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Nguyen TT, Breeze J, Masouros SD. Penetration of Energised Metal Fragments to Porcine Thoracic Tissues. J Biomech Eng 2021; 144:1129240. [PMID: 34897379 DOI: 10.1115/1.4053212] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Indexed: 11/08/2022]
Abstract
Energised fragments from explosive devices have been the most common mechanism of injury to both military personnel and civilians in recent conflicts and terrorist attacks. Fragments that penetrate into the thoracic cavity are strongly associated with death due to the inherent vulnerability of the underlying structures. The aim of this study was to investigate the impact of fragment-simulating projectiles (FSPs) to tissues of the thorax in order to identify the thresholds of impact velocity for perforation through these tissues and the resultant residual velocity of the FSPs. A gas-gun system was used to launch 0.78-g cylindrical and 1.13-g spherical FSPs at intact porcine thoracic tissues from different impact locations. The sternum and rib bones were the most resistant to perforation, followed by the scapula and intercostal muscle. For both FSPs, residual velocity following perforation was linearly proportional to impact velocity. These findings can be used in the development of numerical tools for predicting the medical outcome of explosive events, which in turn can inform the design of public infrastructure, of personal protection, and of medical emergency response.
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Affiliation(s)
- Thuy-Tien Nguyen
- Department of Bioengineering, Imperial College London, UK; Imperial College London, London, W12 0BZ, United Kingdom
| | - John Breeze
- Department of Bioengineering, Imperial College London, UK; Imperial College London, London, W12 0BZ, United Kingdom
| | - Spyros D Masouros
- Department of Bioengineering, Imperial College London, UK; Imperial College London, London, W12 0BZ, United Kingdom
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2
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Hazell GA, Pearce AP, Hepper AE, Bull AMJ. Injury scoring systems for blast injuries: a narrative review. Br J Anaesth 2021; 128:e127-e134. [PMID: 34774294 DOI: 10.1016/j.bja.2021.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/10/2021] [Accepted: 10/03/2021] [Indexed: 11/25/2022] Open
Abstract
Injury scoring systems can be used for triaging, predicting morbidity and mortality, and prognosis in mass casualty incidents. Recent conflicts and civilian incidents have highlighted the unique nature of blast injuries, exposing deficiencies in current scoring systems. Here, we classify and describe deficiencies with current systems used for blast injury. Although current scoring systems highlight survival trends for populations, there are several major limitations. The reliable prediction of mortality on an individual basis is inaccurate. Other limitations include the saturation effect (where scoring systems are unable to discriminate between high injury score individuals), the effect of the overall injury burden, lack of precision in discriminating between mechanisms of injury, and a lack of data underpinning scoring system coefficients. Other factors influence outcomes, including the level of healthcare and the delay between injury and presentation. We recommend that a new score incorporates the severity of injuries with the mechanism of blast injury. This may include refined or additional codes, severity scores, or both, being added to the Abbreviated Injury Scale for high-frequency, blast-specific injuries; weighting for body regions associated with a higher risk for death; and blast-specific trauma coefficients. Finally, the saturation effect (maximum value) should be removed, which would enable the classification of more severe constellations of injury. An early accurate assessment of blast injury may improve management of mass casualty incidents.
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Affiliation(s)
- George A Hazell
- Centre for Blast Injury Studies, Imperial College London, London, UK.
