit holes, if sufficient temporary cavitation forces are generat- ed inside the brain to cause significant outwardly directed tissue splash forces inside the skull, pushing out the calvarium. 14 Because a fracture will not cross a preexisting fracture line, the temporal sequence of the occur- rence of the fractures sometimes can be determined from the pattern of the fractures. Brain tissue properties include near-water density, very little elasticity, enclosure in the rigid cranial vault, and poor tissue cohesiveness, so the brain is extremely sensitive to disruption by temporary cavitation forces.

SHOTGUN PELLET WOUNDS

Compared with a pointed rifle bullet, spherical pellets slow down more rapidly in their flight through air or tissue. The entire wounding poten-

tial of a shot pellet at its entrance velocity is likely to be delivered to the target tissue, with no exit wound. At close range (<3 m), shotgun pellets remain tightly clustered. Therefore, shot pellet size makes little difference because the entire load of the pellets functions as a unit, with

a velocity virtually equal to muzzle velocity. Shotgun wounds at ranges

of <5 m consist of multiple parallel wound channels. This grossly dis- rupts the blood supply to tissue between the wound channels. The most severe civilian firearm wounds typically seen are those in- flicted by a shotgun from close range. After a close-range or contact shotgun wound to the trunk, external examination of the patient, partic- ularly after adequate volume resuscitation, often does not disclose the se- verity of the internal injuries present. Major neural injury after shotgun wounding of the extremities may be more important than fracture or major vascular injury in determin- ing the final outcome. 15 Fractures and vascular injuries have a higher like- lihood of being successfully repaired than do major neural injuries. During surgical exploration of a close-range shotgun wound, it is im- portant to search for wadding, the plastic shot cup, and surface materials carried into the wound (e.g., clothing, glass, or wood). Many of these are radiolucent. 3 Diagnosing long-range injury based on the pattern of pellet spread is difficult. When shotgun pellets are tightly clustered or widely spread out, close-range injury or long-range injury (respectively) is usually suspected. However, in close-range injuries, the billiard-ball effect may cause con- siderable pellet spread. 16 When the tightly clustered group of shot at close

range contacts the skin, the pellets at the front of the group are slowed. The pellets behind them in the group strike the pellets in front, with an effect like a billiard-ball break. This causes much more pellet spread in tissue than would be expected at close range. On radiographs, particularly in trunk wounds, this effect can simulate the pellet spread of a longer-range injury. 16 Correlate the physical examination with the radiologic findings.

If there is only one entrance wound hole, it is a close-range injury. If the

distribution of the multiple skin entrance wounds is the same as the pellet spread on the radiograph, the injury occurred at longer range. Newer generation BB guns and air guns that fire small pellets have 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

fatal. Air guns should not be considered toys. A BB pellet wound may appear to cause a simple scalp wound when in fact the pellets have pen- etrated the scalp, skull, and brain. 17

ASSESSMENT OF MISSILE TYPE AND LOCATION IN THE BODY

Radiographic localization of the bullet requires two views at 90 de- grees or a tomographic image. CT of the head and body is often useful for analysis of bullet path. 3 The CT digital scout radiograph, which can be used for missile local- ization, usually can be taken in anteroposterior and lateral projections without moving the patient. The ability to manipulate the display win- dow and center enables localization of bullets seen through dense struc- tures such as the shoulders and pelvis.

CHAPTER e263.1: Wound Ballistics

e42

ASSESSMENT OF MISSILE TYPE

On a radiograph, assessment of missile caliber is difficult because of magnification and missile deformation. If an undeformed bullet is seen in two views at 90 degrees and its degree of magnification is known, the approximate caliber of the bullet can be determined. Some bullets are difficult to distinguish because their diameter is equal to, or similar to, others ( Table 263.1-1 ). Sometimes, deformed bullets can be character- ized accurately radiologically to determine original bullet caliber and weight. 18 Many radiographs show only fragments of the bullet and cannot de- termine the type of weapon and projectile that caused the wound. How- ever, certain bullets deform or fragment in a characteristic pattern that can aid in identification. Bullets with characteristic deformation patterns include the M16 military bullet, the Winchester Black Talon (now desig- nated the SXT) handgun bullet, and the .357 Magnum 125-grain Remington semi-jacketed soft-point bullet. Deformation of large lead shotgun pellets (e.g., 00 buckshot) by contact with bone may cause shot- gun pellets to be confused with deformed bullet fragments.

