Firearms, bullets, and wound ballistics: an imaging primer

A historical perspective on ballistic evolution and its implications for maxillofacial surgery

Ballistics has undergone significant evolution, shaping its role in both military and civilian contexts. This article explores the trajectory of ballistic advancements and their profound implications for maxillofacial surgery. From the early days of firearms in tenth-century China to the modern understanding of terminal ballistics, the study highlights how advancements in projectile technology have transformed injury mechanisms. Ballistic injuries, particularly in the head and neck regions, pose unique challenges, due to their complexity, often involving high-energy transfer and extensive tissue disruption. These injuries necessitate a multidisciplinary approach, incorporating ballistic principles into surgical planning to enhance outcomes. By examining 162 studies, including retrospective analyses, clinical trials, and ballistic research, this review identifies trends in ballistic trauma and its management. The findings reveal a shift in injury patterns, with firearm-related facial injuries decreasing, but exhibiting increased morbidity and mortality. The integration of knowledge on projectile dynamics, tissue response, and energy transfer empowers surgeons to anticipate complications, refine surgical techniques, and mitigate long-term sequelae. Advancements in ballistic technology have also influenced treatment protocols, emphasizing the need for interdisciplinary research and collaboration. Historical and modern scenarios, from the Battle of Thermopylae to conflicts in Lebanon and Ukraine, underscore the evolving nature of ballistic injuries. The study concludes that a comprehensive understanding of ballistics is essential for improving patient care in maxillofacial surgery, advocating for continued research to address emerging challenges and refine interventions for complex trauma cases.

Assault rifle injuries in civilians: ballistics of wound patterns, assessment and initial management

PURPOSE

Wounds from assault rifles and their commercial offspring have been encountered with increasing frequency in civilian practice. Our aim is to summarize wound ballistics related to the main injury patterns that can also affect management strategies.

METHODS

An online search of the PubMed was conducted for research and review articles published after 2000 in English, using the MeSH terms "gunshot wounds", "mass casualty incidents", "war-related injuries", "soft tissue injuries", "vascular system injuries", "colon injuries", "wound infection", "antibiotic prophylaxis", "debridement", "hemorrhage", "penetrating head injuries", "pneumothorax" and additional free-text terms. Other academic databases were also searched for relevant articles and book chapters.

RESULTS

Consensus regarding recognition of high energy wounds from assault rifle projectiles is largely based on war experience. Studies of such wounds inflicted by expanding projectiles suggest that their wounding effects significantly increase tissue damage and adverse outcomes following injury, as a result of the temporary cavity and bullet fragmentation. The use of assault rifles in mass shootings has prompted utilization of tourniquet for control of life-threatening hemorrhage, also derived from military experience, while limited evidence indicates that tension pneumothorax rather than extremity wounds is the leading cause of potentially preventable death in these incidents.

CONCLUSIONS

Wound ballistics provides a system for evaluation of injuries from assault rifles and risk analysis of shooting incidents. Lessons learned from armed conflicts can improve the management of victims, with due consideration given to characteristics of civilian injuries. Further research is required to define the impact on survival by key life-saving procedures in the prehospital setting, in order to prioritize these interventions.

Three-dimensional visualization of gunshot cavities in ballistic gelatine with computed tomography - A forensic ballistics case study

Three-dimensional (3D) imaging, primarily computed tomography (CT), has proven valuable in the documentation and analysis of gunshot injuries. Explicit visualization of findings may play a pivotal role in judicial settings. This forensic ballistics case study aimed to examine the potential of CT-based 3D reconstruction to digitally visualize gunshot cavities in ballistic gelatine. Three .30 caliber bullets of different types (full metal jacket, soft point, and expanding monolithic) were fired into standardized blocks of 10% ballistic gelatine. The blocks underwent CT scanning with clinical equipment. Gelatine and air were segmented from the CT data using an open-source software. 3D reconstruction views of the segmented gelatine and air components were created. The gunshot cavities were clearly observed in both gelatine and air segmentation. The differences in cavitation between bullet types were evident in both reconstruction approaches, although gelatine segmentation produced higher resolution of small details. The obvious benefit of digital reconstruction was the ability to freely tilt and rotate the 3D images, with the possibility of taking measurements manually or automatically from any plane. Moreover, all the data can be stored for future analysis. This study introduces a preliminary method for digital visualization and documentation of gunshot cavitation in ballistic gelatine, to be fine-tuned and implemented for research purposes and routine practice in forensic institutions.

