Imaging assessment of gunshot wounds

Dual-energy index variation when evaluating the potential ferromagnetism of ex vivo bullets

Background

An MRI is potentially hazardous for patients with retained ferromagnetic bullets. Recent studies have aimed to develop dual-energy computed tomography (DECT) as a screening tool for recognising highly ferromagnetic bullets. Inconsistent findings have been ascribed to inherent CT technology differences. Previous research demonstrated significant Hounsfield unit (HU) measurement variation among single-source CT machines.

Objectives

This study investigated the theoretical dual-energy index (DEI) variation between DECT machines when evaluating the potential ferromagnetic properties within the same sample of ex vivo bullets and metal phantoms.

Method

An experimental ex vivo study was conducted on eight metal phantoms and 10 unused bullets individually positioned in the same Perspex head phantom and scanned on two DECT machines. Two senior radiology registrars independently recorded the HU readings, and DEI values were calculated. Statistical analysis was performed using non-parametric methods for paired data, namely the Signed Rank Test. The DEI values based on mean HU readings between the DECT machines were compared.

Results

Inter- and intra-reader agreement was not statistically significant. The metal phantoms had poor interscanner agreement, with an overlap of the ferromagnetic and non-ferromagnetic ranges. The bullets had good interscanner agreement, with a similar ferromagnetic to non-ferromagnetic relationship.

Conclusion

The use of DEI values negates the previous assumption that significant interscanner variability exists among different DECT technologies while assessing highly attenuative ex vivo bullets.

Contribution

This investigation demonstrated that even though HU readings may be variable, the implementation of the DEI equation translates this into comparable values with good interscanner agreement.

Gunshot injury to the chest wall with an unusual bullet trajectory: A rare case report

INTRODUCTION AND IMPORTANCE

Gunshot injuries are always a challenging case for a surgeon. Early assessment of trajectory of bullet leads to effective surgical plan. These cases require multidisciplinary approach for the satisfactory outcome.

CASE PRESENTATION

We present a case of 38-year-old male with gunshot injury over left anterior chest wall with an entry wound and no detectable exit wound. Contrast enhanced computed tomogram (CECT) thorax and abdomen was suggestive of an unusual route of a bullet from left anterior chest wall at the level of 5th costochondral junction to the right iliac fossa region. Emergency exploration for the bullet was performed based on CECT findings which confirmed bullet in subcutaneous plane in right iliac fossa. Patient was discharged on 3rd post-operative with satisfactory clinical improvement.

CLINICAL DISCUSSION

Unusual presentations of bullet trajectory in gunshot injury can create surgical and/or medico-legal diagnostic problems. An effective surgical plan requires an effective clinic-radiological assessment. Accurate detection of entry wound, exit wound, path and extent of tissue damage is significant in preoperative planning and prognosis of patient. However not every patient with gunshot injury has an unusual trajectory. But accurate radiological assessment in such challenging cases is a necessity. Multidisciplinary approach with preoperative planning is required for satisfactory outcome.

CONCLUSION

Management of patients of gunshot injury is challenging for the attending surgeon. Multidisciplinary approach for preoperative planning along with good post-operative care is required in such cases of gunshot injury with atypical course.

An Evaluation of Firearm Injuries in the Emergency Department

Introduction

Firearm injuries are a significant cause of mortality and morbidity. Our study aims to evaluate the injury patterns, results of imaging studies, treatment methods, outcomes, and mortality rates of patients who were admitted to the emergency department with firearm injuries.

Methods

Our study was designed as a retrospective descriptive study. To this end, adult patients who were admitted to our hospital with gunshot wounds between January 1, 2017, and July 31, 2021, were screened. The files of 527 patients who were admitted with gunshot wounds were analyzed. A total of 30 patients were excluded from the study due to missing data. Statistical analyses were performed using the data of a total of 497 patients. Independent variables of the study included sex, age, systolic blood pressure (SBD), diastolic blood pressure (DBD), pulse, respiratory rate, Glasgow Coma Scale (GCS) score, range of shot, injury site, X-ray, cranial CT, thorax CT, abdominal CT, and extremity CT angiography findings, and the need for treatment and referral. Mortality was the dependent variable of the study. A logistic regression model was created to predict factors affecting the survival of the patients who were admitted to the emergency department with gunshot wounds and to identify the independent variables affecting survival. A p-value of <0.05 was considered sufficient for significance.