| | - A Phill Pearce
- Department of General Surgery, The Royal London Hospital, Barts NHS Trust, London, UK
| | - Alan E Hepper
- Defence Science and Technology Laboratory, Porton Down, Salisbury, UK
| | - Anthony M J Bull
- Centre for Blast Injury Studies, Imperial College London, London, UK
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Lichtenberger JP, Kim AM, Fisher D, Tatum PS, Neubauer B, Peterson PG, Carter BW. Imaging of Combat-Related Thoracic Trauma – Review of Penetrating Trauma. Mil Med 2017. [DOI: 10.1093/milmed/usx034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Affiliation(s)
- John P Lichtenberger
- Department of Radiology and Radiological Sciences, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Andrew M Kim
- Department of Radiology and Radiological Sciences, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Dane Fisher
- Department of Radiology and Radiological Sciences, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Peter S Tatum
- Rowan School of Osteopathic Medicine, 42 East Laurel Road, Stratford,NJ 08084
| | - Brian Neubauer
- Department of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda,MD 20814
| | - P Gabriel Peterson
- Department of Radiology, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda,MD 20889
| | - Brett W Carter
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030
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Dussault MC, Smith M, Hanson I. Evaluation of trauma patterns in blast injuries using multiple correspondence analysis. Forensic Sci Int 2016; 267:66-72. [DOI: 10.1016/j.forsciint.2016.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Revised: 05/20/2016] [Accepted: 08/03/2016] [Indexed: 10/21/2022]
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Staruch RM, Hettiaratchy S. Military plastic surgery. Plast Reconstr Surg 2015. [DOI: 10.1002/9781118655412.ch78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Singleton JAG, Gibb IE, Bull AMJ, Clasper JC. Blast-mediated traumatic amputation: evidence for a revised, multiple injury mechanism theory. J ROY ARMY MED CORPS 2014; 160:175-9. [DOI: 10.1136/jramc-2013-000217] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Lozano JD, Munera F, Anderson SW, Soto JA, Menias CO, Caban KM. Penetrating wounds to the torso: evaluation with triple-contrast multidetector CT. Radiographics 2013; 33:341-59. [PMID: 23479700 DOI: 10.1148/rg.332125006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Penetrating injuries account for a large percentage of visits to emergency departments and trauma centers worldwide. Emergency laparotomy is the accepted standard of care in patients with a penetrating torso injury who are not hemodynamically stable and have a clinical indication for exploratory laparotomy, such as evisceration or gastrointestinal bleeding. Continuous advances in technology have made computed tomography (CT) an indispensable tool in the evaluation of many patients who are hemodynamically stable, have no clinical indication for exploratory laparotomy, and are candidates for conservative treatment. Multidetector CT may depict the trajectory of a penetrating injury and help determine what type of intervention is necessary on the basis of findings such as active arterial extravasation and major vascular, hollow viscus, or diaphragmatic injuries. Because multidetector CT plays an increasing role in the evaluation of patients with penetrating wounds to the torso, the radiologists who interpret these studies should be familiar with the CT findings that mandate intervention.
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Affiliation(s)
- J Diego Lozano
- Department of Radiology, University of Miami Leonard Miller School of Medicine, University of Miami Health System, Jackson Memorial Hospital, and Ryder Trauma Center, 1611 NW 12th Ave, West Wing 279, Miami, FL 33136, USA
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Ramasamy A, Hughes A, Carter N, Kendrew J. The effects of explosion on the musculoskeletal system. TRAUMA-ENGLAND 2013. [DOI: 10.1177/1460408613484683] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Explosions remain the leading cause of death and injury to combatants in conflict. The current ‘Global War on Terror’ has resulted in a shift of explosive-related injuries from the battlefield into civilian centres. Despite musculoskeletal injuries being the most common injury witnessed in blast, there remains little research into the effects of blast on this system. In order to develop new treatment regimens and mitigation systems, there is a requirement to have a better understanding of skeletal trauma in this unique environment. The aim of this review article is to deconstruct the complex injury mechanisms witnessed in blast and relate them to its effects on the musculoskeletal system.
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Affiliation(s)
- Arul Ramasamy
- Academic Department of Traumatology, Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Birmingham, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, ICT Centre, Birmingham, UK
| | - Anna Hughes
- Academic Department of Traumatology, Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Birmingham, UK
| | - Nicholas Carter
- Academic Department of Traumatology, Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Birmingham, UK
| | - Jon Kendrew
- Academic Department of Traumatology, Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Birmingham, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, ICT Centre, Birmingham, UK
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Jakab L, Szántó Z, Benkő I, Szalai Z, Pótó L, Molnár FT. [Ethiopathogenesis of spontaneous primary pneumothorax. Marijuana: cause or a blame?]. Magy Seb 2012; 65:421-5. [PMID: 23229034 DOI: 10.1556/maseb.65.2012.6.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE There are contradictory data on chronic lung injury caused by marijuana, which is partially due to insufficient basic research. Anecdotic reports draw attention to an increased rate of primary spontaneous pneumothorax (PSP) among young marijuana smokers, suggesting a causative link. METHODS A retrospective analysis of 20 patients treated for PSP in our department in the last two years was performed. Demographics, treatment modality and outcome data were analysed. Chi-square, Mann-Whitney and Fisher tests were applied for statistical evaluation. Gender distribution: 16 male, 4 female, age 23.95 ± 4,57 years: min: 18, max: 32. 13/20 patients admitted to be regular cannabis users (CU), among them 11 male, 2 female, age 24.54 ± 4.77 years. Altogether 7/20 patients had a history of previous pneumo-thorax, with a higher recurrence rate among CU (odds ratio 1.56). RESULTS In the non-cannabis user group (NCU) 3/7 patients were managed with thoracic drainage alone. 4/7 NCH patients needed major surgery, VATS was performed on all 4 patients. 4/13 CU patients were managed with thoracic drainage, 9/13 patients needed thoracotomy (8 VATS, 1 open thoracotomy). We found a shorter drainage time among NCU patients (4.00 ± 1.00 days NCU vs 4.5 ± 1.73 days CU, p = 0.651). Operative treatment was needed more frequently among cannabis users (69.23% vs NCU 57.14%, p = 0.651) due to impaired lung expansion. Recurrence was detected in 2 patients after drainage, 1 CU, 1 NCU patients, respectively, both of them were managed with VATS. On histological examination there were no major differences between the two groups, 11/13 of operative cases had pulmonary emphysaema . Based on county demographical and clinical data, there's a higher risk for PSP among cannabis users (odds ratio 3.86). CONCLUSIONS Despite the small sample size, there seems to be a connection between marijuana use and PSP prevalence. It's unclear if marijuana directly contributes to the development of pneumothorax, or just aggravates a fundamentally fragile lung parenchyma condition. In this group of young patients a more aggressive surgical approach is recommended, considering underlying parenchymal impairment and higher recurrence rate.