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

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

Current concepts review: Management of civilian transpelvic gunshot fractures

INTRODUCTION

Civilian gunshot fractures of the pelvic ring represent a unique challenge for orthopaedic surgeons due to a high incidence of complicating associated injuries. Internationally accepted guidelines for these injuries are not available. The aim of this review is to summarize the available literature and to provide concise management recommendations.

METHODS

Literature search was performed using PubMed. The review focuses on civilian gunshot fractures of the pelvic ring and includes the acetabulum and hip joint only where it was deemed necessary for the understanding of the management of these patients.

RESULTS

The management of civilian transpelvic gunshot fractures is complicated by potentially life-threatening associated injuries, the risk of contamination with bowel content and retained bullets in joints. The infection risk is higher compared to extremity gunshot fractures. There is no clear evidence for the use of antibiotics available. The studies focusing on civilian pelvic ring gunshot fractures reported no case of orthopaedic fracture fixation in their series. Routine wash-out and debridement of fractures is not warranted based on the literature but conflicting recommendations for surgical interventions exist.

CONCLUSION

There is limited evidence available for civilian transpelvic gunshot fractures. The high frequency of associated injuries requires a thorough clinical examination and multidisciplinary management. We recommend routine antibiotic prophylaxis for all transpelvic gunshots. For fractures with a high risk of infection, a minimum of 24 h broad-spectrum antibiotics is recommended. The indication for orthopaedic fixation of civilian transpelvic gunshot fractures is based on the assessment of the stability of the fracture and is rarely necessary. Although conflicting recommendations exist, routine wash-out and debridement is not recommended based on the literature. Bullets buried in bone without contact to synovial fluid do not warrant removal, unless they have traversed large bowel and are accessible without undue morbidity. Furthermore, bullets should be routinely removed if they are retained in the hip joint, if mechanical irritation of soft tissues by projectiles is expected or if the bullet traversed large bowel before entering the hip joint.

Gunshot Injury to the Face With Atypical Non-linear Bullet Trajectory: A Case Report

The disruptive effect of firearm missiles on body tissues depends on many factors. However, it mainly relates to the bullet's physical and dynamic properties and tissue-related factors. We encountered an unusual case of a gunshot injury wherein the bullet traversed the neck with an upward and non-linear trajectory with an exit from the contralateral side of the neck without damaging any vital neck organs. A 26-year-old male presented with a gunshot wound to the chin from close range. A bullet entry hole was observed on the right side of the chin, encircled by the abrasion collar, with tattoo marks around the area. The patient was conscious, with normal vital signs and no injury to the cranial nerves or aerodigestive tract. The CT imaging of the patient revealed the injury tract traversing through the muscles of the floor of the mouth to involve the left carotid and left parapharyngeal space, along with the left sternocleidomastoid muscle, with an exit hole below the left mastoid in the posterior triangle of the neck. A bullet usually travels through the body in a straight line or pathway; however, its non-linear trajectories depend on the projectile's dynamics and its interaction with the body tissues. The present case emphasizes understanding wound ballistics to know the erratic bullet trajectories in the victim's body and their interpretation, irrespective of their entry site.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Lead toxicity due to retained intracranial bullet fragments: illustrative case

BACKGROUND

Lead toxicity (plumbism) secondary to retained lead bullet fragments is a rare complication in patients with gunshot wounds. To the authors' knowledge, there has been no definitive case reported of lead toxicity due to retained intracranial bullet fragments.

OBSERVATIONS

The authors reported the case of a 23-year-old man who presented after being found down. Computed tomography scanning of the head revealed bullet fragments within the calvaria adjacent to the left transverse sinus. During follow-up, he developed symptoms of plumbism with paresthesias in his bilateral hands and thighs, abdominal cramping, labile mood, and intermittent psychosis. Plumbism was confirmed with sequentially elevated blood lead levels (BLLs). The patient opted for surgical removal of the bullet fragments, which led to reduction in BLLs and resolution of his symptoms.

LESSONS

Although rare, lead toxicity from retained intracranial bullet fragments should be considered in patients who have suffered a gunshot wound to the head and have symptoms of lead toxicity with elevated BLLs. For safe and accessible intracranial bullet fragments in patients with plumbism, surgical intervention may be indicated.