Results

The majority of patients who were admitted to the emergency department due to gunshot wounds were male and the median age of the patients was 32 years (18-70 years). The comparison of the descriptive characteristics with respect to survival revealed that the systolic and diastolic blood pressures and GCS scores of the deceased patients were significantly lower than those of the survivors. The rate of shooting at short range was significantly higher in the deceased patients when compared to that of the survivors. In addition, the rate of the need for surgical intervention and the incidence of pneumocephaly in cranial CT were higher in the deceased patients than in the survivors. Significantly higher rates of deceased patients required referral to neurosurgery and thoracic surgery clinics than survivors. The patients who were referred to the thoracic surgery clinic had an increased death rate by 29-fold and the patients who were referred to the thoracic surgery clinic had an increased death rate by about nine-fold. On the other hand, the probability of death was reduced by about half when the GCS scores of the patients were higher.

Discussion

We evaluated GCS in our patient group and determined a significantly lower score in the patients who did not survive, which agrees with the findings of other studies. Patients with higher SBD and DBD showed a higher probability of survival, which agrees with the results in other studies. Most patients were shot from their extremities and none had died while the death rate was significantly higher in the patients who suffered injuries to the head or neck. The patients with pneumocephalus had a very low chance of survival. Compared to wound care and dressing, patients who received surgical treatment were more likely to die as these patients had more critical injuries.

Conclusion

Although most injuries were to the extremities, there were no mortalities in the cohort of patients referred to orthopedics. The patients who suffered injuries to the head/neck had the highest mortality rate.

Right ventricular shotgun pellet embolism: Case report and radiological aspect

Pellet embolism to the heart following gunshot injuries is an unusual event that requires a fast diagnosis. Imaging assessment is necessary to locate the projectiles and look for associated injuries. We present a case of a 41-year-old woman admitted after sustaining 2 gunshot wounds in the abdomen and left thigh, with the initial computed tomography (CT) scan showing a metallic object next to the right ventricle. Further radiological evaluation included transthoracic echocardiography and electrocardiogram-gated cardiac CT scan which confirmed the diagnosis of a migrating pellet to the right ventricle, entrapped within the trabeculations. Electrocardiogram-gated cardiac CT has a major role in detailed evaluation of bullet embolism to the heart cavities and guides the management.

Follow the Shoestring: A Unique Case of Bullet Extraction

Firearm-related injuries and deaths remain a major issue in the United States. Gunshot injuries to the foot can be particularly difficult to manage when they occur as they can cause fractures or devastating neurovascular damage. There are limited reasons for routine bullet removal in most cases. Acute indications include wounds involving joints, palms, and soles as well as increased risk of infection, persistent pain, and lead intoxication. Here, we bring attention to a case of a gunshot wound to the left foot of a 53-year-old male, in which the bullet was able to be extracted using a shoe fiber that had become wrapped around the bullet.

A silver bullet? The role of radiology information system data mining in defining gunshot injury trends at a South African tertiary-level hospital

Background

South Africa (SA) has no national injury surveillance system, and hence, non-fatal gunshot injuries are not routinely recorded. Most firearm-related injuries require multi-detector computer tomography (MDCT) assessment at a tertiary-level facility. MDCT scanning for victims with gunshot injuries thus provide an indication of the societal burden of firearm trauma. The potential of the modern radiology information system (RIS) to serve as a robust research tool in such settings is not fully appreciated.

Objective

The aim of this study was to evaluate the use of institutional RIS data in defining MDCT scanning trends for gunshot victims presenting to a tertiary-level SA hospital.

Method

A single-institution, retrospective, comparative study was conducted at the Tygerberg Hospital (TBH) Trauma Unit for the years 2013 and 2018. Using data-mining software, customised RIS searches for information on all gunshot-related emergency computed tomography scans in the respective years were performed. Demographic, temporal, anatomical and scan-protocol trends were analysed by cross tabulation, Chi-squared and Fisher’s exact tests.

Results

Gunshot-related emergency MDCT scans increased by 62% (546 vs. 887) from 2013 to 2018. Lower-limb CT angiography was the commonest investigation in both periods. A higher proportion of victims in 2018 sustained thoracic injuries (12.5% vs. 19.8%; p < 0.01) and required imaging of more than two body parts (13.1% vs. 19.2%; p < 0.01).