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Affiliation(s)
- László Jakab
- Pécsi Tudományegyetem, Általános Orvostudományi Kar Klinikai Központ, Sebészeti Klinika 7624 Pécs Rákóczi út 2
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Luo W, Liu H, Hao S, Zhang Y, Li J, Liu B. Penetrating brain injury caused by nail guns: two case reports and a review of the literature. Brain Inj 2012; 26:1756-62. [PMID: 22823496 DOI: 10.3109/02699052.2012.700085] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND To the best of the authors' knowledge, there are few case reports of penetrating brain injuries (PBI) caused by nail guns and these have usually involved incomplete penetration of the skull. Complete penetration of a nail into the intracranial cavity is extremely rare. CASE STUDY Here, two such cases are presented. In the first, the nail entered through the right temporal bone, lodged in the right temporal lobe and was removed via craniotomy with intra-operative ultrasound guidance. In the second, the nail destroyed the left parietal bone, damaged the left internal capsule and lodged in the left temporal lobe near the left petrous apex and the brain stem. According to the latest literature retrieval, this is the first reported case of nail-gun injury to the internal capsule. The position of the nail precluded removal without further neurologic damage. Treatment strategies designed to optimize outcome, with or without surgery, and possible complications are discussed in this report.
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Affiliation(s)
- Wei Luo
- Department of Neurosurgery, Zhongda Hospital, Southeast University, Nanjing, PR China
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Mortality pattern of the 26/11 Mumbai terror attacks. J Trauma Acute Care Surg 2012; 72:1329-34; discussion 1334. [DOI: 10.1097/ta.0b013e31824da04f] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bala M, Willner D, Keidar A, Rivkind AI, Bdolah-Abram T, Almogy G. Indicators of the need for ICU admission following suicide bombing attacks. Scand J Trauma Resusc Emerg Med 2012; 20:19. [PMID: 22405507 PMCID: PMC3313896 DOI: 10.1186/1757-7241-20-19] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2011] [Accepted: 03/09/2012] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Critical hospital resources, especially the demand for ICU beds, are usually limited following mass casualty incidents such as suicide bombing attacks (SBA). Our primary objective was to identify easily diagnosed external signs of injury that will serve as indicators of the need for ICU admission. Our secondary objective was to analyze under- and over-triage following suicidal bombing attacks. METHODS A database was collected prospectively from patients who were admitted to Hadassah University Hospital Level I Trauma Centre, Jerusalem, Israel from August 2001-August 2005 following a SBA. One hundred and sixty four victims of 17 suicide bombing attacks were divided into two groups according to ICU and non-ICU admission. RESULTS There were 86 patients in the ICU group (52.4%) and 78 patients in the non-ICU group (47.6%). Patients in the ICU group required significantly more operating room time compared with patients in the non-ICU group (59.3% vs. 25.6%, respectively, p=0.0003). For the ICU group, median ICU stay was 4 days (IQR 2 to 8.25 days). On multivariable analysis only the presence of facial fractures (p=0.014), peripheral vascular injury (p=0.015), injury≥4 body areas (p=0.002) and skull fractures (p=0.017) were found to be independent predictors of the need for ICU admission. Sixteen survivors (19.5%) in the ICU group were admitted to the ICU for one day only (ICU-LOS=1) and were defined as over-triaged. Median ISS for this group was significantly lower compared with patients who were admitted to the ICU for >1 day (ICU-LOS>1). This group of over-triaged patients could not be distinguished from the other ICU patients based on external signs of trauma. None of the patients in the non-ICU group were subsequently transferred to the ICU. CONCLUSIONS Our results show that following SBA, injury to ≥4 areas, and certain types of injuries such as facial and skull fractures, and peripheral vascular injury, can serve as surrogates of severe trauma and the need for ICU admission. Over-triage rates following SBA can be limited by a concerted, focused plan implemented by dedicated personnel and by the liberal utilization of imaging studies.