Gunshot Wounds: Ballistics, Pathology, and Treatment Recommendations, with a Focus on Retained Bullets

As the epidemic of gunshot injuries and firearm fatalities continues to proliferate in the United States, knowledge regarding gunshot wound (GSW) injury and management is increasingly relevant to health-care providers. Unfortunately, existing guidelines are largely outdated, written in a time that high-velocity weapons and deforming bullets were chiefly restricted to military use. Advances in firearm technology and increased accessibility of military grade firearms to civilians has exacerbated the nature of domestic GSW injury and complicated clinical decision-making, as these weapons are associated with increased tissue damage and often result in retained bullets. Currently, there is a lack of literature addressing recent advances in the field of projectile-related trauma, specifically injuries with retained bullets. This review aims to aggregate the available yet dispersed findings regarding ballistics, GSW etiology, and treatment, particularly for cases involving retained projectiles.

Wandering Bullet Embolization in Suicidal Near-Contact Gunshot Wound

Suicidal firearm injuries with bullet embolization following wandering bullet path are infrequent findings where the penetrated bullet could not be detected in the expected location. If this condition exists, one entrance wound will be present without an exit wound. Through necro-radiographs and postmortem autopsy, forensic experts can determine the nonlinear trajectory of the bullet. To understand the internal bullet path properly, forensic experts should interpret the medicolegal investigation results in the context of tissue and ballistics factors. Various medical specialties, including forensic experts, should be aware of the possibility of the nonlinear bullet trajectory and the possibility of bullet embolization in distant sites in order to save lives and/or interpret the collected evidence to support the justice in such uncommon incident.

Low-velocity, civilian firearm extremity injuries-review and update for radiologists

Firearm injuries are a preventable epidemic in the USA. Extremities are commonly affected in gunshot injuries. Such injuries may be complex with concomitant osseous, soft tissue, and neurovascular components. The maximum wounding potential of a projectile is determined by its kinetic energy and the proportion of the kinetic energy that is transmitted to the target. Accurate assessment of ballistic injuries is dependent on utilizing the principles of wound ballistics, accurate bullet count, and ballistic trajectory analysis. The goals of this article are to review wound ballistics and the imaging evaluation of extremity civilian firearm injuries in the adult population, with emphasis on ballistic trajectory analysis, specific ballistic fracture patterns, and diffuse, secondary soft tissue ballistic injuries.

Multimodality Imaging of Foreign Bodies: New Insights into Old Challenges

Traumatic wounds and lacerations are a common reason for patients to present to emergency departments, with retained foreign bodies (FBs) accounting for 7%-15% of cases, particularly those involving the extremities. These retained materials result in a granulomatous tissue response known as an FB reaction, a pathologic attempt to isolate the FB from the host. The most common FB materials are glass, metal, and wood, but other compositions can also be found, such as plastic and animal-derived materials. Clinical history, physical examination, and wound exploration are essential in investigation of retained material but are not sufficient to exclude an FB, and additional investigation is required. Imaging evaluation is a useful tool to help depict and locate an FB, assess possible complications, and guide removal. Conventional radiography, the first-line method in this scenario, is a widely available low-cost depiction method that has good sensitivity for depicting FBs. If the retained material is not depicted at conventional radiography, US can be performed. US is highly sensitive in depicting both radiolucent and radiopaque FBs in superficial locations. For deeper objects, CT may be necessary. MRI is the best imaging modality to delineate local soft-tissue and osseous complications. Retained FBs can result in early and delayed complications, with infection being the most frequent complication. To avoid preventable morbidities related to FBs, radiologists should be familiar with imaging findings and provide essential information to help the attending physician treat each patient. Online supplemental material is available for this article. ^©RSNA, 2020.