Conclusion

By using RIS data to demonstrate the increasing gunshot-related MDCT workload in the review period, as well as a pattern of more complex and potentially life-threatening injury, this study highlights the burden of firearm trauma in the society and the potential role of the modern RIS as a robust research tool.

Heavy metal in radiology: how to reliably differentiate between lodged copper and lead bullets using CT numbers

BACKGROUND

The in situ classification of bullets is of interest in forensic investigations when the bullet cannot be removed. Although computed tomography (CT) is usually performed on shooting victims, visual assessment, or caliber measurements using CT can be challenging or infeasible if the bullets are deformed or fragmented. Independent from the bullet's intactness, x-ray attenuation values (CT numbers) may provide information regarding the material of the bullet.

METHODS

Ethical approval was not required (animal cadavers) or waived by the ethics committee (decedents). Copper and lead bullets were fired into animal cadavers, which then underwent CT scanning at four energy levels (80, 100, 120, and 140 kVp). CT numbers were measured within regions of interest (ROIs). In addition to comparing CT numbers, the dual-energy index (DEI), representing the ratio between the CT numbers of two energy levels, was calculated. The most appropriate method was applied for decedents with fatal gunshot wounds.

RESULTS

CT numbers demonstrated no significant difference between copper and lead bullets, and false classifications can easily occur. DEI calculations revealed significant differences between the two groups of bullets. The 120/140 DEIs calculated from the maximum CT numbers obtained from ROIs at the edge of copper versus lead bullets presented a significant difference (p = 0.002) and a gap between the CT numbers of copper and lead bullets and was successfully applied for the decedents.

CONCLUSIONS

This study presents a viable method for distinguishing copper and lead bullets in situ via CT and highlights the potential pitfalls of incorrect classifications.

Imaging Ballistic Injuries

Here in Canada, we often think of gun violence as confined to conflict zones, terrorism, and more of a problem for our southern neighbor. However, in recent years, it has also become a Canadian problem with increased gun violence related to criminal activity presenting in daily practice. Radiologists play a critical role in the evaluation of ballistic trauma and must therefore be familiar with both the common and uncommon patterns of ballistic injury. In this article, we review the mechanisms of ballistic trauma as well as their resultant injury patterns in order to guide image interpretation.

Magnetic resonance enterography (MRE) and ultrasonography (US) in the study of the small bowel in Crohn's disease: state of the art and review of the literature

Crohn’s disease (CD) is a chronic idiopathic disease and its diagnosis is based on a combination of clinical symptoms, laboratory tests and imaging data. There isn’t a diagnostic gold standard: the ileocolonoscopy with mucosal biopsies represents the standard for luminal disease, while cross-sectional imaging such as Ultrasound (US), Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) can show transmural alterations and extraintestinal manifestations. CD is usually diagnosed in the young age and after baseline diagnosis, the patients have to undergo to variable follow-up depending on remission or active disease. The aim of our review is to compare Magnetic Resonance Enterography (MRE) to Ultrasonography (US) in the follow-up of CD. (www.actabiomedica.it)

Determining Trajectory to Predict Injury: The Use of X-Ray During Resuscitation in Gunshot Wounds

BACKGROUND

The practice of marking gunshot wounds and obtaining X-rays (XRs) has been performed to determine the trajectory of missiles to help identify internal injuries. We hypothesized that surgeons would have poor accuracy in predicting injuries and that X-rays do not alter the clinical decision.

METHODS

We developed a 50-patient (89 injury sites) PowerPoint survey based on cases seen at our level 1 trauma center from 2012 to 2014. Images of a silhouetted BodyMan (BM) with wounds marked, XRs, and vital signs (VSs) were shown in series for 20 s each. Surgeons were asked to record which organs they thought could be injured and to document their clinical decision. Data were analyzed to determine the inter-rater reliability (agreement, intraclass correlation coefficient [ICC]) for each mode of clinical information (BM, XR, VS). Predicted versus actual injuries were compared using absolute agreements.