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Affiliation(s)
- Miklosh Bala
- Department of General Surgery and Trauma Unit, Hadassah-Hebrew University Medical Centre, Jerusalem, Israel
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Abstract
The authors report their 10-year experience in the treatment of war injuries in the Gaza strip. Bullet injuries to nerves can be assessed using Sunderland's classification. Grade 4 and 5 lesions must be repaired in the same way as any traumatic nerve injuries. A detailed series of sciatic nerve repair is presented. In this series, 12 nerve gaps were repaired by direct nerve coaptation using 90° knee flexion for six weeks. The results of this technique at 1 to 4 years follow-up are better than to those of sciatic nerve grafting.
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Satoh Y, Sato S, Saitoh D, Tokuno S, Hatano B, Shimokawaji T, Kobayashi H, Takishima K. Pulmonary blast injury in mice: A novel model for studying blast injury in the laboratory using laser-induced stress waves. Lasers Surg Med 2010; 42:313-8. [DOI: 10.1002/lsm.20899] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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An atypical ballistic traumatic cauda equina syndrome with a positive outcome. Focus on prognostic factors. Ann Phys Rehabil Med 2009; 52:687-93. [PMID: 19896916 DOI: 10.1016/j.rehab.2009.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Accepted: 09/25/2009] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Traumatic cauda equina syndromes due to projectile wounds often have a poor prognosis. We report on an unusual ballistic cauda equina traumatism with a good functional outcome. CLINICAL CASE A 44-year-old man was admitted to emergency room for an incomplete cauda equina syndrome after trying to kill himself by means of a pneumatic nail gun. The nail had gone right through the third lumbar vertebra. Because of the stability of the fracture, orthopaedic surgery was not indicated. Neurological recovery was progressive. At 6 months, there was still a partial L5-S1 motor deficit on the left side but the patient could walk without crutches, and within an unlimited walking distance. DISCUSSION Initial imaging displayed a projectile trajectory focused on the spinal canal on level L3, which could have been considered as bad prognosis. The positive analytic and functional outcome correlates with the limited neurological tissue damage, probably explained by the ballistic properties of the projectile. CONCLUSION Apart from the influence of a possible surgical act, the neurological and functional prognosis of a traumatic cauda equina syndrome caused by a projectile also depends on its physical characteristics.
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Persson C, McLure SWD, Summers J, Hall RM. The effect of bone fragment size and cerebrospinal fluid on spinal cord deformation during trauma: an ex vivo study. J Neurosurg Spine 2009; 10:315-23. [DOI: 10.3171/2009.1.spine08286] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The purpose of the study was to assess the effect of CSF and the size of the impacting bone fragment area on spinal cord deformation during trauma.
Methods
A transverse impact rig was used to produce repeated impacts on bovine and surrogate cord models. Tests were recorded with high-speed video and performed on specimens with and without CSF and/or dura mater and with 3 different impactor areas.
Results
The CSF layer was found to reduce the maximum cord deformation significantly. A 50% reduction in impact area significantly increased the maximum cord deformation by 20–30%. The surrogate model showed similar trends to the bovine model but with lower absolute deformation values.
Conclusions
Cerebrospinal fluid protects the cord during impact by reducing its deformation. A smaller bone fragment impact area increases the deformation of the cord, in agreement with clinical results, where a higher impact energy—possibly giving rise to smaller fragments—results in a worse neurological deficit.
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Goonewardene SS, Mangat KS, Sargeant ID, Porter K, Greaves I. Tetraplegia following cervical spine cord contusion from indirect gunshot injury effects. J ROY ARMY MED CORPS 2007; 153:52-3. [PMID: 17575878 DOI: 10.1136/jramc-153-01-12] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
We present the case of a 31 year old British soldier who sustained a high energy gunshot injury to the neck with delayed onset tetraplegia. The bullet's transcervical track was subsequently shown to have had no direct contact with the spinal cord, but four to five minutes after injury the patient developed tetraplegia. Subsequent Magnetic Resonance Imaging confirmed this to be due to contusion of the cervical spinal cord. This case illustrates the high levels of energy potentially transferred to surrounding tissues by the passage of a high available energy projectile, causing significant injury to nearby structures not actually impacted by the missile.
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Affiliation(s)
- S S Goonewardene
- South Birmingham Trauma Unit, Selly Oak Hospital, Raddlebarn Road B29
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