CT of Penetrating Abdominopelvic Trauma

Penetrating abdominopelvic trauma usually results from abdominal cavity violation from a firearm injury or a stab wound and is a leading cause of morbidity and mortality from traumatic injuries. Penetrating trauma can have subtle or complex imaging findings, posing a diagnostic challenge for radiologists. Contrast-enhanced CT is the modality of choice for evaluating penetrating injuries, with good sensitivity and specificity for solid-organ and hollow viscus injuries. Familiarity with the projectile kinetics of penetrating injuries is an important skill set for radiologists and aids in the diagnosis of both overt and subtle injuries. CT trajectography is a useful tool in CT interpretation that allows the identification of subtle injuries from the transfer of kinetic injury from the projectile to surrounding tissue. In CT trajectography, after the entry and exit wounds are delineated, the two points can be connected by placing cross-cursors and swiveling the cut planes obliquely in orthogonal planes to obtain a double-oblique orientation to visualize the wound track in profile. The path of the projectile and its ensuing damage is not always straight, and the imaging characteristics of free fluid of different attenuation in the abdomen (including hemoperitoneum) can support the diagnosis of visceral and vascular injuries. In addition, CT is increasingly used for evaluation of patients after damage control surgery and helps guide the management of injuries that were overlooked at surgery. An invited commentary by Paes and Munera is available online. Online supplemental material is available for this article. ©RSNA, 2021.

The G2 research R.I.P. fragmenting bullet-radiographic features of a recently encountered projectile

Gunshot wounds (GSWs) are an important cause of disability and death in the USA. Although radiography is limited in its ability to detect bullet types, a projectile introduced during the last decade, the R.I.P. bullet by G2 Research, consists of a base slug connected to 6 to 8 sharp trocars designed to diverge within soft tissue following impact, resulting in what we believe to be a unique imaging appearance that can be confusing to those not familiar with this particular projectile. Furthermore, this bullet is 100% copper, which may allow for safe imaging with magnetic resonance imaging if correctly identified prior to scanning.

Multidetector CT Findings in the Abdomen and Pelvis after Damage Control Surgery for Acute Traumatic Injuries

After experiencing blunt or penetrating trauma, patients in unstable condition who are more likely to die of uncorrected shock than of incomplete injury repairs undergo emergency limited exploratory laparotomy, which is also known as damage control surgery (DCS). This surgery is part of a series of resuscitation steps, with the goal of stabilizing the patient's condition, with rapid surgical control of hemorrhage followed by supportive measures in the intensive care unit before definitive repair of injuries. These patients often are imaged with multidetector CT within 24-48 hours of the initial surgery. Knowledge of this treatment plan is critical to CT interpretation, because there are anatomic derangements and foreign bodies that would not be present in patients undergoing surgery for other reasons. Patients may have injuries beyond the surgical field that are only identified at imaging, which can alter the care plan. Abnormalities related to the resuscitation period such as the CT hypoperfusion complex and ongoing hemorrhage can be recognized at CT. Familiarity with these imaging and clinical findings is important, because they can be seen not only in trauma patients after DCS but also in other patients in the critical care setting. The interpretation of imaging studies can be helped by an understanding of the diagnostic challenges of grading organ injuries with surgical materials in place and the awareness of potential artifacts on images in these patients. Online supplemental material is available for this article. ^©RSNA, 2019 See discussion on this article by LeBedis .

Shotgun Wounds: Nationwide Trends in Epidemiology, Injury Patterns, and Outcomes from US Trauma Centers

BACKGROUND

Shotguns represent a distinct form of ballistic injury because of projectile scatter and variable penetration. Due in part to their rarity, existing literature on shotgun injuries is scarce.

OBJECTIVE

This study defined the epidemiology, injury patterns, and outcomes after shotgun wounds at a national level.

METHODS

Patients with shotgun injury were identified from the National Trauma Data Bank (2007-2014). Transferred patients and those with missing procedure data were excluded. Demographics, injury data, and outcomes were collected and analyzed. Categorical variables are presented as number (percentage) and continuous variables as median (interquartile range).

RESULTS

Shotgun wounds comprised 9% of all firearm injuries. After exclusions, 11,292 patients with shotgun injury were included. The median age was 29 years (21-43) and most were male (n = 9887, 88%). Most injuries occurred in the South (n = 4092, 36%) and among white patients (n = 4945, 44%). The median Injury Severity Score was 9 (3-16). Overall in-hospital mortality was 14% (n = 1341), with 669 patients (7%) dying in the emergency department. Assault was the most common injury intent (n = 6762, 60%), followed by accidental (n = 2081, 19%) and self-inflicted (n = 1954, 17%). The lower and upper extremities were the most commonly affected body regions (n = 4071, 36% and n = 3422, 30%, respectively), while the head was the most severely injured (median Abbreviated Injury Scale score 4 [2-5]).