RESULTS

Ten surgeons completed the survey. We found that no single piece of information was helpful in allowing the surgeon to accurately predict injuries. Pulmonary injury had the highest agreement among all injuries (ICC = 0.727). VSs had the highest ICC in determining the clinical plan for the patient (ICC = 0.342), whereas both BM and XR had low ICCs (0.162 and 0.183, respectively).

CONCLUSIONS

We found that marking wounds and obtaining X-rays, other than a chest X-ray, did not result in accuracy in predicting injury nor alter the clinical decision. VSs were the only piece of information found significant in determining clinical management. We conclude that marking wounds for X-rays is an unnecessary step during the initial resuscitation of patients with gunshot wounds.

Synergistic Role of Newer Techniques for Forensic and Postmortem CT Examinations

OBJECTIVE

The aim of this article is to provide an overview of newer techniques and postprocessing tools that improve the potential impact of CT in forensic situations.

CONCLUSION

CT has become a standard tool in medicolegal practice. Postmortem CT is an essential aid to the pathologist during autopsies. Advances in technology and software are constantly leading to advances in its performance.

Diagnostic value of unenhanced postmortem computed tomography in the detection of traumatic abdominal injuries

OBJECTIVE

To determine the diagnostic capabilities of unenhanced postmortem computed tomography (UPMCT) in detecting traumatic abdominal injuries.

MATERIAL AND METHODS

Cases of traumatic death with both UPMCT and classical autopsy were collected retrospectively from our institution "virtopsy" database in a period of 5 years. Cadavers with gunshot injuries were excluded. Sensitivity, specificity, accuracy, negative (NPV) and positive (PPV) predictive values of PMCT globally and for hemoperitoneum, liver, spleen, pancreas and kidney injuries individually were estimated using the autopsy report as gold standard.

RESULTS

Seventy-one cadavers were included. UPMCT had a sensitivity of 80% and a specificity 94%, with an accuracy of 83%, a PPV of 98% and a NPV of 59% for the diagnosis of traumatic abdominal injuries. The highest sensitivity was obtained for the detection of hepatic injuries (71%) and the lowest for pancreatic injuries (12%). UPMCT had a specificity of 100% for the detection of hemoperitoneum. A NPV of 98% was found for the detection of perihepatic hematomas.

CONCLUSION

The low sensitivity and low NPV do not support the use of UPMCT as an alternative to conventional autopsy to diagnose and/or rule out traumatic abdominal injuries. Nevertheless, UPMCT remains a helpful tool as it helps detect hemoperitoneum and virtually exclude presence of perihepatic hematomas.

Weight-bearing MRI of the knee: a review of advantages and limits

Standard knee imaging with MRI is usually performed with patient in recumbent position under non-weight-bearing conditions. Recently, magnetic resonance imaging systems to scan the knee joint under weight bearing conditions has been proposed as an approach to improve the clinical utility of musculoskeletal MRI. Imaging under loading can be useful to understand the natural motion behavior of the knee joint and to identify conditions that are challenging to diagnose by using standard position. We reviewed the literature on weight-bearing MR imaging of the knee to describe the current state of use of such MRI technologies, evaluating the advantages and the potential limitations of these technologies.

Clinical and instrumental assessment of herniated discs after nucleoplasty: a preliminary study

BACKGROUND AND AIM

The therapy for low back pain boasts different approaches; one of these is nucleoplasty. We wanted to assess the effectiveness of nucleoplasty both by clinical response both by MR imaging evaluation, including even extrusions larger than one third of the spinal canal.

METHODS

Fifty-seven patients were treated with nucleoplasty in our hospital, 11 of these patients accepted both clinical and MRI evaluation after six months from treatment. The clinical evaluation was performed with Visual Analogue Scale (VAS) of pain, scored before and after the procedure. MRI evaluation consisted of analysing some imaging parameters of disc protrusions before and after the treatment.

RESULTS

In 10 out of 11 (91%) patients, VAS was reduced and only 1 out of 11 (9%) had the same pain after procedure. The mean of decrease of VAS score was 64%. In our population 8/11 (72%) patients had a herniation larger than 1/3 of the sagittal diameter of spinal canal and 100% of them had an improvement with a mean VAS reduction value of 75%. With MRI evaluation, the mean percentage of expulsion before and after treatment was respectively 40% and 34%. The expulsion decreased in 7/13 discs, remained equal in 4/13, and increased in 2/13 discs. Among the 9 larger protrusions, 3 didn't change, 6 reduced with a decrease mean value of 13%. Other MRI parameters didn't change significantly.