MISSILE EMBOLIZATION

If the bullet’s path from the entrance wound is not consistent with the bullet’s current location, the bullet may have reached its present loca- tion by embolization. Bullets and shotgun pellets can embolize through the venous or arterial system. Bullets have been noted to move within the subarachnoid space in the head and spine. Bullets and pellets have embolized from the heart to the head during cardiopulmonary resusci- tation, causing stroke. Even small missiles can cause morbidity from embolization. Bullets loose in the pleural space or peritoneal cavity can also move because of the effect of gravity (not embolization). A missile freely floating within a cardiac chamber should be removed to prevent embolization. Missiles clearly embedded in chamber walls are relatively safe. 19 Echocardiography may be useful in determining wheth- er a missile is embedded in a chamber wall. CT and MRI (for nonmag- netic missiles) also have a role. On chest radiographs, blurring of the margins of a pericardiac missile or fragment is a reason to suspect that the missile is in, or next to, the heart. 16 Whenever a bullet is not found on radiographs of the body part pre- dicted based on the entrance wound, the bullet’s location is not cur- rently known, and there is no exit wound, additional radiographs or fluoroscopy to find the bullet are mandatory. Immediately before sur- gery for missile removal, repeat radiographic confirmation of the exact location of the missile is usually indicated. Interventional radiologic techniques are useful in bullet removal, in- cluding the removal of intravascular and intrarenal bullets. Significant deformation of an intravascular bullet is a relative contraindication to retrieval using a transarterial catheter because of potential damage to the vessel intima. Arthroscopy sometimes can be used for removing bullets from joints, especially the knee.

BULLET RICOCHET

Most bullets follow straight paths through the body, but sometimes a bul- let, particularly a handgun bullet, will ricochet off body structures. Rico- 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) are the ones most likely to be deflected by anatomic structures or to follow tissue planes.

LEAD FRAGMENTS AND LEAD POISONING

Lead fragments in soft tissue usually become encapsulated with fibrous tissue and do not cause problems. Bullet-induced lead poisoning is most common with intra-articular, disk space, and bursal locations of bullet fragments because of the solubility of lead in synovial fluid. 20,21 Lead fragments in the brain are usually relatively benign unless they are copper-plated (as are many civilian .22 caliber bullets). 22 Copper-plated

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SECTION 21: Trauma

lead pellets produced a sterile abscess or granuloma in the brain of cats surgically implanted with missiles of this type. 22 This can result in down- ward migration of the missile, resorption of copper from the surface of 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- icant damage to the articular cartilage visible at surgery may be present as a result of lead synovitis, even when the only radiographic finding is bullet fragments. 20 If large fragments are present in the joint, they can cause severe mechanical trauma during motion. This motion can lead to further lead fragmentation. Whether lead poisoning occurs depends largely on the surface area of the retained lead particles and their location in the body. 21 Sometimes, the onset of clinical lead poisoning can be quite rapid, but usually, it takes years. Patients with retained lead pellets or lead bullet fragments should be advised that, on rare occasions, a fragment may erode into a bursa or joint space and cause lead poisoning. Assure patients that lead poisoning poses a threat only if unrecognized and untreated. Advise patients to seek treatment for problems such as headache, abdominal pain, personality change, or neurologic symptoms. Once lead poisoning is considered, a lead level can easily confirm or exclude the diagnosis.