CONCLUSIONS

In the United States, shotgun wounds are an infrequent mechanism of injury. Shotgun wounds as a result of interpersonal violence far outweigh self-inflicted and accidental injuries. White men in their 20s in the southern parts of the country are most commonly affected and thereby delineate the high-risk patient population for injury by this mechanism at a national level.

Air gun wound: bihemispheric penetrating brain injury in a paediatric patient

Air guns are classified as low-velocity missiles and they usually considered safe and harmless. Despite that fact, air guns still can make serious or life-threatening injuries. Most of air gun injuries occur in paediatric population. A 2-year-old boy was shot in the forehead withan air gun accidentally. Skull radiography and non-contrast CT scan of the head were performed and showed penetrating bihemispheric brain injury from the left frontal to right occipital lobes at the level of the lateral ventricle with a metal-density foreign body at the right occipital. A projectile was successfully extracted via craniotomy, without complications. Air guns have the potential to cause fatal, life-threatening injury especially in children. Imaging is crucial for the evaluation of wound ballistics. Understanding about the mechanism of projectiles and wound ballistics is very helpful for radiologists to conceptualize these injuries when interpreting these cases. The role of radiology in ballistic wound cases is critical and important, both for clinical and forensic settings.

The American Association for the Surgery of Trauma Organ Injury Scale 2018 update for computed tomography-based grading of renal trauma: a primer for the emergency radiologist

The most widely used trauma injury grading system is the Organ Injury Scale (OIS) by the American Association for the Surgery of Trauma (AAST). The AAST OIS for renal trauma was revised in 2018 to reflect necessary updates based on decades of experience with computed tomography (CT)-based injury diagnosis and, specifically, to better incorporate vascular injuries, which were not comprehensively addressed in the original OIS. In this review article, we describe CT findings of the AAST OIS for the kidney according to the 2018 revision, with an emphasis on real-world application, and highlight important differences from the prior grading scheme. Routine use of this grading system allows for a standardized classification of the range of renal injuries to aid in management, adding value in the imaging care of trauma patients.

The diagnostic dilemma of shotgun injuries

PURPOSE

Shotgun wounds pose diagnostic challenges due to variable fragment penetration and degradation of CT images. This study compared epidemiology and outcomes between shotgun wounds and gunshot wounds (GSWs), and defined the diagnostic capabilities of CT scan after shotgun wounds.

METHODS

All patients presenting to our Level I trauma center after ballistic injury (01/2008-03/2017) were included. Study groups were defined by shotgun vs GSW. Demographics, clinical data, and outcomes were compared using univariate analysis. The diagnostic yield of CT scan after shotgun wounds was calculated.

RESULTS

Of 3177 patients, 3126 (98%) were injured by GSWs and 51 (2%) by shotguns. Of the shotgun-injured patients, 5 (10%) had superficial wounds, 8 (16%) underwent emergency surgery, and 38 (74%) underwent CT scan [10 (26%) were then brought to OR and 28 (74%) were managed nonoperatively]. The sensitivity, specificity, PPV, and NPV of CT scan after shotgun wounds were 0.93, 0.96, 0.93, and 0.97. There was one false-negative CT scan, which missed a hollow viscus injury. There was one false-positive CT scan, which suggested a hollow viscus injury, although none was found on exploratory laparotomy. Patients injured by shotgun required fewer cavitary explorations (25% vs 59%, p = 0.006) but more soft tissue (21% vs 8%, p = 0.013) and extremity vascular surgeries (86% vs 9%, p < 0.001) than GSW-injured patients.

CONCLUSIONS

Shotgun injuries are far less frequent than GSWs but generally follow the same diagnostic and therapeutic considerations. Clinicians must be aware of the pitfalls of CT scanning after shotgun injuries, which can be falsely positive or falsely negative. A high index of suspicion for injury and a period of observation after negative CT scan may, therefore, be prudent.

New fragmenting bullet leads to unexpected injury pattern: A case report involving the Radically Invasive Projectile

New developments in bullet technology are challenging what is commonly known about penetrating injuries from gunshot wounds. The so-called ‘bullet-rule’ posits the number of wounds and projectiles associated with a patient should add to an even number. This trauma paradigm is being shattered by the advent of new fragmenting projectiles. These frangible rounds break into several pieces after soft tissue penetration changing the expected trajectory, injury location, and extent of tissue damage. In this case report, the authors describe the case of a 15-year-old boy injured by a G2 Radically Invasive Projectile (RIP). The patient’s resultant pattern of injuries and the diagnostic utility of imaging were imperative for guiding his clinical management. The case serves as a useful example of the challenges and recommended strategies in managing a patient injured by a new fragmenting bullet.