CONCLUSIONS

Our preliminary experience supports the success of coblation on pain relief, aiming to show progressively that this treatment is suitable even in case of great extrusions, which are generally treated only with surgical approach. It's not clear the usefulness of MRI control yet, even if in most of cases we could have found a certain reduction of expulsion degree.

Scapular fractures: a common diagnostic pitfall

Scapular fractures are one of the most difficult fractures to diagnose on radiographs. Detection can be challenging because of the obscuration by the overlying structures or incomplete imaging due to difficult patient collaboration. Familiarity with imaging characteristics of these abnormalities will allow radiologists to better diagnose and characterize scapular fractures. Three-dimensional computed tomographic scans are considered the gold standard for scapular diagnoses. Treatment strategies differ depending on the type of scapular fractures, but the site and degree of displacement will determine whether surgical intervention should be considered. Complications can occur in fractures that are undiagnosed or improperly evaluated. The purpose of this article is to describe imaging features of traumatic scapular injury, and discuss the role of diagnostic imaging in clinical decision making after shoulder trauma. (www.actabiomedica.it)

Imaging of pediatric foot disorders

Infants and children undergo imaging studies to evaluate a wide variety of congenital and acquired disorders. Imaging protocols have to consider the patient’s comfort, level of anxiety, and smaller size. The first imaging study is usually made with plain radiographs. The routine radiographic examination of the foot includes the anteroposterior (AP), lateral, and oblique projections. Magnetic Resonance Imaging (RMI) provides excellent anatomic detail of cartilage, vasculature and soft tissue thanks to superior soft tissue contrast and spatial resolution, so is valuable in many cases. According to the clinical and objective signs, guided by the radiographs images, we can be oriented to perform Computed Tomography (CT), CT imaging or MRI imaging. CT imaging is useful to observe the bones but it has the disadvantage of using radiation and doesn’t adequately define the bone’s non-ossified portions. On the contrary, MRI imaging is very useful in identifying the cartilaginous parts and vascular and soft tissues, thanks to its superior contrast and spatial resolution. Finally, it is important to orientate the diagnostic process keeping in mind the clinical sign of the patient and to use the most appropriate diagnostic technique. (www.actabiomedica.it)

Magnetic Resonance Imaging correlates of benign and malignant alterations of the spinal bone marrow

Background and aim of the work: Bone marrow (BM) abnormalities in the spine are a common, sometimes unexpected, finding on Magnetic Resonance Imaging (MRI), which is the most sensitive imaging modality to evaluate the marrow, and their interpretation can be difficult for the unexperienced radiologist. In this review, the MRI appearance of normal age-related BM changes, as well as the imaging features of benign and malignant diseases, are presented. Discussion: A large variety of BM signal alterations has been identified and described, including normal variants, BM reconversion, degenerative changes, infections, spondyloarthritis and osteonecrosis, trauma, neoplastic lesions (both primary or metastatic), post-radiation and chemotherapy sequelae. Conclusions: Knowledge of normal age-related BM appearance, normal variants and patterns of involvement in focal and diffuse bone diseases is essential, together with clinical and laboratory data, to narrow the list of the possible differential diagnoses. The radiologist should be familiar with these signal changes, as they can sometimes be discovered incidentally. In this context, it is equally important not to attribute pathological significance to benign alterations and to promptly detect signs of malignant diseases. (www.actabiomedica.it)

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.

Unusual route of a bullet: From scapula to eye

Herein, an awkward case of globe perforation with a bullet-entering from the right posterior scapular region and leaving the body from the right orbit through the eye - is reported. Route of the bullet could be devastating - as it passed through the neck and the maxillofacial region-however by chance no vital damage occurred. Its path was assessed by plain radiography and computed tomography scans. Sometimes prediction of the trajectory is very difficult without additional radiological investigations. Especially, in the case of any high velocity projectile wounding, physician must be aware of the fact that the bullet's course will not be a linear but most probably a complicated one. Prognosis of the injury depends on the path of the bullet or shrapnel fragment, close clinical observation, an open-minded approach, and the multidisciplinary care. Moreover, even the crime investigation might be needed.