EVIDENTIARY CONCERNS

Physicians and nurses must preserve evidence in patients being resusci- tated after penetrating trauma. Do not cut through bullet holes or knife holes in clothing when removing it. Do not incise through skin wounds unless absolutely necessary. To preserve powder marks, do not scrub wounds unless necessary. Whenever possible, take photographs before initiating wound treatment . EMS systems and EDs should have a protocol for collecting clothing and other evidence and keeping it secure. Do not describe wounds as entry or exit wounds; instead, describe the appearance of wounds in detail, without interpretation. Describe the location, size, and shape of all gunshot wounds. Include the presence or absence of a soot ring, skin, or subcutaneous tissue tattooing with gunpowder, or the presence of subcutaneous gas (such as from a contact wound with injection into the subcutaneous tissues of gases from burning gunpowder). When a bullet or fragment is encountered, do not pick it up with a metallic clamp because the clamp can alter ballistic markings. Take care to avoid injury from the sharp bullet jacket edges of some soft-point and hollow-point

handgun bullets. Infectious diseases, such as hepatitis and human im- munodeficiency virus, could pass from the victim to the health care pro- vider as a result of skin punctures from these sharp edges.

vider as a result of skin punctures from these sharp edges. REFERENCES 1. Hollerman JJ, Fackler

REFERENCES

1. Hollerman JJ, Fackler ML, Coldwell DM, Ben-Menachem Y: Gunshot wounds: 1. Bul- lets, ballistics and mechanisms of injury. AJR Am J Roentgenol 155: 685, 1990.

2. Hollerman JJ, Fackler ML: Gunshot wounds: radiology and wound ballistics. Emerg Radiol 2: 171, 1995.

3. Hollerman JJ, Fackler ML, Coldwell DM, Ben-Menachem Y: Gunshot wounds: 2. Radiology. AJR Am J Roentgenol 155: 691, 1990.

4. Fackler ML, Surinchak JS, Malinowski JA, Bowen RE: Bullet fragmentation: a major cause of tissue disruption. J Trauma 24: 35, 1984.

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.

6. Hollerman JJ: Wound ballistics is a model of the pathophysiology of all blunt and penetrating trauma. Emerg Radiol 5: 279, 1998.

7. Harvey EN, Korr IM, Oster G, McMillen JH: Secondary damage in wounding due to

pressure changes accompanying the passage of high-velocity missiles. Surgery 21: 218,

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8. DeMuth WE Jr: Bullet velocity and design as determinants of wounding capability: an experimental study. J Trauma 6: 222, 1966.

9. Wolberg EJ: Performance of the Winchester 9-mm 147-grain subsonic jacketed hollow 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 Clin North Am 16: 17, 1998.

12. Fackler ML, Surinchak JS, Malinowski JA, Bowen RE: Wounding potential of the Rus- sian AK-74 assault rifle. J Trauma 24 :263, 1984.

13. Smith HW, Wheatley KK Jr: Biomechanics of femur fractures secondary to gunshot wounds. J Trauma 24: 970, 1984.

14. Smith OC, Berryman HE, Lahren CH: Cranial fracture patterns and estimate of direction from low velocity gunshot wounds. J Forensic Sci 32: 1416, 1987.

15. Deitch EA, Grimes WR: Experience with 112 shotgun wounds of the extremities. J Trauma 24: 600, 1984.

16. Messmer JM, Fierro MF: Radiologic forensic investigation of fatal gunshot wounds. Radiographics 6: 457, 1986.

17. Lucas RM, Mitterer D: Pneumatic firearm injuries: trivial trauma or perilous pitfalls? J Emerg Med 8: 433, 1990.

18. Bixler RP, Ahrens CR, Rossi RP, Thickman D: Bullet identification with radiography. Radiology 178: 563, 1991.

19. Robison RJ, Brown JW, Caldwell R, et al: Management of asymptomatic intracardiac missiles using echocardiography. J Trauma 28: 1402, 1988.

20. Sclafani SJ, Vuletin JC, Twersky J: Lead arthropathy: arthritis caused by retained intra- articular bullets. Radiology 156: 299, 1985.

21. Linden MA, Manton WI, Stewart RM, et al: Lead poisoning from retained bullets:

pathogenesis, diagnosis, and management. Ann Surg 195: 305, 1982.

22. Sights WP, Bye RJ: The fate of retained intracerebral shotgun pellets: an experimental study. J Neurosurg 33: 646, 1970.

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