CHAPTER e263.
1: Wound Ballistics e38
CHAPTER Wound Ballistics
e263.1 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.1–3 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 fragments4
and deforms.
Two major mechanisms of wounding occur: the crushing of the tissue
struck by the projectile (forming the permanent cavity) and the radial
stretching of the projectile path walls (forming a temporary cavity; Figure
Copyright © 2010 The McGraw-Hill Companies, Inc. All rights reserved.
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-
e39 SECTION 21: Trauma

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
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
Bullet
cavity
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
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.
Copyright © 2010 The McGraw-Hill Companies, Inc. All rights reserved.
CHAPTER e263.1: Wound Ballistics e40
Animal experiments using military rifle bullets5 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
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

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


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.
Copyright © 2010 The McGraw-Hill Companies, Inc. All rights reserved.
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
e43 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
Copyright © 2010 The McGraw-Hill Companies, Inc. All rights reserved.
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.
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