Bony injuries in homicide cases (1994-2014). A retrospective study

Even when human skeletal remains are found in contexts indicative of body disposal after homicide, none of the bones may manifest injuries. When skeletons are incomplete, there are two possibilities, the injured bones are missing or none were injured. This leads to the question how frequently bones are injured during homicide, where the injuries tend to be placed, and whether the frequency of injury is related to the type of homicide. To answer these questions, the postmortem reports from all autopsies performed for homicide victims at the Institute of Legal Medicine at the University Hospital in Frankfurt am Main, Germany, between 1994 and 2014, were retrospectively evaluated for bony injuries discovered during autopsy. In 90 cases, a preliminary postmortem computed tomography (pmCT) examination had been performed. The cases were categorized into the following five groups by type of fatal trauma: blunt force, sharp force, gunshot injury, strangulation, or other. In total, the postmortem reports for 897 homicides (527 male, 370 female) were evaluated. The number of victims per trauma category were sharp force, 309; blunt force, 179; gunshot injury, 242; strangulation, 92; and other, 75. Bony injuries had been reported in 70.9 % of the homicides. The "gunshot" category contained the highest proportion of victims with bony injuries (92.6 %). With 80.4 %, the second-highest proportion of victims with bony injuries was in the "blunt force" category, followed by 66.3 % of victims in the "sharp force" group. In contrast, with 53.3 %, the second-lowest proportion of victims with bony injuries was in the "strangulation" category, which contained a preponderance of female victims, followed by 17.3 % of victims with bony injuries in the "other" category. Bony injuries thus occurred in the majority of homicides. Forensic osteological analysis should, therefore, always be performed on badly decomposed human remains. Where necessary, the additional use of visualization techniques, in particular, pmCT, or maceration may be considered. The absence of bony injuries does not rule out homicide; e.g., in strangulations, bony injuries are manifest in only half the victims, even when the skeleton is intact. The relevant structures are also easily lost to decomposition, scavenging, or scattering.

A Fortunate Story of an Unusual AK-47 Bullet Trajectory: Always Keep a Smartphone in Your Pocket

This is a report of a fortunate story of an unusual AK-47 bullet trajectory which took place during the Paris (France) attack of November 13th, 2015. A young man, trying to protect his girlfriend, interfered between her and a shooter. He had been wounded in the posterior compartment of the thigh. The bullet penetrated him and, instead of exiting, rebound against his Smartphone, which was in the front pocket of his pants. Thanks to that, the missile bullet did not injure his girlfriend but ended its trajectory in the fat tissue of his thigh. Thabouillot O , Perrier P , Roche NC , Agard D , Barbier O , Martin G , Viant E , Leclere JB . A fortunate story of an unusual AK-47 bullet trajectory: always keep a Smartphone in your pocket. Prehosp Disaster Med, 2016;31(3):343-345.

Atypical gunshot wound: Bullet trajectory analyzed by computed tomography

INTRODUCTION

Gunshot injuries are a result of a bullet or projectile fired from a weapon that penetrates the body. Homicide, suicide, and occasionally, accidental events are a significant cause of firearm-related injuries. In rare cases, the damage from the gunshot injury can be masked due to an atypical bullet trajectory.

PRESENTATION OF CASE

A 63-year-old male was found with a gunshot wound to the anterior left knee. Computed tomography (CT) scans revealed a bullet track extending from the anterior aspect of the left knee that traveled cephalad subcutaneously and entered into the peritoneal cavity, perforating the distal descending colon. The bullet was found to be at rest adjacent to the spleen and posterior chest wall, with no injury to the lungs, kidneys or the spleen. The patient required a sigmoid colectomy with descending colostomy and was subsequently discharged home without any complications.

DISCUSSION

Intra-abdominal organ damage from a gunshot wound to the distal limb is a rare occurrence. Atypical gun shot wounds, such as this case, have the potential for multiple issues including: delayed diagnostic tests, inaccurate radiological readings, and inappropriate medical management.

CONCLUSION

If an abnormal trajectory is maintained, it is possible for a bullet to traverse half the length of the body without the patient realizing it. Accurate CT analysis and quick decisions in surgical and medical management are critical takeaways to provide quality care to patients with these injuries.