Forensic Radiology Pitfalls: CT Imaging in Gunshot Wounds of the Head

Computed tomography (CT) imaging is increasingly used in emergency departments and trauma services and is being offered as a supplemental tool with autopsy in coroner's and medical examiner's offices throughout the United States. The availability of CT images in lieu of traditional X-rays for medicolegal autopsies may lead to misinterpretation of images for forensic pathologists who are not familiar with these types of images. Forensic pathologists must become familiar with CT imaging, the basis of CT image formation and how to interpret CT images appropriately. We highlight potential pitfalls of CT image interpretation through two cases of fatal gunshot wounds of the head. Antemortem CT imaging available at the time of autopsy led to discrepancy between the initial image findings and the autopsy due to inexperienced manipulation of the images. With appropriate understanding of CT image interpretation and manipulation, forensic personnel should be able to avoid most sources of misinterpretation.

Management of Vascular Trauma during the Paris Terrorist Attack of November 13, 2015

BACKGROUND

On November 13, 2015, Paris and Saint-Denis were the targets of terrorist attacks. The Public Hospitals of Paris Organization and the Percy Armed Forces Instruction Hospitals were mobilized to face the mass casualty situation. The objective of this study is to analyze the management of the victims presenting with a nonthoracic vascular trauma (NTVT).

METHODS

All the data relating to the victims of NTVT who required a specific vascular open or endovascular treatment were analyzed retrospectively. A 6-month follow-up was obtained for all the patients.

RESULTS

Among the 351 wounded, 20 (5.7%) patients had an NTVT and were dispatched in 8 hospitals (11 men of average age 32). NTVTs were gunshots in 17 cases (85%) or due to a handmade bomb in 3 cases (15%). Twelve patients (60%) received cardiopulmonary resuscitation during prehospital care. NTVT affected the limbs (14 cases, 70%) and the abdomen or the small pelvis (6 cases, 30%). All the patients were operated in emergency. Arterial lesions were treated with greater saphenous vein bypasses, by ligation, and/or embolization. Eleven venous lesions were treated by direct repair or ligation. Associated lesions requiring a specific treatment were present in 19 patients (95%) and were primarily osseous, nervous, and abdomino-pelvic. Severe postoperative complications were observed in 9 patients (45%). Fourteen patients (70%) required blood transfusion (6.4 U of packed red blood cells on average, range 0-48). There were no deaths or amputation and all vascular reconstructions were patent at 6 months.

CONCLUSIONS

The effectiveness of the prehospital emergency services and a multisite and multidisciplinary management made it possible to obtain satisfactory results for NTVT casualties. All the departments of vascular surgery must be prepared to receive many wounded victims in the event of terrorist attacks.

Deaths resulting from the use of firearms by police against motor vehicles: Study of cases in Porto, Portugal

The objective of this study was to investigate the terminal ballistics of police shootings in which the bullets went through any motor vehicle structure before fatally wounding the occupants. 6 cases that occurred in Porto district between 1998 and 2013 were studied. The firearms used were 7.65 mm (n = 1) or 9 mm (n = 3) calibre semi-automatic pistols and 9 mm calibre submachine guns (n = 2); the bullets were full metal jacket type. The metal jacket of the collected projectiles was totally or partially destroyed in 3 cases. It exhibited a deformed structure in all cases. The trajectories of the bullets in the vehicles were always more or less linear, even when initial impact was at an oblique angle. The entry holes in the victims' bodies were larger or much larger in size than the calibre of the bullets. They were located, with the exception of one of the cases, in the left half of the body. The trajectories in the victims' bodies were from front to back, in one case, and from back to front in all others. Exit wounds were only found in two cases. Death occurred immediately after the victim was shot only in one case, despite a vital structure has been hit in all cases. The cases studied support the idea that the use of firearms against vehicles with the sole intention of immobilisation entails uncontrollable danger to the lives of the occupants, and especially when done by police forces not specifically trained for that purpose. Therefore, such use of firearms should be avoided.